Prediction of persistent post-operative pain: Pain-specific psychological variables compared with acute post-operative pain and general psychological variables.

BACKGROUND: Psychological variables and acute post-operative pain are of proven relevance for the prediction of persistent post-operative pain. We aimed at investigating whether pain-specific psychological variables like pain catastrophizing add to the predictive power of acute pain and more general psychological variables like depression. METHODS: In all, 104 young male patients undergoing thoracic surgery for pectus excavatum correction were studied on the pre-operative day (T0) and 1 week (T1) and 3 months (T2) after surgery. They provided self-report ratings (pain-related: Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale = PASS, Pain Vigilance and Awareness Questionnaire = PVAQ; general psychological: Screening for Somatoform Symptoms, State-Anxiety Inventory-X1, Center for Epidemiologic Studies Depression Scale = CES-D). Additional predictors (T1) as well as criterion variables (T2) were pain intensity (Numerical Rating Scale) and pain disability (Pain Disability Index). RESULTS: Three months after surgery, 25% of the patients still reported clinically relevant pain (pain intensity ≥3) and over 50% still reported pain-related disability. Acute post-operative pain as well as general psychological variables did not allow for a significant prediction of persistent post-operative pain; in contrast, pain-related psychological variables did. The best single predictors were PASS for pain intensity and PVAQ for pain disability. CONCLUSIONS: Pain-related psychological variables derived from the fear-avoidance model contributed significantly to the prediction of persistent post-operative pain. The best possible compilation of these measures requires further research. More general psychological variables may become relevant predictors later in the medical history. SIGNIFICANCE: Our results suggest that pain-specific psychological variables such as pain anxiety and pain hypervigilance add significantly to the prediction of persistent post-operative pain and might even outperform established predictors such as acute pain and general psychological variables. Clinicians might benefit from the development of time-economic screening tools based on these variables.

[Use of negative pressure wound therapy on surgical incisions (prevena™) after surgery of pectus deformities reduces wound complications]. / Einsatz einer präventiven, epikutanen Unterdrucktherapie (Prevena™) bei offener Korrektur von Deformitäten der vorderen Brustwand reduziert das Auftreten von Wundheilungsstörungen.

INTRODUCTION: Pectus surgery can lead to postoperative wound complications in some cases. The purpose of this study is to determine whether preventive negative pressure wound therapy (NPWT) could reduce wound complications after open pectus surgery. MATERIAL AND METHODS: 100 patients after open procedure for the treatment of pectus excavatum or pectus carinatum in the years 2010 to 2012 were retrospectively analysed. 50 patients treated with Prevena™ (KCI Medical Products GmbH, Wiesbaden, Germany) were compared with 50 patients whose wounds were covered with OPSITE® film (Smith & Nephew, Hamburg, Germany). Wound closure was performed following a standard procedure as well as the placement of subcutaneous drains. Therefore two comparable groups of patients were formed and analysed by standardised parameters. The wound dressing was placed epicutaneously immediately after wound closure in the operating room and removed after 5 days in each case. Follow-ups were performed immediately after removal of the wound dressing, at the time of discharge from hospital as well as 6 and 12 weeks after operation. The wounds were checked for tenderness, pain, secretion, redness and fistulas. RESULTS: The Prevena group showed 10 % wound complications which needed operative treatment, whereas the OPSITE group showed complications in 24 %. Some patients who were treated with Prevena showed superficial skin lesions at the rim of the foam and the film. All of these lesions healed well. CONCLUSION: Treating wounds postoperatively with preventive measures (NPWT) showed a remarkable reduction of wound complications following open pectus surgery whereas statistically the difference was not significant (p = 0.074).

[Psychological prophylaxis training for coping with postoperative pain. Long-term effects]. / Psychologisches Prophylaxetraining zur Bewältigung postoperativer Schmerzen. Langfristige Effekte.

