To investigate the frequency and duration of hypo- and hyperglycemia, assessed by continuous glucose monitoring (CGM) during and after major surgery, in departments with implemented diabetes care ...protocols.
Inadequate glycemic control in the perioperative period is associated with serious adverse events, but monitoring currently relies on point blood glucose measurements, which may underreport glucose excursions.
Adult patients without (A) or with diabetes non-insulin-treated type 2 (B), insulin-treated type 2 (C) or type 1 (D) undergoing major surgery were monitored using CGM (Dexcom G6), with an electrochemical sensor in the interstitial fluid, during surgery and for up to 10 days postoperatively. Patients and health care staff were blinded to CGM values, and glucose management adhered to the standard diabetes care protocol. Thirty-day postoperative serious adverse events were recorded. The primary outcome was duration of hypoglycemia (glucose <70 mg/dL). Clinicaltrials.gov: NCT04473001.
Seventy patients were included, with a median observation time of 4.0 days. CGM was recorded in median 96% of the observation time. The median daily duration of hypoglycemia was 2.5 minutes without significant difference between the 4 groups (A-D). Hypoglycemic events lasting ≥15 minutes occurred in 43% of all patients and 70% of patients with type 1 diabetes. Patients with type 1 diabetes spent a median of 40% of the monitoring time in the normoglycemic range 70 to 180 mg/dL and 27% in the hyperglycemic range >250 mg/dL. Duration of preceding hypo- and hyperglycemia tended to be longer in patients with serious adverse events, compared with patients without events, but these were exploratory analyses.
Significant duration of both hypo- and hyperglycemia was detected in high proportions of patients, particularly in patients with diabetes, despite protocolized perioperative diabetes management.
Background Respiratory complications secondary to intermittent intra-abdominal hypertension and/or atelectasis are common after abdominal wall reconstruction for large incisional hernias. It is ...unknown if the respiratory function of this patient group is affected long term or impairs activities of daily living. We hypothesized that abdominal wall reconstruction for large incisional hernia would not lead to improved, long-term pulmonary function or respiratory quality of life. Methods Eighteen patients undergoing open abdominal wall reconstruction with mesh for a large incisional hernia (horizontal fascial defect width >10 cm) were compared with 18 patients with an intact abdominal wall who underwent colorectal resection. Patients were examined pre- and 1-year postoperatively. Examined measures included forced vital capacity, forced expiratory volume in first second, peak expiratory flow, maximal in- and expiratory mouth pressure, and 2 validated questionnaires on respiratory quality of life. In order to decrease heterogeneity, objectively examined parameters were presented relative to the predicted values, which were normality adjusted pulmonary measures. Results At 1-year follow-up, the abdominal wall reconstruction group showed significant improvement in percent predicted peak expiratory flow and maximal expiratory mouth pressure, whereas all other measurements of lung function remained unchanged. Respiratory quality of life did not change significantly. Patients who underwent abdominal wall reconstruction showed a significantly greater improvement of percent predicted peak expiratory flow compared with patients undergoing colorectal resection. Conclusion Abdominal wall reconstruction for large incisional hernia improved long-term expiratory lung function. Respiratory quality of life did not change significantly after abdominal wall reconstruction.
The COVID-19 pandemic has had a global impact on cancer care but the extent to which this has affected the management of colorectal cancer (CRC) in different countries is unknown. CRC management in ...Denmark was thought to have been relatively less impacted than in other nations during the first wave of the pandemic. The aim of this study was to determine the pandemic's impact on CRC in Denmark.
The Danish national cancer registry identified patients with newly diagnosed with CRC from 1 March 2020 to 1 August 2020 (pandemic interval) and corresponding dates in 2019 (prepandemic interval). Data regarding clinicopathological demographics and perioperative outcomes were retrieved and compared between the two cohorts.
Total CRC diagnoses (201 versus 359 per month, P = 0.008) and screening diagnoses (38 versus 80 per month, P = 0.016) were both lower in the pandemic interval. The proportions of patients presenting acutely and the stage at presentation were, however, unaffected. For those patients having surgery, both colonic and rectal cancer operations fell to about half the prepandemic levels: colon (187 (i.q.r. 183-188) to 96 (i.q.r. 94-112) per month, P = 0.032) and rectal cancers (63 (i.q.r. 59-75) to 32 (i.q.r. 28-42) per month, P = 0.008). No difference was seen in surgical practice or postoperative 30-day mortality rate (colon 2.2 versus 2.2 per cent, P = 0.983; rectal 1.0 versus 2.9 per cent, P = 0.118) between the cohorts. Treatment during the pandemic interval was not independently associated with death at 30 or 90 days.
