Is There a Benefit of Frequent CT Follow-up After EVAR?

ObjectiveImaging follow-up (FU) after endovascular aneurysm repair (EVAR) is usually performed by periodic contrast-enhanced computed tomography (CT) scans. This study aims to evaluate the effectiveness of CT-FU after EVAR.MethodsIn this study, 279 of 304 consecutive patients (261 male, aged 74 years (interquartile range (IQR): 70–79 years) with a median abdominal aortic aneurysm (AAA) diameter of 58 mm (IQR: 53–67 mm)) underwent at least one of the yearly CT scans and plain abdominal films after EVAR. All patients received Zenith stent-grafts for non-ruptured AAAs at a single institution. Patients were considered asymptomatic when a re-intervention was done solely due to an imaging FU finding. The data were prospectively entered in a computer database and retrospectively analysed.ResultsAs a follow-up, 1167 CT scans were performed at a median of 54 months (IQR: 34–74 months) after EVAR. Twenty-seven patients exhibited postoperative AAA expansion (a 5-year expansion-free rate of 88 ± 2%), and 57 patients underwent 78 postoperative re-interventions with a 5-year secondary success rate of 91 ± 2%. Of the 279 patients, 26 (9.3%) undergoing imaging FU benefitted from the yearly CT scans, since they had re-interventions based on asymptomatic imaging findings: AAA diameter expansion with or without endoleaks (n = 18), kink in the stent-graft limbs (n = 4), endoleak type III due to stent-graft limb separation without simultaneous AAA expansion (n = 2), isolated common iliac artery expansion (n = 1) and superior mesenteric artery malperfusion due to partial coverage by the stent-graft fabric (n = 1).ConclusionsLess than 10% of the patients benefit from the yearly CT-FU after EVAR. Only one re-intervention due to partial coverage of a branch by the stent-graft would have been delayed if routine FU had been based on simple diameter measurements and plain abdominal radiograph. This suggests that less-frequent CT is sufficient in the majority of patients, which may simplify the FU protocol, reduce radiation exposure and the total costs of EVAR. Contrast-enhanced CT scans continue, nevertheless, to be critical when re-interventions are planned.     

The influence of timing on the effectiveness of epidural blood patches in parturients

BackgroundPostdural puncture headache is common in parturients following lumbar puncture. If headache is severe and persistent, an epidural blood patch is recommended. In this paper we reviewed the efficacy of epidural blood patches over a 13-year period at two hospitals in Finland with a particular emphasis on its timing.MethodsThe hospitals’ databases were searched to identify parturients who underwent an epidural blood patch from March 1998 to June 2011. Parturients’ records were reviewed to establish the characteristics and associated symptoms of headache and the effectiveness of the epidural blood patch.ResultsA total of 129 parturients received 151 epidural blood patches. These followed spinal (n = 49), epidural (n = 47) or combined spinal–epidural blocks (n = 33). The success rate of the first procedure was 89%, with permanent relief in 76%. The first procedure provided permanent relief of postdural puncture headache for 86% of 78 patients having the procedure after 48 h, compared to 65% of 37 patients when it was performed between 24 and 48 h, and 50% of 14 patients with the procedure within the first 24 h after dural puncture (P = 0.003). A second procedure was performed for 22 parturients due to incomplete relief (n = 5) or recurrent symptoms (n = 17); all had complete resolution of symptoms.ConclusionsEpidural blood patch performed later than 48 h following lumbar puncture or accidental dural puncture is effective in parturients with postdural puncture symptoms. The recurrence rate of symptoms after an initially successful epidural blood patch is high, and therefore patients should be provided with counselling and contact information.     

The effect of second-stage pushing and body mass index on postdural puncture headache

