Day case breast augmentation under paravertebral blockade: a prospective study of 100 consecutive patients.

BACKGROUND: An increasing trend toward day surgery management requires plastic surgeons not only to be cognizant of block techniques, but also to assess their safety and efficacy objectively. Paravertebral block offers benefits by enhancing surgical anesthesia and postoperative analgesia. This study aimed to assess the safety and efficacy of paravertebral block for day patients undergoing submuscular breast augmentation. The primary outcome measure was the rate of block failure. The secondary outcome measures included recovery room stay, pain management, and block complications. On the basis of a literature review and audit results, the study objective also aimed to propose safe guidelines for ambulatory paravertebral block patients undergoing breast surgery. METHODS: A total of 100 patients undergoing 172 single-level paravertebral blocks (72 bilateral blocks) and sedation for submuscular breast augmentation were studied prospectively. A single-injection paravertebral block was performed at the T4 level using a loss of resistance technique. Surgical, anesthetic, and recovery room details were recorded. Analyses were performed to determine the association between recovery room times, body mass index, pain scores, and requirements for opioids, antiemetics, and vasopressors. RESULTS: The findings showed that 87% of the blocks were successful for surgical anesthesia and 94% of the blocks were successful for postoperative analgesia. The pain score for 74% of the subjects was 3 or less. Antiemetics were given for 10% of the patients with significantly longer recovery room times. Vasopressors were required for 6% of the patients. A surgically caused pneumothorax resulted in the only unplanned admission. CONCLUSION: The study findings suggest that paravertebral block is a safe and effective technique for day case submuscular breast augmentation.

Impediments to the use of ankle block in Australia.

Anaesthetic trainees and consultants who enrolled in a regional anaesthetic workshop completed a questionnaire regarding their own ankle block practice. The questionnaire focused on frequency of use, barriers to use, technique and perceived success rate. One hundred and twelve respondents participated, with 73% performing less than 10 ankle blocks per year. Forty-eight per cent believed that they did not have an appropriate operating list or a suitable patient, whilst 27% believed time constraints were the major barrier. Of those performing less than 10 ankle blocks peryear, 22% cited lack of anatomical knowledge or technique as their major barrier and 71% perceived their success rate as medium to low. Eighty per cent performed their ankle block with the patient fully awake or sedated. Sixty-five per cent did not know the length of action of their ankle block. This survey supports recent suggestions that the practice of ankle block is under-utilized. Teaching workshops and clinical training for peripheral nerve blocks should receive high priority for the future.

Bone morphogenetic protein-2 (BMP-2) and transforming growth factor-beta1 (TGF-beta1) alter connexin 43 phosphorylation in MC3T3-E1 Cells.

BACKGROUND: Bone morphogenetic proteins (BMPs) and transforming growth factor-betas (TGF-betas) are important regulators of bone repair and regeneration. BMP-2 and TGF-beta1 have been shown to inhibit gap junctional intercellular communication (GJIC) in MC3T3-E1 cells. Connexin 43 (Cx43) has been shown to mediate GJIC in osteoblasts and it is the predominant gap junctional protein expressed in these murine osteoblast-like cells. We examined the expression, phosphorylation, and subcellular localization of Cx43 after treatment with BMP-2 or TGF-beta1 to investigate a possible mechanism for the inhibition of GJIC. RESULTS: Northern blot analysis revealed no detectable change in the expression of Cx43 mRNA. Western blot analysis demonstrated no significant change in the expression of total Cx43 protein. However, significantly higher ratios of unphosphorylated vs. phosphorylated forms of Cx43 were detected after BMP-2 or TGF-beta1 treatment. Immunofluorescence and cell protein fractionation revealed no detectable change in the localization of Cx43 between the cytosol and plasma membrane. CONCLUSIONS: BMP-2 and TGF-beta1 do not alter expression of Cx43 at the mRNA or protein level. BMP-2 and TGF-beta1 may inhibit GJIC by decreasing the phosphorylated form of Cx43 in MC3T3-E1 cells.

