Stefan K. Burgdorf

Impact of sleep and circadian disturbances in urinary 6-sulphatoxymelatonin levels, on cognitive function after major surgery

Abstract:  Sleep and circadian disturbances may underlie cognitive dysfunction after major surgery. The aim of this study was to examine the association between sleep and circadian disturbances (as assessed by changes in the melatonin rhythm) and postoperative cognitive dysfunction (POCD). We measured subjective and objective sleep quality, excretion of the major metabolite of melatonin, 6‐sulphatoxymelatonin (aMT6s) in urine and cognitive function before and 4 days after major abdominal surgery in 36 patients. Subjective sleep quality was measured by visual analogue scale, objective sleep quality was measured by actigraphy, and cognitive function was assessed by neuropsychological testing. Eighteen patients (50%) had POCD on day 4 after surgery. At that time, the excretion of aMT6s was disturbed with significantly higher daytime excretion and a reduced night/day ratio compared with the preoperative measure (P = 0.05). Patients with POCD had significantly worse sleep quality and more night awakenings (P < 0.05) but we found no significant differences in day time (06:00–22:00 hr), night‐time (22:00–06:00 hr) or total aMT6s excretion (μg/24 hr). A significant correlation was found between the total excretion of aMT6s and actigraphically measured sleep efficiency (rs = 0.45, P = 0.03) and wakefulness after sleep onset (rs = −0.44, P = 0.04). In conclusion, POCD was associated with worse subjective sleep quality and more awakenings. Circadian rhythmicity as assessed by aMT6s excretion was disturbed after surgery but we were unable to show an association with POCD. Strategies to improve postoperative sleep quality should be investigated in the future.

Inadequate Preoperative Colonic Evaluation for Synchronous Colorctal Cancer

Background and Aims: Synchronous cancers (SC) are well known (2–11%) in patients with colorectal carcinoma (CRC). One study has shown that intraoperative palpation can miss up to 69% of the SC while other studies have shown altered planned surgical procedure due to preoperatively diagnosed synchronous lesions in 11–44%. The purpose of this study was to review all patients having surgery for CRC in our department since 2001, and to evaluate the extent of the perioperative colonic evaluation. Materials and Methods: The records of all patients operated for CRC between Jan. 2001 and Dec. 2007 in our department were reviewed. Only patients with CRC were included. Information regarding pre-, per- and postoperative colonic evaluation were obtained and occurrences of SC were evaluated. Results: Of the 534 patients included 124 (23%) patients had an impassable stenosis. Full preoperative colonic evaluation (FPCE) were done in 305 (26%) patients without stenosis. In 36 patients 39 SC were diagnosed. Seven SC were diagnosed postoperatively, of which five patients never had a FPCE. Three of these five patients had an inoperable SC, one patient died due to anastomosis leakage following re-operation and one patient had pulmonary embolism as a complication to re-operation. Conclusions: The results show that many patients (78%) never underwent FPCE, but also that many of these patients never had a full postoperative colonic evaluation. SC being overlooked can lead to increased morbidity and the possibility of advanced staging of the cancer which is also exemplified in this study.

Capsule Endoscopy: A Cause of Late Small Bowel Obstruction and Perforation

Case Report. A 71-year-old man was admitted to the department of gastroenterology with diffuse abdominal pain. Through the previous 12 months, the patient had experienced episodes of vomiting and watery diarrhea of increasing intensity as well as weight loss. The patient was evaluated with ultrasound, MRI, and subsequently a capsule endoscopy. Six months later, the patient presented, and an abdominal CT-scan showed mechanical small bowel obstruction with suspicion of metallic foreign body and perforation. Laparotomy showed perforation, stenosis, and foreign body, approximately 5 cm from the ileocecal valve. A right hemicolectomy and distal ileectomy (60 cm) with an ileostomy were performed. On further inspection of resection, a capsule endoscope was found impacted in a stenosis. The ileostomy was later reversed without complications. Conclusion. It is important to be aware of the possibility of capsule retention, especially in patients with known or suspected Crohns disease, due to the propensity of Crohns disease to form stenosis of the bowel. In cases where a stenosis is suspected, it is warranted to perform a patency capsule swallow before subjecting the patient to a capsule endoscopy.