Study objectiveTo explore how pushing during labor and body mass index affect the development of postdural puncture headache in parturients who experienced dural puncture with Tuohy needles.DesignRetrospective cohort.SettingObstetric ward and operating rooms at a university-affiliated hospital.PatientsOne hundred ninety parturients who had witnessed dural puncture with 17 or 18 gauge Tuohy needles from 1999-2014.InterventionsPatients were categorized by pushing status and body mass index (kg/m²): nonobese <30, obese 30-39.99, morbidly obese 40-49.99, and super obese ≥50.MeasurementsHeadache, number of days of headache, maximum headache score, and epidural blood patch placement.Main resultsCompared with women who did not push, women who pushed during labor had increased risk of postdural puncture headache (odds ratio [OR], 2.1 [1.1-4.0]; P = .02), more days of headache (P = .02), and increased epidural blood patch placement (P = .02). Super obese patients were less likely to develop headache compared with nonobese (OR, 0.33 [0.13-0.85]; P = .02), obese (OR, 0.37 [0.14-0.98]; P = .045], and morbidly obese patients (OR, 0.20 [0.05-0.68]; P < .01). In a multivariate logistic regression model, lack of pushing (OR, 0.57 [0.29-1.10]; P = .096) and super obesity (OR, 0.41 [0.16-1.02]; P = .056] were no longer significantly associated with reduced risk of postdural puncture headache.ConclusionsParturients who did not push before delivery and parturients with body mass index ≥50 kg/m² were less likely to develop postdural puncture headache in a univariate analysis. Similar trends were demonstrated in a multivariate model, but were no longer statistically significant.     

Continuous epidural pumping of saline contributes to prevent and treat postdural puncture headache

Study ObjectivePostdural puncture headache (PDPH) is the most common symptom of accidental dural puncture, a frequent complication of intraspinal anesthesia. We developed a postoperative intervention technique to prevent and treat PDPH in accidental dural puncture patients, including epidural pumping of saline. This retrospective study aimed to retrospectively evaluate this new technique for PDPH prevention and treatment.DesignRetrospective study.SettingBeijing Obstetrics and Gynecology Hospital affiliated to the Capital Medical University, between January 2006 and December 2012.PatientsEighty-seven cases undergoing intraspinal anesthesia were assessed.InterventionsOf these patients, 68 cases had successful repuncture and were assigned to group A (epidural filling group, n = 68), receiving continuous epidural pumping of 0.9% NS (150 mL) at a rate of 6 mL/h; the remaining cases were assigned to group B (conservative therapy group, n = 19).MeasurementsAge, height, and body weight were collected, and postoperative headache was assessed using a visual analog scale.Main ResultsOf 68 patients in group A, 49 (72.1%) developed PDPH, whereas all in group B developed PDPH (P = .009). In addition, all patients showed PDPH within 3 days after surgery regardless of treatment group. However, a statistically significant difference was obtained for PDPH duration between groups A and B (P < .001). Multivariate logistic regression analysis showed that frequency of epidural puncture and continuous epidural pumping of saline were significant risk factors for PDPH.ConclusionsOur data indicated that application of 6 mL/h saline effectively contributes to PDPH management, and its clinical application should be broadened.     

Minimally invasive radiologic techniques in the treatment of uretero-enteric fistulas

ObjectivesThe goal of this study was to assess the efficacy of minimally invasive interventional radiologic (IR) techniques in the management of uretero-enteric fistulae in comparison to established surgical modalities.Materials and methodsTwenty-five patients (16 men, 9 women) with a mean age of 47 (range: 19–77 years) with uretero-enteric fistulae were treated with percutaneous nephrostomy, double “J” stent, radiologic uretero-neocystostomy, and radiologic uretero-pyelocalicostomy. All patients had a single fistula each. Uretero-enteric fistulas were due to direct or iatrogenic trauma in 14 patients (uretero-ileal fistulas, n = 6; uretero-colonic fistulas, n = 4; uretero-duodenal fistulas, n = 2; uretero-pancreatic fistula, n = 1; uretero-fallopian tube, n = 1), complications of pelvic neoplasms in 4 patients (uretero-sigmoid fistulas, n = 4), inflammatory disease in 4 patients (uretero-ileal fistulas, n = 2; uretero-sigmoid fistulas, n = 2), and avascular necrosis of renal transplants in 3 patients (uretero-sigmoid fistulas, n = 3).ResultsDrainage by percutaneous nephrostomy and double “J” stent resulted in closure of 8 uretero-enteric fistulae over 7–16 weeks. Four uretero-enteric fistulae obliterated after re-routing urine flow using 3 radiologic uretero-neocystostomies and one IR pyelocalicostomy. In other patients, flow through the fistulae was substantially decreased by five double “J” stents and 3 percutaneous nephrostomies. The duration of inpatient hospitalization was significantly less for patients managed successfully by IR procedures than those treated by surgical modalities, 5.07 versus 10.5 days mean (P < 0.05).ConclusionsIR procedures provided definitive treatment in 48% of uretero-enteric fistulae at significantly reduced inpatient hospitalization and cost. As palliative treatment, it improved the quality of life.     