Effect of serial passage on gene expression in MC3T3-E1 preosteoblastic cells: a microarray study.

The osteoblastic function of mouse preosteoblastic MC3T3-E1 cells, as measured by alkaline phosphatase activity and osteocalcin secretion, decreases after serial passage. To uncover genes responsible for decreased osteoblastic function in high-passage cells, we have studied passage-dependent change of gene expression in MC3T3-E1 cells. Changes in the expression pattern of 2000 selected genes were examined simultaneously by comparing mRNA levels between MC3T3-E1 cells at passage 20 and passage 60 using the cDNA microarray analysis. Significant changes in the steady-state abundance of 27 mRNAs were observed in response to different passage numbers, including 17 known genes, 4 ESTs with homology to known genes, and 6 genes with no previously described function or homology. Northern blot analysis was used to verify and quantify the expression of selected genes, and revealed a significant higher level of up- and down-regulation compared to microarray data. These results indicate the existence of a significant change in gene expression in osteoblastic cells undergoing serial passages. Such changes might be responsible for a reduction in bone regeneration in older osteoblasts. Potential roles of selected genes in bone aging are discussed.

Digitally assisted acromioplasty: the effect of interscalene block on this new surgical technique.

PURPOSE: Interscalene brachial plexus (ISBP) block has been shown to be safe and effective for shoulder surgery with significant benefits. The purpose of this study was to introduce the technique of digitally assisted acromioplasty and assess the effect of ISBP on rehabilitation. TYPE OF STUDY: Randomized controlled prospective trial. METHODS: In a randomized prospective trial of 40 patients undergoing acromioplasty under general anesthesia, 20 patients received an ISBP block (group 1) and 20 had no block (group 2). A digitally assisted acromioplasty was performed using a burr introduced via a posterior portal. The undersurface of the acromion was debrided, directing the burr with the surgeon's index finger introduced via a small lateral incision. Independent review was at day 1, day 2, week 1, week 6, and 1 year. RESULTS: Group 1 had significantly greater shoulder motion and shoulder score, and less pain and analgesic requirements on the first day. These differences did not persist. Both groups had improved pain and function over time compared with preoperative scores. CONCLUSIONS: ISBP provides superior initial results but does not offer any significant persistent functional or rehabilitative advantage in the medium to long term. Digitally assisted acromioplasty is simple to perform and does not violate the deltoid insertion.

Lateral subcutaneous brow lift and interbrow muscle resection: clinical experience and anatomic studies.

The authors report consistent improvement in 65 patients with lateral brow ptosis by using a lateral subcutaneous brow lift at the temporal hairline. In 48 of these patients, vertical glabellar wrinkles were improved by the direct excision of procerus, corrugator, and orbicularis muscles through 3-mm medial brow incisions. Anatomic dissections in 10 cadavers and examinations of 50 skulls were used to study the location of the supraorbital and supratrochlear nerves. Dissections revealed that the supratrochlear nerve was never closer than 1.6 cm to the midline at the level of the supraorbital ridge. In no dissection was a supratrochlear foramen noted. Lateral subcutaneous brow lift was consistently successful in elevating the lateral brow. In no patient was nerve damage to the supraorbital nerve noted. In most patients, the temporal hairline was improved by excising a triangle of balding scalp. Through 3-mm medial brow incisions, the interbrow musculature can be excised by using a small rongeur in an area 3.2 cm wide without risk of nerve damage, improving vertical glabellar wrinkles.

Serial passage of MC3T3-E1 cells alters osteoblastic function and responsiveness to transforming growth factor-beta1 and bone morphogenetic protein-2.

