Adenosine-induced non-sustained polymorphic ventricular tachycardia

Adenosine has become widely used because of its diagnostic and therapeutic value in the emergency management of arrhythimias. it produces transient heart block by slowing conduction through tile AV node and thus terminates supraventricular tachycardias that involve the atrioventricular node. Bradyarrhythmias of short duration are common side effects of the use of this drug. Premature atrial and ventricular beats have also been reported. The very short half-life and lack of serious adverse effects generally lead to the consideration that adenosine is a safe drug. We describe a 56-year-old woman with a supra ventricular tachycardia. To terminate this rhythm disorder intravenous adenosine was given. Interruption of tile supra ventricular tachycardia was followed by non-sustained polymorphic ventricular tachycardi

Role of nutrition in liver transplantation for end-stage chronic liver disease

Patients with end-stage liver disease often reveal significant protein-energy malnutrition, which may deteriorate after listing for transplantation. Since malnutrition affects post-transplant survival, precise assessment must be an integral part of pre- and post-surgical management. While there is wide agreement that aggressive treatment of nutritional deficiencies is required, strong scientific evidence supporting nutritional therapy is sparse. In practice, oral nutritional supplements are preferred over parenteral nutrition, but enteral tube feeding may be necessary to maintain adequate calorie intake. Protein restriction should be avoided and administration of branched-chain amino acids may help yield a sufficient protein supply. Specific problems such as micronutrient deficiency, fluid balance, cholestasis, encephalopathy, and comorbid conditions need attention in order to optimize patient outcom

Loop Ileostomy Closure: Comparison of Cost Effectiveness between Suture and Stapler

Background: Closure of loop ileostomy can be safely performed using sutures or staplers. The aim of the present study was to compare the cost effectiveness of three different techniques. Methods: A total of 128 consecutive patients who underwent closure of loop ileostomy between January 2002 and December 2008 were analyzed retrospectively. The primary outcome parameter was operative cost. Results: Closure of ileostomy was performed in 66 patients with hand-sewn anastomosis, in 25 patients with stapler only, and in 37 patients with a combination of stapler and suture. There were no differences in terms of early and late postoperative complications. Operative time was significantly longer for "suture only” (101.4±26min) than for "stapler/suture” (−4.9min) and "stapler only” (−17.8min); the difference between the three groups is significant (p=0.05). Duration of hospital stay was not different among the three groups. Operative costs with "stapler/suture” (1,755.9±355.6 EUR) were significantly higher than with "suture only” (−254 EUR; p=0.001) and "stapler only” (−236 EUR; p=0.005). Conclusions: Operative time using the stapler only is significantly shorter than with hand-sewn anastomosis or combinations of stapler and suture. Operative costs are significantly higher for a procedure that includes suture and staple

Long-term Follow-up of Open and Laparoscopic Repair of Large Incisional Hernias

Background: Long-term results after laparoscopic repair of large incisional hernias remain to be determined. The aim of this prospective study was to compare early and late complications between laparoscopic repair and open repair in patients with large incisional hernias. Methods: Only patients with a hernia diameter of ≥5cm were included in this study and were prospectively followed. We compared 56 patients who underwent open incisional hernia repair with 69 patients who underwent laparoscopic repair. Median follow-up in the laparoscopic group was 32.5months (range 1-62months) and in the open group 65months (range 1-80months). Results: The demographic parameters were not significantly different between the two groups. However, the median hospital stay (6.0days, range 1-23days vs. 7.0days, range 1-67days; p=0.014) and incidence of surgical site infections (SSIs) (5.8% vs. 26.8%; p=0.001) were significantly lower in the laparoscopic group than in the open surgery group. Bulging of the implanted mesh was observed in 17.4% in the laparoscopic group and in 7.1% in the open group (p=NS). The recurrence rate was 18% in the open group and 16% in the laparoscopic group (p=NS). Multivariate analysis revealed that width of the hernia ≥10cm, SSI, and BMI ≥30kg/m2 were significant risk factors for hernia recurrence. Conclusions: The incidence of SSIs was significantly lower after laparoscopic incisional hernia repair. At long-term follow-up, the recurrence rate was not different between the two techniques. Abdominal bulging is a specific problem associated with laparoscopic repair of large incisional hernias. Size of the hernia, BMI, and SSI are risk factors for hernia recurrence irrespective of the techniqu

Validation of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) Score in Liver Surgery

