Combination of familial Barlow’s disease with bilateral axillary artery aneurysms in two brothers

We encountered two brothers with a combination of Barlow’s disease and bilateral axillary artery aneurysms who were operated on during their third decade of life. A symmetrical form of true bilateral axillary artery aneurysms is uncommon. Recurrent mitral regurgitation was presented in the older brother with an endocardial defect in the left atrium, suggesting connective tissue fragility. A hereditary connective tissue disorder was strongly suspected because of the similar presentation and an unusual cluster of pathologies in siblings. Careful follow-up is required to detect recurrence of mitral regurgitation or aneurysm formation in other vessels.     

Comparison of donor scores in bilateral lung transplantation—A large single-center analysis

Objectifying donor lung quality is difficult and currently there is no consensus. Several donor scoring systems have been proposed in recent years. They all lack large-scale external validation and widespread acceptance. A retrospective evaluation of 2201 donor lungs offered to the lung transplant program at the Medical University of Vienna between January 2010 and June 2018 was performed. Five different lung donor scores were calculated for each offer (Oto, ET, MALT, UMN-DLQI, and ODSS). Prediction of organ utilization, 1-year graft survival, and long-term outcome were analyzed for each score. 1049 organs were rejected at the initial offer (group I), 209 lungs declined after procurement (group II), and 841 lungs accepted and transplanted (group III). The Oto score was superior in predicting acceptance of the initial offer (AUC: 0.795; CI: 0.776–0.815) and actual donor utilization (AUC: 0.660; CI: 0.618–0.701). Prediction of 1-year graft survival was best using the MALT score, Oto score, and UMN-DLQI. Stratification of early outcome by MALT was significant for length of mechanical ventilation (LMV), PGD3 rates, ICU stay and hospital stay, and in-hospital-mortality, respectively. To the best of our knowledge, this study is the largest validation analysis comparing currently available donor scores. The Oto score was superior in predicting organ utilization, and MALT score and UMN-DLQI for predicting outcome after lung transplantation.     

Sole stenting of large and giant intracranial aneurysms with self-expanding intracranial stents—limits and complications

Background  

Intracranial aneurysms may be difficult for endovascular treatment due to size, fusiform shape, or wide neck. In such patients, intracranial stents are used to support the coils in the aneurysm sac, or they may be used as a sole stenting technique to divert the blood flow without coils. The aim of this paper is to contribute to the existing data by reviewing the risks of sole stenting of large and giant aneurysms.     

The rupture rate of large abdominal aortic aneurysms: is this modified by anatomical suitability for endovascular repair?

BACKGROUND: There are no precise estimates of the rate of rupture of large abdominal aortic aneurysms (AAA). There is recent suspicion that anatomic suitability for endovascular repair may be associated with a decreased risk of AAA rupture. METHODS: Systematic literature review of rupture rates of AAA with initial diameter > or =5 cm in patients not considered for open repair, with stratification by size (<6.0 cm and 6.0+ cm), and gender, combined using random-effects meta-analysis. Proportional hazards regression to analyze factors (including gender, diabetes, initial AAA diameter, aneurysm neck, and sac lengths) associated with rupture in patients anatomically suitable for endovascular repair (EVAR 2 trial). RESULTS: Previous studies (2 prospective, 2 retrospective, and 1 mixed) were identified for meta-analysis and patients with elective repair excluded. The pooled rupture rates was 18.2 [95% confidence interval (CI) 13.7-24.1] per 100 person-years. There was a 2.5-fold increase in rupture rates for patients with AAA of 6.0+ cm versus <6.0 cm, rupture rates = 2.54 (95% CI 1.69-3.85). The pooled rupture rates was nonsignificantly higher in women than men, rupture rates = 1.21 (95% CI 0.77-1.90). For EVAR 2 patients with 6+ cm aneurysms the rupture rates was 17.4 [95% CI 12.9-23.4] per 100 person-years significantly lower than the pooled rate from the meta-analysis, rupture rates = 27.0 [95% CI 21.1-34.7] per 100 person-years, P = 0.026. Patients with shorter neck lengths appeared to have a higher rupture rates than those with longer necks, but this was of borderline significance P = 0.10. CONCLUSIONS: Rupture rates of large AAAs reported in different studies are highly variable. There is emerging evidence that patients anatomically suitable for endovascular repair have lower rupture rates.     