INTRODUCTION: The present study was performed to investigate the effect of multidimensional psychological prophylaxis training focusing on coping with cognitive-emotional pain on recovery within the first 12 months after surgery. The training included the following three components: (1) education about pain, analgesia and psychological aspects of coping with pain, (2) training for coping with pain and (3) body-centered relaxation. MATERIAL AND METHODS: In the study 48 young male patients (surgical correction of a chest malformation) were assessed 1 day before surgery, at discharge and 3, 6 and 12 months postoperatively concerning postoperative pain intensity and pain disability as well as pain anxiety, pain catastrophizing and pain hypervigilance. Additionally, 24 of these patients received training on cognitive-emotional coping with pain 1 day before surgery and 1-3 days after surgery (each session 1 h). RESULTS: The proportion of patients with clinically relevant improvement was significantly higher in the training group compared to the control group. This was the case for acute pain intensity (approximately 1 week after surgery), pain disability 3 months later and pain anxiety 12 months after surgery. CONCLUSION: The resurgence of pain anxiety after 12 months could only be found in the control group and could be due to the upcoming surgical removal of the transsternal metal implant. The prophylaxis training can therefore be seen as a protective factor for long-term management of surgery-related consequences and future pain experiences.

Malignant peritoneal mesothelioma in a 16-year-old girl: presentation of a rare disease.

Malignant peritoneal mesothelioma is extremely rarely seen in young patients.A 16 year-old girl presented with appendicitis-like acute abdominal pain. Intra-operatively, multiple confluent peritoneal nodules were seen on the entire greater omentum and in the pelvis infiltrating the uterus and both ovaries. Biopsies were obtained and interpreted as serous ovarian carcinoma. Radical surgical resection and hyperthermic intraperitoneal chemotherapy -(HIPEC) with carboplatin was performed and followed by 2 cycles of carboplatin/paclitaxel. Histological reevaluation showed characteristic features of epithelioid peritoneal mesothelioma and ruled out serous ovarian cancer. Therapy was continued with 6 cycles of pemetrexed/cisplatin.3 months after end of chemotherapy vital tumor tissue was found in the recess behind the liver, which could be resected completely. The patient is currently disease-free 17 months after initial diagnosis.Malignant peritoneal mesothelioma in young female patients might be under-recognized and possibly misdiagnosed as ovarian serous carcinoma in some cases. International and interdisciplinary cooperation is necessary in order to provide evidence based guidelines for diagnosis and treatment in the future.

Pericardial cyst or teratoma? Change of strategy during mediastinal tumor surgery.

This report describes the management of an 8 × 8-cm cystic mass that arose from the anterior mediastinum and prolapsed into the right pleural cavity adherent to the pericardium in an asymptomatic 16-year-old girl. The patient was scheduled for a video-assisted thoracoscopic operation with exposure, puncture and suction of a suspected pericardial cyst. However, during the procedure the strategy was changed due to the solid consistency of the mass, and the lesion was extirpated in toto by a short anterolateral thoracotomy. The complete histopathological investigation showed a highly fibrous, cystic, mature teratoma.

[Benefits and risks of tube feeding via gastrostoma in infants and children with peritoneal dialysis]. / Nutzen und Risiko eines Gastrostomas bei Säuglingen und Kleinkindern mit chronischer Peritonealdialyse.