The initial wave of the COVID-19 pandemic reduced the number of new diagnoses made and number of operations but had limited impact on technique or outcomes of CRC care in Denmark.
Background and Aim
A risk‐stratified approach for selecting patients likely to harbor common bile duct (CBD) stones to proceed directly to endoscopic or surgical stone clearance, rather than undergo ...less invasive testing, has been proposed. We assessed the performance of three clinical algorithms used to predict CBD stones.
Methods
All patients undergoing first‐time endoscopic retrograde cholangiopancreatography (ERCP) in 2011–2012 as a result of suspected CBD stones were enrolled prospectively in a clinical database. Data such as imaging test findings and liver function tests (LFTs) were collected 48 h prior to and on the day of ERCP. Patients were stratified into different risk groups for harboring CBD stones according to three clinical algorithms using imaging and laboratory data. Findings on ERCP were used as gold standard. Performance characteristics of each algorithm were separately calculated for each time point of LFT assessment.
Results
Overall, 186 patients were analyzed, 75% of whom presented CBD stones on ERCP. Proportion of patients categorized as high‐risk for harboring CBD stones varied among the three algorithms (67% vs 73% vs 56%). Also, the algorithms showed only moderate, albeit comparable, accuracy for predicting the presence of CBD stones (0.65, 95% confidence interval CI 0.62–0.68 vs 0.68, 95% CI 0.63–0.67 vs 0.59, 95% CI 0.57–0.61). Similar results were obtained when performance characteristics were recalculated using LFT from 48 h prior to ERCP (data not shown).
Conclusion
Three diagnostic algorithms commonly used for predicting CBD stones have comparable but only moderate accuracy. Further research is warranted to improve risk stratification of patients with suspected CBD stones.
Although preoperative administration of high-dose glucocorticoid may lead to improved recovery after operative procedures, this regimen has not been examined in patients undergoing abdominal wall ...reconstruction for repair of large ventral hernias. The aim of the current trial was to examine the effects of preoperative, single high-dose glucocorticoid on recovery after abdominal wall reconstruction.
Forty patients undergoing abdominal wall reconstruction for repair of ventral incisional hernias with a horizontal fascial defect >10 cm were randomized to intravenous administration of either 125 mg methylprednisolone or placebo at the induction of anesthesia. The primary endpoint was pain in the supine position as assessed by a numeric rating scale of 0 to 10 at rest at 8 am on the first postoperative day. Secondary outcomes included postoperative pain during activity, nausea, fatigue, inflammatory response (measured by plasma levels of C-reactive protein), duration of stay, and 30-day complications or readmissions.
There was no difference in pain at rest on the first postoperative day (methylprednisolone mean 1.7 vs placebo 2.2, P > .95), whereas patients in the methylprednisolone group reported less pain during activity (mean 3.0 vs 5.0; P = .011) and during coughing (3.4 vs 5.9; P = .010). There were no differences between the 2 groups regarding postoperative fatigue or nausea. Postoperative levels of C-reactive protein were less in the methylprednisolone group (P = .039).
A single-shot, high-dose methylprednisolone before abdominal wall reconstruction for a large incisional hernia decreased early postoperative pain and attenuated the inflammatory response.
Summary
Background
Appendicitis is a common disease with a lifespan risk of approximately 8%. The full range of specific causes for the disease remains elusive, but an aberrant microbiota have been ...identified as a potential risk factor.
Aim
To investigate if use of antibiotics in a paediatric population increases the risk of appendicitis in childhood and adolescence
Methods
We conducted a cohort study from 1 January 1995 to 31 December 2014. A total of 1 385 707 children (0‐19 years of age) including 7 406 397 antibiotic prescriptions and 11 861 cases of appendicitis were included. Primary outcome was appendicitis requiring appendectomy according to previous use of antibiotics. Appendicitis and appendectomy were identified from nationwide hospital records, and exposure to antibiotics was identified from nationwide prescription register. Rate ratios (RRs) with 95% confidence intervals were estimated from Poisson and logistic regression models.
Results
Children who received at least one course of antibiotics were at increased risk of developing appendicitis compared to unexposed children (adjusted RR 1.72 95% confidence interval 1.61‐1.85), mean age of developing appendicitis was 9.8 years (SD 4.1 years). The RR of appendicitis increased by 1.04 (1.04‐1.04) per antibiotic course. A higher risk of appendicitis was observed in children exposed to antibiotics within the first 6 months of life (RR 1.46 1.36‐1.56) and children exposed to broad‐spectrum antibiotics (RR 1.33 1.27‐1.39). After adjustment for number of antibiotic courses, the association between early age of antibiotic exposure and risk of appendicitis and the association between exposure to broad‐spectrum antibiotics and the risk of appendicitis both disappeared.