Organ-sparing surgery of the bilateral testicular large cell calcifying sertoli cell tumor in patient with atypical Peutz–Jeghers syndrome

Large cell calcifying sertoli cell tumor (LCCSCT) is an exceptionally rare neoplasm originating from sperm cord cells. The tumors have relatively low malignant potential and unlikely proceed to metastasis formation. The lesions may occur in an isolated form or in ca. 40% of cases may be associated with genetic abnormalities, by and large Peutz-Jeghers syndrome and Carney complex. At presentation, 20% of LCCSCT cases are bilateral and/or multifocal. Owning to characteristic skin lesions and particular hyperechoic ultrasound image of the tumor, preliminary diagnosis of the syndromic LCCSCT is possible in the preoperative period. Consequently, testicle organ-sparing procedure can be attempted, which is especially justified in bilateral lesions. Here, we report a case of a bilateral LCCSCT in a 20-year-old man with atypical Peutz-Jeghers syndrome due to amplification of the exon 1 of STK11 gene who was successfully treated with bilateral testicle-sparing tumorectomies.     

Kissing式胰肠吻合的动物实验研究

目的 通过动物实验探索Kissing式胰肠吻合的可行性和安全性,明确胰管、黏膜愈合的病理过程.方法 通过测定胰肠吻合后吻合口耐受压,求证该吻合的严密性;通过吻合后不同时间的手术探查、胰肠管造影和病理学检查证实吻合后胰腺残端与空肠黏膜之间愈合情况和病理演变过程.结果 所有实验犬均顺利完成胰肠吻合术,耐受压测定均在90 cm H2O以上,各时间段处死的实验犬均见吻合口紧密,无出血、瘘口,造影见胰管与肠腔连续,充盈良好,未见造影剂外渗现象.病理切片提示4周后胰管与空肠黏膜间形成瘢痕愈合,连接紧密.结论 Kissing胰肠吻合简便,易推广,胰管、空肠黏膜间可形成严密瘢痕愈合,未见积液或脓腔等,具有临床应用价值.     

Kissing melanoma or kissing nevus of the penis?

Divided, or so-called kissing nevi of the penis, which are separated during embryogenesis, are very rare, with only seven studies reported to date. We present a case of a 30-year-old patient with a divided nevus located at the penis that rapidly changed in size and color within 4 months. These clinical features and the histopathologic appearance of both parts led to the diagnosis of malignant melanoma. Melanoma of the penis is very rare, and the prognosis is poor. This could be the first case of a "kissing melanoma" of the penis reported in published studies.     

Kissing式胰肠吻合在胰十二指肠切除术中的应用

胰腺残端的处理是胰十二指肠切除术的关键步骤,一旦发生胰漏或胰腺残端出血将大大增加围手术期病死率[1].受启发于尿道会师的原理,我们提出了Kissing式胰肠吻合,即不直接缝合胰管和肠黏膜,而是让它们尽量接近后(kissing),用内支架支撑使其自然愈合.从2006年开始我们利用该方法已完成胰十二指肠切除术81例,现报告如下.     

Unruptured aneurysms: Why observational studies fall short no matter how “Big” the Data

