Delayed Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement: A Case Report.

When used for a selected patient population, percutaneous endoscopic gastrostomy (PEG) can provide enteral nutrition percutaneous endoscopic gastrostomy (PEG) safely. PEG tubes generally possess a very low chance of life-threatening complications but due to the patient population that requires PEG tubes, a delayed diagnosis of minor complications could be fatal. In this study, we present a case of delayed pneumoperitoneum, discovered weeks after our patient underwent PEG placement for enteral nutritional needs. The patient recovered without the need for operative intervention. The development of a pneumoperitoneum in the setting of recent PEG needs a thorough clinical evaluation, and caution must be taken before immediately proceeding to operative exploration.

Estimate of mortality reduction with implementation of advanced automatic collision notification.

OBJECTIVE: Advanced Automatic Collision Notification (AACN) is a system on a motor vehicle that notifies a public safety answering point (PSAP), either directly or through a third party, that the vehicle has had a crash. AACN systems enable earlier notification of a motor vehicle crash and provide an injury prediction that can help dispatchers and first responders make better decisions about how and where to transport the patient, thus getting the patient to definitive care sooner. The purposes of the current research are to identify the target population that could benefit from AACN, and to develop a reasonable estimate range of potential lives saved with implementation of AACN within the vehicle fleet. METHODS: Data from the Fatality Analysis Reporting System (FARS) years 2009-2015 and National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) years 2000-2015 were obtained. FARS data were used to determine absolute estimates of the target population who may receive benefit from AACN. These estimates accounted for a number of factors, such as whether a fatal occupant had nearby access to a trauma center and also was correctly identified by the injury severity prediction algorithm as having a "high probability of severe injury." NASS-CDS data were used to provide relative comparisons among subsets of the population. Specifically, relative survival rate ratios between occupants treated at trauma centers versus at non-trauma centers were determined using the nonparametric Kaplan-Meier estimator. Finally, the fatality reduction rate associated with trauma center care was combined with the previously published fatality reduction rate for faster notification time to develop a range for possible lives saved. RESULTS: Two relevant target populations were identified. A larger subset of 6893 fatalities can benefit only from earlier notification associated with AACN. A smaller subgroup of between 1495 and 2330 fatalities can benefit from both earlier notification and change in treatment destination (i.e., non-trauma center to trauma center). A Kaplan-Meier life curve and a multiple proportional hazard model were used to predict the benefits associated with transport to a trauma center. The resulting range for potential lives saved annually was 360 to 721. CONCLUSIONS: This analysis provides the estimates of lives that could potentially be saved with full implementation of AACN and universal cell coverage availability. This represents a fatality reduction of approximately 1.6% to 3.3% per year, and more than double the lives saved by earlier notification alone. In conclusion, AACN is a postcrash technology with a promising potential for safety benefit. AACN is therefore a key component of integrated safety systems that aim to protect occupants across the entire crash spectrum.

Long-term outcomes of laparoscopic adrenalectomy for adrenal masses.

BACKGROUND: Laparoscopic adrenalectomy is the gold standard procedure for most adrenal masses. However, long-term data regarding this procedure are limited. We report our institution's experience with laparoscopic adrenalectomy, determine if this procedure results in durable weight loss and resolves hypertension, diabetes mellitus, or hyperlipidemia, and identify predictors of pathology in nonfunctioning tumors. MATERIALS AND METHODS: We retrospectively reviewed laparoscopic adrenalectomies performed for adrenal masses between May 2000 and September 2010 by nine surgeons at a single institution. Data gathered included demographics, body mass index (BMI), preoperative and postoperative imaging and biochemical testing results, length of stay, complications, pathology, medications, and resolution of hypertension, diabetes, or hyperlipidemia. RESULTS: We removed 96 adrenal glands in 95 patients. Their average age was 55.6 years. The average length of stay was 1.8 days. Average BMI was 32.9 kg/m(2) preoperatively and 31.9 kg/m(2) postoperatively (P=.46). We experienced no conversions to open procedure and no perioperative mortality. Minor complications occurred at a rate of 1.2%. Indications for adrenalectomy were nonfunctioning tumor (n=35), pheochromocytoma (n=18), aldosteronoma (n=17), subclinical Cushing's syndrome (n=15), Cushing's syndrome (n=9), and sex hormone-secreting tumor (n=1). Hypertension improved or resolved in 63% of patients with Cushing's syndrome, 56% with aldosteronoma, and 47% with pheochromocytoma. When adrenalectomy was performed for nonfunctioning tumors, neoplasia was identified in 22.9% of patients. The most predictive factors for neoplasia were previous history of cancer and abnormal appearance on computed tomography, magnetic resonance imaging, or positron emission tomography scan. CONCLUSIONS: Laparoscopic adrenalectomy is a safe procedure with a low complication rate and short hospital stay. Hypertension improves in the majority of patients with Cushing's syndrome and aldosteronoma and just under the majority of those with pheochromocytoma. In our study, abnormal radiologic appearance was a better predictor of neoplasia than size.

