Ranula: Current Concept of Pathophysiologic Basis and Surgical Management Options

Background

There is no consensus opinion on a definitive surgical management option for ranulas to curtail recurrence, largely from the existing gap in knowledge on the pathophysiologic basis.

Aim

To highlight the current scientific basis of ranula development that informed the preferred surgical approach.

Design

Retrospective cohort study.

Setting

Public Tertiary Academic Health Institution.

Method

A 7-year 7-month study of ranulas surgically managed at our tertiary health institution was undertaken—June 1, 2008–December 31, 2015—from case files retrieved utilising the ICD-10 version 10 standard codes.

Results

Twelve cases, representing 0.4 and 1.2% of all institutional and ENT operations, respectively, were managed for ranulas with a M:F = 1:1. The ages ranged from 5/12 to 39 years, mean = 18.5 years, and the disease was prevalent in the third decade of life. Main presentation in the under-fives was related to airway and feeding compromise, while in adults, cosmetic facial appearance. Ranulas in adults were plunging (n = 8, 58.3%), left-sided save one with M:F = 2:1. All were unilateral with R:L = 1:2. Treatment included aspiration (n = 2, 16.7%) with 100% recurrence, intra-/extraoral excision of ranula only (n = 4, 33.3%) with recurrence rate of 50% (n = 2, 16.7%), while marsupialisation in children (n = 1, 8.3%) had no recurrence. Similarly, transcervical approach (n = 5, 41.7%) with excision of both the ranula/sublingual salivary gland recorded zero recurrence. Recurrence was the main complication (n = 4, 33.3%).

Conclusion

With the current knowledge on the pathophysiologic basis, extirpation of both the sublingual salivary gland and the ranula by a specialist surgeon is key for a successful outcome.

     

Cross-cultural adaptation and validation of the International Knee Documentation Committee Subjective Knee Form in Greek

Background

Patient-reported outcomes require validation in a particular language and culture before administration for clinical use.

Materials and methods

A systematic translation of the IKDC Subjective Knee Form was initially tested in 30 patients with various knee pathologies to develop the first Greek version (IKDC/SKF-GR). It was then administered to another 80 patients. The test–retest reliability (n = 35) and internal consistency (n = 80) were examined. Construct validity was tested by correlating the IKDC/SKF-GR with the SF-36 subscales (n = 80) and content validity by measuring floor/ceiling effects. Responsiveness was measured in patients with meniscus pathology (n = 24).

Results

Patients filled the form without omissions/questions regarding the phrasing of items. Internal consistency was good (Cronbach’s α = 0.87) and test–retest reliability very good (ICC_2,1 = 0.95, SEM = 4.4 and SDC = 12.2). Correlations with the SF-36 subscales confirmed its construct validity. No floor/ceiling effects were recorded. The effect size was large (ES = 1.26).

Conclusions

The IKDC/SKF-GR has comparable measurement properties to the original form.

Level of evidence

Level II.

     

A new classification system for degenerative spondylolisthesis of the lumbar spine

Purpose

There is no consensus for a comprehensive analysis of degenerative spondylolisthesis of the lumbar spine (DSLS). A new classification system for DSLS based on sagittal alignment was proposed. Its clinical relevance was explored.

Methods

Health-related quality-of-life scales (HRQOLs) and clinical parameters were collected: SF-12, ODI, and low back and leg pain visual analog scales (BP-VAS, LP-VAS). Radiographic analysis included Meyerding grading and sagittal parameters: segmental lordosis (SL), L1–S1 lumbar lordosis (LL), T1–T12 thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), and sagittal vertical axis (SVA). Patients were classified according to three main types—1A: preserved LL and SL; 1B: preserved LL and reduced SL (≤5°); 2A: PI–LL ≥10° without pelvic compensation (PT < 25°); 2B: PI–LL ≥10° with pelvic compensation (PT ≥ 25°); type 3: global sagittal malalignment (SVA ≥40 mm).

