The Super-Magenstrasse and Mill operation with pyloroplasty: preliminary results.

BACKGROUND: Our strategy for performing various types of bariatric operations in order to make them suitable for the individual morbidly obese patient, has led us to take into account the original Magenstrasse and Mill (M&M) operation and modify it. This resulted in the so-called Super-Magenstrasse and Mill with pyloroplasty (SM&M-P). METHODS: In the past 3 years, 34 patients with mean BMI 48 and mean age 43 years underwent the SM&MP operation for morbid obesity. A digitoclasic pyloroplasty was performed and a 36-Fr bougie was used to calibrate the Magenstrasse. A 21-mm circular stapler was used to create a gastric window 10 cm proximal to the pylorus. The stapled division of the stomach to 3-4 cm from the pylorus and to the angle of His was performed first distally via the gastric window and then proximally from the window. RESULTS: 2 patients have reached 3 years since the operation: one could not be assessed due to the development of rectal cancer 1 year after surgery, and the other one has had an excellent outcome with 3-year BMI 26 kg/m2. 8 patients who underwent the surgery 2 years ago have a mean percent excess BMI loss (%EBL) of 69, and 19 patients who have reached 1 year have %EBL 64. All patients have experienced a clear reduction of appetite, with vomiting absent or rare. CONCLUSIONS: The SM&M-P procedure confers to this restrictive intervention some characteristics similar to gastric bypass, including rapid transit of the alimentary contents in the prepyloric "mill", scarse reflux into the gastric fundus, possible entero-endocrine effects and loss of interest in food.

Can anesthesiologic strategies for caesarean section influence newborn jaundice? A retrospective and prospective study.

RATIONALE AND OBJECTIVES: Neonatal jaundice is a frequent problem in neonatology and can be influenced by many factors. Our study arose from the clinical observation that among all newborns delivered by caesarean section in our center, some had a more intense physiological jaundice. We began by reviewing clinical anesthesiological case-sheets to ascertain whether this difference was linked to the use of different anesthesiologic strategies. We then performed a prospective study on healthy preterm and term newborns to verify this hypothesis. STUDY DESIGN: We retrospectively considered all healthy term newborns with weight > 2,400 g delivered by caesarean section from January 1998 to May 1999. In the prospective studies we included healthy term and preterm newborns consecutively delivered by caesarean section from May 1999 to December 1999. We excluded preterm newborns with gestational age < 31 weeks and with weight < 1,400 g. RESULTS: Both in retrospective and in prospective studies anesthetic agents employed were isoflurane (A), sevoflurane (B), or bupivacaine (C). The statistical comparison of the three groups in retrospective study confirmed the clinical observation: the total bilirubin levels were significantly higher in the isoflurane group than in the sevoflurane group (p = 0.0000) and bupivacaine group (p = 0.0002). Analysis of data from the prospective study on term newborns confirmed our previous results. In preterm infants total bilirubin is statistically higher in group A starting from 96 h postdelivery. CONCLUSIONS: It is likely that anesthetic technique can be included among factors with possible influence on neonatal jaundice.

Case reports in anesthesiology: their trend through 17 years.

UNLABELLED: The study objective was to delineate the trend of case reports (the simplest of the descriptive forms of study) in the anesthesiological literature by analyzing the frequency of publication, and citation, and especially of the place of citation of a sample of published case reports. It is our opinion that case report in anesthesia is particularly suitable for this specialty rather than for others and is often the first signal of a complication, an adverse event, an anesthetic problem in rare disease and alerts other anesthesiologists to the possibility of unexpected events. METHODS: We analyzed the case reports published on an Anesthesiological journal placed in the middle in term of Impact Factor, from January 1980 to December 1997. Citations of each case report were obtained using computer searches of the Science Citation Index (SCI). For each of these case reports we collected in a custom-designed data base the following data: year of publication, number of authors, number of citations per year, place of citation, type of article quoting the case report, number of self-citations, year of first citation. MAIN RESULTS: We identified 637 case reports and 1946 citations. The number of case reports increased through the years up to a peak in 1994-95 and the same trend was observed for citations and self-citations, the number of authors per case report was < or = 4 in 90.4%; 74.2% of total case reports cited were first cited within two years of publication, while 34.7% were never cited. The type of article quoting the case reports has been, in the majority of cases, an original article. CONCLUSIONS: The analysed case reports and the number of citations can give us information about the importance of a clinical situation at a particular time.