The relationship between body mass index and post-dural puncture headache in obstetric patients

BackgroundDifficult epidural insertion and accidental dural puncture are more likely in the obese pregnant population. Low-level evidence suggests that the risk of post-dural puncture headache declines as body mass index increases.MethodsWe retrospectively reviewed prospective data on 18 315 obstetric epidural and combined spinal–epidural insertions, identifying 125 (0.7%) accidental dural punctures or post-dural puncture headaches between 2007 and 2012. The audit record and patient medical record were examined to determine patient body mass index, headache characteristics and use of a therapeutic epidural blood patch. Women were classified into two groups: non-obese (body mass index <30 kg/m², Group <30) or obese (body mass index ⩾30 kg/m², Group ⩾30). Statistical analysis was by chi-square or Fisher exact tests, with P < 0.05 considered significant.ResultsCompared to Group <30 (n = 65), women in Group ⩾30 (n = 60) did not significantly differ in the incidence of post-dural puncture headache (82% vs 80%, P = 0.83); its intensity (severe 36% vs. 23%, P = 0.34); or the need for epidural blood patch (57% vs. 54%, P = 0.81). Groups also did not differ significantly when confining analysis to those who had a witnessed accidental dural puncture (n = 93) or to women with a body mass index >40 kg/m² (n = 10) vs. Group <30.ConclusionThis retrospective study found no evidence that women of higher body mass index are less likely to develop a post-dural puncture headache or that the characteristics of the headache and use of epidural blood patch were different.     

Contribution of the foetal uro-MRI in the prenatal diagnosis of uronephropathies

PurposeTo study the complementary diagnostic value and role in the perinatal management of foetal MRI in the prenatal diagnosis of abnormalities of the urinary tract.Patients and methodsRetrospective monocentric study from November 2002 to June 2011 of foetuses benefiting from an MRI after ultrasound diagnosis of uronephropathy abnormalities. Ultrasound and MRI data were compared with postnatal radiological and/or surgical data or with the foetopathology. The MRI analysis focused on the diagnostic concordance with the ultrasound, the complementary diagnostic contribution and/or a change in perinatal care.ResultsOf the 154 MRI examined, a follow-up was obtained for 108 cases. The indications for MRI were classified into six groups: suspected renal agenesis (n = 20, 18.5%), posterior urethral valve (n = 20, 18.5%), reflux or megaureter (n = 14, 13%), uretropelvic junction syndrome (n = 24, 22.5%), enlarged kidneys (n = 7, 6.5%) and others (n = 23, 21%). The information supplied by ultrasound was confirmed by MRI in 72 patients (67%). MRI provided additional data for 36 patients (33%) and changed the perinatal care for 16 patients (15%).ConclusionFoetal uro-MRI is a useful complementary tool in the prenatal diagnosis of some uropathy abnormalities.     

Positron emission tomography/computed tomography guided percutaneous biopsies of Ga-68 avid lesions using an automated robotic arm

PurposeThe purpose of this prospective study was to evaluate the feasibility of positron emission tomography/computed tomography (PET/CT)-guided biopsy of Ga-68 avid lesions using an automated robotic arm and determine the diagnostic yield of this technique.Material and methodsPatients who underwent Ga-68 labelled tracers imaging followed by PET/CT-guided biopsies of tracer-avid lesions were prospectively included. Biopsies were performed using a dedicated automated-robotic-arm assisted PET/CT-guided biopsy device on the same-day of diagnostic PET/CT-imaging. The tissue samples were retrieved after confirming the position of needle-tip in the target lesion. Procedure-related complications and radiation exposure of the interventionist were recorded. Histopathological reports were reviewed for diagnostic yield.ResultsA total of 25 patients (19 men, six women) with a mean age of 50.8 ± 17.3 (SD) years (range: 17-83 years) were included. The biopsies were performed after PET/CT using Ga-68 DOTANOC (n = 16) or Ga-68 PSMA (n = 8) and Ga-68 chemokine-analogue (n = 1). The biopsy samples were obtained from the liver (n = 9), bone (n = 8), lymph-nodes (n = 3), lung (n = 1), pancreas (n = 1), anterior mediastinal lesion (n = 1), peritoneal-deposit (n = 1) and thigh-lesion (n = 1). No immediate or delayed procedure-related complications were documented in any patient. PET/CT-guided molecular sampling was technically successful in all the patients. Histopathology revealed malignancies in all the biopsied specimens without the need for repeat sampling or further invasive-diagnostic workup, with a diagnostic yield of 100%. The estimated absorbed-radiation dose was 566.7 μSv/year for the interventionist.ConclusionPET/CT-guided molecular biopsy using Ga-68 labelled radiotracers is feasible and can be performed safely and accurately with a high-diagnostic yield. It is helpful in accurately staging the disease when tracer-avid isolated distant lesion evident on imaging and highly practical in patients with previous inconclusive sampling.     