The murine-derived clonal MC3T3-E1 cell is a well-studied osteoblast-like cell line. To understand the effects of serial passages on its cellular function, we examined changes in cell morphology, gap junctional intercellular communication (GJIC), proliferation, and osteoblastic function between early passage (<20) and late passage (>65) cells. MC3T3-E1 cells developed an elongated, spindle shape after multiple passages. Intercellular communication decreased significantly (33%) in late vs. early passage cells. Transforming growth factor-beta1 (TGF-beta1) stimulated cell proliferation in early passage cells and induced c-fos expression, while it inhibited proliferation in late passage cells. Using alkaline phosphatase (ALP) activity and osteocalcin (OC) secretion as markers for osteoblastic function and differentiation, we demonstrated that both markers were significantly reduced after multiple cell passages. Bone morphogenetic protein-2 (BMP-2) significantly enhanced ALP activity and OC secretion in early passage cells while TGF-beta1 exerted an opposite effect. Both BMP-2 and TGF-beta1 had minimal effects on late passage cells. We conclude that serial passage alters MC3T3-E1 cell morphology, and significantly diminishes GJIC, osteoblastic function, TGF-beta1-mediated cell proliferation, and responsiveness to TGF-beta1 and BMP-2. Cell passage numbers should be clearly defined in functional studies involving MC3T3-E1 cells.

Aging nasolabial fold and treatment by direct excision.

The anatomy, terminology, and management of the aging nasolabial fold represent a subject of some controversy in the plastic surgery literature. A variety of rhytidectomy techniques and adjuncts, and directed surgical procedures, have been designed to improve the aesthetics of the aging nasolabial region. Experience with direct excision of the nasolabial fold in more than 30 patients is presented, and the anatomy and terminology of the nasolabial region are discussed. Direct excision has proven to be an effective therapy for the management of the aging nasolabial fold in selected patients, primarily men with sun-damaged skin.

Can medical students contribute to quality assurance programmes in day surgery?

CONTEXT AND OBJECTIVES: Health care delivery has undertaken a major shift from inpatient management to ambulatory surgical care with increasing emphasis on quality assurance (QA) processes. Educational opportunities for medical undergraduate programmes are being sought in the day surgery environment. Our study was undertaken to explore ways in which senior medical students can actively contribute to QA processes as part of an undergraduate day surgery educational programme. SUBJECTS AND METHODS: Health care delivery has undertaken a major shift from inpatient management to ambulatory surgical care with increasing emphasis on quality assurance (QA) processes. Educational opportunities for medical undergraduate programmes are being sought in the day surgery environment. Our study was undertaken to explore ways in which senior medical students can actively contribute to the QA processes as part of an undergraduate day surgery educational programme. SUBJECTS AND METHODS: Fifty-nine final year medical students followed allocated patients with common surgical conditions through all phases of the day surgery process. Students kept records about each case in a log book and also presented their cases at weekly Problem Based Learning tutorials. An audit of student log books and review of tutorial records was conducted for the 1996 and 1997 academic years, in order to evaluate student contribution to QA. RESULTS: Students followed 621 cases, representing a sampling of 14. 1% day surgery cases. Categories of problems highlighted by students included inappropriate patient and procedure selection, inadequate pain management, discharge, communication and resource issues. Students made a number of recommendations including the development of multilingual videotapes and patient information sheets for non-English speaking patients, avoidance of bilateral surgical procedures and improved links with local medical officers. They also developed new guidelines and protocols. CONCLUSIONS: Our study confirms that students are able to identify QA issues and propose solutions. We recommend that students have a formally recognized place in day surgery QA programmes, to close the QA loop and to adequately prepare them for medical practice in the 21st century.

Day-case haemorrhoidectomy.

BACKGROUND: Ligation excision haemorrhoidectomy is usually performed on an inpatient basis. This study was designed to assess the feasibility of day-case haemorrhoidectomy. METHODS: Patients fulfilling criteria for day surgery underwent ligation excision haemorrhoidectomy with the intention of a same-day discharge from hospital. A standardized protocol for anaesthesia, perioperative analgesia and antiemesis was followed. Patients received daily home nursing visits until they felt both comfortable and confident. Staff recorded pain and nausea scores on a visual analogue scale (range 1-10) until the first bowel action. Patient satisfaction was assessed independently after operation. RESULTS: Fifty-one patients underwent planned day-case haemorrhoidectomy. Forty-two (82 per cent) were discharged on the day of surgery. All patients were discharged within 26 h of surgery. Four patients required readmission, two with reactive bleeding, one with urinary retention and one for pain control. Pain and nausea were well controlled. Forty-four patients (86 per cent) were totally or very satisfied with their overall care. CONCLUSION: Ligation excision haemorrhoidectomy can be performed successfully as a day-case procedure.

