D. C. Winter

Perioperative Topical Nitrate and Sphincter Function in Patients Undergoing Transanal Stapled Anastomosis: A Randomized, Placebo-Controlled, Double-Blinded Trial

PURPOSEThe use of transanal stapling devices may impair continence because of digital dilatation and/or instrumentation. This study assessed the effect of pharmacological dilatation of the sphincter prior to stapler insertion.METHODSA randomized, placebo-controlled, double-blinded study of 60 patients undergoing transanal stapled anastomosis was undertaken. Consenting patients were randomly assigned to receive a single intraoperative dose of topical 0.2 percent nitroglycerin (glyceryl trinitrate) ointment or nitroglycerin-free placebo. All patients were assessed preoperatively and postoperatively by clinical methods (Wexner incontinence scores and examination), anorectal manometry by a station pull-through technique, and endoanal ultrasonography.RESULTSIntraoperative mean (±SEM) resting pressures (mmHg) were significantly reduced by nitroglycerin compared with prenitroglycerin levels (9.9 ± 0.9 vs. 50.5 ± 2.7; P = 0.002) or controls (56.0 ± 3.2; P = 0.001). Twenty-one of the 28 controls (75 percent) but only 4 of the 32 patients in the nitroglycerin group (12.5 percent) required digital dilatation to insert the stapling instrument (P = 0.003). Squeeze pressures were unaltered by the intervention but mean resting pressures were higher in the nitroglycerin group postoperatively (52.9 ± 3.2 − 31.6 ± 1.3 = 21.3 mmHg; 95 percent confidence interval, 14–27). Incontinence scores were lower in the nitroglycerin group at the 3-month (1.1 ± 0.2 vs. 4.6 ± 0.3; P = 0.003) and 12-month (0.9 ± 0.1 vs. 4.4 ± 0.3; P = 0.002) clinic visits.CONCLUSIONPreoperative nitroglycerin dilatation protects sphincter function in patients undergoing transanal stapled anastomoses.

Ingested foreign bodies in the paediatric patient

BackgroundPaediatric foreign body (FB) ingestion is a common problem and while most can be managed conservatively, a sub-population require intervention.AimsTo establish clear guidelines for management of paediatric FB ingestion.MethodsA retrospective chart review analysing all paediatric admissions with FB ingestion over a 10-year period from 1990 to 1999.ResultsOf 339 patients presenting to the accident and emergency department with FB ingestion, 59 required admission. Ingestion was accidental in 93.0% of patients. The reasons for admission were as follows: large FBs; dangerous FBs; and living far from the hospital. Nineteen patients (32.2%) were discharged without intervention. Thirty-seven (82.7%) required endoscopic retrieval, in two, the FB was not identified at endoscopy. Only three (5%) required surgery.ConclusionConservative management of FB ingestion in the paediatric population is possible in the majority of cases. However, a minority require intervention. While guidelines for intervention are ill-defined, definitive indications include symptomatic patients, or dangerous objects.

Predicting outcome after appendicectomy

AbstractAim To validate an intraoperative appendicitis severity score (IASS) and examine outcome following emergency appendectomy. Methods A prospective study was undertaken, enrolling consecutive patients undergoing emergency appendicectomy. Data were obtained independently on preoperative Alvarado scores, IASS (0-3: 0 no inflammation, 1 engorged appendix/no peritonitis, 2 peritoneal reaction/exudate or 3 evidence of perforation/abscess) and postoperative outcome parameters. Results There were 149 patients identified with a mean age of 20.7 years. There was no association between Alvarado score and length of hospital stay, septic complication, patient sex or duration of symptoms (p>0.05). IASS was found to be an independent risk factor for septic complication, wound infection (p<0.05) and length of hospital stay (p<0.001). There was no correlation between preoperative duration of symptoms or time until surgery and intraoperative score. Conclusions This simple scoring system can identify patients more likely to suffer morbidity following emergency appendicectomy. Specifically, this system identifies patients who have a high risk of sepsis and therefore could be of use when comparing healthcare performance.

Hypertonic saline infusion attenuates pulmonary injury due to ischaemia-reperfusion

ConclusionsResuscitation with HTS attenuates pulmonary oedema and tissue injury due to lower torso IR, and maintains a more benign immunological profile.

Hypertonic saline potentiates host response to Gram-negative sepsis despite disruption of mitogen-activated protein kinase activation

ConclusionsHTS significantly enhances intraceilular killing of bacteria while attenuating receptor-mediated activation of pro-inflammatory cascades.

Hypertonic saline attenuates adenocarcinoma β-1 integrin expression by sodium-dependent induction of cytoskeletal rearrangement

ConclusionsHTS significantly attenuates adenocarcinoma adhesion molecule expression by inducing conformational changes in the cytoskeleton. The failure of non-ionic and ionic sodiumfree hypertonic solutions to engender a decline in adhesion molecule expression suggests a pivotal role for sodium in the determination of the cellular response to electrical perturbation by hypertonic saline solutions.

Green fluorescent protein — a word of caution

ConclusionIn vitro GFP expression in LS174T cells decreases with time despite various attempts at enhancing overall expression. In vivo studies confirm this phenomenon as GFP expression was completely lost in the primary tumour model. Fluorescence was found to be variable in liver micrometastases depending on the time of FACScan analysis.In conclusion, the authors recommend the cautious use of the GFP reporter gene in tumour research. The variable nature of GFP expression in vivo and in vitro significantly limits its use in both quantitative and qualitative studies of tumour biology.