BACKGROUND: Nutrition of children with end-stage renal disease and peritoneal dialysis (PD) is often difficult. Tube feeding via a gastrostoma is discussed controversially, and some authors consider this as a contraindication because of the risk of peritonitis. METHODS: In our centre 16 infants and children with end-stage renal disease were treated with PD and tube feeding over a gastrostoma in the last 12 years. The patients showed dystrophy (mean BMI -1.73 SDS) and were too small (mean body length -4.56 SDS). Seven of them (median age 11 months) received a gastrostoma before insertion of a Tenkhoff-catheter and start of PD. Nine children (median age 5 months) had PD primarily before insertion of the gastrostoma and start of tube feeding. RESULTS: Patients with start of PD while a gastrostoma was already inserted had 15 events with peritonitis in the observation time of 91 months (1.98 per patient year). Patients with primary start of PD had 12 events with peritonitis in a total time of 43 month (3.34 per patient year), after insertion while PD was already running the number of events fell significantly to 25 peritonitis events in a total of 271 months (1.11 per patient year, p < 0.01). The children had a benefit from tube feeding via a gastrostoma in regard of body weight (BMI + 1.61 SDS, p < 0.01) as well as growth (body height + 2.29 SDS, p < 0.05). CONCLUSION: Tube feeding via a gastrostoma is a good and safe option for alimentation, even under peritoneal dialysis. A decrease of PD-associated peritonitis under tube feeding was observed while physical development was positively influenced.

Considering laparoscopic salvage options--is pre-emptive omentectomy necessary in paediatric peritoneal patients?

BACKGROUND: In paediatric peritoneal dialysis patients, pre-emptive omentectomy is discussed controversially and literature provides only little data concerning this issue. Our aim was to evaluate the rate of omentum-majus-related problems in our patients, in whom omentectomy was generally not performed. Furthermore, we were interested in the success rates of laparoscopic adhesiolysis. PATIENTS AND METHODS: Between 09/2006 and 03/2008, we regularly saw 18 peritoneal dialysis patients in whom we retrospectively analysed medical records to determine the rate of catheter-related complications. In addition, we evaluated the success rates of laparoscopic adhesiolysis. RESULTS: During 355 dialysis months in 18 patients, we observed 7 omentum-majus-related obstructions in 6 patients (1/50.7 PM). The median age of the patients affected was 9 years, median filling volume at the time of the obstruction was 671 ml/m (2). Laparoscopic adhesiolysis was successful in 4 out of 7 episodes. In 3 cases, the catheter lumen was plugged by necrotic portions of the omentum and the catheters had to be replaced. CONCLUSION: Our data confirm omentum-majus-related catheter obstruction as a major cause of catheter dysfunction. However, in comparison to literature, it remains unclear to which extent omentectomy can reduce the incidence of catheter obstruction in general (including e. g. obstruction due to coagulation). Thus, the decision to perform an omentectomy should be taken individually after careful consideration. In case of omentum-majus-associated obstruction, early but not late laparoscopic intervention proved to be a successful, minimally invasive technique to restore catheter function.

Review article: percutaneous endoscopic gastrostomy in infants and children.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) placement is widely accepted in children needing long-term gastrostomy feeding and clinical experience has been accumulated using PEG in children for nearly three decades. AIM: To discuss the current knowledge about clinical application of percutaneous endoscopic gastrostomy in children as well as associated complications and special aspects. METHODS: We reviewed literature on PEG, primarily in children, with a focus on complications, gastro-oesophageal reflux, potential benefits and parental perceptions. In addition to reviewing scientific literature, we considered clinical experience and judgment in developing recommendations for special aspects concerning PEG in children. RESULTS: Since its introduction in 1980, the use of PEG in paediatric patients has become widely accepted. With expanded experience, the number of medical conditions for which PEG is indicated, as well as the use of new techniques has increased. Published reports have helped improve expertise in dealing with associated complications; however, several key issues remain unresolved such as the implications of gastro-oesophageal reflux associated with PEG placement. CONCLUSIONS: Percutaneous endoscopic gastrostomy insertion for enteral nutrition in children and adolescents is an efficient and safe technique, even in small children, and is associated with a tolerable complication rate.

Maturation of the expression of adrenomedullin, endothelin-1 and nitric oxide synthases in adipose tissues from childhood to adulthood.