The laryngeal mask airway in experimental pig anaesthesia.

The pig is used as a large animal model in many research projects. Standard practice for airway maintenance under general anaesthesia is using endotracheal (ET) intubation after intravenous induction to a near surgical plane. This is a technically demanding skill, requiring the assistance of an experienced technician. A technique is required which simplifies pig anaesthesia. This study examined the feasibility and potential advantages of using the laryngeal mask airway (LMA) in 10 pigs during laparotomy under spontaneous breathing anaesthesia. The results show that the LMA can be inserted rapidly, with minimal time for airway control by researchers relatively inexperienced in anaesthesia and is associated with few complications. By removing the need for intravenous induction, an entire step in the anaesthetic process is removed. The LMA designed for humans fits well in the pig hypopharynx; all pigs could be manually ventilated with no detectable gas leak. Although the pigs in this study were spontaneously breathing it is proposed that the LMA should be further investigated in studies of artificially ventilated pigs.

Staged skin and subcutaneous excision for lymphedema: a favorable report of long-term results.

Numerous surgical procedures have been proposed for the management of lymphedema. The postoperative results vary, and unfortunately none of the procedures are curative. As a result, some degree of recurrence of leg edema is seen in all patients postoperatively. Reported here is a long-term follow-up of patients with lower extremity lymphedema managed by skin and subcutaneous tissue excision. Thirty-eight patients (6 male; 32 female) with lower extremity lymphedema have been followed up for an average of 14 (3 to 27) years after staged subcutaneous excisions performed beneath skin flaps. Seven patients had been treated previously by other procedures. Of the 38 lymphedema patients, 10 patients developed edema after pelvic or groin ablative surgery, radiation therapy, or both. Results were documented by various methods: physical examination, circumferential measurements, volume displacement, serial photography, lymphoscintigraphy, and patient survey. Of these, it is believed that photographs are the easiest and as representative as any other method, all of which have great variability. Of the 38 patients, 30 patients had significant and long-lasting reduction in extremity size associated with improved function and extremity contour. Episodes of recurrent cellulitis were reduced or completely eliminated. No differences in the long-term results were seen in patients with acquired as opposed to congenital lymphedema. Men did not have as much improvement as women. Two patients had no change in leg swelling, and six patients (three men) had progressive swelling after surgery. Partial wound separation occurred immediately postoperatively in one patient, and three patients had loss (less than 2 cm) of the skin flap, all in the ankle region. None of these instances required further surgery, and no other significant complications were encountered. Staged skin and subcutaneous excision beneath skin flaps appears to provide long-lasting improvement for lower extremity lymphedema, regardless of cause, in the majority of patients treated.

Day surgery: teaching the next generation.

The advent of day surgery presents new opportunities and challenges for medical education. The opportunity to see patients pre-operatively and follow them through surgery to discharge on the same day is unique to day surgery. However, with rare exceptions, the development of educational programmes in ambulatory surgical settings is still largely at a rudimentary level. An undergraduate pilot programme was conducted at the University of Adelaide to explore the practicalities, acceptance and educational value of a day surgery programme for final-year medical students. The programme had three components: day surgery patient follow through, practical procedure tutorials and problem-based learning tutorials. It incorporated assessment of practical skills and theoretical knowledge with the use of log books and clinical and practical simulations as important elements in the assessment process. The pilot programme was accepted by all stakeholders and students' perceived significant gains in knowledge and skills. This programme may provide a teaching model that could be adapted for use in other medical schools.