Pledgeted repair of giant hiatal hernia provides excellent long-term results.

BACKGROUND: Use of mesh in hiatal hernia repairs is a topic of debate. We present our experience in laparoscopic primary (nonmesh) repair of giant hiatal hernia. MATERIALS AND METHODS: All laparoscopic antireflux procedures done by a single surgeon from November 1997 to October 2006 were retrospectively reviewed. Inclusion criteria were primary crural closure with pledgets and giant hiatal hernia (greater than one-third of the stomach in the chest by esophagram, greater than 5 cm in length endoscopically, or greater than one-third of the stomach in the chest operatively). We attempted to reach all patients who met inclusion criteria and administered the Reflux Symptom Index (RSI) and Quality of Life Scale for Gastroesophageal Reflux Disease (QLSGR) questionnaires. RESULTS: In total, 89 patients met inclusion criteria. The male-to-female ratio was 32:57. Average age was 62.7 years. Average body mass index was 29.3 kg/m(2). Average length of stay was 2 days, and mean clinic follow-up was 161 days. At the most recent follow-up, 62% of patients were asymptomatic. The most common postoperative symptoms were dysphagia (16%), reflux/emesis (5%), bloating (5%), nausea (4%), epigastric pain (4%), and heartburn (3%). There were six (6.7%) recurrences on esophagogastroduodenoscopy or upper gastrointestinal examination. Five patients with recurrence were symptomatic. Of the 89 patients, 29 (33%) completed the questionnaire, with a mean follow-up of 69.7 months. Average RSI score was 12 (maximum possible score, 45). In six of nine categories, the average score was less than 1 (possible score, 0-5). Average QLSGR score was 12 (maximum possible score, 45). For satisfaction with the present condition, the average score was 4.34 (maximum score, 5), and 82.7% of respondents were satisfied or very satisfied with their present condition. CONCLUSIONS: Laparoscopic primary repair of giant hiatal hernia provides excellent long-term results. We found that 62% of patients were asymptomatic at the last follow-up and that 82% of respondents were satisfied or very satisfied. The recurrence rate was 6.7%.

Bariatric surgery significantly improves body proportion.

BACKGROUND: It is well known that bariatric surgery provides excellent weight loss and resolution of comorbid conditions. We propose an additional benefit: Because body proportion is an independent predictor of diabetes and cardiovascular risk, we hypothesize that bariatric surgery results in improved body proportion and may thus improve health risk independent of overall weight loss and resolution of comorbid conditions. METHODS: A total of 168 patients underwent laparoscopic bariatric surgery at our institution from December 2006 to September 2009. Prospective data gathered preoperatively and at 3, 6, and 12 months postoperatively included body mass index (BMI); excess weight loss (EWL); waist-hip ratio (WHR); and discontinuation of hypertensive, hyperlipidemic, and diabetic medications. RESULTS: Of the 168 patients, 122 underwent Roux-en-Y gastric bypass, 40 gastric band, and 6 gastric sleeve procedures. Mean preoperative BMI was 48.6 kg/m(2) (SD â€Š=  7.8 kg/m(2)). Mean EWL was 33.7 lbs (SD â€Š=  11.9 lbs) at 3 months, 46.35 lbs (SD â€Š=  15.58 lbs) at 6 months, and 52.48 lbs (SD â€Š=  24.19 lbs) at 1 year. Mean WHR was 0.91 (SD â€Š=  0.1) preoperatively, 0.87 (SD â€Š=  0.1) at 3 months (P < .0001), 0.87 (SD â€Š=  0.09) at 6 months (P < .0001), and 0.86 (SD â€Š=  0.1) at 1 year (P â€Š=  .0006). At 1-year follow-up, 52% of patients had discontinued hypertensive medications, 64% had discontinued diabetic medications, and 56% had discontinued hyperlipidemic medications. CONCLUSIONS: Along with well-known improvements in overall weight and comorbid conditions, bariatric surgery significantly improves body proportion, which may decrease health risk. Continued follow-up will determine if this change is long term or if patients will revert to preoperative WHRs. Future studies with sufficient power to study individual bariatric procedures will determine which procedures, if any, provide patients with the greatest improvement in WHR and if inferior WHR results are associated with cardiovascular events.

