Video-assisted transthoracic sympathectomy in the treatment of primary hyperhidrosis: friend or foe?

The authors hypothesize that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function; consequently, thoracoscopic sympathectomy to alleviate symptoms in the hands may result in heat dissipation because sweating is transferred to other sites. To investigate this phenomenon and to determine whether it adversely affects patient satisfaction, a standard questionnaire was administered to 626 patients who underwent sympathectomy at a university-associated public hospital between 1991 and 1998; only patients treated at least 6 months before questionnaire distribution were included in the study. Replies were received from 336 (53.7%) individuals. The surveyed patients underwent bilateral T2, T3 (palmar sweating), or T3, T4 (axillary sweating) sympathectomy by a standard video-assisted transthoracic technique. Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena; in addition, patient perception of the success of the surgical procedure was assessed. After sympathectomy, 97.3% (P < 0.0001) and 29.2% (P < 0.001) of patients reported significant improvement in palmar hyperhidrosis and axillary sweating, respectively. Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), and axillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients. Thirty-seven patients (11%) regretted having undergone the surgical procedure. In contrast, 25% and 64% of patients were either satisfied or very satisfied with the outcome of the procedure. From the survey results, the authors conclude that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function and that thoracic sympathectomy may alleviate symptoms in a large proportion of patients. However, for some individuals, compensatory sweating may prove to be an equally troublesome handicap. Because the occurrence of severe compensatory sweating is unpredictable, a reversible sympathectomy may be desirable.     

Destruction of choroid plexus cells in vitro: a new concept for the treatment of hydrocephalus?

OBJECTIVE: The current treatment of hydrocephalus using ventriculoperitoneal shunts and third ventriculostomies remains problematic. We revisited the concept of destruction of the choroid plexus for the treatment of hydrocephalus by using an immunotoxin-based technique to specifically destroy this tissue. This approach was based on the observation that, as an epithelial tissue, choroid plexus expresses a number of specific cell-surface proteins that represent excellent potential targets for the creation of a choroid plexus-specific immunotoxin. METHODS: In this study, we characterized sheep and human choroid plexus cells (including atypical and carcinoma cell lines) using fluorescence microscopy in combination with histochemical staining of rat brain and confirmed the presence of a number of epithelium-specific proteins in choroid plexus cells. Immunotoxins were then manufactured by linking these antibodies to ricin A chain and ricin A-B chain. These immunotoxins were delivered to choroid plexus-derived cells in culture, and the results were compared with results of exposure to a nonspecific immunotoxin. RESULTS: Complete cell death of choroid plexus cells was seen after only a 1-hour exposure to the specific immunotoxin, as opposed to the minimal cell death seen with a nonspecific immunotoxin after several hours of exposure. CONCLUSION: These results suggest that immunotoxin-mediated ablation of choroid plexus may be a viable method of treating hydrocephalus and choroid plexus-derived tumors.     

Focal segmental glomerulosclerosis in IgA nephropathy: a result of primary podocyte injury?

Segmental sclerosis is frequently seen in IgA nephropathy and is an adverse prognostic indicator in the Oxford classification. Hill and colleagues have studied patients with IgA nephropathy and show that the segmental sclerotic lesions have features that suggest they are due to primary podocyte injury. They confirm the validity of the Oxford classification in predicting outcome and also show that categorizing the type of FSGS is of prognostic significance, with collapsing and cellular forms having the worst outcome.     

Can the displacement of a conservatively treated distal radius fracture be predicted at the beginning of treatment?

The aim of this study was to investigate whether the final displacement of conservatively treated distal radius fractures can be predicted after primary reduction. We analysed the radiographic documents of 311 patients with a conservatively treated distal radius fracture at the time of injury, after reduction and after bony consolidation. We measured the dorsal angulation (DA), the radial angle (RA) and the radial shortening (RS) at each time point. The parameters were analysed separately for metaphyseally "stable" (A2, C1) and "unstable" (A3, C2, C3) fractures, according to the AO classification system. Spearman's rank correlations and regression functions were determined for the analysis. The highest correlations were found for the DA between the time points 'reduction' and 'complete healing' (r = 0.75) and for the RA between the time points 'reduction' and 'complete healing' (r = 0.80). The DA and the RA after complete healing can be predicted from the regression functions.     