Surgical management of posterior fossa medulloblastoma in children: The Lyon experience

IntroductionModern approach for the treatment of posterior fossa medulloblastomas remains a challenge for pediatric neurosurgeons and pediatric oncologists and requires a multidisciplinary approach to optimize survival and clinical results.Material and methodsWe report the surgical principles of the treatment of posterior fossa medulloblastomas in children and how to avoid technical mistakes especially in very young patients. We also report our experience in a series of 64 patients operated from a medulloblastoma between 2000 and 2018 in Lyon.ResultsAll patients had a craniospinal MRI. Eighty-one percent of the patients (n = 50) had strictly midline tumor while 19% (n = 14) had lateralized one. Eleven percent (n = 7) had metastasis at diagnosis on the initial MRI. Forty-one percent (n = 29) had an emergency ETV to treat hydrocephaly and the intracranial hypertension. All patient underwent a direct approach and a complete removal was achieved in 78% (n = 58) of the cases on the postoperative MRI realized within 48 h postsurgery. Histological findings revealed classical medulloblastoma in 73% (n = 46), desmoplastic medulloblastoma in 17% (n = 11) and anaplastic/large cell medulloblastoma in 10% (n = 7). Patients were classified as low risk in 7 cases, standard risk in 30 cases and high risk in 27 cases.Ninety-six percent (n = 61) of the patient received radiotherapy. Seventy-six percent (n = 48) received pre-irradiation or adjuvant chemotherapy. At last follow-up in December 2018, 65% (n = 41) of the patient were in complete remission, 12% (n = 8) were in relapse and 27% (n = 15) had died from their disease. The overall survival at five , ten and fifteen years for all the series was of 76%, 73% and 65.7% respectively.ConclusionsMedulloblastomas remain a chimiosensible and radiosensible disease and the complete surgical removal represents a favorable prognostic factor. The extension of surgery has also to be weighted in consideration of the new biomolecular and genetic knowledge that have to be integrated by surgeons to improve quality of life of patients.     

Surgical management of persistent post-traumatic trans-tentorial brain hernia

IntroductionTemporal engagement may persist after etiologic surgical treatment of acute subdural hematoma (ASH) without clinical improvement despite normalized intracranial pressure (ICP). The aim of this study was to assess the feasibility of secondary direct temporal lobe disengagement (DTLD) after surgery for supratentorial ASH and to evaluate clinical outcome.Materials and methodsThis was a retrospective analysis of 4 patients undergoing secondary DTLD. Patient data were recorded at admission, pre- and postoperatively and at 6 months’ follow-up (FU): age, gender, Rotterdam score, Glasgow Coma Scale (GCS), neurological deficits, oculomotor nerve palsy (ONP), ICP, midline shift, complications and Extended Glasgow Outcome Scale (GOS-E).ResultsAt postoperative evaluation 48 h after DTLD, we observed a significant improvement in GCS score (initial 6 ± 3, preoperative 7 ± 3, postoperative 14 ± 1; P = 0.02), midline shift (initial 16 ± 3 mm, preoperative 13 ± 5 mm, postoperative 9 ± 2 mm; P = 0.049) and ONP (P = 0.01). In all cases, early postoperative imaging documented visualization of a patent ipsilateral peri-mesencephalic cistern. At 6-month FU, GOS-E showed 75% good recovery and 25% disability. Complete ONP recovery was observed in 75% of patients (P = 0.01). Neurological deficits were present at FU in 25% of patients. No surgery-related complications or mortality were recorded.ConclusionsIn traumatic brain injury, secondary DTLD may allow simple, effective and safe management of trans-tentorial uncal herniation, avoiding more challenging procedures. Clinical results are promising, as this technique seems to favorably influence neurological outcome in this selected subgroup of patients with persistent clinical and radiological signs of temporal engagement after etiological treatment with normal ICP values.     

