A Colon Resection and Pump Implantation in the Same Surgical Procedure: Is it Safe?

Annals of Surgical Oncology -     

Dual Hip DXA. Is it Time to Change Standard Protocol?

Previous studies have examined the utility of bilateral DXA hip bone mineral density (BMD) scans. While most studies demonstrate an advantage of bilateral hip scanning, the studies have been limited by size, or have not included simultaneous lumbar spine scans. To analyse the utility of dual hip scans in a clinical environment, a large retrospective study was performed of DXA BMD of both hips, and lumbar spine, in 17,169 individuals assessed at one centre over 10 years. There was no clinically significant difference in the population mean femoral neck BMD of the left vs the right leg (0.878 vs 0.881g/cm2) or total proximal femoral BMD of the left vs the right leg (0.920 vs 0.919g/cm2). There were however discrepancies in individuals between hip t-scores. For the total hip 1,977 (11.5 %) and 147 (0.9 %) of subjects had absolute t score differences ≥ 0.50 or ≥ 1.00. respectively. For the femoral neck 3,320 (19.3%) and 337 (2.0%) of subjects had absolute t score differences ≥ 0.50 or ≥ 1.00. respectively. Of the total 17,169 individuals there were 2,776 subjects with osteoporosis (T≤ -2.5) using the lumbar spine and right hip, compared to 2,834 subjects using the lumbar spine and left hip. Using the lumbar spine and both hips identified 3,214 individuals with osteoporosis. Diagnosis based on use of the lumbar spine and right hip BMD, or lumbar spine and left hip BMD, therefore failed to identify 15.8%, or 13.4%, of osteoporotic subjects respectively. Additional scanning time required was assessed in 40 subjects prospectively. Performing lumbar spine and both hips, compared to lumbar spine and one hip, required an average additional scan time of 55 seconds. The recommendation of best practise for DXA BMD measurements should be reviewed to consider lumbar spine and dual hip DXA as standard of care.     

Open Repair for Ruptured Abdominal Aortic Aneurysm: Is It Possible to Predict Survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.     

Is it Time for Cementless Hip Resurfacing?

Background

Metal-on-metal bearing with cemented femoral component and cementless acetabular fixation is the current standard in surface replacement arthroplasty (RSA) of the hip. Because of concerns about the long-term survivorship of cemented stems in conventional hip arthroplasty, it seems logical to achieve cementless fixation on the femoral side with RSA.

Questions/Purposes

The goals of this review were to evaluate clinical and radiological data reported from previously published cementless RSA series. In addition, we intend to review author’s preliminary experience with Conserve Plus cementless devices specifically assessing the clinical outcomes, the complications rate, the survivorship, and the metallic ions levels measured in follow-up.

Methods

A references search was done with PubMed using the key words “cementless hip resurfacing”, “cementless hip resurfacing prosthesis”, and “femoral cementless hip resurfacing”. Additionally, the clinical outcomes, the complications rate, the survivorship, and the metallic ions levels were measured in 94 cementless Conserve Plus^© devices in 90 patients (68 males and 22 females) with a mean age of 41.1 years (18–59). Mean follow-up was 13.1 months (8–16).

Results

No revision was performed during the observed follow-up. Neither radiological signs of loosening nor neck narrowing >10% were evident. Chromium and cobalt levels in whole blood samples rose respectively from 0.53 μg/l (0.1–1.7) to 1.7 μg/l (0.6–2.9) and from 0.54 μg/l (0.1–1.4) to 1.98 μg/l (0.1–2.8).

Conclusions

Cementless “fit and fill” femoral-side fixation, which seems to be potentially evolved and design-related, should be considered for future hip-resurfacing device generations.     

Is it Time to Stop Checking Frozen Section Neck Margins During Pancreaticoduodenectomy?

Background

Residual disease after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) adversely impacts survival. The value of taking additional neck margin after a positive frozen section (FS) to achieve a negative margin remains uncertain.

Methods

All patients who underwent PD for PDAC from January 2000 August 2012 were identified and classified as negative (R0) or positive (R1) based on final neck margin. We examined factors for association with a positive FS neck margin and overall survival (OS). We assessed the value of converting an R1 neck margin to R0 via additional parenchymal resection.

Results

A total of 382 patients had FS neck margin analysis, of which 53 (14 %) were positive. Positive FS neck margin was associated with decreased OS (11.1 vs. 17.3 months, p = 0.01) on univariate analysis. On multivariate analysis poor histologic grade (p = 0.007), increased tumor size (p = 0.003), and a positive retroperitoneal margin (p = 0.009) were independently associated with decreased OS, but positive FS neck margin was not. Of the 53 patients with positive FS, 41 underwent additional neck resection and 23 were converted to R0. On permanent section, R0 neck margin was achieved in 322 patients (84 %), R1 in 37 patients (10 %), and R1 converted to R0 in 23 patients (6 %). Both the converted and the R1 groups had significantly poorer OS than the R0 group (11.3 vs. 11.1 vs. 17.3 months respectively; p = 0.04).

Conclusions

Positive FS margin at the pancreatic neck during PD for PDAC is associated with poor survival. Extending the neck resection after a positive FS to achieve R0 margin status does not appear to improve OS.