A look at noteworthy articles from international journals

Insulin Sensitivity and Mitochondrial Function Are Improved in Children With Burn Injury During a Randomized Controlled Trial of Fenofibrate.

Randomized Controlled Trial
Annals of Surgery. 245(2):214-221, February 2007.
Cree, Melanie G. PhD *; Zwetsloot, Jennifer J. PhD, BS #; Herndon, David N. MD +[//]; Qian, Ting PhD [S]; Morio, Beatrice PhD [P]; Fram, Ricki MD +[//]; Sanford, Arthur P. MD +[//]; Aarsland, Asle MD, PhD *++[//]; Wolfe, Robert R. PhD *+[//]

Abstract:
Objective: To determine some of the mechanisms involved in insulin resistance immediately following burn trauma, and to determine the efficacy of PPAR-[alpha] agonism for alleviating insulin resistance in this population.

Summary Background Data: Hyperglycemia following trauma, especially burns, is well documented. However, the underlying insulin resistance is not well understood, and there are limited treatment options.

Methods: Twenty-one children 4 to 16 years of age with >40% total body surface area burns were enrolled in a double-blind, prospective, placebo-controlled randomized trial. Whole body and liver insulin sensitivity were assessed with a hyperinsulinemic-euglycemic clamp, and insulin signaling and mitochondrial function were measured in muscle biopsies taken before and after ~2 weeks of either placebo (PLA) or 5 mg/kg of PPAR-[alpha] agonist fenofibrate (FEN) treatment, within 3 weeks of injury.

Results: The change in average daily glucose concentrations was significant between groups after treatment (146 +/- 9 vs. 161 +/- 9 mg/dL PLA and 158 +/- 7 vs. 145 +/- 4 FEN; pretreatment vs. posttreatment; P = 0.004). Insulin-stimulated glucose uptake increased significantly in FEN (4.3 +/- 0.6 vs. 4.5 +/- 0.7 PLA and 5.2 +/- 0.5 vs. 7.6 +/- 0.6 mg/kg per minute FEN; pretreatment vs. posttreatment; P = 0.003). Insulin trended to suppress hepatic glucose release following fenofibrate treatment (P = 0.06). Maximal mitochondrial ATP production from pyruvate increased significantly after fenofibrate (P = 0.001) and was accompanied by maintained levels of cytochrome C oxidase and citrate synthase activity levels. Tyrosine phosphorylation of the insulin receptor and insulin receptor substrate-1 in response to insulin increased significantly following fenofibrate treatment (P = 0.04 for both).

Conclusions: Fenofibrate treatment started within 1 week postburn and continued for 2 weeks significantly decreased plasma glucose concentrations by improving insulin sensitivity, insulin signaling, and mitochondrial glucose oxidation. Fenofibrate may be a potential new therapeutic option for treating insulin resistance following severe burn injury.

---

Comparison of the Outcomes Between Open and Minimally Invasive Esophagectomy.

Original Articles
Annals of Surgery. 245(2):232-240, February 2007.
Smithers, Bernard M. MBBS, FRCS(Eng), FRACS *+; Gotley, David C. MD *+; Martin, Ian MBBS, FRACS *; Thomas, Janine M. BcHSc *

Abstract:
Objective: We report patient outcomes from esophageal resection with respect to morbidity and cancer survival comparing open thoracotomy and laparotomy (Open), with a thoracoscopic/laparotomy approach (Thoracoscopic-Assisted) and a total thoracoscopic/laparoscopic approach (Total MIE).

Methods: From a prospective database of all patients managed with cancer of the esophagus or esophagogastric junction, patients who had a resection using one of three techniques were analyzed to assess postoperative variables, adequacy of cancer clearance, and survival.

Results: The number of patients for each procedure was as follows: Open, 114; Thoracoscopic-Assisted, 309; and Total MIE, 23. The groups were comparable with respect to preoperative variables. The differences in the postoperative variables were: less median blood loss in the Thoracoscopic-Assisted (400 mL) and Total MIE (300 mL) groups versus Open (600 mL); longer time for Total MIE (330 minutes) versus Thoracoscopic-Assisted (285 minutes) and Open (300 minutes); longer median time in hospital for Open (14 days) versus Thoracoscopic-Assisted (13 days), Total MIE (11 days) and less stricture formation in the Open (6.1%) versus Thoracoscopic-Assisted (21.6%), Total MIE (36%). There were no differences in lymph node retrieval for each of the approaches. Open had more stage III patients (65.8%) versus Thoracoscopic-Assisted (34.4%), Total MIE (52.1%). There was no difference in survival when the groups were compared stage for stage for overall median or 3-year survival.

