Intermediate outcome after carotid stenting: what should we expect?

Atherosclerosis of the extracranial carotid artery is a major public health burden. Stroke is the third leading cause of death in Western countries, after heart disease and cancer, and the leading cause of long-term disability. In the United States, there are more than 500,000 strokes annually, accounting for approximately 3 million stroke survivors with varying degrees of disability. Data from stroke registries suggest that internal carotid artery atheroembolic disease accounts for approximately 35% of all ischemic cerebral infarctions; therefore, approximately 150,000 strokes in the United States per year may be ascribed to carotid disease. Surgical endarterectomy has been shown to be superior to medical management in the management of severe carotid stenosis in both symptomatic and asymptomatic patients. Indeed, carotid endarterectomy has been one of the most heavily scrutinized operations over the past 40 years, and newer methods of revascularization are being actively explored. With the great technological advances in the endovascular treatment of both peripheral and coronary atherosclerotic disease, many of these techniques are now being applied to the extracranial circulation. We explore the rapidly expanding field of carotid artery angioplasty and stenting. The upcoming prospective randomized clinical trials of surgical endarterectomy versus carotid angioplasty and stenting also are reviewed.     

Aneurysm regression after endovascular aneurysm repair: what should we expect?

This study reviewed a large national core laboratory database for the Ancure (Guidant, Menlo Park, California) phase I and II trial of overall aneurysm sac regression after endovascular aneurysm repair. Data were reviewed for aneurysm size and endoleak in follow-up. Endoleak was recorded as well as maximum major and minor axis aortic diameters. Included were patients with baseline assessment within 3 months of implantation and at least 24 months of follow-up, and 444 were available for review. The mean baseline aortic diameter was 56.6 mm; mean follow-up was 48.7 months. Of these patients, 129 (29.5%) had aneurysm regression to less than 40 mm, 42 (9.5%) regressed to less than 35 mm, and 12 (2.7%) had complete aneurysm sac obliteration. Multivariate analysis demonstrated that baseline aneurysm size was the only predictor of aneurysm size regression. Significant sac regression is common after Ancure aneurysm repair and appears to be related primarily to initial aneurysm size.     

Laparoscopic cholecystectomy after a quarter century: why do we still convert?

Background  

Laparoscopic cholecystectomy (LC) is the gold standard procedure for gallbladder removal. However, conversion to open surgery is sometimes needed. The factors underlying a surgeon’s decision to convert a laparoscopic case to an open case are complex and poorly understood. With decreasing experience in open cholecystectomy, this procedure is however no longer the “safe” alternative it once was. With such an impending paradigm shift, this study aimed to identify the main reasons for conversion and ultimately to develop guidelines to help reduce the conversion rates.     

What injuries should we expect in the emergency room?

IntroductionBeside serious and potentially fatal injuries, the majority of pediatric trauma patients present with minor injuries to emergency departments. The aim of this study was to evaluate age-related injury pattern, trauma mechanism as well as the need for surgery in pediatric patients.Patients and methodsRetrospective Study from 01/2008 to 12/2012 at a level I trauma center. All patients <18 years of age following trauma were included. Injury mechanism, injury pattern as well as need for surgery were analyzed according to different age groups (0–3 years, 4–7 years, 8–12 years and 13–17 years). Major injuries were defined as fractures, dislocations and visceral organ injuries. Minor injuries included contusions and superficial wounds.ResultsOverall, 15300 patients were included (59% male, median age 8 years). A total of 303 patients (2%) were admitted to the resuscitation room and of these, 69 (0.5% of all patients) were multiply injured (median Injury Severity Score (ISS) 20 pts). Major injuries were found in 3953 patients (26%). Minor injuries were documented in 11347 patients (74%). Of those patients with a major injury, 76% (2991 patients) suffered a fracture, 3% (132 patients) a dislocation and 3% (131 patients) an injury of nerves, tendons or ligaments. The majority of fractures were located in the upper extremity (73%) (elbow fractures 16%; radius fractures 16%; finger fractures 14%). Patients with minor injuries presented with head injuries (34%), finger injuries (10%) and injuries of the upper ankle (9%). The most common trauma mechanisms included impact (41%), followed by falls from standing height (24%), sport injuries (15%) and traffic accidents (9%). Overall, 1558 patients (10%) were operated. Of these, 61% had a major and 39% a minor injury.ConclusionAlmost 75% of all children, who presented to the emergency department following trauma revealed minor injuries. However, 25% suffered a relevant, major injury and 0.5% suffered a multiple trauma with a median ISS of 20. Overall, 10% had to be operated. The most frequently found major injuries were extremity fractures, with elbow fractures as the most common fracture.     

Laparoscopic adjustable gastric banding: is there a learning curve?