BackgroundThe best management of unruptured intracranial aneurysms (UIAs) remains unknown, despite multiple observational studies. A randomized trial (RCT) is in order. Yet, a National Institute Neurological Disorders and Stroke workshop has once again proposed to use prospective observational studies (POS) of large databases to address such problems.MethodsWe review the historical misconceptions that have been associated with observations of UIAs and their treatments. We critically examine some recent methods that have been proposed to address shortcomings of observational studies. We finally review the ethical principles underlying the use of trial methods in the care of patients.ResultsReplacing RCTs with POS submits patients to management options that have never been proven beneficial, while making them involuntary research subjects of studies that are inevitably biased. A science of practice cannot be an outsider's examination of the behavior of clinicians incapable of questioning their practice. The thesis we propose is that a science of practice must not only eventually determine what best practice will be; It must engage agents involved in medical practice to transparently reveal the uncertainty that calls for management options to be offered under the guidance of declared and controlled care research, to optimize patient outcomes in spite of the uncertainty.ConclusionTo use POS rather than RCTs in medical practice is to renege on scientific and ethical principles that characterize modern medicine. Instead, we must learn to integrate care research into our practice to provide optimal medical care in real time.     

Simultaneous bilateral shoulder and bilateral central acetabular fracture dislocation: What to do?

Musculoskeletal injuries following seizures have a high morbidity and mortality. These injuries are often missed and the diagnosis is delayed due to a lack of clinical suspicion and appropriate investigations. We report a case of 72 years old male with simultaneous bilateral central acetabular fracture dislocation and bilateral posterior shoulder fracture dislocation secondary to an epileptic seizure. Present study highlights the significance of clinical suspicion and clinico-radiological evaluation for diagnosis of a rare injury following episode of seizures. Simultaneous fracture dislocation of all four limbs treated with a holistic approach can lead to a good functional recovery. Surgical management with open reduction and internal fixation is preferred and replacement arthroplasty should be reserved for cases with implant failure and elderly patients.     

“Weber B” bilateral malleolus fracture and interfragmentary screw placement: a cadaveric study

Aim

A study was performed on cadaver ankles to assess the biomechanical stability of two different ways of interfragmentary screw fixation for lateral malleolus fracture of the ankle.

Materials and methods

Ten ankles from five female cadavers were used. The distal fibulae were osteotomized at the level of the syndesmosis with a saw and the fracture fixations were divided into two groups. In Group I, the fractures were fixed with traditional antero-posterior cortical screws and in Group II, the contralateral fractures from the same cadaver were fixed with postero-anterior cortical screws. The distal fibulae in both groups were subjected to biomechanical compression and torsion forces and the force at which the fixation gave way was recorded.

Results

In the former group, the breaking force was significantly lower than that required in the latter group by a mean of 0.4 kN.

Conclusion

The fixation done in Group II was found to be better.     

The ALPPS technique for bilateral colorectal metastases: three “variations on a theme”

The aim of this study was to assess feasibility of technical variations of the associating liver partition and portal vein ligation for staged hepatectomy technique (ALPPS) with regard to three different ways of liver splitting. The ALPPS technique was applied in the classic form consisting in ligation of the right portal vein, limited resections on the left lobe and splitting along the umbilical fissure; the right lobe was removed 1 week later. The first variation was “left ALPPS”: ligation of the left portal vein, multiple resections on the right hemiliver and splitting along the main portal fissure. The second variation was “rescue ALPPS”, consisting in simple splitting of the liver along the main portal fissure several months after a radiological portal vein embolization that did not allow satisfactory liver hypertrophy. The third variation was “right ALPPS”, consisting in ligation of the posterolateral branch of right portal vein, left lateral sectionectomy, multiple resections on the right anterior and left medial section and splitting along the right portal fissure. In all cases auxiliary deportalized liver was removed 1 week later. 4 patients with colorectal metastases were included. Morbidity was defined according to the Clavien–Dindo classification: grade I (2 events), grade IIIb (1 event). Postoperative mortality was nil. Median follow-up was 4 months and to date all patients are still alive. ALPPS technique, in its “classical” and modified forms, is a good option for selected patients with bilateral colorectal metastases and represents a feasible alternative to classical two-stage hepatectomy.     

Early and long-term outcome of surgically treated giant internal carotid artery aneurysms—comparison with smaller aneurysms

Background  

Internal carotid artery (ICA) is predominant localization of giant intracranial aneurysms (GIAs). The rupture of GIA is supposed to be related to higher risk of poor clinical outcome. Although endovascular techniques are still being developed, they seem to be unsatisfactory in the mean of GIAs.