Anesthesia in surgical treatment of pyo-necrotic forms of diabetic foot]

Examinations of 48 patients with the syndrome of "diabetic foot" (IV-V degree according to Wagner classification), have shown advantages of prolonged epidural anesthesia (EA) carried out during pre-, intra-, and postoperative (6-7 days) period. This method has relieved pain during postoperative period with minimal impact on carbohydrate metabolism and central hemodynamics. Moreover prolonged EA is a basic prophylactic method against the development of phantom painful syndrome in patients with amputated extremity. The prolonged postoperative EA is a reliable method for modification of surgical stress-response, being especially important in patient, afflicted with a severe form of diabetes mellitus who represent a high surgical and anesthesiological risk group.     

Reduction mammaplasty using superior pedicle in macromastia

SUBJECT: The authors present technical details, complications, morphologic and aesthetic results of 26 breast reduction mammaplasty for macromastia (breast reduction more than 1000 g) showing advantages and reliability of technique. MATERIALS AND METHODS: From January 2000 to December 2001, 223 patients underwent bilateral reduction mammaplasty with superior-based pedicled dermo-glandular flap. In 26 of them the weight of removed mammary tissue was over 1000 g in each breast. These 26 cases were evaluated, and the criteria adopted to analyse the results was morphologic and aesthetic evaluation of patient herself (very good, good, acceptable, unacceptable). RESULTS: Mean follow-up for all patients was 15 months. Twenty-six patients (mean age 33.2 years) underwent an average weight of 1131 g (930/2200 g) removed per breast. The following complications were observed: 1 Nipple Areolar Complex ischemia without necrosis; three infections (abscess); four delayed wound closure. The patient subjective evaluation of result was: "very good" in 19 cases (73%); "good" in 5 cases (19.2%) and "acceptable" in the others two cases (7.8%). No case was evaluated "unacceptable". CONCLUSION: Superior dermoglandular pedicle mammaplasty represent a very good and reliable solution for the treatment of macromastia, giving satisfactory cosmetics results with good nipple viability without necrosis. This technique is actually our first choice in the management of macromastia.     

Living donor kidney transplant in Italy: is the underutilization justified?

Living donor transplants (LDtx) represent an underutilized resource in Italy. It is, however, a therapeutic option that deserves greater consideration not only due to the increasing gap between the number of uremic patients on waiting lists (6956) and the number (1464) of cadaveric transplants (CADtx), as evidenced in 2002, but also due to the advantages of LDtx over CADtx. The superiority of LDtx include better graft survival, independent of the donor/recipient relationship, less need for dialytic treatment with preemptive transplants and reduced immunogenicity of the graft due to the brain death-related "cytokine storm." Moreover, some emerging procedures namely laparoscopic nephrectomy instead of open surgery and spiral CT instead of renal angiography namely, reduce the physical and socioeconomic burden of the donor. In the light of these considerations, LDtx should be reconsidered in the Italian scenario of kidney transplantation.     

Organic hypoglycemia of pancreatic cause

Insulinomas represent the most common cause of organic hypoglycemia. They are rare tumors: a review of the world literature reported a total number of 2000-3000 cases. The clinical diagnosis is based on the Whipple triad, which consists of: a) symptoms of hypoglycemia, b) blood glucose level: 40-50 mg/dl during the crisis, c) relief of symptoms after oral or intravenous administration of glucose. The most ticklish problem is the settlement of the accurate location of the tumor. Nowadays, there are many diagnostic methods; one of the best appears to be intra-operative ultrasonography. The authors analyse a series of 16 patients, operated between 1985 and 2002 in "I. Juvara" Surgical Clinic and present their opinions concerning tactic and technical aspects of different surgical procedures, with their advantages and limits. The results of the surgical treatment are detailed. There are also mentioned new imagery techniques and laparoscopic procedures, from recent medical issues.     

The surgical risk of laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the treatment of choice for gallbladder stones. As a matter of fact, the advantages related to the significant reduction of postoperative pain and the early mobilization of the patient, with a decrease of general surgical risk, have been well demonstrated. Also the complications of the surgical wound have been drastically reduced. On the contrary, iatrogenic trocar-related injuries represent specific complications of laparoscopic technique. However, the incidence of these complications, mostly the more severe ones, may be significantly reduced with routine use of the "open" technique. The increased incidence of common bile duct (CBD) injuries in laparoscopic cholecystectomy compared with the conventional technique may be partly explained with the learning curve related to the rapid diffusion of this new approach. An appropriate training, a meticulous operative technique and an early conversion to open procedure in case of intraoperative difficulties may reduce the risk of a CBD injury. In this work the authors' experience of 400 laparoscopic cholecystectomies without CBD injury and major complications is presented. Conversion rate was 5.2% in patients with simple symptomatic cholelithiasis and 37.5% in patients with acute or subacute cholecystitis.     