Periorbital reconstruction: brows and eyelids.

The eyes and periorbital structures are principle components of the upper region of the face. A thorough understanding of orbital and periorbital anatomy and function is important for anyone wishing to perform reconstructive surgery in this region. This article discusses the unique challenges presented to the surgeon when performing reconstruction of the eyelids and periorbital structures.

Effects of copper tripeptide on the growth and expression of growth factors by normal and irradiated fibroblasts.

OBJECTIVE: To evaluate the effects of copper tripeptide (GHK-Cu) on the growth and autocrine production of basic fibroblast growth factor, transforming growth factor beta1, and vascular endothelial growth factor by normal and irradiated fibroblasts in a serum-free in vitro environment. METHODS: Primary human dermal fibroblast cell lines were established after explantation from intraoperative specimens obtained from patients who had undergone radiation therapy for head and neck cancer. Normal and irradiated fibroblasts were propagated in serum- and growth factor-free media. Treatment groups were exposed to GHK-Cu (1 x 10(-9) mol/L). We measured cell counts and production of basic fibroblast growth factor, transforming growth factor beta1, and vascular endothelial growth factor. RESULTS: Irradiated fibroblasts survived and replicated in serum-free media. The population-doubling times of normal and irradiated fibroblasts exposed to GHK-Cu were faster than those of nontreated controls. Irradiated fibroblasts treated with GHK-Cu doubled at a rate that approximated that of untreated controls, and produced significantly more basic fibroblast growth factor and vascular endothelial growth factor than untreated controls early after GHK-Cu exposure. CONCLUSIONS: Irradiated fibroblasts survive and replicate in serum-free media, establishing this model as ideal for evaluating growth factor production in vitro. Copper tripeptide accelerates the growth of normal and irradiated fibroblasts to the point where treated irradiated fibroblasts approximate the population-doubling time of normal controls. An early increase in basic fibroblast growth factor and vascular endothelial growth factor production by GHK-Cu-treated irradiated fibroblasts may improve wound healing.

Effect of hyperbaric oxygen on the growth factor profile of fibroblasts.

OBJECTIVES: Hyperbaric oxygen (HBO) has been used in the clinical setting to heal problem wounds, yet its direct effects on fibroblasts are not clear. The present study evaluates the effects of HBO on the growth and autocrine production of growth factors by fibroblasts grown in an in vitro, serum-free environment. METHODS: Human dermal fibroblasts were propagated in serum-free media and subjected to daily 90-minute HBO treatments at 1.0, 1.5, 2.0, 2.5, and 3.0 atm of pressure for 7 consecutive days. Cell proliferation and growth-factor assays for basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), and transforming growth factor beta1 (TGF-beta1) were performed on days 1, 3, 5, and 7. RESULTS: On day 1, HBO inhibited growth of fibroblasts at all atmospheric pressures compared with control. By day 7, cell proliferation was significantly enhanced only in cells treated with 2.0-atm HBO compared with controls. Secretion of bFGF was significantly increased by HBO-treated fibroblasts on day 1; VEGF levels slightly increased with HBO treatment on day 1, but this effect was not statistically significant; TGF-beta1 levels were detectable on day 1 only for control and HBO-treated cells at 1.0 atm, and not detectable for any cell groups after day 1. CONCLUSIONS: These results suggest that daily HBO treatment enhances the growth of fibroblasts when administered to a critical degree. Also, HBO appears to directly effect fibroblast production of autocrine growth factors on initial exposure. We postulate that fibroblasts possess the ability to respond to hyperoxia directly, which causes changes in cell signaling pathways involved in cellular proliferation and growth factor production.

Facial nerve grading systems (1985-2002): beyond the House-Brackmann scale.

OBJECTIVE To assess methods of evaluating the function of the facial nerve that have been introduced over the past 15 years, particularly in comparison with the House-Brackmann scale. DATA SOURCES A Medline search was undertaken of the English-language medical literature between 1983 and 2000 to identify proposed methods of evaluating facial nerve function. STUDY SELECTION Although all grading systems were considered, attention was focused on the systems that provided improvements in either precision or ease of use. CONCLUSIONS Because of the limitations and subjectivity of the House-Brackmann scale, several new scales of various degrees of objectivity and ease of use have been introduced. The Nottingham system offers a more objective but easy-to-use facial nerve grading system that has been demonstrated to be valid and that would be easy for the average practitioner to adopt. The authors propose a more systematic evaluation of this system to determine whether its widespread application is appropriate.