Background: To be certified for laparoscopic placement of adjustable gastric banding, surgeons must have advanced laparoscopic experience. Despite previous exposure to other kinds of laparoscopy, there may a learning curve specific to Lap-Band placement. Methods: Sixty consecutive patients were prospectively separated into two groups: the first 30 patients operated on (group 1) and the second 30 patients operated on (group 2). Results: Both groups were similar statistically in regard to gender, age, and body mass index. Operative time for group 1 was 79 ± 31.1 min. There were 11 (37%) complications in 10 patients. Operative time for group 2 was 59 ± 19.9 min. There were two complications (7%). All operations were completed laparoscopically. Operative time was significantly lower in group 2 (t-test; p = 004). Complications were also significantly lower (chi-square; p = 0.005). The number of reoperations was also reduced and approached statistical significance (chi-square; p = 0.054). Readmissions, although reduced, were not statistically significant. There were no deaths in either group. Conclusions: Despite a surgeons history of advanced laparoscopic experience, there is a definite learning curve associated with the laparoscopically placed adjustable gastric band.     

Complete radiological response of colorectal liver metastases after chemotherapy: what can we expect?

Missing metastases, also called vanishing or disappearing liver metastases, concern about 5% of patients with colorectal liver metastasis undergoing chemotherapy, and this phenomenon is likely to become more frequent in the near future, with the widespread use of highly efficient chemotherapy. As their definition is highly dependent on the quality of initial imaging, a DLM on preoperative computed tomography scan should be systematically confirmed by a second imaging modality, ideally magnetic resonance imaging. It is important to note that a complete clinical response does not mean a complete pathologic response. Currently, there are no absolute criteria of a complete pathologic response. However, treatment with neoadjuvant and adjuvant hepatic arterial infusion in patients <60 years old with an initially low carcinoembryonic antigen level that normalizes under chemotherapy and who have no detectable lesion on both computed tomography and magnetic resonance imaging is probably more likely to yield a complete pathologic response. Whatever their treatment, patients with DLM run a high risk of recurrence that could be decreased with the use of HAI. Despite a high recurrence rate, the overall 5-year survival rate of patients with DLM ranges from 40 to 80%. Having a DLM should no longer be a contraindication to hepatic surgery since long-term survival is expected in these highly chemosensitive patients. The use of adjuvant HAI in addition to efficient systemic chemotherapy could reduce the risk of hepatic relapse.     

Transobturator midurethral sling: What should patients expect after surgery?

Introduction and hypothesis

Midurethral sling (MUS) surgeries are minimally invasive procedures; however, they are not free of postoperative complications. The aim of the study was to assess the occurrence of lower urinary tract symptoms (LUTS) (urgency, nocturia, frequency, splitting/spraying, hesitancy, terminal dribbling, and subjective feeling of postvoid residual) in patients suffering from stress (SUI) or mixed (MUI) urinary incontinence with a predominant SUI component before and after transobturator MUS placement.

Methods

The study group consisted of 88 women with SUI and 18 with MUI who underwent transobturator MUS. All participants were questioned with a self-developed questionnaire before and after surgery regarding the presence of LUTS.

Results

Seven days after surgery, 62 patients (58.5%) noted voiding and postmicturition symptoms, whereas 67 (63.2%) reported problems in storage. The more commonly reported LUTS at week 1 after surgery were urgency (52.8%), splitting/spraying (41.5%), and feeling of incomplete bladder emptying (34.0%). Patients perceived that splitting/spraying was the most bothersome. After 6 months, the most common LUTS reported were hesitancy (14.1%), terminal dribbling (10.4%), and splitting/spraying (9.4%). We noticed a decrease in the number of urgency episodes >2.7 times (p < 0.001) compared with baseline. After 6 months, 97 (91.5%) patients reported the lack of incontinence episodes.

Conclusions

A vast majority of patients after MUS suffer from LUTS in the early postoperative period; however, the majority of undesired symptoms resolve spontaneously within the first 6 months postsurgery.

     

Computer-assisted knee surgery, what can we expect?

Navigation systems for operative assistance in knee joint surgery have been established in the last 5 years. Among the large number of variable systems, the image-free kinematic systems have won widespread acceptance. The C-arm based systems are not superior to the image-free systems. The CT-based systems are advantageous in completely destroyed joints (with marked joint erosion) or advanced congenital or traumatic deformities. The intraoperatively-performed Iso-C (3D) technique presents data sets in CT-quality, but because of its small data volume currently is limited to the reconstruction of articular surfaces following fractures. The use of image-free navigation in resurfacing knee arthroplasty is in the meantime beyond controversy whereby deviations in the mechanical axis from normal values can be significantly reduced. For high tibial osteotomies navigation modules will be soon available for marketing. However, with these modules, intraoperative imaging is indispensable, but it will be image-free in the future. The early clinical results are promising. Cruciate ligament navigation is not yet a clinical standard be-cause of the considerable associated time expenditure. The appropriate modules are still under development.