Does the Presence of Abscesses in Diverticular Disease Prelude Surgery?

Background

Information on long-term outcome of patients treated conservatively for diverticular abscess is scarce. This study aims to compare diverticulitis patients with abscess to patients without abscess with regard to readmission, complications, and surgical treatment during a follow-up period of at least 12 months.

Methods

A chart review of all patients admitted for a primary manifestation of diverticulitis between January 2005 and January 2011 was performed.

Results

Fifty-nine patients with abscess and 663 without abscess were identified. Median follow-up was 28 months (range 12–103). Initial conservative management was achieved in 54 (91.5 %) patients with diverticular abscess and 635 (96.8 %) without abscess. Readmission occurred more frequently among patients with abscess (hazard ratio (HR) 2.6; confidence interval (CI) 1.51–4.33) with a first-year risk of 27.3 versus 10.7 % and second-year risk of 8.2 versus 4.6 %. Surgery was more frequently performed in patients with diverticular abscess (HR 2.3; CI 1.42–3.66). The first-year risk was 35.1 versus 16.6 % and second-year risk was 12.9 versus 2.4 %. The most frequent indication for surgery was persisting or recurrent disease.

Conclusion

Patients with diverticular abscess have a higher risk of being readmitted and/or requiring surgical treatment. The pattern suggests that readmission and need for surgery are the results of an ongoing inflammation of the initial episode.     

Does transitional zone pull-through in Hirschsprung's disease imply a poor prognosis?

Purpose: Accurate frozen section interpretation of intraoperative biopsies is critical to the success of the Duhamel procedure. Errors during sampling or interpretation may result in an abnormal pull-through. The authors’ aim was to determine the incidence and outcome of transitional zone pull-through (TZPT).Methods: Ninety-six children who underwent a Duhamel procedure between January 1987 and May 2002 were followed up prospectively. The outcome of 18 children with TZPT was compared statistically with that of a cohort of 58 patients with a ganglionic pull-through.Results: The incidence of TZPT was 18.8%. Concordance rate between frozen and paraffin-section analyses was 88.5%. The incidence of enterocolitis (P = .003) and intractable constipation (P = .02) was found to be significantly higher in TZPT. There was no significant difference in continence (P = .34), rectal sensation (P = .35), and control (P = .53). Five (27.8%) TZPT patients required a revisional surgery for failure of conservative management. The incidence of stoma placement and revision was significantly less in the ganglionic group (3.4%, P = .007).Conclusions: Up to one third of patients with TZPT will require revisional surgery for intractable symptoms. Vigilance is warranted in view of the greater risk of enterocolitis. Continence is not significantly affected.     

Does Hyperthermia Induce Peritoneal Damage in Continuous Hyperthermic Peritoneal Perfusion?

To investigate the mechanisms of the peritoneal damage induced by continuous hyperthermic peritoneal perfusion (CHPP), protein and fluid loss during and after CHPP and continuous normothermic peritoneal perfusion (CNPP) was studied. Sixteen patients with advanced gastric cancer underwent peritoneal perfusion therapy with saline solution containing 150 to 300 mg cisplatin and 30 to 60 mg mitomycin C for 60 minutes. The temperature in Douglas' pouch was maintained at 42.0°C in the CHPP group (n= 9) and 37.0°C in the CNPP group (n= 7) during perfusion. No statistical differences were found in patients' characteristics between the groups except the maximum temperature in Douglas' pouch during perfusion (41.6°± 0.4°C and 37.6°± 0.4°C in CHPP and CNPP groups, respectively, p < 0.05). The amount of protein lost into the perfusate was 0.35 ± 0.22 g/kg body weight in the CHPP group and 0.37 ± 0.19 g/kg in the CNPP group, showing no significant difference. On the day of surgery, there was no significant difference in the amount of protein and fluid lost through the abdominal drains between the CHPP group (27.9 ± 24.6 mg/kg/hr and 0.94 ± 0.63 ml/kg/hr, respectively) and the CNPP group (25.9 ± 8.6 mg/kg/hr and 1.03 ± 0.31 ml/kg/hr, respectively). We could not find any significant differences in postoperative protein and fluid loss between the groups on the following 3 days either. We conclude that the peritoneal damage by CHPP is not caused by the hyperthermia but by the peritoneal perfusion with saline solution containing anticancer drugs.     

How Does the Level of Nerve Root Resection in En Bloc Sacrectomy Influence Patient-Reported Outcomes?

Background

For patients with sacral tumors, who are well enough for surgery, en bloc resection is the preferred treatment. Survival, postoperative complications, and recurrent rates have been described, but patient-reported outcomes often are not included in these studies.

Questions/purposes

The purposes of this study were (1) to compare patient-reported outcomes after en bloc sacrectomy, based on the level of sacral nerve root resection, in terms of mental health, physical health, bowel function, and sexual function; and (2) to assess differences in terms of mental health, physical health, and pain between patients with and without a colostomy.