Palatal lengthening following use of the buccal myomucosal flap in primary palatoplasty—real or apparent? A study of the physical variables

Lengthening of the nasal layer during cleft-palate surgery is frequently performed. The buccal myomucosal flap is a versatile source of tissue, for this very purpose. In an analysis of 47 consecutive patients in whom this procedure was followed, an analysis of the physical variables was undertaken, with a view to determine the true relevance of the flap. An attempt is also made to co-relate the extent of tissue shortage with the nature of the cleft.     

Partial cystectomy: Is it a reliable option for the treatment of bladder leiomyosarcoma?

Bladder leiomyosarcoma is a unique mesenchymal tumour, accounting for less than 0.5% of all primary bladder malignancies. Bladder leiomyosarcoma used to be treated with radical surgery in either old or young patients, often resulting in significant impact on the patients’s quality of life after surgery. We report on a case of bladder leiomyosarcoma in a 31-year-old female who was treated with partial cystectomy. Fortunately, no tumour metastasis or relapse was observed during the 7-year follow-up period and the patient now has a good quality of life. We found that partial cystectomy may be an acceptable option to treat bladder leiomyosarcoma in the low MSKCC (Memorial Sloan-Kettering Cancer Center) stage.     

“Sandwich technique” in the surgical treatment of primary complex fractures of the femur and humerus

In this prospective study, our aim was to determine the clinical and radiographic outcomes of the surgical treatment of primary complex problem femoral and humeral shaft fractures treated by a new technique called “sandwich technique.” A total of 45 patients with comminuted, complex and/or osteopoenic fractures of the femur or humerus (30 femoral and 15 humeral fractures) were treated using this technique. The patients were followed up for a mean of 25 months. In 24 (85.7%) of 28 patients with femoral fractures and in 14 (93.3%) of 15 patients with humeral fractures, union was achieved within 3–6 months of the operation (mean: 4.5 months). The total union rate was 88.4%. The pseudoarthrosis rate was 12%. There was no infection or implant failure seen during the follow-up period. The cortical allograft struts can be used to provide collateral support to weakened osteopoenic/osteoporotic bone. This technique provides a union rate of about 88% in osteoporotic and/or complex primary humerus or femur fractures.

---

Résumé Etude prospective de l’évolution clinique et radiographique des fractures complexes de l’humérus et du fémur avec une technique appelée “sandwich technique”. 30 fractures du fémur et 15 de l’humérus avaient été traitées avec un suivi moyen de 25 mois. Pour 24 des 28 patients opérés du fémur et 14 des 15 opérés de l’humérus, la consolidation était obtenue en 3 à 6 mois après l’opération, en moyenne 4,5 mois. Le taux total de consolidation était de 88,4% et celui des pseudarthroses de 12%. Il n’y a pas eu d’infection ni d’échec d’implant durant ce suivi. Les baguettes d’allogreffes corticales peuvent être utilisés pour renforcer les os ostéopéniques ou ostéoporotiques. Cette technique permet 88% de consolidation pour les fractures primaires mais complexes de l’humérus et du fémur.

     

Does surgical resection have a role in the treatment of large or multinodular hepatocellular carcinoma?