Laparoscopic aortobifemoral bypass.

PURPOSE: To determine the potential benefits of applying laparoscopic techniques for the intraabdominal insertion of aortofemoral grafts and to compare results with those of conventional surgery. METHODS: Having previously demonstrated the feasibility of a totally laparoscopic aortofemoral bypass technique using carbon dioxide peritoneal insufflation in a porcine model, we now report our first human experience with this laparoscopic technique in a 49-year-old man. RESULTS: The patient's postoperative course was marked by his minimal requirements for analgesia, early ambulation, and discharge from the hospital in the morning of the third postoperative day. CONCLUSIONS: The benefits of a laparoscopic approach to aortobifemoral bypass grafting in terms of financial savings and earlier rehabilitation in this patient was significant. This less-invasive procedure warrants further investigation.

Laparoscopic aortobifemoral bypass: a case report.

In the past six years, laparoscopic surgery has gained widespread acceptance by both surgeon and patient. When compared to open surgical approaches, laparoscopic techniques for abdominal procedures lessen postoperative pain and morbidity, improve cosmesis, reduce hospital stay, facilitate early rehabilitation and return to normal activities. The application of laparoscopic techniques to intra-abdominal vascular procedures can be expected to provide similar benefits over conventional surgery.

Does a teaching programme in day surgery impact on efficiency and quality of care?

BACKGROUND: Recent medical advances have led to an explosion in the use of day surgery, making traditional teaching untenable and necessitating a transfer of undergraduate teaching programmes into the day surgery setting. concerns have been raised about the impact of teaching on efficiency and quality of care in this environment. METHODS: Thirty-one final year medical students participated in a new teaching programme conducted in a dedicated day surgery unit in a major Australian public teaching hospital, Five commonly performed procedures were audited and analysed by a mixed model analysis of variance to determine whether students impacted significantly on operation time. Student performance was monitored using a logbook. Surgeons and nursing staff completed questionnaires about their perceptions of the impact of the programme on the overall efficiency of the day surgery unit. RESULTS: Students had no significant effect on operation time for the procedures examined. Staff did not perceive that students had significantly detracted from the overall efficiency of the unit. An unexpected finding was the substantial contribution that students made to quality of patient care.

Evaluation of a novel osteogenic factor, bone cell stimulating substance, in a rabbit cranial defect model.

A novel osteogenic factor, bone cell stimulating substance (BCSS), was recently isolated from bovine bone. Unlike the bone morphogenetic proteins, which are generally 20- to 40-kDa glycoproteins belonging to the transforming growth factor-beta superfamily, BCSS is a 2.5-kDa, water-soluble polypeptide. This study evaluated the osteogenic potential of BCSS in combination with coralline-derived porous hydroxyapatite to reconstruct a large, nonhealing cranial defect in the rabbit. Twenty-four rabbits underwent a 16 x 20 mm full-thickness (extradural) excision of the parietal bones and were divided into six groups of four rabbits each. Group 1 through 5 were reconstructed with 16 x 20 x 1.5 mm hydroxyapatite implants treated with: (1) 20 osteogenic units (424 micrograms) BCSS, (2) 8 osteogenic units (170 micrograms) BCSS, (3) 4 osteogenic units (85 micrograms) BCSS, (4) 0 osteogenic units (424 micrograms) inactive BCSS analog, or (5) left untreated. Group 6 was left unreconstructed. Implants were harvested at 12 weeks and analyzed for percentage of lamellar bone formation by a computerized microscope video image analysis system. Groups reconstructed with BCSS-treated hydroxyapatite implants demonstrated more bone ingrowth than did the control hydroxyapatite groups not treated with BCSS (inactive BCSS analog or untreated). Linear regression dose-response analysis indicated an average 3.2 percent increase in bone ingrowth for a 10-U increase in BCSS (p = 0.043). The unreconstructed control group demonstrated no healing. With a molecular mass of only 2.5 kDa and its identity not completely known, BCSS is a novel factor that seems to possess osteogenic potential similar to that of previously investigated osteogenic proteins.