Methods

A total of 74 patients, of whom 58 (78%) were diagnosed with chordoma, were surveyed between February 2012 and October 2014. This represented 48% of patients with sacral chordoma who were alive and who had been treated with a transverse sacral resection between June 2000 and August 2013 at three institutions with a minimum followup of 6 months (mean, 59 months; range, 6–255 months). We chose 6 months because we believe that neurologic deficits generally are stable by this point and that patients generally have recovered from the operation by this time. Patients were divided into five groups based on the most caudal nerve root spared: L5 (N = 10), S1 (N = 22), S2 (N = 17), S3 (N = 18), and S4 (N = 7). Only postoperative outcomes were collected using the National institute of Health’s Patient Reported Measurement Information System (PROMIS) Global Health survey, PROMIS Pain Interference survey, PROMIS Pain Intensity survey, PROMIS Sexual Function survey, and the Modified Obstruction and Defecation Score survey.

Results

Differences between two adjacent levels were found in terms of mental health, physical health, and sexual function. Patients in whom the S2 nerve roots were spared had a lower mental health score (median = 44, interquartile range [IQR] = 41–51) than patients in whom the S3 nerve roots were spared (median = 53, IQR = 48–56, q = 0.049). Patients in whom the S2 nerve roots were spared had a slightly lower physical health score (median = 42, IQR = 40–51) than patients in whom the S3 nerve roots were spared (median = 47, IQR = 45–54, q = 0.043). Patients in whom the S1 roots were spared (median = 1.0, range = 1.0–1.0) had a lower orgasm score than patients in whom the S2 nerve roots were spared (median = 3, range = 2–5, q = 0.027). No differences in terms of mental health, physical health, or pain were found between the colostomy group and the no colostomy group.

Conclusions

The combination of our findings can be used to further educate patients and discuss expectations. In an operative setting, these data can be considered when deciding to place a colostomy.

Level of Evidence

Level III, therapeutic study.

     

Poor Hormone Receptor Expression in East African Breast Cancer: Evidence of a Biologically Different Disease?

Background  Few studies have examined breast cancer hormone receptor expression in Africans. We report on the hormone receptor profile of breast cancer in East Africans in the largest prospective study for this region. Methods  Consecutive breast cancer presentations to a hospital in Kijabe (2001–2007) were included. Demographic, clinical, and test data were collected. ER/PR and Her2 testing was based on immunohistochemistry (IHC). Results  There were 129 subjects (median 47 years), most had invasive ductal cancer and locally advanced disease and/or metastases. ER/PR testing was done in 120: 24% had ER-positive tumours, 34% were ER- and/or PR-positive, 10% were ER-negative but PR-positive tumours, and 66% were negative for ER and PR. ER/PR positivity was not associated with stage (P = 0.28) and was not related to age, parity, menopausal status, or node metastases. Increasing tumour grade was associated with PR expression (P = 0.02) with decreasing frequency of PR positive tumours as histological grade increased; there was weak evidence of an association between grade and ER expression (P = 0.06). Of cases tested, 26.5% overexpressed Her2. Conclusions  Breast cancer in Kijabe is an advanced-stage disease, comprised mainly of poorly differentiated cancers that are less likely to be hormone sensitive (across all stages of disease). ER/PR testing of all those affected by breast cancer should be supported as a global priority in cancer control. International and inter-African research collaborations are needed to allow genetic detailing of tumours in indigenous Africans to assess possible racial heterogeneity in the biology of breast cancer.     

Does Radial Styloid Abnormality in de Quervain’s Disease Affect the Outcome of Management?

Radiological changes have been described in de Quervain’s disease of the wrist. The author analyzed the clinical data of 114 patients who reported to the orthopedic clinic of a Regional Referral Hospital for a period of 4 years [2003 to 2007]. Radiographs of the wrist were available for 39 cases, of which 14 [35.89%] were found abnormal. Two patients with abnormal radiographs [14.28%] required surgery where as 7 out of 25 [28%] with normal radiographs were managed surgically. Radial styloid abnormality was not found statistically significant [p < 0.05], and the outcome of management was irrespective of the changes in the radial styloid.     

Positive anterior margins in breast conserving surgery: Does it matter? A systematic review of the literature

Positive margins are associated with an increased risk of ipsilateral breast tumor recurrence (IBTR); therefore re-excision of positive margins is recommended. Involvement of anatomically non-breast margins, such as anterior margins, has been associated to a lower risk of IBTR than radial margins. Although many surgeons do not re-excise positive anterior margins (PAM); there is no consensus regarding this approach. The objective of this study is to find evidence that assesses this practice.A systemic literature review was performed through six databases from January 1995 to July 2014. Studies that discussed anatomical location of involved margins in BCS were included.Six studies were identified evaluating PAM. One study reported a 2.5% rate of IBTR in patients with non-negative margins treated with radiotherapy (of which 23% had a PAM). Another study showed 4% of residual disease after re-excision of PAM, but did not report IBTR rates. A later observational study reported that 87.5% of positive anterior and posterior margins were re-excised. One survey from America and one from the UK showed that 47% and 71% of surgeons would not re-excise PAM, respectively. A later survey in the UK reported that 43.8% of surgeons would not re-excise PAM in DCIS, whilst 29.2% would not for invasive carcinoma.Common surgical practices to not re-excise PAM contradict current guidelines that recommend obtaining negative margins to reduce the risk of IBTR. However, there is little evidence detailing the relationship between PAM and IBTR rates. Low residual disease after re-excision of PAM supports the limited benefit of re-excise this margin; however further studies are required to evaluate this topic.     