Current status of acetabular fixation in primary total hip arthroplasty.

Factors that influence the outcome of acetabular replacement are design materials, means of fixation, operative technique, and patient-related parameters (e.g., etiology of osteoarthrosis). Whereas improved cementing techniques have produced a marked reduction in the rate of femoral component loosening, the incidence of acetabular loosening has been only slightly influenced by such improvements. Presently, uncemented porous-coated acetabular components represent the state of the art in total hip arthroplasty. Experimental and clinical data have shown in histologic, radiologic, clinical, and survivorship studies that hemispheric cups are superior to other designs and that primary stability can be better maintained by creating "intrinsic" stability (e.g., "oversized cup") rather than by screw fixation. Threaded cups have failed to demonstrate any improvement in results and have been virtually abandoned in the United States. The idea of metal backing has some obvious theoretical advantages. However, metal backing has failed to provide any improvement with respect to cemented cups. There are great reservations concerning metal backing in cementless fixation. Although there is some enthusiasm about hydroxyapatite, a "wait-and-see" attitude is justified because of the brittleness of the material, its questionable strength of bonding to substrate, and its unproven long-term behavior in vivo. Polyethylene as a bearing surface remains problematic, and the future will show whether new technologies are able to solve the problems encountered with metal-to-metal combinations. For the size of the femoral head, a compromise between smaller (22 mm) and larger (32 mm) components seems to be most effective.     

Treatment of bile leaks from the cystohepatic ducts after laparoscopic cholecystectomy

The cystohepatic ducts represent accessory bile ducts of variable size which frequently travel within the gallbladder fossa or in the posterior wall of the gallbladder. These ducts can be injured during laparoscopic cholecystectomy and can result in bile collections if transected. Successful treatment by operative means or radiologically guided percutaneous drainage is possible, but endoscopic management has several advantages. We describe cases managed by endoscopic retrograde cholangiopancreatography (ERCP) with stent placement and discuss the advantages of this method. Also discussed is the anatomy of these accessory bile ducts, additional management options, and techniques for avoiding this injury during open or closed cholecystectomy.     

Effect of Nd∶YAG laser on experimental disc degeneration part II. Histological and MR imaging findings

Summary The potential advantages of percutaneous procedures over traditional discectomy are multiple, but the use of laser energy to ablate disc tissue appears entirely empirical. To date, no experimental study exists investigating the results of laser on degenerated intervertebral disc. The present study was therefore undertaken to determine the histological and radiological changes induced by neodymium-yttrium-aluminum-garnet (NdYAG) laser on such disc tissue.It was shown that the vaporization of disc tissue was caused by NdYAG laser in the early period, but this was gradually replaced by cartilaginous fibrous tissue at 60 days after laser irradiation as a result of the proliferation of cartilaginous cells and fibrous tissues. Accordingly the magnetic resonance (MR) imaging index histogram moved to the left in the early period, but it moved to the right again at 60 days after laser irradiation.In view of these data, we conclude that the use of laser in degenerated disc disease does not represent an effective treatment as an alternative to conventional surgical methods.This study was presented in part at the 8^th National Congress of the Turkish Neurosurgical Society, Marmaris, May 8–12, 1994.     

Bone preserving technique for reverse arthroplasty: The preferred management option for osteoarthritis with glenoid bone loss in patients 70 and older

Elderly patients with shoulder arthritis and glenoid bone loss represent a challenging patient population. Surgical treatment options include hemiarthroplasty, anatomic total shoulder arthroplasty (TSA) with bone grafting or augmentation, and reverse total shoulder arthroplasty (RSA). The RSA has multiple advantages compared to anatomic TSA, particularly in an older patient population with glenoid bone loss.RSA with an augmented glenoid baseplate is ideal for the treatment of patients who have glenoid bone loss. The augmented base plate has many advantages including bone preservation, longer central and peripheral screws, ability to dial the augment to match the region of bone deficiency, and lateralization to improve tensioning on the deltoid and rotator cuff. Additionally, a bone preserving RSA is possible with an augmented glenoid baseplate in patients with no glenoid bone loss.     