Short Hospital Stay after Laparoscopic Colorectal Surgery without Fast Track

Purpose. Short hospital stay and equal or reduced complication rates have been demonstrated after fast track open colonic surgery. However, fast track principles of perioperative care can be difficult to implement and often require increased nursing staff because of more concentrated nursing tasks during the shorter hospital stay. Specific data on nursing requirements after laparoscopic surgery are lacking. The purpose of the study was to evaluate the effect of operative technique (open versus laparoscopic operation), but without changing nurse staffing or principles for peri- or postoperative care, that is, without implementing fast track principles, on length of stay after colorectal resection for cancer. Methods. Records of all patients operated for colorectal cancer from November 2004 to December 2008 in our department were reviewed. No specific patients were selected for laparoscopic repair, which was solely dependent on the presence of two specific surgeons at the same time. Thus, the patients were not selected for laparoscopic repair based on patient-related factors, but only on the simultaneous presence of two specific surgeons on the day of the operation. Results. Of a total of 540 included patients, 213 (39%) were operated by a laparoscopic approach. The median hospital stay for patients with a primary anastomosis was significantly shorter after laparoscopic than after conventional open surgery (5 versus 8 days, P < 0.001) while there was no difference in patients receiving a stoma (10 versus 10 days, ns), with no changes in the perioperative care regimens. Furthermore there were significant lower blood loss (50 versus 200 mL, P < 0.001) and lower complication rate (21% versus 32%, P = 0.006) in the laparoscopic group. Conclusion. Implementing laparoscopic colorectal surgery in our department resulted in shorter hospital stay without using fast track principles for peri- and postoperative care in patients not receiving a stoma during the operation. Consequently, we aimed to reduce hospitalisation without increasing cost in nursing staff per hospital bed. Length of stay was not reduced in patients receiving a stoma pointing at this group for specific intervention in the future. Furthermore, the complication rate was reduced in the laparoscopic group.

In vivo and ex vivo sentinel node mapping does not identify the same lymph nodes in colon cancer

IntroductionIdentification of lymph nodes and pathological analysis is crucial for the correct staging of colon cancer. Lymph nodes that drain directly from the tumor area are called “sentinel nodes” and are believed to be the first place for metastasis. The purpose of this study was to perform sentinel node mapping in vivo with indocyanine green and ex vivo with methylene blue in order to evaluate if the sentinel lymph nodes can be identified by both techniques.MethodsPatients with colon cancer UICC stage I–III were included from two institutions in Denmark from February 2015 to January 2016. In vivo sentinel node mapping with indocyanine green during laparoscopy and ex vivo sentinel node mapping with methylene blue were performed in all patients.ResultsTwenty-nine patients were included. The in vivo sentinel node mapping was successful in 19 cases, and ex vivo sentinel node mapping was successful in 13 cases. In seven cases, no sentinel nodes were identified. A total of 51 sentinel nodes were identified, only one of these where identified by both techniques (2.0%). In vivo sentinel node mapping identified 32 sentinel nodes, while 20 sentinel nodes were identified by ex vivo sentinel node mapping. Lymph node metastases were found in 10 patients, and only two had metastases in a sentinel node.ConclusionPlacing a deposit in relation to the tumor by indocyanine green in vivo or of methylene blue ex vivo could only identify sentinel lymph nodes in a small group of patients.

Successful resuscitation after carbon dioxide embolism during laparoscopy.

Venous air embolism (VAE) is a rare life-threatening complication that can occur during laparoscopy. A 50-year-old previously healthy woman underwent laparoscopic cholecystectomy and liver cyst fenestration. Immediately after the surgeon had left the operating room, the patient became hypotensive and developed cardiac arrest. Resuscitation was initiated and a precordial ultrasound examination suspected VAE in the right cardiac chambers. The patient was positioned in Durant’s position and air was aspirated through a central venous line. The patient was resuscitated and stabilized, and was transferred to another hospital, where she received hyperbaric oxygen treatment. The patient was discharged 14 days after surgery without any sequelae. It is important that the general surgeon suspects VAE during laparoscopy whenever the patient develops sudden and unexplained severe hypotension or cardiac arrest during or immediately after laparoscopy.

Intussusception in an adult with cystic fibrosis successfully reduced with contrast enema

A 34-year-old woman with cystic fibrosis and diabetes mellitus type I was admitted with a 1-week history of intermittent pain localised to the lower right quadrant of the abdomen. She presented with mild diarrhoea, but no nausea or vomiting. She had no history of prior abdominal surgery. On clinical examination, the abdomen was soft with local tenderness in the lower right quadrant and active bowel sounds. There was no palpable mass. Blood test analysis showed …

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Stefan K Burgdorf and colleagues find that medical students fall short in a test for Danish citizenship