What is the difference between IgA nephropathy and Henoch-Schönlein purpura nephritis?

Henoch-Sch?nlein purpura nephritis (HSPN) and IgA nephropathy (IgAN) are considered to be related diseases since both can be encountered consecutively in the same patient, they have been described in twins, and bear identical pathological and biological abnormalities. Apart from the presence of extrarenal clinical signs found only in HSPN, other differences are noticed between the two diseases. The peak age ranges between 15 and 30 years for a diagnosis of IgAN, whereas HSPN is mainly seen in childhood. Nephritic and/or nephrotic syndromes are more often seen at presentation in HSPN. In contrast to IgAN, HSPN has been described in association with hypersensitivity. Endocapillary and extracapillary inflammations as well as fibrin deposits in the glomerulus are more frequent in HSPN. No major biological differences have been found between the two illnesses, except for a larger size of circulating IgA-containing complexes (IgA-CC) and a greater incidence of increased plasma IgE levels in HSPN. As tissue infiltration by leukocytes is a major feature of HSPN vasculitis, a possible role of a more potent activation of the latter cells by IgA-CC and/or circulating chemokines in HSPN should be considered. Further studies are required to elucidate this possible mechanism as well as the role of hypersensitivity in HSPN.     

Can the intraoperative leak test prevent postoperative leakage of esophagojejunal anastomosis after total gastrectomy?

Purpose

Anastomotic failures that cannot be detected during surgery often lead to postoperative leakage. There have been no detailed reports on the intraoperative leak test for esophagojejunal anastomosis. Our purpose was to investigate the utility of routine intraoperative leak testing to prevent postoperative anastomotic leakage after performing esophagojejunostomy.

Methods

We prospectively performed routine air leak tests and reviewed the records of 185 consecutive patients with gastric cancer who underwent open total gastrectomy followed by esophagojejunostomy.

Results

A positive leak test was found for six patients (3.2 %). These patients with positive leak tests were subsequently treated with additional suturing, and they developed no postoperative anastomotic leakage. However, anastomotic leakage occurred in nine patients (4.9 %) with negative leak tests. A multivariate analysis demonstrated that a patient age >75 years and the surgeon’s experience <30 cases were risk factors for anastomotic leakage.

Conclusion

Intraoperative leak testing can detect some physical dehiscence, and additional suturing may prevent anastomotic leakage. However, it cannot prevent all anastomotic leakage caused by other factors, such as the surgeons’ experience and patients’ age.

     

No clinical difference between large metal-on-metal total hip arthroplasty and 28-mm-head total hip arthroplasty?

Purpose  

We aimed to test the claim of greater range of motion (ROM) with large femoral head metal-on-metal total hip arthroplasty.     

What is the place of antrectomy with Roux-en-Y in the treatment of reflux disease? Experience with 83 total duodenal diversions

Antrectomy with Roux-en-Y gastrojejunostomy was performed in 83 patients with complicated forms of peptic esophagitis. The esophagitis was considered complicated either because of the severity of the lesions (stricture, brachyesophagus, or endobrachyesophagus) or because of postoperative conditions after one or more previous operations (Heller's myotomy, esophagogastric resections, or hiatal hernia repair).A standard procedure was performed in 56 patients while technical adjustments were required for 27 patients who had previously undergone surgery. Two patients died from pulmonary embolism. Early postoperative complications occurred in 11% of patients. Healing of esophagitis was observed for all the patients treated with the standard procedures. Six partial regressions and 1 complete regression of Barrett's mucosa were observed. Digestive sequellae were minor and decreased with time. Assessment of pH and small bowel manometry showed that the reflux was controlled and no small bowel motility disturbance was observed when the standard technique was used including a small gastric resection. The main digestive sequellae, including lack of healing of esophagitis, dumping syndrome, and gastrojejunal anastomotic ulcer, occurred when a two-thirds gastrectomy was performed in order to avoid vagotomy.