Impact of the Hawthorne effect in a longitudinal clinical study: the case of anesthesia.

Clinical research can be influenced by many factors that are capable of invalidating results, and one of these factors is known as the Hawthorne effect: the mere awareness of being under observation can alter the way in which a person behaves. In experimental research this effect can be the undesired effect of the experiments themselves, and the stronger its presence, the greater it can influence the results. In anesthesia practice, owing to the particular emotional condition of a patient facing a surgical operation, the Hawthorne effect could be especially strong. The aim of our study was to show the impact that the knowledge of being included in a study has (Hawthorne effect), by comparing the postoperative changes in psychological well-being in two groups of patients undergoing knee arthroscopy and receiving different information about the study from the anesthetist during the preoperative interview. Other signs and symptoms such as postoperative knee pain, nausea, vomiting (the most feared occurrences), headache, return of spontaneous diuresis, analgesic request, anesthesia complications, as well as the intensity of anxiety were also assessed as secondary endpoints. Our results show that subjects who were aware that they were part of a study scored significantly better on postoperative measures of psychological well-being and postoperative knee pain, compared to subjects who were unaware. The size of the effect, as measured by the odds ratio, remains unchanged when controlling for potential confounding factors. The study has enabled us to demonstrate the presence of the Hawthorne effect in clinical research. Therefore, the Hawthorne effect should be acknowledged and accounted for in the design of a study and in the interpretation of results.

Unexpected finding of barium sulphate on the surface of a microspinal catheter.

During a study with a scanning electron microscope to evaluate the structure of microspinal catheter after its removal from subarachnoid space, we found an unusual case. The observation with the microscope of the tip of a catheter removed at the end of an operation for hip replacement in a old female showed the presence of grounded particles with a crystal shape covering the outer surface. Further analysis of this material with an Energy-Dispersive Spectrometer (EDS) showed that it was barium. The patient performed a large bowel barium enema 8 months earlier for a painful syndrome to the lower abdomen. Authors rule out the contamination from the skin and suggest two possible mechanisms of passage of barium from blood to cerebrospinal fluid (CSF) and so to the surface of the catheter.

Is there a bilateral block of the thoracic sympathetic chain after unilateral intrapleural analgesia?

UNLABELLED: This study was designed to ascertain, by telethermography and clinical observation, the effect of injecting anesthetic solutions into the intrapleural space on thoracic sympathetic chains and splanchnic nerves. We studied 15 patients with neoplastic (n = 8) or benign (n = 7) pain, divided into three groups of 5 patients each. The first group received 20 mL of bupivacaine 0.25% in the intrapleural space, the second received 20 mL of bupivacaine 0.5%, and the third received 20 mL of isotonic sodium chloride solution. Each patient was examined telethermographically 30, 60, 90, and 120 min after the blockade. Visceral pain intensity was measured in eight patients using a visual analog scale. Patients receiving bupivacaine had a uniform bilateral increase of cutaneous temperature (+2 degrees C). In those with diffuse visceral pain, the mean value of the pain score decreased from 82 +/- 10 mm at the time of injection to 16 +/- 5 at 120 min. We conclude that intrapleural bupivacaine 0.25% and 0.5% results in bilateral blockade of the thoracic sympathetic chain and also of the splanchnic nerves, which pass in front of the spinal column between the two thoracic sympathetic chains. Our data indicate that intrapleural analgesia can be used in the treatment of not only unilateral visceral and somatic pain, but also diffuse abdominal visceral pain. The bilateral increase of the cutaneous temperature of the trunk (measured telethermographically) and the reduction of the diffuse visceral pain suggest a bilateral block of the sympathetic chain and of the splanchnic nerves. IMPLICATIONS: We subjected 10 patients to monolateral intrapleural analgesia. Five other patients served as controls. The bilateral increase of the cutaneous temperature of the trunk (measured telethermographically) and the reduction of the diffuse visceral pain suggest a bilateral block of the sympathetic chain and of the splanchnic nerves. Our data indicate that intrapleural analgesia can be used in the treatment of not only unilateral visceral and somatic pain, but also diffuse abdominal visceral pain.