Background: The estimation of physiologic ability and surgical stress (E-PASS) has been used to produce a numerical estimate of expected mortality and morbidity after elective gastrointestinal surgery. The aim of this study was to validate E-PASS in a selected cohort of patients requiring liver resections (LR). Methods: In this retrospective study, E-PASS predictor equations for morbidity and mortality were applied to the prospective data from 243 patients requiring LR. The observed rates were compared with predicted rates using Fisher's exact test. The discriminative capability of E-PASS was evaluated using receiver-operating characteristic (ROC) curve analysis. Results: The observed and predicted overall mortality rates were both 3.3% and the morbidity rates were 31.3 and 26.9%, respectively. There was a significant difference in the comprehensive risk scores for deceased and surviving patients (p=0.043). However, the scores for patients with or without complications were not significantly different (p=0.120). Subsequent ROC curve analysis revealed a poor predictive accuracy for morbidity. Conclusions: The E-PASS score seems to effectively predict mortality in this specific group of patients but is a poor predictor of complications. A new modified logistic regression might be required for LR in order to better predict the postoperative outcom

Implantation of Prophylactic Nonabsorbable Intraperitoneal Mesh in Patients With Peritonitis Is Safe and Feasible

Background: Patients with peritonitis undergoing emergency laparotomy are at increased risk for postoperative open abdomen and incisional hernia. This study aimed to evaluate the outcome of prophylactic intraperitoneal mesh implantation compared with conventional abdominal wall closure in patients with peritonitis undergoing emergency laparotomy. Method: A matched case-control study was performed. To analyze a high-risk population for incisional hernia formation, only patients with at least two of the following risk factors were included: male sex, body mass index (BMI) >25kg/m2, malignant tumor, or previous abdominal incision. In 63 patients with peritonitis, a prophylactic nonabsorbable mesh was implanted intraperitoneally between 2005 and 2010. These patients were compared with 70 patients with the same risk factors and peritonitis undergoing emergency laparotomy over a 1-year period (2008) who underwent conventional abdominal closure without mesh implantation. Results: Demographic parameters, including sex, age, BMI, grade of intraabdominal infection, and operating time were comparable in the two groups. Incidence of surgical site infections (SSIs) was not different between groups (61.9 vs. 60.3%; p=0.603). Enterocutaneous fistula occurred in three patients in the mesh group (4.8%) and in two patients in the control group (2.9%; p=0.667). The incidence of incisional hernia was significantly lower in the mesh group (2/63 patients) than in the control group (20/70 patients) (3.2 vs. 28.6%; p<0.001). Conclusions: Prophylactic intraperitoneal mesh can be safely implanted in patients with peritonitis. It significantly reduces the incidence of incisional hernia. The incidences of SSI and enterocutaneous fistula formation were similar to those seen with conventional abdominal closur

Endothelin and cardiac arrhythmias: do endothelin antagonists have a therapeutic potential as antiarrhythmic drugs?

Endothelin-1 (ET-1), the predominant isoform of the ET peptide family and a potent vasoconstrictor, has been shown to aggravate ischemia-induced ventricular arrhythmias. However, there is also evidence that ET-1 may have a direct arrhythmogenic action that is not solely attributable to myocardial ischemia. Proposed mechanisms for the arrhythmogenic effects of ET-1 are prolongation or increased dispersion of monophasic action potential duration, QT prolongation, development of early afterdepolarizations, acidosis, and augmentation of cellular injury. As for an ionic basis for the observed electrophysiologic effects, ET-induced Ca2+ release from intracellular stores, generation of inositol triphosphate, inhibition of delayed rectifier K+ current, and stimulation of the Na+/H+ exchanger may be involved. Recently, some studies have shown that ET receptor antagonists, which promise to be powerful tools in cardiovascular medicine, may also demonstrate antiarrhythmic properties. This review describes the current state of knowledge on the interactions between the ET system and cardiac arrhythmias, and discusses the therapeutic potential of ET antagonists as antiarrhythmic drug

Operation time and body mass index are significant risk factors for surgical site infection in laparoscopic sigmoid resection: a multicenter study

Background: Surgical site infection (SSI) in patients who underwent colorectal surgery is a common complication associated with increased morbidity and costs. The aim of this study was to assess risk factors for SSI in laparoscopic sigmoid resection for benign disease. Methods: Using a multicenter database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery, we prospectively identified 4,488 patients who underwent laparoscopic colorectal surgery between 1995 and 2008; of these, 2,571 patients who underwent sigmoid resection for benign disease were included. Uni- and multivariate analyses were used to determine risk factors for SSI. Results: The incidence of SSI was 3.5% (90/2,571). Among SSI patients, incisional superficial infections were found in 71%, incisional deep infections in 22%, and organ-space infections in 7%. Patients' age, underlying disease, and surgeons' experience had no impact on SSI. Multivariate analyses showed that operation time >240min (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.0-2.8), BMI≥27kg/m2 (OR 2.3 [1.3-4.5]), organ lesions (OR 7.9 [2.0-31.8]), and male gender (OR 2.3 [1.2-4.5]) were significant risk factors for SSI. Reoperations in the SSI group were significantly more frequent than in the Non-SSI group (30% vs. 3%; p240min, BMI ≥27kg/m2, organ lesions, and male gender. SSI was significantly associated with more reoperations, longer hospital stay, and higher mortality rat