OBJECTIVE: To investigate if the vasoactive systems adrenomedullin (ADM) and endothelin-1 (ET-1) are expressed in human adipose tissues in children and in adults and to determine the distribution pattern of nitric oxide synthases (NOS). DESIGN AND SUBJECTS: Subcutaneous, mesenterial and omental adipose tissue specimens taken from 15 children (age 0.5-16 y, median 6 y) and 13 adults (age 43-79 y, median 60 y) were analyzed. The body mass indices (BMI) were within the normal range. All patients were normotensive, and were free of infectious disease, and metabolic or endocrine disorders. The specimens were taken during elective laparotomies after informed consent was obtained. MEASUREMENTS: ADM, ET-1, the endothelial (eNOS) and inducible (iNOS) NOS as well as two housekeeping genes were measured using quantitative real-time PCR. RESULTS: ADM gene expression was found at all locations, and was significantly higher in adults than in children (P<0.01 for subcutaneous and omental adipose tissue). ET-1 mRNA was distributed in a similar way, showing significantly higher levels in the subcutaneous and mesenterial adipose tissue sections of adults than of children. For eNOS, the adult patients exhibited a higher expression in subcutaneous and mesenterial specimens than the children (P<0.01 and P<0.05). The iNOS mRNA was increased in subcutaneous, mesenterial and omental adipose tissues in the adult cohort compared to the children's levels (P<0.05 to P<0.01). CONCLUSION: Human adipose tissue expresses many vasoactive substances including ADM and ET-1. In adults, the amounts of ET-1 and ADM as well as eNOS and iNOS mRNA are higher, possibly due to a physiological upregulation with increasing age. Although there are differences depending on the locations of the tissues, the expression patterns of the antagonists ADM and ET-1 are quite similar, indicative of a well-balanced pattern of local gene expression in normotensive individuals with normal body weight.

Objective evaluation of small bowel and colonic transit time using pH telemetry in athletes with gastrointestinal symptoms.

BACKGROUND: Gastrointestinal (GI) disturbances are often reported by long distance runners and are more common in women, particularly after prolonged high intensity exercise. OBJECTIVES: To determine whether these symptoms could be associated with alterations in GI motility. METHODS: Small bowel and colonic transit were measured using pH telemetry in a group of 11 female athletes (age 22 to 53 years), six of whom experienced lower GI symptoms during exercise. Subjects participated in two experimental sessions: a control measurement, where small bowel transit was estimated during a rest period (R) of six hours; and an exercise session (E), where small bowel transit was measured during a one hour period of high intensity exercise (cross country running) at >70% VO(2)max. Colonic transit was estimated indirectly from determinations of whole gut transit time by radio-opaque marker. RESULTS: Small bowel transit time was 3.5 to 10.6 h (R) and 3.0 to 8.7 h (E) in asymptomatic athletes, versus 4.0 to 6.6 h (R) and 4.6 to 7.3 h (E) in symptomatic athletes (NS). Colonic transit time was 35.0 to 62.5 h (R) and 30.5 to 70.9 h (E) in asymptomatic athletes versus 20.4 to 42.9 h (R) and 21.5 to 67.2 h (E) in symptomatic athletes (NS). CONCLUSIONS: Small bowel and colonic transit times were similar in the two groups in the rest and exercise sessions. The diarrhoea seen in this study did not result from accelerated colonic transit. Other mechanisms must be sought.

Comparison of leptin gene expression in different adipose tissues in children and adults.