Conclusion: Minimally invasive techniques to resect the esophagus in patients with cancer were confirmed to be safe and comparable to an open approach with respect to postoperative recovery and cancer survival.

---

Randomized clinical trial of Lichtenstein's operation versus mesh plug for inguinal hernia repair
D. M. Frey 1, A. Wildisen 2, C. T. Hamel 1, M. Zuber 3, D. Oertli 1, J. Metzger 4 *
1Department of Surgery, Divisions of General Surgery and Surgical Research, University Hospital Basle, Basle, Switzerland
2Department of Surgery, Kantonales Spital Sursee, Sursee, Switzerland
3Department of Surgery, Kantonsspital Olten, Olten, Switzerland
4Department of Surgery, Kantonsspital Luzern, Lucerne, Switzerland
email: J. Metzger (juerg.metzger@ksl.ch)
*Correspondence to J. Metzger, Department of Surgery, Kantonsspital Luzern, CH-6000 Lucerne 16, Switzerland

British Journal of Surgery. Volume 94, Issue 1  , Pages 36 - 41

Abstract

Background:
Two of the most commonly used open prosthetic tension-free techniques for inguinal hernia repair are Lichtenstein's operation and the mesh plug repair. The technique of choice remains a subject of ongoing debate. The objective of the present investigation was to compare the two surgical procedures with respect to associated morbidity and recurrence rates.

Methods:
Five hundred and ninety-five patients with 700 primary or recurrent inguinal hernias were randomized to undergo either Lichtenstein's operation or mesh plug repair. The primary endpoint of the investigation was the recurrence rate 1 year after surgery. Secondary endpoints were perioperative complications and reoperation rates.

Results:
At 12-month follow-up, 597 hernia repairs (85·3 per cent) were evaluated. There were no significant differences regarding recurrence rates and perioperative complications. However, there was a significant difference in the overall reoperation rate between the two treatment groups, with 13 reoperations (4·2 per cent) in the Lichtenstein group and four (1·4 per cent) in the mesh plug group (P = 0·047).

Conclusion:
Lichtenstein's operation and the mesh plug repair are comparable with respect to perioperative complications and recurrence rates. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

---

Tissue oxygen saturation, measured by near-infrared spectroscopy, and its relationship to surgical-site infections
C. L. Ives 1, D. K. Harrison 1 *, G. S. Stansby 2
1Department of Medical Physics, University Hospital of North Durham, Durham, UK
2Northern Vascular Unit, Freeman Hospital, Newcastle upon Tyne, UK
email: D. K. Harrison (david.harrison@cddah.nhs.uk)

*Correspondence to D. K. Harrison, Department of Medical Physics, University Hospital of North Durham, North Road, Durham DH1 5TW, UK

British Journal of Surgery Volume 94, Issue 1  , Pages 87 - 91

Abstract

Background:
Surgical-site infections (SSIs) are common after major abdominal and groin bypass surgery. Tissue oxygen tension has been shown to predict these infections accurately. This study assessed whether a non-invasive measurement of tissue oxygenation, tissue oxygen saturation as measured by spectrophotometry, was as accurate.

Methods:
Fifty-nine patients having major abdominal or groin bypass surgery had tissue oxygen saturation measured by near-infrared spectrophotometry at the incision site and in the arm before operation, and at 12, 24 and 48 h after surgery. Masked outcome assessments for SSI were made at 7 and 30 days after operation.

Results:
In this retrospective analysis, 17 patients (29 per cent) developed an SSI. At 12 h after operation there was a significant difference in tissue oxygen saturation at the surgical site between patients who developed an SSI and those who did not (mean(s.d.) 43·4(18·1) versus 55·8(22·0) per cent; P = 0·032). These oxygen saturation readings were found to be more specific and sensitive in predicting SSIs than the National Nosocomial Infection Surveillance system.

Discussion:
There is a difference in postoperative surgical-site oxygen saturation between patients who subsequently develop SSIs and those who do not. Prediction of SSIs provides opportunities for intervention and prevention. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.