Several effective treatments are available for patients with small solitary hepatocellular carcinomas (HCCs). Conversely, the management of patients with large or multinodular HCCs is controversial, and the role of surgical resection is not well defined. Between 2000 and 2006, 51 patients with large or multinodular HCC underwent liver resection. Clinicopathologic and follow-up data were prospectively collected and retrospectively reviewed. The perioperative and long-term outcomes were analyzed. Univariate and multivariate analysis of prognostic factors were conducted. Although 20 patients had multinodular HCCs, 31 had large solitary tumors. Perioperative mortality occurred in eight patients and complications in 15. In patients with large solitary tumors, 5-year disease-free and overall survival were 41.3 per cent and 56.1 per cent, respectively. Those with multinodular HCCs demonstrated 5-year disease-free and overall survival rates of 0 per cent and 33.6 per cent, respectively. Liver resection can result in long-term survival in select patients with large or multinodular HCCs, even in select patients with impaired liver function. Large solitary HCCs seem to have better prognoses than multinodular tumors, with lower recurrence and higher survival rates after surgery. Randomized controlled trials comparing resection to other treatment modalities are indicated to determine optimal patient management.     

Anthracyclines in the treatment of early breast cancer friend or foe?

Standard chemotherapy for early breast cancer consists generally of an anthracycline – taxane - based regimen, preferably in sequence. Anthracyclines are among the most active cytotoxic drugs against breast cancer. Nevertheless, benefits attained by the use of the more potent anthracycline schedules must be balanced against increased short – and long – term toxicity, and treatment options must be individualized for each patient. Authors review available data regarding anthracycline efficacy and toxicity in the early breast cancer setting and the potential directions for future research.     

Is omentectomy necessary in the treatment of benign or malignant abdominal pathologies? A systematic review

BACKGROUNDThe omentum is an organ that is easily sacrificed during abdominal surgery. The scope of omentectomy and whether a routine omentectomy should be performed are still unknown. AIMTo review the literature in order to determine the physiological functions of the omentum and the roles it plays in pathological events in order to reveal the necessity for removal and preservation of the omentum. METHODSA clinical review of the English language literature based on the MEDLINE (PubMed) database was conducted using the keywords: “abdomen”, “gastrointestinal”, “tumor”, “inflammation”, “omental flap”, “metastasis”, “omentum”, and “omentectomy”. In addition, reports were also identified by systematically reviewing all references in retrieved papers.RESULTSThe omentum functions as a natural barrier in areas where pathological processes occur in the abdominal cavity. The omentum limits and controls inflammatory and infectious pathologies that occur in the abdomen. It also aids in treatment due to its cellular functions including lymphatic drainage and phagocytosis. It shows similar behavior in tumors, but it cannot cope with increasing tumor burden. The stage of the disease changes due to the tumor mass it tries to control. Therefore, it is considered an indicator of poor prognosis. Due to this feature, the omentum is one of the first organs to be sacrificed during surgical procedures. However, there are many unknowns regarding the role and efficacy of the omentum in cancer.CONCLUSIONThe omentum is a unique organ that limits and controls inflammatory processes, foreign masses, and lesions that develop in the abdominal cavity. Omental flaps can be used in all anatomical areas, including the thorax, abdomen, pelvis, and extremities. The omentum is an organ that deserves the title of the abdominal policeman. It is generally accepted that the omentum should be removed in cases where there is tumor invasion. However, the positive or negative contribution of omental resection in the treatment of abdominal pathologies should be questioned.     

Which primary shoulder and elbow replacement? A review of the results of prostheses available in the UK.

To assist surgeons select a suitable prosthesis, we have undertaken a detailed review of all shoulder and elbow replacements currently marketed in the UK. Twenty shoulder and 8 elbow implants, manufactured by 16 companies, have been identified. Twelve of the shoulder and one of the elbow implants have been introduced or modified in the last 8 years and have no clinical results published in peer-reviewed journals. Only the Biomodular, Bipolar, Copeland, Isoelastic, Neer hemi, Neer II, Roper-Day and Select shoulders accounting for less than 40% of the UK shoulder market, possess published results. The Capitello-condylar, Coonrad-Morrey, GSB III, Kudo, Liverpool, Roper-Tuke and Souter-Strathclyde elbows all have published results. These account for over 95% of all UK elbow replacements. The implications of these findings in an era of evidence-based medicine is discussed. Reviewing the clinical results should be of primary importance in the selection of a suitable prosthesis. Implants with a proven long-term record must represent the 'gold standard'. New or modified implants should only be used if they are part of a properly conducted clinical trial.