Factors influencing surgical decisions in chronic pilonidal sinus disease

Summary  BACKGROUND: Pilonidal sinus disease (PSD) may be present as chronic PSD, which may eventually exacerbate. Factors associated with the progression of chronic PSD to acute abscess-forming PSD were investigated. METHODS: Records of 1962 patients admitted to the surgical departments of three hospitals of the German Armed Forces between 1980 and 1996 with PSD were analyzed. RESULTS: Patients with chronic PSD showed higher sinus numbers (p < 0.001) and longer disease history (p < 0.001), while acute abscess-forming PSD was associated with smoking (p < 0.001). Surgeons were more likely to opt for primary wound closure when fewer sinus were present. Primary wound closure was similarly successful in chronic (67.2%) and acute (66.9%) PSD. Primary wound healing rate was negatively influenced by a high BMI in chronic PSD (p = 0.012). CONCLUSIONS: Early elective surgery in chronic PSD seems justified in patients presenting with a short duration of disease, low sinus number and smoking history.      

Comparison of the classic limberg flap and modified limberg flap in the treatment of pilonidal sinus disease: A retrospective analysis of 416 patients

Purpose  

Pilonidal sinus disease (PSD) is usually seen on the sacrococcygeal region in adolescent patients. The current study analyzed the outcome of the rhomboid excision and the Limberg flap procedure (cLF) in comparison to the modified Limberg flap procedure (mlF) for PSD.     

Peritoneal Surface Disease from Colorectal Cancer: Comparison with the Hepatic Metastases Surgical Paradigm in Optimally Resected Patients

Background  Surgical resection is the treatment of choice for colorectal hepatic metastases (HM). In contrast, metastatic disease to the peritoneum is treated with systemic therapy. We examined our experience with cytoreductive surgery (CS) and intraperitoneal hyperthermic chemotherapy (IPHC) for peritoneal surface disease (PSD) compared with liver resection for HM. Methods  A review of prospective databases of colorectal cancer patients undergoing surgery for metastatic disease to the peritoneum or liver (1992–2005) was carried out. Results  One hundred and twenty-one patients underwent CS + IPHC and 101 patients underwent hepatic resection with median follow-up of 86 and 56 months, respectively. Fifty-five (45%) patients in the IPHC group had complete resection of all gross tumor. Ninety-five (94%) of the HM patients had negative surgical margins. Comparison of the R0/R1 PSD and margin-negative HM group demonstrated significant differences in age, performance status, and preoperative chemotherapy. The 1-, 3-, and 5-year overall survival for the R0/R1 PSD patients was 91, 48, and 26%; while it was 87, 59, and 34% for the HM patients (P = 0.32). Perioperative morbidity was 42% versus 34% (P = 0.38) and mortality was 5.5% versus 4.2% (P = 0.71) between the PSD and HM patients, respectively. Conclusion  R0/R1 resection during CS + IPHC compared with margin-negative hepatic resection demonstrated no significant difference in overall survival and for select patients should be considered a viable treatment option. Further studies to improve the resectability of PSD patients and define the role of neoadjuvant and adjuvant drug strategies are needed. Oral presentation at the Society of Surgical Oncology Annual Meeting, Chicago, IL, March 14, 2008.     

A simple formula for predicting diameter of safely inserted cortical bone trajectory screws for fixation of the lower lumbar spine