OBJECTIVE: Adipose tissue displays depot-specific metabolic properties and a predominant gene expression of leptin in subcutaneous tissue. The aim of the study was to evaluate leptin mRNA expression in various adipose tissues and to relate it to plasma leptin concentrations. Furthermore, developmental changes in leptin gene expression from childhood to adulthood were examined. DESIGN AND METHODS: Thoracic subcutaneous and intrathoracic adipose tissue specimens were obtained in 22 adults (51-81 years) and 23 children (0.1-17 years) undergoing cardiac surgery, and abdominal subcutaneous, omental and mesenterial fat specimens were collected from 21 adults (38-79 years) and 22 children (0.2-17 years) before abdominal surgery. Preoperative plasma leptin concentrations were measured by RIA. Leptin mRNA expression was quantified by TaqMan real-time PCR. RESULTS: In adults, there was no difference between leptin gene expression in subcutaneous and intrathoracic fat, whereas in children leptin mRNA expression was significantly higher in subcutaneous adipose tissue. In omental fat, leptin mRNA levels were significantly lower compared with subcutaneous and mesenterial sites in both children and adults. Adults revealed a significantly higher leptin gene expression in subcutaneous, omental and mesenterial adipose tissues than children. Subcutaneous and omental leptin gene expression are independent factors for plasma leptin concentrations in children and adults. CONCLUSION: Leptin is differentially expressed at different adipose tissue sites, a situation which is even more pronounced in children. There is a developmental increase in leptin mRNA expression in adipose tissue during childhood, reaching maximal capacity in adulthood.

Laparoscopically performed gastric banding in a 13 year-old girl with morbid obesity and end stage renal insufficiency allows lifesaving weight loss and hemodialysis.

OBJECTIVE: In adults, laparoscopic gastric banding is applied to treat morbid obesity, usually in combination with dietary and psychological intervention and increased physical exercise. However, little information is available on gastric banding in children. PATIENT AND METHODS: The 13 year-old girl suffered from end stage renal failure. Complications with hemodialysis catheters due to her extensive subcutaneous fat pads led to a life-threatening deterioration of her uremia. Intensive conventional schedules for weight reduction failed to be effective, so the morbidly obese girl (body mass index [BMI] 37.7 kg/m2, +3.6 standard deviation score [SDS]) underwent laparoscopic gastric banding at the age of 13 years after informed parental consent was obtained. RESULTS: After laparoscopic gastric banding there was a notable weight loss of 14 kg and an eventually adequate hemodialysis was possible. Total weight loss of the now 15 year-old girl was 24 kg (present BMI 28.3 kg/m2, +2.2 SDS). CONCLUSION: Even in childhood, laparoscopic gastric banding may be considered in cases of morbid obesity in critically ill patients.

Intestinal perforations in a premature infant caused by Bacillus cereus.

Although Bacillus cereus is a ubiquitous bacterium, the incidence of neonatal infections is very low with only a few cases of B. cereus infections in neonates reported in the literature. We report the case of a premature infant with multiple intestinal perforations and an abdominal B. cereus infection. The initial course was characterized by severe cardiovascular shock, anemia, thrombocytopenia and disseminated intravascular coagulation, leading to periventricular leukomalacia, alopecia capitis and toxic epidermal necrolysis. The possible role of B. cereus-associated enterotoxins for the clinical manifestations are discussed. Our case confirms previous reports of severe clinical symptoms in B. cereus infection in premature neonates. We speculate that the systemic complications of B. cereus infection are at least partly related to the effect of B. cereus-associated enterotoxins.

Multiple endocrine neoplasia 2A syndrome: Surgical management.

BACKGROUND/PURPOSE: Currently, molecular genetic diagnostics allow familial types of medullary thyroid carcinoma to be detected at an asymptomatic stage and surgery thus to be performed at a time when prognosis is good. The current report aims to determine the appropriate age for safe prophylactic thyroidectomy in children with multiple endocrine neoplasia (MEN) 2A and mutations at codon 609 according to genotype-phenotype correlations and will discuss surgical procedures. METHODS: The authors describe the case of a family with hereditary MEN 2A syndrome. A DNA analysis of 7 family members confirmed the diagnosis by a mutation at codon 609 of the RET proto-oncogene. RESULTS: A phaeochromocytoma developed in 2 family members. Four had medullary thyroid carcinoma. A grandson underwent a prophylactic thyroidectomy at the age of 5 on account of genetic evidence. Despite the negative preoperative and intraoperative findings he already had an invasive medullary thyroid carcinoma. CONCLUSIONS: Few genotype-phenotype correlations have been established for MEN 2A disease. According to the natural history of the disease, families with the genotype RET cys609gly should have a more benign disease than high-risk families (mutations at codon 634, 618). From this report the authors conclude that prophylactic thyroidectomy in "609" families should be performed earlier than actually recommended, favorably at the age of 2 to 4 years. Further multicenter studies are needed to provide more clinical and prognostic data for less frequent (codon 609, 630, 791, and 891) RET genotypes.