Contemporary management of ureteral stones

Context

Ureteral calculi represent a common condition that urologists encounter in everyday practice. Several treatment options are available for calculi that do not pass spontaneously or are unlikely to do so.

Objective

In this nonsystematic review, we summarize the existing data on contemporary management of ureteral stones focusing on medical expulsive therapy (MET) and different treatment modalities.

Evidence acquisition

A PubMed search was performed. We reviewed the recent literature on the management of ureteral calculi. Articles were considered between 1997 and 2011. Older studies were included selectively if historically relevant.

Evidence synthesis

For stones that do not pass spontaneously or with MET, shock wave lithotripsy (SWL) and ureteroscopy (URS) are the most common and efficient treatment modalities. Both techniques have obvious advantages and disadvantages as well as different patterns of complications. For select cases or patients, other modalities may be useful.

Conclusions

Ureteral stones of up to 10 mm and eligible for observation may be offered MET. For most ureteral calculi that require treatment, advances in SWL and URS allow urologists to take a minimally invasive approach. Other more invasive treatments are reserved for select “nonstandard” cases.     

Frakturen des Kniegelenks im hohen Lebensalter

Background

The aim of open reduction and internal fixation (ORIF) of fractures around the knee joint is the exact anatomic reconstruction of joint surfaces in order to achieve an early and load stable bone situation. Primary endoprosthetics as the initial treatment can represent an alternative treatment option for a closely selected number of geriatric patients.

Objectives

The chances and risks of primary endoprosthetics in comparison to ORIF as the gold standard for initial treatment of fractures close to the knee joint in the elderly are presented

Material and methods

A selective search of the literature was carried out in consideration of national recommendations and own experience gained as head of a center for geriatric traumatology.

Results

If the soft tissue coverage is not damaged by the injury, primary endoprosthetics can offer advantages compared to ORIF when a load stable joint is indispensable due to poor compliance, pre-existing arthritis and advanced age.

Discussion

The risk of postoperative loss of correction is minimized by the prosthesis but the revision possibilities are very limited due to voluminous prostheses with a high degree of coupling. The indications for primary prosthesis implantation for acute treatment of fractures close to the knee should therefore be closely controlled because this should be the first and last intervention for fracture treatment in geriatric patients.     

Non-invasive positive pressure mechanical ventilation in acute respiratory failure

Known for two centuries, positive pressure non invasive mechanical ventilation (VMNPP) has been widely applied in acute respiratory failure (IRA) only in the last ten years. The fact that VMNPP is able to improve gas exchange by avoiding endotracheal intubation and its complications is the most attractive aspect in both general and respiratory intensive care units and in the respiratory ward. Characteristics of VMNPP (interface, ventilator and modality of ventilation), the side where it is performed as well as severity of IRA, underlying disease, and the team's experience are important factors which influence outcome. The addition of VMNPP to conventional medical therapy reduces the need for IE, mortality and hospitalisation in a selected population of BPCO patients in IRA. As there are no available data for comparison between invasive mechanical ventilation (VMI) and VMNPP, the latter has not to be considered as an alternative to VMI but able to prevent it and, even if VMNPP fails, it may be used as a weaning technique. In IRA due to other than BPCO diseases VMNPP seems not to be more effective than standard treatment in avoiding IE but it may give efficient support with fewer complications as compared to VMI. Acute cardiogenic pulmonary edema and "terminal" diseases represent some of the most interesting application fields of VMNPP in non-BPCO patients. According to the latest literature data, in this review history, technique, advantages, limits, indications, nursing and cost of VMNPP are examined.     

Living Donor Liver Transplantation for Hepatocellular Carcinoma: Long-Term Results Compared With Deceased Donor Liver Transplantation

Objective

Living donor liver transplantation (LDLT) may represent a valid therapeutic option allowing several advantages for patients affected by hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT). However, some reports in the literature have demonstrated worse long-term and disease-free survivals among patients treated by LDLT than deceased donor liver transplantation (DDLT) for HCC. Herein we have reported our long-term results comparing LDLT with DDLT for HCC.

Patients and Methods

Among 179 patients who underwent OLT from January 2000 to December 2007, 25 (13.9%) received LDLT with HCC 154 (86.1%) received DDLT. Patients were selected based on the Milan criteria. Transarterial chemoembolization, radiofrequency ablation, percutaneous alcoholization, or liver resection was applied as a downstaging procedure while on the waiting list. Patients with stage II HCC were proposed for LDLT.