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Resumen Se ha realizado antrectomía con gastroyeyunostomía de Roux-en-Y en 83 pacientes con formas complicadas de esofagitis péptica debidas a la severidad de la lesión (estrechez, braquiesófago, endobraquiesófago) en 52 casos, o a condiciones postoperatorias desarrolladas después de una o varias operaciones tales como miotomía de Heller, resecciones esofagogástricas o reoperaciones después de corrección de hernia hiatal. Los propósitos del presente estudio fueron: a) informar los resultados de la exclusión duodenal total en 83 pacientes con esofagitis péptica complicada; b) analizar los resultados del seguimiento de estos pacientes; c) valorar la utilidad de este procedimiento en el tratamiento de la enfermedad por reflujo.Se realizó un procedimiento estándar en 56 casos, en tanto que fué necesario practicar ajustes técnicos en 27 pacientes que habían sido previamente operados. Dos pacientes murieron por embolia pulmonar. Se registraron complicaciones postoperatorias tempranas en 11% de los casos. Se observó cicatrización de la esofagitis en todos los pacientes tratados con el procedimiento estándar; se registró regresión parcial de mucosa de Barrett en 6 casos y regresión completa en uno. Las secuelas digestivas fueron menores y disminuyeron con el paso del tiempo. La determinación del pH y la manometría de intestino delgado demostraron que el reflujo fue controlado, y no se observó anormalidad de la motilidad intestinal cuando se utilizó la técnica operatoria estándar, incluyendo una resección gástrica menor. Las principales secuelas digestivas, incluyendo escape anastromótico, síndrome de dumping y úlcera anastomótica gastroyeyunal ocurrieron cuando se realizó gastrectomía de dos tercios para evitar vagotomía. Al final del seguimiento 80% de los pacientes consideraban tener un resultado excelente, 17% presentaban alguna secuela y 3% estaban peor que antes de procedimiento. La mortalidad fue de 2.4% y la morbilidad de 11%.

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Résumé On a pratiqué une antrectomie associée à une gastrojéjunostomie chez 83 patients ayant une oesophagite peptique compliquée, soit en raison de la sévérité des lésions (sténose, endobrachyoesophage) soit, dans 52 cas, en raison de conditions post-opératoires induites par une ou plusieurs interventions comme la myotomie de Heller, une résection oesogastrique ou certains cas sélectionnés de patients réopérés pour une cure de hernie hiatale.Une intervention standard a été pratiquée chez 56 patients alors que des adaptations techniques ont été nécessaires chez 27 patients déja opérés antérieurement. Deux patients sont décédés d'embolie pulmonaire. Des complications précoces ont été observées chez 11% des patients. La cicatrisation de l'oesophagite a été obtenue chez tous les patients ayant bénéficié d'une intervention standard. On a observé 6 régressions complètes et une régression incomplète chez les patients porteurs d'un endobrachyoesophage (oesophage de Barett). Les séquelles digestives ont été minimes et ont diminué avec le temps. La pHmétrie et la manométrie du grêle ont confirmé que le reflux était contrôlé et qu'il n'y avait pas de trouble moteur de l'intestin grêle après l'intervention standard comprenant une résection gastrique minime. Les principales séquelles digestives, comprenant l'absence de cicatrisation de l'oesophagite, le dumping syndrome et l'ulcère anastomotique ont été observées en cas de gastrectomie des 2/3 sans vagotomie.

     

Is there a difference between the ability to kneel after unilateral and bilateral total knee replacement?

This study investigates the difference between the ability to kneel in patients after unilateral and bilateral total knee replacement. We used the Oxford knee questionnaire to assess knee function, and an additional question was introduced to identify the reasons for any difficulty or inability to kneel. Responses were received from 424 patients representing an 88.9% response rate. There was a statistically significant (p < 0.01) difference in kneeling ability between the two groups. With bilateral total knee replacement, 73% of patients found it extremely difficult or impossible to kneel, compared to 62% of patients with unilateral total knee replacement. There was no statistical difference between the two groups in their overall Oxford knee function score or in their responses on reasons for difficulty or inability to kneel.     

What is the best reconstruction method after distal gastrectomy for gastric cancer?

Background

We performed this prospective randomized study to evaluate what is the best reconstruction method after distal gastrectomy for gastric cancer.

Methods

One hundred fifty-nine patients who underwent laparoscopy-assisted or open gastrectomy for gastric cancer were analyzed from March 2006 to August 2007. Billroth I (B-I) anastomosis, Billroth II (B-II) with Braun anastomosis, and Roux-en-Y (R-Y) anastomosis were applied randomly. Additionally, the patients were divided into two groups based on treatment type: laparoscopic and open operation. Endoscopy and hepatobiliary scans were performed to investigate gastric stasis and enterogastric reflux. The Gastrointestinal Quality of Life Index (GIQLI) was used to evaluate postoperative quality of life, and the hematologic test was used to assess nutritional aspect.

Results

Endoscopy revealed that reflux after the R-Y anastomosis procedure was significantly less frequent than after the other anastomosis types at 12?months. Comparison of the GIQLI and the nutritional parameters between the reconstruction types revealed that there were no differences, but a significantly higher GIQLI score was observed in the laparoscopic group immediately following the procedure (P?=?0.042).