[Prognostic risk factors in children and adolescents with craniocerebral injuries with multiple trauma]. / Prognostische Risikofaktoren bei schädelhirnverletzten polytraumatisierten Kindern und Jugendlichen.

220 of 268 polytraumatized patients (82.1%) presented an additional head injury, which increased the mortality significantly. By the Hannover Polytrauma Score we could demonstrate that the severity of the polytrauma and the prognosis depended on the extent of the brain injury. Important risk factors were skull fractures and shock on arrival. 66.7% of the patients with a severe brain trauma and a skull fracture died; without this fracture, only 36.8% died. 76.1% of the children with a systolic blood pressure (SBP) > 80 mm Hg survived, but only 31.2% with a SBF < or = 80 mm Hg did not die. For all polytraumatized children we recommend a computer tomography of the head. In spite of a negative initial CT a follow up CCT should be performed.

[Propofol-remifentanil versus sevoflurane-remifentanil for anesthesia for pediatric procedures in infants, children and adolescents]. / Propofol/Remifentanil versus Sevofluran/Remifentanil zur Anästhesie bei Unterbaucheingriffen im Säuglings-, Kindes- und Jugendalter.

INTRODUCTION: The aim of this study was to compare total intravenous anaesthesia (TIVA) using propofol and remifentanil (P/R-group) and balanced anaesthesia (BA) using sevoflurane and remifentanil (S/R-group) for paediatric surgery. PATIENTS AND METHODS: A total of 120 patients aged 6 months to 16 years scheduled for elective minor lower abdominal surgery were randomly assigned to receive either propofol (5-10 mg/kg/h) and remifentanil (0.125-1.0 microgram/kg/min) or sevoflurane (1.0-1.5 MAC) and remifentanil (0.125-1.0 microgram/kg/min). Perioperative haemodynamics as well as recovery and discharge times, PONV and side-effects were studied. The patients vigilance, comfort and pain intensity were assessed postoperatively using the objective pain discomfort scale, the Steward post-anaesthetic recovery score and a visual analogue scale. RESULTS: Postoperative recovery (9.0 vs 11.6 min) and extubation times (11.8 vs. 15.0 min) as well as the time taken until a Steward post-anaesthetic recovery score > 3/4 (15.2 vs. 21.4 min) was reached were significantly shorter in the P/R-group. However, the length of time until discharge to the ward, postoperative comfort, pain intensity and analgesic requirements as well as PONV were comparable in both groups. CONCLUSIONS: With regards to the investigated parameters, TIVA with propofol and remifentanil is equally effective as BA with sevoflurane and remifentanil in paediatric patients. However, considering the selected dosing regimen, recovery times were significantly shorter for children after TIVA.

[Two rare complications of percutaneous endoscopic gastrostomy: obstruction of the pylorus and gastrocolic fistula occurring in one patient]. / Zwei seltene Komplikationen der perkutanen endoskopischen Gastrostomie: Pylorusobstruktion und gastrokolische Fistel bei einem Patienten.

UNLABELLED: We report an 10 month old male infant, who developed an obstruction of the pylorus by dislocation of the retention disk 5 months after percutaneous endoscopic gastrostomy (PEG). This could be corrected under endoscopic control. Two years after PEG insertion diarrhoe occurred immediately after feeding caused by a gastrocolic fistula with dislocation of the retention disk in the colon transversum. An excision of the fistula and a resection of the colon segment were performed successfully. CONCLUSION: In patients with PEG and unclear abdominal symptoms a tube dislocation has to be kept in mind at any time.