Results

The overall 3- and 5-year survival rates were 77.3% and 68.7% versus 82.8% and 76.7% for LDLT and DDLT recipients, respectively, with no significant difference by the log-rank test. Moreover, the 3- and 5-year recurrence-free survival rates were 95.5% and 95.5% (LDLT) versus 90.5% and 89.4% (DDLT; P = NS).

Conclusions

LDLT guarantees the same long-term results as DDLT where there are analogous selection criteria for candidates. The Milan criteria remain a valid tool to select candidates for LDLT to achieve optimal long-term results.     

Views of Japanese patients on the advantages and disadvantages of hemodialysis and peritoneal dialysis

Purpose

The preference for dialysis modalities is not well understood in Japan. This study explored the subjective views of Japanese patients undergoing dialysis regarding their treatments.

Methods

The participants were receiving in-center hemodialysis (CHD) or continuous ambulatory peritoneal dialysis (CAPD). In Study 1, 34 participants (17 CHD and 17 CAPD) were interviewed about the advantages and disadvantages of dialysis modalities. In Study 2, 454 dialysis patients (437 CHD and 17 CAPD) rated the advantages and disadvantages of CHD and CAPD in a cross-sectional survey.

Results

Interviews showed that professional care and dialysis-free days were considered as advantages of CHD, while independence, less hospital visits, and flexibility were considered as advantages of CAPD. Disadvantages of CHD included restriction of food and fluids and unpleasant symptoms after each dialysis session. Catheter care was an additional disadvantage of CAPD. Survey showed that the highly ranked advantages were professional care in CHD and less frequent hospital visits in CAPD, while the highly ranked disadvantages were concerns about emergency and time restrictions in CHD, and catheter care and difficulty in soaking in a bath in CAPD. The total scores of advantages and disadvantages showed that CHD patients subjectively rated their own modality better CHD over CAPD, while CAPD patients had the opposite opinion.

Conclusions

The results of this study indicate that the factors affecting the decision-making process of Japanese patients are unique to Japanese culture, namely considering the trouble caused to the people around patients (e.g., families, spouses, and/or caregivers).     

Indeterminate Pulmonary Nodules Represent Lung Metastases in a Significant Portion of Patients Undergoing Liver Resection for Malignancy

Introduction

Despite detection on imaging before resection of hepatic malignancies, the natural history of indeterminate pulmonary nodules (IPN) is unknown. The objective of this study is to determine how often IPN detected on imaging before surgery for hepatic malignancies represent lung metastases.

Methods

Demographics, comorbidities, tumor characteristics, and surgical treatments of patients with pre-operative IPN who underwent liver resection and/or radiofrequency ablation for malignant diagnoses were reviewed.

Results

From 2000 to 2010, 90 patients with at least one IPN underwent liver resection or radiofrequency ablation for malignancy. Of these, 44 (48.9?%), 32 (35.6?%), and 14 (15.6?%) patients had colorectal cancer liver metastases (CRCLM), primary hepatobiliary malignancies (HB), and other cancers, respectively. The median number of IPN was 1. The median size was 4?mm. Twenty (22?%) patients had isolated lung recurrence after hepatic surgical therapy. Eighty percent occurred in the exact location of the pre-operative IPN. Isolated lung recurrence was more common among patients with CRCLM compared to those with HB and other cancers (42.9 vs. 9.4 vs. 14.3?%, p?=?0.004).

Conclusion

Pre-operatively detected IPN represent lung metastases in a substantial portion of patients undergoing surgery for hepatic malignancy. IPN are more likely to represent lung metastases in patients with CRCLM compared to those with primary HB and other cancers.     

Initial results of MR-guided liver resection in a high-field open MRI

Background

The goal of this study was to evaluate high-field open magnetic resonance imaging (MRI) for intraoperative real-time imaging during hand-assisted laparoscopic liver resection. MR guidance has several advantages compared to ultrasound and may represent a future technique for abdominal surgery. Various MRI-safe and -compatible instruments were developed, tested, and applied to realize minimally invasive liver surgery under MR guidance. As proof of the concept, liver resection was performed in a porcine model.

Methods

All procedures were conducted in a 1.0-T open MRI unit. Imaging quality and surgical results were documented during three cadaveric and two live animal procedures. A nonferromagnetic hand port was used for manual access and the liver tissue was dissected using a Nd:YAG laser.