Blunt splenic injury: Outcomes of proximal versus distal and combined splenic artery embolization

PurposeTo assess clinical outcomes of blunt splenic injuries (BSI) managed with proximal versus distal versus combined splenic artery embolization (SAE).Materials and methodsAll consecutive patients with BSI admitted to our trauma centre from 2005 to 2010 and managed with SAE were reviewed. Outcomes were compared between proximal (P), distal (D) or combined (C) embolization. We focused on embolization failure (splenectomy), every adverse events occurring during follow up and material used for embolization.ResultsFifty patients were reviewed (P n = 18, 36%; D n = 22, 44%; C n = 8, 16%). Mean injury severity score was 20. The technical success rate was 98%. Four patients required splenectomy (P n = 1, D n = 3, C n = 0). Clinical success rate for haemostasis was 92% (4 re-bleeds: P n = 2, D n = 2, C n = 0). Outcomes were not statistically different between the materials used. Adverse events occurred in 65% of the patients during follow up. Four percent of the patients developed major complications and 56% developed minor complications attributable to embolization. There was no significant difference between the 3 groups.ConclusionSAE had an excellent success rate with adverse events occurring in 65% of the patients and no significant differences found between the embolization techniques used. Proximal preventive embolization appears to protect in high-grade traumatic injuries.     

The management of right iliac fossa pain – Is timing everything?

BackgroundRight iliac fossa (RIF) pain remains the commonest clinical dilemma encountered by general surgeons. We prospectively audited the management of acute RIF pain, examining the relationship between symptom duration, use of pre-operative radiological imaging and patient outcome.MethodsOver a six-month period, 302 patients, median age 18 years, 59% female, were admitted with RIF pain. Symptoms, clinical findings and laboratory results were documented. Patient management, timing of radiological investigations and operations, and outcome were recorded prospectively.ResultsNon-specific abdominal pain (26%), gynaecological (22%) and miscellaneous causes (14%) accounted for most admissions. Ultimately, 119 patients (39%) had appendicitis. Anorexia, tachycardia or rebound tenderness in the RIF significantly predicted a final diagnosis of appendicitis. Patients with perforated appendicitis (n = 29) had a longer duration of pre-hospital symptoms (median 50 h) compared to those with simple appendicitis (median 17 h) (p < 0.001). The use of pre-operative imaging resulted in an increased time to surgery but was not associated with increased post-operative morbidity or perforated appendicitis.ConclusionThe majority of patients presenting to hospital with RIF pain did not have appendicitis. Increased duration of pre-hospital symptoms was the main factor associated with perforated appendicitis. However, increased in-hospital time to theatre was not associated with perforated appendicitis or post-operative morbidity.     

Omitting pre-operative coagulation screening tests in hip fracture patients: Stopping the financial cascade?

BackgroundCoagulation screening continues as a standard of care in many hip fracture pathways despite the 2011 guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which recommend that such screening be performed only if clinically indicated. This study aims to evaluate the use of pre-operative coagulation screening and explore its financial impact.MethodsProspective data was collected in accordance with the “Standardised Audit of Hip Fractures in Europe” (SAHFE) protocol. All patients admitted to our hospital with hip fractures during a 12-month period from November 2011 to November 2012 were analysed. Data including coagulation results and the use of vitamin K or blood products were collected retrospectively from the hospital computer system. Patient subgroup analysis was performed for intraoperative blood loss, post-operative blood units transfused, haematoma formation and gastrointestinal haemorrhage.Results814 hip fractures were analysed. 91.4% (n = 744) had coagulation tests performed and 22.0% (n = 164) had an abnormal result. Of these, 55 patients were taking warfarin leaving 109 patients who had abnormal results and were not taking warfarin. When this group (n = 109) was compared to those who had normal test results (n = 580) and to all other patients (n = 705) there was no difference in intraoperative blood loss (p = 0.79, 0.78), postoperative transfusion (p = 0.38, 0.30), postoperative haematoma formation (p = 0.79, 1.00), or gastrointestinal haemorrhage (p = 0.45, 1.00), respectively. In those who were not taking warfarin, but had abnormal results, none had treatment to reverse their coagulopathy with either vitamin K or blood products. By omitting pre-operative coagulation tests in patients who are not taking warfarin, we estimate a financial saving of between £66,500 and £432,250 per annum.ConclusionsThis study supports the hypothesis that routine pre-operative coagulation screening is unnecessary in hip fracture patients unless they take warfarin or have a known coagulopathy. Moreover, its omission represents significant cost-saving potential.     