Transforming growth factor-beta, osteogenin, and bone morphogenetic protein-2 inhibit intercellular communication and alter cell proliferation in MC3T3-E1 cells.

Intercellular communication by gap junctions has been implicated to function in the control of cell growth and differentiation in osseous tissues-processes which are regulated, in part, by peptide growth factors, including transforming growth factor-beta (TGF-beta) and the bone morphogenetic proteins (BMPs). Using the osteoblastic cell line MC3T3-E1, we tested the hypothesis that the effects of TGF-beta and BMPs on cell proliferation may be correlated to changes in intercellular communication. In a series of proliferation assays, MC3T3-E1 cells were cultured in the presence of bone morphogenetic protein-2 (BMP-2) or TGF-beta for up to 48 hr. Proliferation of cells during the linear log phase (days 2 to 4) was assessed by 3H-thymidine (3H-TdR) incorporation. After times ranging from 6 to 48 hr, BMP-2 significantly inhibited uptake of 3H-TdR at doses of 50-800 ng/ml. Similarly, TGF-beta inhibited uptake of 3H-TdR at doses of 2-32 ng/ml. In a separate group of experiments, intercellular communication through gap junctions was demonstrated by cell-cell transfer of the fluorescent tracer, lucifer yellow, after microinjection. One series of experiments showed that the gap junctional intercellular communication (GJIC) of cells, incubated for 48 hr in the presence of the higher dose of osteogenin (OG) (5.0 vs. 0.5 microgram/ml) or higher dose of TGF-beta (2.0 vs. 0.2 ng/ml), was significantly inhibited compared to control. In another series of experiments, time and dose dependent effects of BMP-2 and TGF-beta on GJIC were investigated. In the time course experiments (3, 6, 12, 24, and 48 hr), TGF-beta (2.0 ng/ml) demonstrated a statistically significant effect in inhibiting GJIC as early as 6 hr, while BMP-2 (50 ng/ml) inhibited GJIC after 24 and 48 hr of treatment. The dose-dependent effects of BMP-2 and TGF-beta on cell couplings, determined at 48 hr, showed significant inhibitory effects with BMP-2 at 25 and 50 ng/ml and with TGF-beta at 2 and 4 ng/ml. The cell count results and injection study performed at 12 hr, at a fixed cell density, confirmed that the inhibitory effect was not due to differences in cell density. The 50% effective inhibitory concentrations (EC50) calculated for BMP-2 and TGF-beta at 48 hr, showed no dose correlation between proliferation and GJIC, suggesting that these two events are independent occurrences. Additionally, marked morphological change was observed in the cells treated with TGF-beta. The observation may suggest that TGF-beta may have effects upon cytoskeletal elements in osseous tissues.

Laparoscopic cholecystectomy as a day surgery procedure.

Outcome is presented for 40 consecutive laparoscopic cholecystectomies performed in a public teaching hospital day surgery unit. The unanticipated hospital admission rate on the day of surgery was 17.5% (seven patients) and the majority of these (12.5%; five patients) were due to surgery-related considerations. Two other admissions were due to nausea and vomiting. One patient was admitted to hospital on the second postoperative day with nausea and vomiting. Procedure duration for the day cases averaged 98 minutes (SD25; range 60-167). Recovery room times before discharge averaged 272 minutes (SD 58; range 125-365). Each day surgery patient averaged 3.3 postoperative home visits from community nurses. Most patients (94%) mobilized at home by the second postoperative day and 85% resumed normal activities of daily living by two weeks. At follow-up, 25 patients (76%) stated they were happy to spend the first night at home, but seven (21%) would have preferred to remain in hospital for the first postoperative night. Laparoscopic cholecystectomy can be performed successfully as a day-case procedure, but long operating and recovery room times and potentially high admission rates suggest that these factors should be considered in cost equations for day-case management of this procedure.