Obesity increases the risk of postoperative peripheral neuropathy after minimally invasive colon and rectal surgery.

BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twenty-three patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures.

Perioperative stress-dose steroids.

Supraphysiologic corticosteroid doses have routinely been considered the perioperative standard of care over the past six decades for patients on long-term steroid therapy. However, the accumulation of data over this period is beginning to suggest that such a practice may not be necessary. The majority of these studies are retrospective reviews or small prospective cohorts, but there are two small prospective, randomized placebo-controlled trials, one prospective primate trial, and several systematic reviews addressing the issue. Based on this developing evidence, patients on long-term exogenous steroids do not require high-dose perioperative corticosteroids and should instead remain on their baseline maintenance dose, with the understanding that secondary adrenal insufficiency should be considered for unexplained perioperative hypotension in these patients.

Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

BACKGROUND: Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision. METHODS: From March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups. RESULTS: There were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (p = 0.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis. CONCLUSION: A Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.

Duplication cyst of the sigmoid colon.

A 21-year-old male with developmental delay presented with abdominal pain of two days' duration. He was afebrile and his abdomen was soft with mild diffuse tenderness. There were no peritoneal signs. Plain x-ray demonstrated a large air-filled structure in the right upper quadrant. Computed tomography of the abdomen revealed a 9 x 8 cm structure adjacent to the hepatic flexure containing an air-fluid level. It did not contain oral contrast and had no apparent communication with the colon. At operation, the cystic lesion was identified as a duplication cyst of the sigmoid colon that was adherent to the right upper quadrant. The cyst was excised with a segment of the sigmoid colon and a stapled colo-colostomy was performed. Recovery was uneventful. Final pathology was consistent with a duplication cyst of the sigmoid colon. The cyst was attached to the colon but did not communicate with the lumen.

Temporary occlusion of the gastroesophageal junction: a modified technique for stabilization of the neonate with esophageal atresia and tracheoesophageal fistula requiring mechanical ventilation.

Management of newborn infants with esophageal atresia and tracheoesophageal fistula that require mechanical ventilation is challenging. Without rapid control of the fistula, these patients develop profound respiratory failure and massive distention of the gastrointestinal tract. We present the case of a newborn who upon intubation exhibited respiratory failure and cardiovascular collapse, and in whom traditional intra-operative techniques to gain control of the tracheoesophageal fistula were unsuccessful. We describe a technique that temporarily occludes the gastroesophageal junction, and allows for stabilization of the neonate and definitive repair of the tracheoesophageal fistula.

Choledocholithiasis in a 4-month-old infant.

Cholelithiasis is increasingly being diagnosed in newborns and infants because of the more frequent use of abdominal ultrasound. However, common bile duct stones causing obstruction or symptoms in infancy are exceedingly rare and are not often reported in the literature. We report the successful treatment of symptomatic choledocholithiasis in a 4-month-old patient with endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy.

Mesenteric venous thrombophlebitis--septic thrombophlebitis of the inferior mesenteric vein: an unusual manifestation of diverticulitis.

We report a case of a 57-year-old female patient who presented with fever, abdominal pain, and bacteremia. A CT scan demonstrated sigmoid diverticulitis and air within the inferior mesenteric vein. The patient underwent exploratory laparotomy and sigmoid colectomy. She was discharged without complications. Septic thrombophlebitis of the inferior mesenteric vein is a rare complication of diverticulitis. It may manifest as bacteremia not responding to intravenous antibiotics. CT scan findings are diagnostic, and include evidence of intraluminal gas within the inferior mesenteric vein. As with any case of complicated diverticulitis, the treatment is surgical resection of the involved colon.

Indications for non-transplant surgery in primary sclerosing cholangitis.

Primary sclerosing cholangitis (PCS) is a progressive disease leading to secondary biliary cirrhosis. Patients are at increased risk of developing cholangiocarcinoma, which is usually diagnosed at an advanced stage. Treatment of PCS includes medical therapy, endoscopic biliary dilation, percutaneous transhepatic stenting, extrahepatic biliary resection and liver transplantation. The most effective management of primary sclerosing cholangitis before the onset of cirrhosis remains unclear. Non-transplant surgical procedures have a limited but defined role in patients with PCS. Resection of the extrahepatic biliary tree in symptomatic non-cirrhotic patients improves hyperbilirubinaemia and prolongs both transplant-free and overall survival when compared with non-operative dilation and/or stenting. Surgical resection may also definitively establish or exclude a diagnosis of cholangiocarcinoma in patients with dominant extrahepatic or perihilar strictures. Extrahepatic bile duct resection may also reduce the risk of cholangiocarcinoma. Extrahepatic biliary resection should be considered in selected non-cirrhotic patients with symptomatic biliary obstruction and dominant extrahepatic and/or perihilar strictures. Those patients in whom cholangiocarcinoma is suspected should also undergo resection.