Chiari malformations in adults: A single center surgical experience with special emphasis on the kinetics of clinical improvement

BackgroundThe Chiari malformation type I (CM-I) is the most commonly found type in adults. The efforts to further improve the treatment offered for these malformations are hampered by the existence of controversial methods and the absence of a uniform scoring system to evaluate clinical outcomes.ObjectivesThe goal of our study is to analyze the clinical and radiological data concerning patients operated for CM and to expose surgical techniques.Patients and treatmentThis is a retrospective study concerning patients of more than 16 years of age, operated on (from 2000 to 2016) in our institution. These patients underwent bony decompression of the cervico-occipital junction, with a duraplasty enlargement. Clinical and radiological follow-up was assessed sequentially.ResultsThe mean age of patients included in this study was 39. Headaches (n = 19) and sensory disturbances (n = 17) were the most common presenting complaints. Furthermore, syringomyelia symptoms were present in 34.5% of the cases (n = 10). Twenty-three patients displayed a Chiari malformation of type I (79.3%), and six patients were classified as Chiari malformation type I.5 (20.7%). A syringomyelia was present in 58.6% of the cases (n = 17). The postoperative complications that were encountered were: one case of pseudo-meningocele, two cases of cerebrospinal fluid leakage, two cases of meningitis, and one case of delayed wound healing. The mean follow-up period was 18 months, which showed beneficial outcomes in 82.8% of the cases (20.7% cured, and 62.1% improved) and an unfavorable outcome in 17.2% of the cases (13.8% stable patients and 3.4% worsened outcomes). Syringomyelia symptoms were improved in 60% of the patients. Among the patients who presented without a syrinx, 82.3% had good outcomes; and those who presented with a syrinx, 83.4% had good outcomes. Symptoms improved for 69% of patients within 3 months.ConclusionAn optimal craniocervical osteo-dural decompression plus duraplasty offered early and sustainable good clinical results in symptomatic CM-I and CM-I.5 patients.     

Etiology,treatment and long-term results of isolated midfoot fractures

PurposeEtiology, treatment and long-term results of patients with isolated midfoot fractures were evaluated to create a basis for treatment optimization.MethodInjury cause, type and extent, treatment and long-term results (American Association of Foot and Ankle Surgery-Midfoot-Score (AOFAS-M), Hannover Scoring System (HSS), own Questionnaire (Q)) of isolated midfoot fractures (avulsions and Chopart/Lisfranc fracture dislocations excluded) were determined.ResultsFifty-eight patients with isolated midfoot fractures were included. Injury causes were vehicular trauma (n = 40), falls (n = 13), contusions (n = 3) and others (n = 2). The fractures were located as follows: cuboid, n = 28; naviculare, n = 23; cuneiforme I, n = 19; cuneiforme II, n = 11; and cuneiforme III, n = 9. 91.4% (n = 53) of cases were treated operatively, 15 times with closed and 38 times with open reduction. Five patients were treated conservatively.Forty-seven (81.0%) patients had follow-up after 9 (1–22) years. The mean follow-up scores of the entire group were AOFAS-M = 66.7, HSS = 62.8, and Q = 62.2. No significant score differences were determined with regard to age, sex, and time or type of treatment. The highest scores were observed in non-displaced fractures or after early anatomic reduction.ConclusionIsolated midfoot fractures without Chopart's or Lisfranc's joint fracture dislocation are uncommon. The long-term results are mostly characterized by minimal functional restrictions. In cases with poor results, the initial restoration of anatomic conditions have been unsatisfactory. Therefore, we recommend the early reduction and internal fixation in all displaced fractures. The reduction should be open if the closed reduction does not achieve anatomic conditions.     

Fibroadenoma: Can fine needle aspiration biopsy avoid short term follow-up?

ObjectiveTo confirm whether fine needle aspiration biopsy (FNAB) can avoid close monitoring, a source of worry for women patients with a suspected fibroadenoma found by ultrasound, and requiring their compliance.Patients and methodsOver 39 months, 427 nodules with a diagnosis of fibroadenoma were sampled in 372 patients using ultrasound-guided FNAB. The sonographic appearance of all the nodules suggested BI-RADS category 3 fibroadenomas. The mean size of the fibroadenomas was 9 mm. The mean duration of follow-up was 29.7 months.ResultsSeven nodules had atypical cytology: a microbiopsy and/or excision found a simple fibroadenoma (n = 3), mastitis (n = 1), a fibroadenoma associated with a papilloma (n = 1), fibrosis (n = 1) and normal tissue (n = 1). Seven other nodules were resected during treatment for synchronous cancer, and were diagnosed as fibroadenomas. Two hundred and seventy-six nodules were followed-up (121 patients were lost to follow-up [n = 132]) and the appearance of 263 nodules (95.29%) was stable. Seven nodules, which had increased in size, underwent another FNAB or microbiopsy or surgery. Five nodules were not found again. The borders of one nodule showed modifications.ConclusionThe use of fine needle aspiration biopsy, interpreted by an experienced cytologist, means that short term follow-up of fibroadenomas can be avoided.     