Results

166 patients (119 F: 47 M) suffering from DSLS were included. Mean age was 67.1 ± 11 years. DSLS demographics were, respectively: type 1A: 73 patients, type 1B: 3, type 2A: 8, type 2B: 22, and type 3: 60. Meyerding grading was: grade 1 (n = 124); grade 2 (n = 24). Affected levels were: L4–L5 (n = 121), L3–L4 (n = 34), L2–L3 (n = 6), and L5–S1 (n = 5). Mean sagittal parameter values were: PI: 59.3° ± 11.9°; PT: 24.3° ± 7.6°; SVA: 29.1 ± 42.2 mm; SL: 18.2° ± 8.1°. DSLS types were correlated with age, ODI and SF-12 PCS (ρ = 0.34, p < 0.05; ρ = 0.33, p < 0.05; ρ = ?0.20, and p = 0.01, respectively).

Conclusion

This classification was consistent with age and HRQOLs and could be a preoperative assessment tool. Its therapeutic impact has yet to be validated.

Level of evidence

4.

     

The Role of Attachment in Body Weight and Weight Loss in Bariatric Patients

Purpose

The aim of this study is to explore the role of attachment styles in obesity.

Material and Methods

The present study explored differences in insecure attachment styles between an obese sample waiting for bariatric surgery (n = 195) and an age, sex and height matched normal weight control group (n = 195). It then explored the role of attachment styles in predicting change in BMI 1 year post bariatric surgery (n = 143).

Results

The bariatric group reported significantly higher levels of anxious attachment and lower levels of avoidant attachment than the control non-obese group. Baseline attachment styles did not, however, predict change in BMI post surgery.

Conclusion

Attachment style is different in those that are already obese from those who are not. Attachment was not related to weight loss post surgery.

     

Effect of cooled hyperbaric bupivacaine on unilateral spinal anesthesia success rate and hemodynamic complications in inguinal hernia surgery

Purpose

We hypothesized that cooling hyperbaric bupivacaine from 23 to 5 °C may limit the intrathecal spread of bupivacaine and therefore increase the success rate of unilateral spinal anesthesia and decrease the rate of hemodynamic complications.

Methods

A hundred patients scheduled for elective unilateral inguinal hernia surgery were randomly allocated to receive 1.8 ml of 0.5 % hyperbaric bupivacaine intrathecally at either 5 °C (group I, n = 50) or at 23 °C (group II, n = 50). Following spinal block at the L2-3 interspace, the lateral decubitus position was maintained for 15 min. Unilateral spinal anesthesia was assessed and confirmed at 15 and 30 min. The levels of sensory and motor block on the operative side were evaluated until complete resolution.

Results

The rate of unilateral spinal anesthesia at 15 and 30 min was significantly higher in group I (p = 0.015 and 0.028, respectively). Hypotensive events and bradycardia were significantly rarer in group I (p = 0.014 and 0.037, respectively). The density and viscosity of the solution at 5 °C was significantly higher than at 23 °C (p < 0.0001). Compared with group II, sensory block peaked later in group I (17.4 vs 12.6 min) and at a lower level (T9 vs T7), and two-segment regression of sensory block (76.4 vs 84.3 min) and motor block recovery was shorter (157.6 vs 193.4 min) (p < 0.0001).

Conclusions

Cooling of hyperbaric bupivacaine to 5 °C increased the density and viscosity of the solution and the success rate of unilateral spinal anesthesia, and decreased the hemodynamic complication rate.

     

UltraPro Hernia System,Prolene Hernia System and Lichtenstein for primary inguinal hernia repair: 3-year outcomes of a prospective randomized controlled trial

Purpose

Chronic pain and discomfort are common after inguinal hernia repair (IHR). In this study, results from a 3-year follow-up from a randomized controlled study comparing three different mesh repairs for postoperative pain, discomfort, Quality of Life (QoL) and patient satisfaction are reported.

Methods

Between November 1, 2006 and January 31, 2009, 309 men, who underwent day surgery for primary unilateral inguinal hernia under local anesthesia, were randomized to three different mesh repairs; UltraPro Hernia System (U), Prolene Hernia System (P) and Lichtenstein procedure (L).