Conclusion
Children who receive antibiotics are at increased and dose‐dependent risk of appendicitis. The underlying mechanisms merit further investigation.
Reepithelialisation is fundamental to wound healing, but our current understanding largely relies on cellular and animal studies. The aim of the present randomised double-blind three-arm controlled ...trial was to correlate genuine epidermal wound healing with key proteins and topical zinc treatment in humans. Sixty wounds were produced using deroofed suction blisters in 30 healthy volunteers and randomised to topical zinc sulphate (n = 20), placebo (n = 20), or control (n = 20) treatment for 4 days. All wounds with perilesional skin were processed for automatic immunostaining of paraffin tissue sections with monoclonal antibodies against Ki-67, metallothionein (MT) and matrix metalloproteinase (MMP)-1. Protein expression was quantified by automated digital image analysis. Epidermal Ki-67 and MT labelling indices were increased in keratinocytes in the neoepidermis (∼1.1 mm) and at the wound edge (0.5 mm) compared to normal skin. Increased MMP-1 immunostaining was restricted to the neoepidermis. MT was robustly upregulated in the upper dermis of the wounds. Zinc treatment enhanced MMP-1 expression beneath the neoepidermis via paracrine mechanisms and MT under the neoepidermis and in the nonepithelialised wound bed via direct actions of zinc as indicated by the induction of MT2A mRNA but not MMP-1 mRNA in cultured normal human dermal fibroblasts by zinc sulphate. The present human study demonstrates that quantitative immunohistochemistry can identify proteins involved in reepithelialisation and actions of external compounds. Increased dermal MT expression may contribute to the anti-inflammatory activities of zinc and increased MMP-1 levels to promote keratinocyte migration.
BACKGROUND:Repair of large incisional hernias remains a surgical and costly challenge. Temporary paralysis of the lateral abdominal wall muscles with topical administration of botulinum toxin A (BTA) ...is a new therapeutic concept, which may obviate the need for component separation technique (CST) for repair of large incisional hernias. Current literature on the administration of BTA as adjunct to surgical repair of abdominal incisional hernias was investigated.
METHODS:The electronic databases PubMed and Embase were searched for eligible studies. Two independent investigators evaluated the literature. Data were sought regarding primary fascial closure with and without CST, safety, hernia recurrence, method of application, and preoperative radiological imaging.
RESULTS:Six cohort studies including a total of 133 patients receiving BTA were identified. No randomized or case–control studies were found. In total, 83.5% of the patients achieved primary fascial closure. Supplemental CST was necessary in 24.1% of the patients. Two patients developed hernia recurrence during follow-up. No postoperative complications or adverse events were considered related to the administration of BTA, except for impairment of postoperative coughing and sneezing. Additionally, radiological imaging showed that BTA increased the length of lateral abdominal muscles before surgery.
CONCLUSIONS:Preoperative administration of BTA increases muscle length and may facilitate primary fascial closure. Optimal administration is at least 2 weeks before repair, whereas the optimal dose of BTA remains to be defined. Carefully designed randomized controlled trials are warranted to identify patients who would benefit from BTA and to eliminate the confounding effect of CST.
Anastomotic leakage (AL) is a devastating complication after colorectal surgery, possibly due to the loss of stabilizing collagen fibers in the submucosa. Our aim was to assess the formation of ...collagen in the colon versus the rectum with or without transforming growth factor (TGF)-β1 exposure in a human cellular model of colorectal repair. Primary fibroblasts were isolated by an explant procedure from clinically resected tissue rings during anastomosis construction in 19 consecutive colorectal patients who underwent laparoscopy. The cells, identified as fibroblasts by morphologic characteristics and flow cytometry analysis (CD90
), were cultured for 8 days and in 12 patients in the presence of 1 ng/mL TGF-β1. Total collagen deposition was measured colorimetrically after Sirius red staining of fixed cell layers, and type I, III, and VI collagen biosynthesis and degradation were specifically determined by the biomarkers PINP, PRO-C3, PRO-C6, and C3M in conditioned media by competitive enzyme-linked immunosorbent assays. Total collagen deposition by fibroblasts from the colon and rectum did not significantly differ. TGF-β1 treatment increased PINP, PRO-C6, and total collagen deposition. Mechanistically, TGF-β1 treatment increased
and
(encoding α-smooth muscle actin), and decreased
and
mRNA levels in colorectal fibroblasts. In conclusion, we found no effect of anatomic localization on collagen production by fibroblasts derived from the large intestine. TGF-β1 represents a potential therapeutic agent for the prevention of AL by increasing type I collagen synthesis and collagen deposition.
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