Does Age or Bilateral Disease Influence the Value of Hip Arthroplasty?

Background  

Measuring value in medicine is an increasingly important issue as healthcare spending continues to rise and cost containment becomes even more important. However, value assessments can be affected by patient factors and comorbidities.     

Does Previous Head and Neck Irradiation Increase the Chance of Multigland Disease in Patients with Hyperparathyroidism?

Background  

Exposure to therapeutic radiation, whether used to treat lymphoma, breast cancer, or benign conditions, such as acne, is thought to cause an increased risk for thyroid and/or parathyroid neoplasia. We therefore investigated whether patients with a history of head/neck irradiation and hyperparathyroidism (HPT) had a higher incidence of multigland disease.     

Does Squatting Worsen Lower Limb Ischemia in Patients with Peripheral Arterial Disease?

Peripheral arterial disease (PAD) is an important cause of morbidity and mortality in the world affecting up to 20% in people over 70?years of age. The prevalence is increasing in India due to combined effects of increased life expectancy, increased tobacco smoking and increased prevalence of diabetes mellitus. The aim of the study was to examine the hypothesis whether squatting posture reduces blood flow to lower limbs resulting in worsening of symptoms of lower limb ischemia in patients with PAD. 10 patients with arterial disorders due to thromboangiitis obliterans (TAO), atherosclerosis and diabetic macro vascular disease were selected for patients and were compared with 10 healthy volunteers as controls. Clinical examination and duplex scan of posterior tibial artery (PTA) and dorsalis pedis artery (DPA) performed in standing and squatting position in a clinical environment. They were asked about symptoms of numbness, ischemic pain and the results were noted. Results were tabulated and analysed using Microsoft Excel?. Members in the control group complained of numbness of both the limbs after a period of 30?min on an average. In the patients group, members while squatting complained of numbness in the involved limb within 5?min. They complained of ischemic pain in the involved limb within 10?min and developed numbness in the opposite limb in within 15?min. Posterior tibial artery and dorsalis pedis artery pulsations disappeared for the entire duration of squatting in both groups as confirmed by duplex scanning. It may be recommended that patients with established peripheral vascular disease should avoid squatting position, even if it is for a very short period of time. It is desirable to advice such patients to use appropriate structures as supports which will allow them to work without squatting. This may also necessitate a change in occupation.     

Does Patellofemoral Disease Affect Outcomes in Contemporary Medial Fixed-Bearing Unicompartmental Knee Arthroplasty?

BackgroundPre-existing patellofemoral disease has traditionally been a contraindication to unicompartmental knee arthroplasty (UKA), as proposed by Kozinn and Scott. More recently, some propose that patellofemoral disease can be ignored in UKA; however, the supporting research is predominantly in mobile-bearing designs. The study purpose was to evaluate the effect of patellofemoral disease osteoarthritis severity on latest outcomes after fixed-bearing medial UKA.MethodsA retrospective review of 147 consecutive medial fixed-bearing UKAs with minimum 1-year follow-up was performed. The medial and lateral patellofemoral compartments were graded according to the Kellgren & Lawrence grading system, Osteoarthritis Research Society International atlas, and intraoperative assessment performed using the Outerbridge classification. Prospectively collected University of California Los Angeles Activity Level, modern Knee Society pain and function scores, and Likert scale satisfaction were correlated with presence and severity of pre-existing patellofemoral disease.ResultsOne hundred forty-three medial UKAs were analyzed with mean age, body mass index, and follow-up of 64.1 years, 30.7 kg/m², and 24.0 months, respectively. No correlations were observed between patellofemoral disease severity and patient-reported outcome measures at latest follow-up or improvement scores for Kellgren & Lawrence grading system or Osteoarthritis Research Society International atlas (P ≥ .058). Improvement in activity level scores was significantly higher for patients with less patellar and trochlear chondral damage despite not reaching minimal clinically important difference of 2.0 (P ≤ .028). Regardless of patellofemoral disease severity, 93% of UKAs were satisfied or very satisfied.ConclusionClinical outcomes of fixed-bearing medial UKA were not adversely impacted by intraoperatively visualized or radiographically evaluated patellofemoral disease. Furthermore, long-term follow-up is warranted and caution should be used before considering patellofemoral disease as a contraindication for UKA.