Results

The intervention time ranged from 126 to 145 min, with a dissection time from 11 to 15 min. Both live animals survived the intervention with a blood loss of 250 and 170 ml and a specimen weight of 138 and 177 g. A dynamic T2W fast spin-echo sequence allowed real-time imaging (1.5 s/image) with good delineation of major and small hepatic vessels. The newly developed MR-compatible instruments and camera system caused only minor interferences and artifacts of the MR image.

Conclusion

MR-guided liver resection is feasible and provides additional image information to the surgeon. We conclude that MR-guided laparoscopic liver resection improves the anatomical orientation and may increase the safety of future minimally invasive liver surgery.     

Modified "stent-graft sandwich" technique for treatment of isolated common iliac artery aneurysm in patient with Marfan syndrome

Isolated iliac artery aneurysms are rare in the general population (0.03%) and represent 2% of all abdominal aneurysms, and the association with Marfan syndrome is even rarer. We report a Marfan syndrome case with an isolated common iliac artery aneurysm treated by using a modified "stent-graft sandwich" technique, with preservation of the internal iliac artery perfusion. The modified "stent-graft sandwich" technique involves building an appropriate proximal neck just in the common iliac artery for fittingly housing two new stent-grafts inside, both deployed simultaneously and each one going to both distal iliac arteries (internal and external).     

The place of local/regional perforator flaps in complex traumas of the forearm

Background

Our aim was to conduct a retrospective study regarding the advantages of doing the all-in-one reconstruction in the same step with the debridement, and the possibility of using the local/regional perforator flaps to cover the tissue defects.

Methods

We reviewed a series of 137 cases from 1999 until now, for acute traumas with tissue defects of the forearm. We performed a regional perforator flap in 16 cases, and a local perforator flap in 121 cases. These flaps were used for both simple and complex defects coverage, including 26 cases with fractures and devascularization.

Results

The follow-up was between 2 months and 2 years. In all the cases the extremity was salvaged and an useful functional recovery was obtained. A very good evolution, with complete survival of the flap was recorded in 133 cases. We completely lost only one flap, and registered minor complications in three cases.

Conclusion

The local perforator flaps represent a good and safe indication for small and medium defects in the forearm.     

Arthroskopische Materialentfernung nach winkelstabiler Plattenosteosynthese am proximalen Humerus

Background

Implant removal is necessary in up to 25% of patients with plate osteosynthesis after proximal humeral fracture. Our new technique of arthroscopic implant removal offers all the advantages of minimally invasive surgery. This study outlines the first results after arthroscopic implant removal in comparison with those of open implant removal.

Material and methods

Twenty patients [median age 64 (30-82) years] had arthroscopic and nine patients [median age 53 (34-76) years] had open implant removal. Median 9.5 months after implant removal subjective patient satisfaction, Constant-Murley Score (CMS) and Simple Shoulder Test (SST) were determined.

Results

Arthroscopic implant removal showed first results comparable to open implant removal. The SST outlined advantages for the arthroscopic technique. In 85% of arthroscopically treated patients concomitant intra-articular lesions were observed.

Conclusion

Arthroscopic implant removal offers all the advantages of minimally invasive surgery and first results comparable to open implant removal. The subjective and objective satisfaction of the patients is high. The technique can be applied and established by all skilled arthroscopic shoulder surgeons.     

骨质疏松性骨折中西医协同诊疗专家共识

骨质疏松性骨折是骨质疏松症最严重并发症,发病隐匿、致死致残率高,发病率逐年上升,带来巨大社会经济负担。西医诊疗在诊断和手术方面存在优势,传统中医强调整体调理、恢复机体平衡,中西医协同诊疗是骨质疏松性骨折诊疗的有效策略。为推广中西医协同诊疗理念,促进骨质疏松性骨折中西医协同诊疗技术发展,建立规范化、标准化疾病预防、诊断和治疗方案,中国老年学和老年医学学会老年病学分会骨科专家委员会、中华医学会骨科学分会青年骨质疏松学组、中国医师协会骨科医师分会骨质疏松学组、上海中西医结合学会骨质疏松专业委员会牵头成立共识专家组,讨论并制订《骨质疏松性骨折中西医协同诊疗专家共识》,从预防、诊断和治疗三方面阐述中西医协同理念并提供推荐意见,期望改善骨质疏松性骨折预后,提高生活质量。