Results

Preoperatively, there were no differences between groups regarding demographics, symptoms, inguinal pain or QoL (SF-36 and a hernia-specific questionnaire). Operating time, postoperative pain, complications and time to full recovery were similar. At 36 months, 21 patients indicated pain [L, n = 6, P, n = 6 and U, n = 9; VAS (median (IQR)): L 0.4 (0.2–1.7), P 0.2 (0.1–2.3) and U 1.6 (0.7–4.6), p = ns]. Physical QoL was reduced in all groups before surgery and was similarly increased to normal levels after 3 months without further changes throughout the study. Although 92 % of participants were satisfied, sixteen percent reported any discomfort from the groin (ns between groups). Five recurrences were reported (L, n = 2, P, n = 1 and U, n = 2, p = ns).

Conclusions

After 3 years of follow-up, all three procedures provided equally good results regarding, pain, discomfort and QoL and could therefore be recommended for primary IHR in LA.

     

Comparative study of high tibial osteotomy using dynamic axial fixator and locked low-profile plate in medial osteoarthritis of knee

Purpose

The purpose of this study was to evaluate the role of medial opening wedge high tibial osteotomy (HTO) in medial unicompartmental osteoarthritis (MCOA) of knee and to compare between the two methods of osteotomy using either dynamic axial fixator (DAF) or locking compression plate (LCP).

Methods

A total of 20 patients with medial osteoarthritis of knee were enrolled in this prospective study who were divided into two groups of 10 each. First group comprising of two males and eight females were treated by HTO using DAF. Second group comprising of five males and five females were treated by HTO using LCP. We assessed various radiological parameters including hip knee ankle angle (HKA), tibiofemoral angle (TFA), weight-bearing line on tibia, Insall Salvati index and tibial slope. Functional outcome of knee at final follow-up was assessed by Oxford knee score (OKS) and visual analogue scale.

Results

In first group, mean HKA angle changed from 187° to 178.30° (p = 0.006), mean TFA from 182.40° to 172° (p = 0.003), average position of weight-bearing line from 11.24 to 59.54 % (p = 0.004), and mean OKS 43.3–16.9 (p = 0.004). In second group, mean HKA angle changed from 186° to 178.80° (p = 0.004), mean TFA from 180.90° to 173.60° (p = 0.004), average position of weight-bearing line from 14 to 61.3 % (p = 0.004), and mean OKS 43.2–16.5 (p = 0.002).

Conclusion

HTO is an established treatment for patients with symptomatic MCOA knee with significant improvement in the clinical and radiographic parameters. There is no significant difference between the two methods; however, external fixator has the complication of pin tract infections.

Level of evidence

II.

     

Feasibility of the liver-first approach for patients with initially unresectable and not optimally resectable synchronous colorectal liver metastases

Purpose

To investigate the outcomes of patients with colorectal cancer and initially unresectable or not optimally resectable liver metastases, who were treated using the liver-first approach in the era of modern chemotherapy in Japan.

Methods

We analyzed and compared data retrospectively on patients with asymptomatic resectable colorectal cancer and initially unresectable or not optimally resectable liver metastases, who were treated either using the liver-first approach (n = 12, LF group) or the primary-first approach (n = 13, PF group).

Results

Both groups of patients completed their therapeutic plan and there was no mortality. Postoperative morbidity rates after primary resection and hepatectomy, and post-hepatectomy liver failure rate were comparable between the groups (p = 1.00, p = 0.91, and p = 0.55, respectively). Recurrence rates, median recurrence-free survival since the last operation, and 3-year overall survival rates from diagnosis were also comparable between the LF and PF groups (58.3 vs. 61.5 %, p = 0.87; 10.5 vs. 18.6 months, p = 0.57; and 87.5 vs. 82.5 %, p = 0.46, respectively).

Conclusions

The liver-first approach may be an appropriate treatment sequence without adversely affecting perioperative or survival outcomes for selected patients.

     

Oxidative stress markers in type 2 diabetes patients with diabetic nephropathy

Background

Epidemiological studies show that 5–40 % of type 2 diabetes (T2DM) patients have diabetic nephropathy, and oxidative stress is one of several underlying mechanisms. We investigated associations between oxidative stress markers and severity of diabetic nephropathy.

Methods

Fifty-nine T2DM patients from the endocrinology outpatient department were included, and their levels of oxidative stress markers were measured. Three groups were determined by their urine albumin-to-creatinine ratio (UACR): group A (UACR < 30 mg/g, n = 22); group B (30 ≤ UACR < 300 mg/g, n = 22); and group C (UACR ≥ 300 mg/g, n = 15).