BackgroundCortical bone trajectory (CBT) screws are popular for spinal fixation, but their ideal diameter has not been determined. Studies using postoperative computed tomography (CT) have revealed ample bone marrow space around 5.5-mm screws, which are commonly used. However, evidence indicates that a larger screw diameter provides a greater fixation strength. This study aimed to develop a generalizable formula for computing the diameter of CBT screws that could be inserted safely for fixation of the lower lumbar spine.MethodsRecords of 44 consecutive patients who had undergone posterior fusion with CBT screws for single-level degenerative lumbar spondylolisthesis were retrospectively reviewed. We estimated the maximum diameter for conventional pedicle screws by the minimum diameter of the pedicle using preoperative CT (PSD). We measured the minimum endosteal diameter of the pedicle on the reconstructed plane of the postoperative CT which passed through the cannula used for the screw and estimated the maximum diameter for the CBT screws that could be inserted within the bone marrow space of the pedicle (CBTD).ResultsAmong the 176 pedicles measured, there were 151 (85.8%) with a PSD of 8.5 mm and 13, 7.5 mm. Because of a slight pedicle wall breach, 13 screws were excluded from the sample. There were 64 (39.3%) screws with a CBTD of 8.5 mm; 45, 7.5 mm; and 40, 6.5 mm. Of 163 screws, 156 (95.7%) had PSD minus CBTD ≤2 mm for each pedicle. PSD minus the minimum outer cortical diameter was ≤1 mm for each pedicle in 155 (95.1%) screws.ConclusionOur results show that CBT screws with a diameter 1 mm smaller than the endosteal diameter of the pedicle were inserted safely.StudyDesign: Clinical study.     

Dialogisches Rehabilitationsmanagement der VBG

Trauma und Berufskrankheit - In der Umsetzung des gesetzlichen Auftrags zur Heilverfahrensteuerung (§§26&nbsp;Abs.&nbsp;5, 34&nbsp;Abs.&nbsp;1&nbsp;SGB&nbsp;VII)...     

Beat‐to‐beat detection of aortic valve opening in HeartWare left ventricular assist device patients

Continuous flow left ventricular assist devices (cfLVADS) result in a significant reduction in aortic valve (AV) opening, which has been associated with several complications. Reliable monitoring of AV opening is needed to determine whether pump speed adjustment may be able to minimize adverse outcomes. We assessed AV status continuously by echocardiography for 4 minutes in 3 states in 18 HeartWare HVAD patients: 2 minutes at rest, and 1 minute each following Valsalva maneuver and supine leg‐raising. Using a previously described algorithm, beat‐to‐beat AV status was compared with the area under the curve of the normalized power spectral density analysis (PSD‐AUC) for the corresponding beats of the pump speed waveform. Five thousand five hundred twenty‐seven beats were analyzed. AV opening varied between 0% and 100% for the cohort with the median AV opening frequency 21.5%, and median duration of opening of 124 msec (range 0–279). The receiver operating characteristic (ROC) curve area for AV opening by the PSD‐AUC algorithm was 0.95 (P < 0.0001). A PSD‐AUC cut‐off of 0.82 distinguished between an open and closed AV with 86% sensitivity and 93% specificity. Accuracy was similar in regular cardiac rhythm, atrial fibrillation or with frequent ventricular ectopic beats. Valsalva maneuver and leg‐raising had no impact on accuracy. The PSD‐AUC was strongly predictive of AV opening duration (P < 0.0001). We found that AV status and opening duration can be determined with high accuracy on a beat‐to‐beat basis irrespective of cardiac rhythm and with low level exercise and changes in filling.     

Correction to: Interleukin 6 is a better predictor of 5-year cardiovascular mortality than high-sensitivity C-reactive protein in hemodialysis patients using reused low-flux dialyzers

International Urology and Nephrology - The article “Interleukin 6 is&nbsp;a&nbsp;better predictor of&nbsp;5-year cardiovascular mortality than&nbsp;high-sensitivity C-reactive...     

Awake craniotomy in a super obese patient using high flow nasal cannula oxygen therapy (HFNC)

Die Anaesthesiologie - Super obesity with a&nbsp;body mass index (BMI) &gt;50&nbsp;kg/m2 presents a&nbsp;challenge for the neuroanesthesiologist during awake craniotomy procedures...     

Outcomes of arteriovenous fistula in elderly patients on maintenance haemodialysis

International Urology and Nephrology - The optimal vascular&nbsp;access strategy in elderly patients receiving haemodialysis (HD)&nbsp;remains controversial. We aim to&nbsp;report the...     

Erratum zu: Infektionen durch multiresistente Erreger

Die Anaesthesiologie - Im ursprünglich veröffentlichten Beitrag wurden 3&nbsp;Antibiotikumdosierungen in Tab.&nbsp;1 falsch angegeben. Korrekt muss es in Tab.&nbsp;1...     