Breast cancer in women under 40 years of age: A series of 57 cases from Northern Ireland

BackgroundThere are few studies examining breast cancer in women under the age of 40 years, particularly in western European populations. Such tumours are reported to be more aggressive, possibly due to a different pathophysiology compared to older patients.MethodsWe performed a retrospective review of all women less than 40 years of age, diagnosed or treated with breast cancer, from June 2001 to June 2007 to assess pathophysiological factors that may influence clinical outcome and prognosis including patient demographics, clinical presentation, pre-operative investigations, surgical and pathological findings, treatment and outcome.ResultsFifty-eight women (mean age 34.9 years, range 27–39 years) were identified. One patient was excluded due to incomplete data; 98.2% (n = 56) patients presented directly to our symptomatic clinic; 89.5% (n = 51) patients had a palpable lump; 71.9% (n = 41) patients had no family history. Mammography was less sensitive than ultrasound (64.3% vs. 82.4%) while fine needle aspiration cytology was 92.5% sensitive for malignancy. Twenty-nine (50.9%) patients underwent breast-conserving surgery (BCS) of which 7 proceeded subsequently to completion mastectomy due to involved margins. Twenty-six (45.6%) patients required total mastectomy primarily while 2 (3.5%) patients were treated palliatively due to metastatic disease. The mean tumour size (nearest resection margin) was 2.13 cm (2.58 mm) for BCS and 3.95 cm (6.38 mm) for mastectomy. From a total of 55 primary resections, 85.5% (n = 47) of tumours were invasive ductal carcinoma; 57.4% (n = 31) and 40.7% (n = 22) were grade II and III tumours respectively. Lymphovascular invasion was identified in 50.9% (n = 28) while 40.0% (n = 22) were lymph node positive for metastatic disease. 76.8% (n = 43), 39.3% (n = 22) and 30.2% (n = 16) were oestrogen, progesterone and human epidermal growth factor receptor-2 positive respectively. The mean Nottingham prognostic index was 4.37 (range 2.2–8.4). Neo-adjuvant and adjuvant chemotherapy was administered to 9.3% (n = 5) and 80.0% (n = 44) of surgically treated patients respectively while 76.4% (n = 42) patients received adjuvant radiotherapy. 76.4% (n = 42) of patients were treated with tamoxifen. Four patients received Herceptin® therapy. Statistically significant univariate factors adversely associated with overall survival were time from referral to out-patient department attendance (p = 0.038), administration of neo-adjuvant treatment (p = 0.019), surgical intervention (p < 0.001), progesterone receptor positivity (p = 0.018) and tumour recurrence (p < 0.001). 86.0% (n = 49) patients were alive at mean follow-up of 52 months; 82.5% (n = 47) remain disease free.ConclusionOur study reports a low familial trait rate combined with a high proportion of hormonally active tumours less than grade III which suggests that breast cancer in this series of young women from Northern Ireland may be less aggressive and more hormonally responsive than anticipated.     

Short-Term Results of A Randomized Trial Comparing Remote Endarterectomy and Supragenicular Bypass Surgery for Long Occlusions of the Superficial Femoral Artery [The REVAS Trial]

ObjectiveTechniques for surgical repair of Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions of the superficial femoral artery (SFA) are supragenicular bypass grafting or the less invasive remote endarterectomy (RSFAE). This trial compares the patency rates of both techniques.DesignRandomized, multicenter trial.Materials and methods116 patients were randomized to RSFAE (n = 61) and supragenicular bypass surgery (n = 55). Indications for surgery were claudication (n = 77), rest pain (n = 21), or tissue loss (n = 18).ResultsMedian hospital stay was 4 days in the RSFAE group compared with 6 days in the bypass group (p = 0.004). Primary patency after 1-year follow-up was 61% for RSFAE and 73% for bypass (p = 0.094). Secondary patency was 79% for both groups. Subdividing between venous (n = 25) and prosthetic grafts (n = 30) shows a primary patency of 89% and 63% respectively at 1-year follow-up (p = 0.086).ConclusionRSFAE is a minimally invasive adjunct in the treatment of TASC C and D lesions of the SFA, with shorter admittance and a comparable secondary patency rate to bypass. The venous bypass is superior to both RSFAE and PTFE bypass surgery, but only 45% of patients had a sufficient saphenous vein available.This study is registered with ClinicalTrials.gov, number NCT00566436.     

