腹腔镜高选择性迷走神经切断术联合Nissen胃底折叠术:效果如何?——腹腔镜Nissen迷走神经切断术治疗胃食管返流

背景：Nissen胃底折叠术（Nissen fundoplication，NF）已不是治疗胃食管返流性疾病（gastroesophageal reflux disease，GERD）的唯一、有效的方法。对于能降低胃酸的手术方式来讲，如高选择性迷走神经切断术（highly selective vagotomy，HSV），也不仅仅是一种辅助治疗方法。对高选择性迷走神经切断术联合Nissen胃底折叠术（Nissen fundoplication with highly selective vagotomy，NFHSV）治疗GERD的作用目前尚无完整的评价。方法：2003年6月～2005年6月8例女性病人接受NFHSV，8例均有6个月GERD病史，经药物治疗症状无缓解，有餐前痛、消化性溃疡或严重的胃炎。平均随访时间12个月，术前、术后进行烧心严重程度评分测定（heart burn severity score，HSS）。结果：平均手术时间110min，无手术并发症。1例术后须用质子泵抑制剂，术后经戒烟5个月后停药。8例术后症状和烧心严重程度评分测定有明显改善。结论：NFHSV是有效的联合手术方式，尚需要进一步的研究证实这一联合术式的完全有效性和安全性。

The Association of Pneumonia with Clinical Outcome in Patients with Inhalation Injury

Introduction: Inhalation injury is a particularly lethal form of thermal burn injury, and is associated with increased morbidity and mortality. Pneumonia is a common complication of inhalation injury, due to the increased susceptibility of lungs that have been stripped of their biologic defense mechanisms, as well as the general susceptibility of the burn population to infections. While older series suggest that pneumonia is associated with worse mortality and morbidity, recent reports suggest that this may not be the case in all populations. Methods: We attempted to clarify the impact of pneumonia in terms of mortality, length of mechanical ventilation, need for tracheostomy, and discharge disposition, in patients admitted with inhalation injury by performing a retrospective review of patients admitted to a regional burn center 2002-2009. Burn registry and electronic chart review were used to obtain demographic, clinical and outcome data. Univariate and multivariate analysis was used to compare outcomes in patients who developed pneumonia versus those who did not. Results: The study cohort comprised 166 patients, of whom 21 (13%) were diagnosed with pneumonia. Development of pneumonia was not predicted by age, surface area burned or other complications such as acute respiratory distress syndrome. Surprisingly, pneumonia was associated with reduced inpatient mortality (p = 0.006). However, patients who developed pneumonia were also more likely to have prolonged ventilator dependence (19 vs 5 days,

Variations in burn perfusion over time as measured by portable ICG fluorescence: A case series

The early determination of healing potential in indeterminate thickness burns may be diffi cult to establish by visual inspection alone,even for experienced burn practitioners.This case series explores the use of indocyanine green(ICG)fl uorescence using portable bedside assessment as a potential tool for early determination of burn depth.Three subjects with indeterminate thickness burns had daily perfusion assessment using ICG fl uorescence assessment using the SPY machine(SPY®,Lifecell Corp.,NJ,USA)in addition to standard burn care.The fl uorescence was quantifi ed as a percentage of the perfusion of intact skin,and areas of hypoand hyper-perfusion were indicated.The study was concluded when the burn surgeon,blinded to the ICG results,made a clinical determination of the need for skin grafting or discharge.The perfusion in areas of diff ering depth of burn were compared over the entire study period to determine both the magnitude of diff erence,and the point in the time course of healing when these changes became evident.Signifi cant diff erences in perfusion were noted between burned areas of varying depth.These diff erences were evident as early as the fi rst post-burn day,and persisted till the completion of the study.ICG fl uorescence represents a potential adjunct in burn assessment in this fi rst longitudinal study of its use;however much more systematic research will be required to judge the feasibility of clinical implementation.

Effect of non-steroidal anti-inflammatory drugs on post-surgical complications against the backdrop of the opioid crisis

The USA is currently going through an opioid crisis, associated with tremendous economic and societal impacts. In response to this crisis, healthcare professionals are looking for alternative pain management methods, and non-steroidal anti-inflammatory drugs (NSAIDs) are a sensible choice because of their effectiveness after surgical procedures. However, before surgeons start prescribing NSAIDs in place of opioids, it is crucial to first understand their potential post-surgical complications. The goal of this review is to summarize the data obtained through both animal and human studies, which suggest how a dramatic increase in NSAID use may affect these post-surgical complications. We first provide a short review outlining the mechanisms of action of NSAIDs, followed by a summary of animal studies, which show a trend towards the negative effects of NSAIDs on wound healing and an association between NSAID use and wound infections. Lastly, we present evidence from human studies on the association of NSAIDs with the following complications:anastomotic leaks, necrotizing soft tissue infections, bleeding complications, orthopedic injuries, wound healing, and cancer care. The human studies are much more variable in their conclusions as to whether NSAIDs are beneficial or not, with the only strong evidence showing that NSAIDs inhibit bone healing. This may partially be explained by male and female differences in response to NSAIDs as many animal studies showing the inhibitory effects of NSAIDs were performed on females, while al the human studies were performed with both sexes. We conclude that strong caution should be used in the prescription of NSAIDs, especially in female patients, but larger scale studies are warranted before solid recommendations can be made.

Increased mortality in women: sex differences in burn outcomes

Background: There is increasing evidence that sex differences may influence responses after thermal injury and affect clinical outcomes. The objective of this study was to evaluate the relationships between sex, thermal injury,body size, and inpatient mortality in burn patients.Methods: Medical records of adults with >20% total body surface area (TBSA) burn injury admitted to two American Burn Association (ABA)-verified burn centers between 2008 and 2014 were retrospectively reviewed.Injury details and baseline characteristics, including body size as estimated by body surface area (BSA) and body mass index (BMI) were recorded, along with details of the hospital course. The primary outcome of inpatient mortality was compared between sexes.Results: Out of 334 subjects, 60 were women (18%). Median TBSA was 33% (IQR 25-49) in this cohort, with 19% full thickness burns and 30% inhalation injury. Despite no significant difference in age, presence of inhalation injury, TBSA,or depth of burn, women had significantly higher rates of inpatient mortality (45 vs. 29%, P = 0.01). BSA was significantly lower in women vs. men (P < 0.001), but this difference was not more pronounced among non-survivors.There was no difference in BMI between men and women non-survivors. Although not significant (P = 0.28), women succumbed to their injuries sooner than men (day 4 vs. 10 post-injury).Conclusions: Women are less likely to survive burn injuries and die sooner than men with similar injuries. Body size does not appear to modulate this effect. Burn centers should be aware of the higher mortality risk in women with large burns.