Good neurological outcome after accidental hyopthermia presenting with asytole

Die Anaesthesiologie - A&nbsp;43-year-old woman became exhausted and fainted on descent at 1127&nbsp;MAMSL altitude and snowfall. A&nbsp;rescue team diagnosed asystole. With manual...     

Abrechnung im niedergelassenen Bereich im Vergleich zur ambulanten Notfallbehandlung in der Notaufnahme unter besonderer Betrachtung von Laborleistungen

Notfall + Rettungsmedizin - Die Versorgung ambulanter Notfälle ist in Deutschland nach §&nbsp;75 Abs.&nbsp;1b SGB&nbsp;V durch die Kassenärztlichen Vereinigungen (KV) zu...     

Clinical Value of Immunohistochemically Detected Lymphovascular Space Invasion in Early Stage Cervical Carcinoma

Background  This study investigates the clinical significance of lymphovascular space invasion (LVSI) as detected by hematoxylin and eosin (LVSI-H&E) and immunohistochemistry (LVSI-IHC) in early stage cervical carcinoma. Methods  Single representative sections from 97 patients with early stage squamous cell cervical cancer were immunostained with pancytokeratin and CD31 endothelial cell marker antibodies. The H&E sections and their corresponding immunostained sections were reexamined to identify LVSI. Associations between LVSI with clinicopathological factors were sought. Results  Overall, LVSI was present in 29 (29.9%) and absent in 68 (70.1%) by IHC, as compared with 18 cases (18.6%) and 79 cases (81.4%), respectively, by H&E. Statistical analysis revealed a significant association between LVSI-H&E and nodal metastasis (P = .004). Follow-up data were available for 76 patients. The median follow-up period was 64 months. During follow-up, 7 of 24 patients with recurrent disease had evidence of LVSI-H&E as opposed to 3 of 52 cases with no recurrence. There was a significant association between tumor recurrence and LVSI-H&E (P = .009). The 5-year recurrence-free survival was 30% for the group with LVSI-H&E compared with 73% without. There was a significant difference in the recurrence-free survival between the two groups (P = .002). In contrast LVSI-IHC was found to be associated with no pathological factors, and survival analysis revealed no statistically significant association with recurrence or survival. Conclusion  LVSI-H&E in early stage cervical cancer remains an important predictive factor of recurrent disease and reduced disease-free interval. Immunohistochemically detected LVSI is a common event and seems to be of no clinical value.     

Kommentar zur aktualisierten S3-Leitlinie zur intravasalen Volumentherapie beim Erwachsenen

Die Anaesthesiologie - Die deutsche Leitlinie zur intravasalen Volumentherapie beim erwachsenen Patienten wurde –&nbsp;sechs Jahre nach ihrer Veröffentlichung&nbsp;– im...     

Persistent fibrinolysis shutdown is associated with increased mortality in traumatic pancreatic injury