Bunionette deformity corrected with “shortening” scarf osteotomy of the fifth metatarsal: mid-term results of a 34-cases

BackgroundThe aim of this study was to evaluate the clinical and radiological outcomes (in mid-term) after “shortening” scarf osteotomy of the fifth metatarsal for the treatment of bunionette deformity.MethodsWe retrospectively reviewed the functional score — American Orthopaedic Foot and Ankle Society (AOFAS) Lesser Toe Metatarsophalangeal-Interphalangeal Scale, radiographic results — 4th/5th intermetatarsal angle, varus angle of the 5th metatarsophalangeal joint and complications in a consecutive series of 34 feet (27 patients) with bunionette. Nine males and 18 females (mean age: 45 years) were included in the study. Three males and four females were operated bilaterally The patients were operated on between 2004 and 2015, and evaluated during 2017.ResultsThe average AOFAS score improved from 59.4 to 93 at a mean follow-up of 7.2 years. The 4th/5th intermetatarsal angle and varus angle of the 5th metatarsophalangeal joint decreased from 13.9°/19.5° preoperatively to 6°/5.9° at final follow-up. No neurovascular damage was recorded. Complications arose in five feet (14.7%): delayed union (n = 1), early infection (n = 1), distal screw migration (n = 1), asymptomatic non-union (n = 1), transverse metatarsalgia (n = 1). The osteotomy healed within less than three months except twoo (delayed union, non-union). Three feet needed additional surgery: screw removal (n = 2), Weil osteotomy of 2nd–4th metatarsals (n = 1).Conclusions“Shortening” scarf osteotomy is an acceptable, but not complication-free, treatment option for the bunionette deformity and offers promising results in the mid-term.     

Nephron-sparing management (distal ureterectomy with reimplantation of ureter) for carcinoma of distal ureter: A single-center experience

ObjectiveRadical nephroureterectomy with bladder-cuff excision has been the traditional treatment for upper tract urothelial carcinoma because of its high rate of recurrence. However, given the morbidity of nephrectomy and the risk of developing chronic kidney disease or dialysis-dependent renal failure, the nephron-sparing approach may be preferable in selected patients.Materials and methodsA total of 118 patients who received unilateral distal ureterectomy with reimplantation at a single center in Taiwan were included, using surgical code numbers, from March 2006 to December 2014. A total of 82 patients were excluded due to nonmalignancy and 17 due to concomitant bladder cancer. Finally, 19 patients with primary, solitary, unilateral ureter lesions and confirmed to have ureter malignancy (urothelial carcinoma, n = 18; squamous cell carcinoma, n = 1) were included.ResultsOf the 19 patients (13 males and 6 females) included, the mean age was 69.3 ± 10.7 years. Tumor pathological staging was Tis (n = 1), Ta (n = 3), T1 (n = 2), T2 (n = 6), and T3 (n = 5). Histopathology grading was low grade (n = 3) and high grade (n = 13). No local recurrence was noted; nine patients had bladder recurrence (47.4%), three had distant metastasis (15.8%), and two had progression and finally underwent radical nephroureterectomy (10.5%). The mean time to bladder recurrence was 12.4 months (3–24 months); the mean follow-up time was 28.1 months (1–90 months). The 5-year overall survival rate was 73.7% (14/19); four patients were lost to follow-up, and one patient expired. The mean 5-year progression-free survival was 67.74%. The mean preoperative creatinine level was 1.61 mg/dL, and at 12 months after operation it was 1.56 mg/dL (p = 0.95).ConclusionIn selected patients, distal ureterectomy with reimplantation, in our experience, is a feasible option for distal ureter tumor. Favorable postoperative outcomes with a low local recurrence rate, a low rate of progression to nephroureterectomy, and renal function preservation may prove the value of this modality and should be taken into consideration in suitable patients.