Results

Vitamin C levels correlated negatively and moderately with serum creatinine (γ = ?0.459, p < 0.001), urine albumin (γ _s = ?0.458, p = 0.001) and UACR (γ _s = ?0.408, p = 0.001), but only weakly with hydroxy-2-deoxyguanosine (8-OHdG) and estimated glomerular filtration rate (eGFR). Vitamin C levels decreased as 8-OHdG, serum creatinine, albumin and UACR increased. T2DM patients with more severe diabetic nephropathy had lower vitamin C levels.

Conclusion

Our results identified several oxidative stress markers that may be clinically important in diabetic nephropathy. Studies with larger sample sizes should be undertaken to confirm these findings.

     

Comparison of pain management after laparoscopic distal gastrectomy with and without epidural analgesia

Purpose

The optimal analgesia following laparoscopic distal gastrectomy (LDG) has not been determined; moreover, it has been unclear whether epidural anesthesia has benefits for laparoscopic surgery. In this study, we evaluated the effectiveness of epidural analgesia after LDG.

Methods

This retrospective study included 84 patients who underwent LDG for gastric cancer. Patients received either combined thoracic epidural and general anesthesia (Epidural group, n = 34) or general anesthesia alone (No epidural group, n = 50). We recorded data on the patients, surgery, postoperative outcomes and anesthesia-related complications.

Results

In the Epidural group, the first day of flatus was significantly earlier (2.21 vs. 2.44 days, p = 0.045) and the number of additional doses of analgesics was significantly lower (2.85 vs. 4.86 doses, p = 0.007) than in the No epidural group. Postoperative urinary retention occurred at a significantly higher rate in the Epidural group (n = 7; 20.6 %) than in the No epidural group (p < 0.001).

Conclusion

Epidural anesthesia may reduce the need for additional analgesics after LDG, but increases the risk of urinary retention.

     

Population-based normative data for the Scoliosis Research Society 22r questionnaire in adolescents and adults,including a comparison with EQ-5D

Purpose

The Scoliosis Research Society (SRS) 22r questionnaire is a widely used instrument. To estimate the disorder´s impact on quality of life and to gain knowledge about treatment effects, normative values are needed.

Methods

Individuals were randomly invited from the general population. 272 individuals (145 females) answered the SRS-22r and EuroQol 5-dimensions (EQ-5D) questionnaires and stratified according to sex and age; ≤19 years (n = 61), 20–39 years (n = 66), 40–59 years (n = 84) and ≥60 years (n = 61). The correlation between SRS-22r and EQ-5D were analyzed.

Results

There were modest variations in mean SRS-22r scores (ranging between 4.3 and 4.7). EQ-5D followed the same pattern. The correlation between the SRS-22r was 0.62 (p = 0.001) and 0.61 (p < 0.001) for the EQ-5D UK tariff and EQ-5D Swedish tariff, respectively.

Conclusion

We provide the first SRS-22r normative data for adolescents and adults overall. We found a good correlation between SRS-22r and EQ-5D in individuals without spinal deformity.

     

Cadaveric assessment of a 3D-printed aiming device for implantation of a hinged elbow external fixator

Introduction

Proper implantation of a hinged external elbow fixator (HEEF) is demanding since it requires precise alignment between the flexion–extension’s and HEEF’s axis. In order to optimize this alignment, we have developed a 3D-printed aiming device. The primary goal of the study was to compare the aiming device-based technique with the conventional pin technique. The secondary goal was to determine whether it is possible to share the aiming device with the surgical community.

Materials and methods

A HEEF was implanted in cadavers with either the aiming device (n = 6) or the conventional pin technique (n = 6). For both techniques the duration of the procedure, the radiation exposure as well as the offset and angular divergence between the HEEF’s and flexion–extension’s axis were compared. To achieve the secondary goal, two surgeons used aiming devices 3D-printed from files sent by email in order to implant HEEF on cadaveric specimens (n = 6).

Results

Duration of the procedure was not significantly different between both techniques. However, the aiming device allowed for reduction of the number of image intensifier shots (p = 0.005), angular divergence (p = 0.02) and offset between both axes (p = 0.05). The aiming devices have been delivered less than 15 days after ordering, and they have allowed proper implantation of six HEEF.