Conclusions

R-Y anastomosis is superior to B-I and B-II with Braun anastomosis in terms of frequency of bile reflux, despite the fact that there is no difference in the postoperative quality-of-life index and nutritional status between reconstructive procedures. The laparoscopic approach is the better option than open surgery in terms of QOL in the immediate postoperative period.     

What is the role of the sleeve gastrectomy in the surgical treatment of morbid obesity?

Background

Laparoscopic sleeve gastrectomy (SG) is a relatively new procedure that is gaining wide acceptance and represents an innovative new approach to the surgical management of morbid obesity. Our purpose is to evaluate the SG as a surgical bariatric procedure.

Methods

We conducted a literature review on “PubMed” based on all publications related to SG since 2000 to July 30, 2014.

Results

The complication rate after SG varies in the literature, ranging from 0 to 29 %. The most feared complication after SG is leakage on the staple line, occurring in 0–7 % of cases. The mortality rate reported varies between 0 and 3.3 %. No consensus has developed on the types of stapling used or the methods of strengthening the staple line. SG may aggravate and be responsible for gastroesophageal reflux disease (GERD). SG improves comorbidities in more than 50 % after 5 years.

Conclusions

SG can be proposed as a surgical technique at first intension in patients not having GERD.     

Acute appendicitis: is there a difference between children and adults?

Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 +/- 4.3 days vs 2.5 +/- 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 +/- 2.7 hours vs 5.7 +/- 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count > or =12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 +/- 3.3 days compared with nonperforated cases, 2.3 +/- 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.     

What is the relationship between free flow and pressure flow studies in women?

Introduction and hypothesis

The relationship between free flow (FFS) and pressure flow (PFS) voiding studies remains uncertain and the effect of a urethral catheter on flow rates has not been determined. The relationship between residuals obtained at FF and PFS has yet to be established.

Methods

This was a prospective cohort study based on 474 consecutive women undergoing cystometry using different sized urethral catheters at different centres. FFS and PFS data were compared for different conditions and the relationship of residuals analysed for FFS and PFS. The null hypothesis was that urethral catheters do not produce an alteration in maximum flow rates for PFS and FF studies.

Results

Urethral catheterisation results in lower flow rates (p?<?0.01) and this finding is confirmed when flows are corrected for voided volume (p?<?0.01). FFS and PFS maximum flow rates are lower in women with DO than USI (p?<?0.01). A 6-F urethral catheter does not have a significantly greater effect than a 4.5-F urethral catheter. A mathematical model can be applied to transform FFS to PFS flow rates and vice versa. There was no significant difference between the mean residuals of the two groups (FFS vs PFS—two-tailed t?=?0.54, p?=?0.59). Positive residuals in FFS showed a good association with positive residuals in the PFS (r?=?0.53, p?<?0.01)

Conclusions

Urethral catheterisation results in lower maximum flow rates. The relationship can be compared mathematically. The null hypothesis can be rejected.     

Evaluation of “Alkaline” reflux esophagitis after total gastrectomy in Henley and Roux-en-Y reconstructive procedures

The occurrence of reflux esophagitis was evaluated in 2 groups of patients who had undergone total gastrectomy. In group 1 (4 patients) gastrointestinal continuity was restored by Henley's method of esophagojejunoduodenostomy, and in group 2 (4 patients) reconstruction was accomplished by Roux-en-Y esophagojejunostomy. Cineradiography, intraesophageal pH measurements, esophagoscopy, esophageal biopsies, and study of intestinal motility were performed. Alkaline esophageal reflux was observed only in group 2, and a high frequency of esophageal symptoms and esophagitis were found in this group. These results can be correlated with the different motor behavior in the jejunum used for reconstruction, occurring in the 2 groups of patients.

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Résumé L'oesophagite par reflux après gastrectomie totale a été comparée dans, 2 groupes d'opérés dont la continuité digestive avait été rétablie, soit par transplant jéjunal selon Henley (groupe 1 4 malades), soit par oesojéjunostomie en Y (groupe 2 4 malades). Tous les opérés ont été étudiés par cinéradiographie, mesure du pH oesophagien, oesophagoscopie, biopsies de l'oesophage et enregistrement de la motilité intestinale. C'est dans le groupe 2 seulement que nous avons observé du reflux alcalin dans l'oesophage et une fréquence élevée de symptomes oesophagiens et d'oesophagites. Ces résultats concordent avec les différences d'activité motrice de l'anse jéjunale anastomosée à l'oesophage.