Two-dimensional ultrasound imaging of the diaphragm: quantitative values in normal subjects.

INTRODUCTION: Real time ultrasound imaging of the diaphragm is an under-used tool in the evaluation of patients with unexplained dyspnea or respiratory failure. METHODS: We measured diaphragm thickness and the change in thickness that occurs with maximal inspiration in 150 normal subjects, with results stratified for age, gender, body mass index, and smoking history. RESULTS: The lower limit of normal diaphragm thickness at end expiration or functional residual capacity is 0.15 cm, and an increase of at least 20% in diaphragm thickness from functional residual capacity to total lung capacity is normal. A side to side difference in thickness at end expiration of > 0.33 cm is abnormal. Diaphragm thickness and contractility are minimally affected by age, gender, body habitus, or smoking history. CONCLUSIONS: This study confirms previous findings in much smaller groups of normal controls for quantitative ultrasound of the diaphragm and provides data that can be applied widely to the general population.

Feasibility of NOTES omental plug repair of perforated peptic ulcers: results from a clinical pilot trial.

BACKGROUND: Ulcer perforation carries up to a 30 % 1-year mortality rate. Intervention-related adverse events are among statistically significant predictors of 1-year mortality. A natural orifice transluminal endoscopic surgical (NOTES) approach may be less invasive and may decrease procedure-related adverse events by diminishing the so-called second hit, thus leading to decreased morbidity and mortality. We sought to assess the feasibility of an endoscopic transluminal omental plug technique in patients with perforated gastroduodenal ulcers under laparoscopic guidance. METHODS: Patients with suspected acute gastroduodenal ulcer perforations were offered participation in this prospective pilot study. Closure of the perforation was attempted using the NOTES omental plug technique. Demographic, clinical, endoscopic, and radiographic data were abstracted, as were data for morbidity, mortality, and pilot data regarding quality of life (QOL). RESULTS: From February 2010 through February 2012, a total of 17 patients presented to a tertiary care center with clinically suspected perforated ulcer. Of seven patients (mean age 79 years, range 64-89 years) who consented to the study, three underwent the study procedure. All patients had multiple comorbidities. Two patients presented with 4-6 mm perforated peptic ulcers and underwent successful laparoscopic-assisted NOTES omental and falciform ligament patch closure, respectively. Postoperative radiographic contrast studies showed no leak, and patients were discharged home on postoperative days 3 and 4. The third patient had undergone enterocutaneous fistula repair with herniorrhaphy 6 weeks before. Although a transluminal endoscopic approach was feasible, the omentum was under too much tension to be secured. This procedure was converted to an open omental patch repair. For all but one patient who provided consent, obtaining QOL data was feasible. CONCLUSIONS: Initial results from a laparoscopic-assisted NOTES approach for closure of perforated peptic ulcers appear promising and enable swift recovery in selected patients. This is especially important in elderly and/or immunocompromised patients. Technical details and patient selection criteria continue to evolve.

Responsiveness of quality of life instruments for the comparison of minimally invasive cholecystectomy procedures.

BACKGROUND: Traditional metrics of postoperative outcomes (morbidity and mortality) are not useful to compare minimally invasive procedures with each other. Patient reported outcomes, such as quality of life (QOL) scores, offer an alternative approach. Compared with a large body of data in cancer treatment, the responsiveness of these instruments for minimally invasive surgery is not well described. To better define expected differences, we analyzed the reported QOL outcomes in randomized, controlled trials (RCTs) comparing single and four-port laparoscopic cholecystectomy. METHODS: Searching Medline, Embase, Psychinfo, Scopus, and the Cochrane Library (1946 to Jan 2012), two independent reviewers identified RCTs comparing single with four-port cholecystectomy in adult patients using perioperative QOL assessments. The quality of the studies was assessed regarding trial design and QOL reporting. RevMan was used for mathematical analysis of the pooled outcome data using a random-effects model. Standardized mean difference estimation was utilized when pooling studies reporting different QOL tools. Statistical heterogeneity was assessed using χ(2) and I(2). RESULTS: Of 743 citations, 37 RCTs were identified. Five studies with a total of 502 patients compared single with four-port cholecystectomy on QOL and were included. Pooled analysis was performed using preoperative and 1-month postoperative outcomes. At 1 month postoperatively, the reported effect size of perioperative QOL changes was up to 5 points (~1/2 SD) on the global SF 12 score. The largest difference in change of perioperative physical functioning was 9.9 points (~1 SD). No difference between the treatments was demonstrated. CONCLUSIONS: Reporting of QOL may improve the comparison of minimally invasive surgical procedures. This systematic review reports clinically important changes and did not demonstrate a difference between treatments at 1 month postoperatively. The optimal timing and trial design for QOL tools in this setting needs to be defined further.