PurposeThe features of fibrinolytic system modifications and their relationship with prognosis are still unknown in traumatic pancreatic injury. The object of this prospective cohort research was to identify fibrinolytic characteristics in patients with pancreatic trauma and to identify the correlation to mortality.MethodA prospective screening of traumatic pancreatic injury patients was done for five years. The fibrinolytic status of patients was determined by thromboelastography (TEG). The percentage reduction in clot strength 30 min (LY30) after the time of maximal clot strength was utilized to distinguish the fibrinolytic phenotype of individuals, including fibrinolytic shutdown (SD), physiologic fibrinolysis (PHYS) and hyperfibrinolysis (HF). Two cohorts, transient fibrinolytic shutdown (TSD) and persistent fibrinolytic shutdown (PSD), were divided according to whether fibrinolytic shutdown persisted within one week. Demographics, injury severity, characteristics of pancreatic injury, treatment, and outcomes were compared.ResultA total of 180 cases enrolled, aged 42(interquartile range 32–51) years, 88% males, 97% were blunt trauma. The median ISS was 19(IQR 10–25), and 76% were AAST grade III to V (high-grade). At admission, there were 159 cases of SD (88%), 15 cases of PHYS (8%) while 6 cases of HF (3%). Of these, the TSD cohort included 54 patients (34%), while the PSD cohort included 105 patients (66%). Compared with the TSD cohort, the PSD cohort had more severe injury (ISS 21[IQR 12–27] vs 16[IQR 9–22], p = 0.006) and a higher proportion of AAST high-grade (83% vs 67%, p = 0.035). Persistent fibrinolytic shutdown was associated with operative treatment (odds ratio [OR] 3.111; 95%CI 1.146–8.447; p = 0.026), associated intra-abdominal injury (OR 8.331; 95% CI 1.301–53.336; p = 0.025) and admission LY30 (OR 0.016; 95% CI 0.002 - 0.120; p < 0.001). It was an independent predictor of mortality (adjusted odds ratio [AOR] 4.674; 95% CI 1.03 to 21.14; p = 0.045).ConclusionFibrinolytic shutdown especially persistence of this phenotype is more common in traumatic pancreatic injury than PHYS and HF, which related with mortality. Risk factors including LY30 at admission, intra-abdominal injury and operative treatment were associated with the persistent fibrinolytic shutdown. Sheltered the patients from these risk factors seems to be beneficial, which need to be confirmed by further large-scale studies.     

Thoracoabdominal approach for traumatic diaphragmatic hernia in a hemodynamically unstable patient

European Surgery - Diaphragmatic hernias with strangulated contents are a&nbsp;surgical challenge. Thoracoabdominal incisions are commonly used for a&nbsp;variety of thoracic and vascular...     

Correction to: Deterioration of sagittal spinal alignment with age originates from the pelvis not the lumbar spine: a 4-year longitudinal cohort study

European Spine Journal - Unfortunately, figure&nbsp;3 was incorrectly published in the original publication. The complete correct figure&nbsp;3 is given below.     

Die Generationen Y und Z – Neue Herausforderungen für Führungskräfte im Krankenhaus

Die Anaesthesiologie - In dieser Studie wurden die Studierenden der Generationen&nbsp;Y und&nbsp;Z des Studiengangs Humanmedizin an der Georg-August-Universität Göttingen...     

Evaluation of anatomic landmarks and safe zones for screw placement in the atlas via the posterior arch

Several studies have evaluated quantitative anatomic data for direct lateral mass screw fixation. To analyze anatomic landmarks and safe zones for optimal screw placement through the posterior arc of the human atlas, morphometric parameters of 41 adult native human atlas specimens were quantitatively measured. Internal dimensions of the atlas (lateral mass, maximum and minimum intraosseous screw length), minimum height and width of the posterior arc and optimal screw insertion angles were defined on pQCT scans. By this, an optimal posterior screw insertion point (OIP) and a preferable screw direction (PSD) through the posterior arch into the lateral mass of C1 were defined. External dimensions (transverse and sagittal diameter) as well as the width of the mid-portion of C1 lateral mass were significantly higher in male specimens. The mean height of the posterior arch at the vertebral artery groove was 4.1 ± 0.8 mm in female and 4.6 ± 0.9 mm in male specimens. The optimal screw insertion point was located 21.6 ± 1.7 mm in female and 23.6 ± 2.3 mm in male lateral from the posterior tubercle of C1 (P < 0.01). The preferable screw direction was a mean medial inclination of 7.9 ± 1.9° in female and 7.3 ± 2.7° in male specimens and a mean rostral direction of 2.4 ± 1.8° in female and 3.1 ± 1.7° in male specimens. In conclusion, the presented study provides information for the use and design of upper cervical spine instrumentation techniques, such as screw placement to C1 via the posterior arch. The characterization of working areas and safe zones (OIP, PSD) might contribute to a minimization of screw malposition in this highly demanding instrumentation technique.     

Disparities in NCCN Guideline Compliant Care for Resectable Cholangiocarcinoma at Minority-Serving Versus Non-Minority-Serving Hospitals

Annals of Surgical Oncology - Racial/ethnic disparities in cancer outcomes may relate to variations in receipt of National Comprehensive Cancer Network (NCCN)&nbsp;guideline&nbsp;compliant...