Conclusion

The 3D-printed aiming device allowed less irradiant and more accurate implantation of HEEF. It is possible to share it with other surgeons.

     

Robotic versus laparoscopic left lateral sectionectomy of liver

Background

A few studies have reported only short-term outcomes of various robotic and laparoscopic liver resection types; however, published data in left lateral sectionectomy (LLS) have been limited. The aim of this study was to compare the long- and short-term outcomes of robotic and laparoscopic LLS.

Methods

We retrospectively compared demographic and perioperative data as well as postoperative outcomes of robotic (n = 12) and laparoscopic (n = 31) LLS performed between May 2007 and July 2013. Resection indications included malignant tumors (n = 31) and benign lesions (n = 12) including intrahepatic duct (IHD) stones (n = 9).

Results

There were no significant differences in perioperative outcomes of estimated blood loss, major complications, or lengths of stay, but operating time was longer in robotic than in laparoscopic LLS (391 vs. 196 min, respectively) and the operation time for IHD stones did not differ between groups (435 vs. 405 min, respectively; p = 0.190). Disease-free (p = 0.463) and overall (p = 0.484) survival of patients with malignancy did not differ between groups. The 2- and 5-year disease-free survival rates were 63.2 and 36.5 %, respectively. However, robotic LLS costs were significantly higher than laparoscopic LLS costs ($8183 vs. $5190, respectively; p = 0.009).

Conclusions

Robotic LLS was comparable to laparoscopic LLS in surgical outcomes and oncologic integrity during the learning curve. Although robotic LLS was more expensive and time intensive, it might be a good option for difficult indications such as IHD stones.

     

Is there a link between the neutrophil-to-lymphocyte ratio and venous thromboembolic events after knee arthroplasty? A pilot study

Background

This study aimed to identify (1) if the postoperative increase in the neutrophil-to-lymphocyte ratio (NLR) is different between contrasting knee arthroplasty procedures, and (2) if the NLR predicts venous thromboembolism (VTE) after total knee arthroplasty (TKA).

Materials and methods

To address the first objective, we retrospectively studied patients who underwent primary unilateral TKA (n = 111) or unicompartmental knee arthroplasty (UKA; n = 74) between 2009 and 2012. Patients who required a blood transfusion, underwent autologous blood salvage, experienced any postoperative complication (such as VTE), or were re-admitted >90 days were excluded from analysis. For the second objective, we retrospectively identified patients (cases, n = 10) who underwent primary unilateral TKA between 2010 and 2012 and developed postoperative VTE (deep venous thrombosis, pulmonary embolism, or both) during inpatient care (postoperative day 1 or day 2). Cases were matched to surgeon, gender, body mass index, age, and date of surgery controls (n = 20) who underwent primary unilateral TKA without developing VTE before patient discharge. The NLR was calculated from the neutrophil and lymphocyte counts extracted from pre- and postoperative (day 1 and day 2) blood chemistry records.

Results

On postoperative day 1, the NLR increase was exacerbated (p = 0.02) following TKA compared to UKA and predicted (p = 0.02) the occurrence of VTE in TKA patients prior to hospital discharge.

Conclusion

We conclude that the NLR increase is greater following TKA compared to UKA and could serve as a matrix to predict or identify a patient susceptible of sustaining VTE after TKA.

Level of evidence

3.

     

Partial nephrectomy versus ablative therapy for the treatment of renal tumors in an imperative setting

Purpose

To compare partial nephrectomy (PN) and percutaneous ablative therapy (AT) for renal tumor in imperative indication of nephron-sparing technique (NST).

Materials and methods

Between 2000 and 2015, 284 consecutive patients with a kidney tumor in an imperative indication of NST were retrospectively included in a multicenter study. PN [open (n = 146), laparoscopic (n = 9), or robotic approach (n = 17)] and AT [radiofrequency ablation (n = 104) or cryoablation (n = 8)] were performed for solitary kidney (n = 146), bilateral tumor (n = 78), or chronic kidney disease (CKD) (n = 60).

Results

Patients in the PN group had larger tumors and a higher RENAL score. There were no differences between the two groups with respect to age, reasons for imperative indication, and preoperative eGFR. Patients in the AT group had a higher ASA and CCI. PN had worse outcomes than AT in terms of transfusion rate, length of stay, and complication rate. Local radiological recurrence-free survival was better for PN, but metastatic recurrence was similar. Percentage of eGFR decrease was similar in the two groups. Temporary or permanent dialysis was not significantly different. On multivariate analysis, PN and AT had a similar eGFR change when adjusted for tumor complexity, reason of imperative indication and CCI.

Conclusion

In imperative indication of nephron-sparing treatment for a kidney tumor, either PN or AT can be proposed. PN offers the ability to manage larger and more complex tumors while providing a better local control and a similar renal function loss.

     

Risk factors for prolapse recurrence: systematic review and meta-analysis

Introduction and hypothesis

Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10–20%. Prolapse procedures are known to have a high reoperation rate. It is assumed that etiological factors for POP may also be risk factors for POP recurrence after surgery. There are few reviews available evaluating risk factors for prolapse and recurrence or recently updated meta-analysis on this topic. Our aim was to perform a systematic review and quantitative meta-analysis to determine risk factors for prolapse recurrence after reconstructive surgery.

Methods

Four electronic databases (MEDLINE, PubMed, EMBASE, and Google Scholar) were searched between 1995 and 1 January 2017, with no language restrictions.

Results

Twenty-five studies met inclusion criteria for a total of 5082 patients with an average recurrence rate of 36%. Variables on which a meta-analysis could be performed were body mass index (BMI) (n = 12), age (n = 11), preoperative stage (n = 9), levator avulsion (n = 8), parity (n = 8), constipation/straining (n = 6), number of compartments involved (n = 4), prior hysterectomy (n = 4), familiy history (n = 3), and several other predictors evaluated in only three studies. The following meta- analyses identified significant predictors: levator avulsion [odds ratio (OR) 2.76, P <?0.01], preoperative stage 3–4 (OR 2.11, P <?0.001), family history (OR 1.84, P = 0.006), and hiatal area (OR 1.06/cm², P = 0.003).

Conclusions

Levator avulsion, prolapse stage, and family history are significant risk factors for prolapse recurrence.

     

A cohort study of the morbidity of combined anterior-posterior cervical spinal fusions: incidence and predictors of postoperative dysphagia

Purpose

To identify risk factors that may lead to the development of dysphagia after combined anterior and posterior (360°) cervical fusion surgery.

Methods

A single center, retrospective analysis of patients who had same-day, 360° fusion at Henry Ford Hospital between 2008 and 2012 was performed. Variables analyzed included demographics, medical co-morbidities, levels fused, and degree of dysphagia.

Results

The overall dysphagia rate was 37.7 %. Patients with dysphagia had a longer mean length of stay (p < 0.001), longer mean operative time (p < 0.001), greater intraoperative blood loss (p = 0.002), and fusion above the fourth cervical vertebra, C4, (p = 0.007). There were no differences in the rates of dysphagia when comparing patients undergoing primary or revision surgery (p = 0.554).

Conclusion

Prolonged surgery and fusion above C4 lead to higher rates of dysphagia after 360° fusions. Prior anterior cervical fusion does not increase the risk of dysphagia development.

     

Massive Weight Loss Obtained by Bariatric Surgery Affects Semen Quality in Morbid Male Obesity: a Preliminary Prospective Double-Armed Study

Objectives

The aim of this study is to evaluate the effect of massive weight loss on the seminal parameters at 6 months from bariatric surgery.

Design

Two-armed prospective study performed in 31 morbidly obese men, undergoing laparoscopic roux-en-Y-gastric bypass (n = 23) or non-operated (n = 8), assessing sex hormones, conventional (sperm motility, morphology, number, semen volume), and non-conventional (DNA fragmentation and seminal interleukin-8), semen parameters, at baseline and after 6 months from surgery or patients’ recruitment.

Results

In operated patients only, a statistically significant improvement in the sex hormones was confirmed. Similarly, a positive trend in the progressive/total sperm motility and number was observed, though only the increase in semen volume and viability was statistically significant (Δ = 0.6 ml and 10%, P < 0.05, respectively). A decrease in the seminal interleukin-8 levels and in the sperm DNA fragmentation was also present after bariatric surgery, whereas these parameters even increased in non-operated subjects. Age-adjusted multivariate analysis showed that the BMI variations significantly correlated with the changes in the sperm morphology (β = ?0.675, P = 0.025), sperm number (β = 0.891, P = 0.000), and semen volume (r = 0.618, P = 0.015).

Conclusion

The massive weight loss obtained with bariatric surgery was associated with an improvement in some semen parameters. The correlations found between weight loss and semen parameter variations after surgery suggest that these might occur early downstream of the testis and more slowly than the changes in the sex hormones.

     

Tube Thoracostomy Complications Increase Cost

Background

Tube thoracostomy (TT) can be an effective therapy for thoracic pathologies. Ineffective placement of TT is common and associated with significant complications. Complications require additional interventions to repair damaged tissues or replace dysfunctional TT. We hypothesize that complicated TT insertion increases cost to the hospital system.

Methods

Adult trauma patients requiring TT at a level 1 trauma center (2012–2013) were reviewed. Intraoperative or image-guided TT placements were excluded. Baseline demographics and TT insertion cost (normalized and assigned by hospital billing records) were recorded. Costs included initial TT equipment, radiographs, and subsequent operative or radiologic intervention to correct TT complications. Complications were categorized using previously validated method. Secondary outcomes included: number of TT inserted, number of chest radiographs performed, and TT dwell time utilizing a standardized TT discontinuation protocol.

Results

A total of 154 patients with 246 TT were included. Ninety TT (37%) had complication. Complication categories are postremoval (n = 15, 16.7%), insertional (n = 13, 14.4%), positional (n = 62, 68.9%). Overall median complicated TT cost was 9 times greater than uncomplicated TT insertion, p = 0.001. Insertional complications median cost 21 times greater than an uncomplicated, due to operative and radiologic interventions (p = 0.0001). Positional and postremoval complication rates increased median cost by 3 times compared to uncomplicated TT (p = 0.03). Operative or radiologic interventions (n = 10) were performed for organ injury or uncontrolled hemo-/pneumothorax. Increased dwell time median [IQR] was associated with complicated TT compared to uncomplicated 3 [1–5] versus 2 [1–3], p = 0.01.

Conclusion

TT is a common procedure. TT complications are often considered benign. However, patients with a complicated TT insertion, especially related to insertional subtypes, have markedly increased hospitalization costs due to need for operative or radiologic repair.

Level of evidence

Level V—retrospective study.

Study type

This is a retrospective single-institution study.

     

Postoperative changes after surgical mesh hernia repair: a pitfall in interpretation of 18F-FDG PET-CT

Objective

A number of case reports have demonstrated FDG uptake around mesh prostheses after hernia repair surgery. This study characterizes FDG PET-CT findings after hernia repair with synthetic mesh in a series of cancer patients.

Materials and methods

FDG PET-CT studies were reviewed for increased FDG uptake consistent with CT appearances of post-surgical hernia repair in cancer patients. The findings were correlated with clinical data and follow-up studies.

Results

53 PET-CT studies in 22 patients (18 males, 31–79 years) were identified. Surgery for repair of inguinal (n = 14), ventral (n = 5) or umbilical (n = 3) hernia was performed, 4–204 months prior to PET-CT. FDG avidity was focal or linear in the region of the anterior abdominal or pelvic wall (mean SUV max 4.0 ± 2.3). Corresponding nonspecific CT findings included soft tissue thickening (n = 18), fat infiltration (n = 20) and fluid collection (n = 19) in the region of the omentum, adjacent to or in the inner abdominal or pelvic wall at the surgical site. Linear hyper-dense structures (n = 9) or metallic clips (n = 8) seen on CT suggested benign postoperative changes. In 10/12 (83.3%) patients with repeat PET-CT, FDG uptake remained unchanged, one showed more diffuse uptake and another showed reduced uptake on follow-up. There was neither significant change in CT appearance at the surgical site in these 12 patients, nor in 3 additional patients with only CT follow-up. Another 3 patients had previous CT demonstrating hernia at the same location.

Conclusion

With increasing use of synthetic mesh, awareness of variations in FDG PET-CT appearance is important to avoid false interpretation in cancer patients.