Suprasellar haemangiopericytoma – challenges in diagnosis and treatment

Summary Haemangiopericytomas of central nervous system (CNS) were first defined as a separate entity in 1942. Previously they were either considered to be a histological variant of an angioblastic meningioma or a distinctive mesenchymal neoplasm. Most commonly they are located in parasagittal and falcine region. Tumours in the sellar/parasellar location are very rare and commonly escape diagnosis before operation. They are characterised by high vascularity, a high rate of local recurrence and extraneuronal metastasis. We report a 35-year-old man with a suprasellar hemangiopericytoma who presented with bilateral diminution of vision in both eyes and frontal headache. Six months after the first operation, he developed a large local recurrence. He again underwent tumour decompression followed by postoperative conformal radiotherapy and is currently asymptomatic and stable clinically and radiologically. The various differential diagnoses, the importance of a preoperative suspicion of this diagnosis and management are issues discussed in this illustrated review. Correspondence: Rakesh Jalali, M.D., Associate Professor, 125 Tata Memorial Hospital, Parel, Mumbai- 400 012, India.     

Systemic fat embolism and the patent foramen ovale—A prospective autopsy study

A fat embolism is a known and common complication of blunt force injuries, especially pelvic and long bones fractures. The aim of this study was to determine the importance of a patent foramen ovale (PFO) in developing systemic fat embolism (SFE) and eventually fat embolism syndrome (FES) in patients suffering from orthopaedic blunt injuries and consequent lung fat embolism. The sample was divided: 32 subjects with a sealed foramen ovale (SFO), and 20 subjects with a PFO. In our sample, there was no difference in either the incidence of renal fat embolism in subjects with PFO compared to those with SFO (Fisher's exact test 0.228, p = 0.154) or in the grade of renal fat embolism (Pearson Chi-square 2.728, p = 0.435). However, there was a statistically significant correlation between the grade of lung fat embolism and the number of fractured bones for the whole sample (Spearman's rho 0.271, p = 0.052), but no correlation between the grade of lung fat embolism and the ISS or NISS (Pearson correlation 0.048, p = 0.736, and 0.108, p = 0.445, respectively). In our study, the presence of fat emboli in the kidney, i.e. SFE, could effectively be predicted by the grade of lung fat embolism (the moderate and slight grades of lung fat embolism were better predictors than the massive one: logistic regression – Wald. Coeff. = 11.446, p = 0.003, Wald. Coeff. = 10.553, p = 0.001, and Wald. Coeff. = 4.128, p = 0.042), and less effectively by presence of PFO (Wald. Coeff. = 2.850, p = 0.091). This study pointed out that lung and SFE are not pure biomechanical events, so the role of a PFO is not crucial in developing a lung fat embolism into a systemic embolism: the fat embolism is more of a biochemical and pathophsyiological event, than a biomechanical one. The appearance of a patent foramen ovale associated with a systemic fat embolism should be less emphasised: maybe arteriovenous shunts and anastomosis between the functional and nutritive, i.e. systemic circulation of lungs play a more important role in developing a SFE than a PFO.     

Systemic analgesics in children – update

A multimodal analgesic approach is key to providing safe and effective analgesia in children. The use of age-appropriate pain scoring systems with regular monitoring and pain assessment is essential to guide treatment and to achieve optimal pain control, while ensuring safety and minimizing unwanted effects.Due to neuroplasticity of immature pain pathways, pain in early life has been shown to lead to heightened sensitivity to pain on future exposure. Effective pain control has therefore the dual benefit of good analgesic control during an episode of pain, as well as reducing the potential for longer term pain pathway neurodevelopmental changes.An understanding of the developmental changes in pharmacokinetics and pharmacodynamics of analgesic drugs in neonates, infants and children is key to safe and effective dosing of analgesic agents across this age range. Considerations for safe and effective use of paracetamol, non-steroidal anti-inflammatory drugs opioids and adjuvant analgesics in children will be discussed.     

A “Beehive” in the Abdomen

A 22 years-old woman presenting with intestinal occlusion by a giant fecaloma. Fecal impaction is often misdiagnosed, especially in non collaborating patients. This demonstrates the necessity of particular attention to avoid unnecessary surgical intervention.     

A “giant” punch for reduction mammoplasty

A new instrument, a kind of giant punch, is useful in Strömbeck's reduction mammoplasty. Its application makes the upper cylinder of tissue excision an easy maneuver. It also guarantees that even, symmetrical amounts of parenchyma will be removed from both sides. Its three sizes permit three different amounts of tissue removal for varying degrees of reduction or asymmetries.     

Sleeve Gastrectomy—A “Food Limiting” Operation

Background  Sleeve gastrectomy (SG), which, thus far, is showing good resolution of comorbidities and good weight loss, shows increasing popularity among bariatric surgeons. The aim of this study was to evaluate clinical outcome and the gastric emptying of solid foods, 24 months after SG. Methods  Fourteen morbidly obese patients, four males and ten females, median age 41 years (range 29–65), median body mass index (BMI) 49.46 kg/m² (range 41.14–55.63), who underwent SG for weight loss, were studied prospectively. Nine patients underwent gastric emptying studies, using radioisotopic technique before, 6 months and 24 months after the operation. The remaining five patients underwent gastric emptying studies, 6 months and 24 months after the operation. Results  A significant reduction in patients’ weight and BMI was evident at 6, 12 and 24 months postoperatively. In the nine patients who underwent gastric emptying studies pre-, 6 and 24 months postoperatively, the T-lag phase duration significantly decreased, following the SG, from 17.30 (range 15.50–20.90) min, to 12.50 (range 9.20–18.00) min at 6 months and 12.16 (range 10.90–20.00) min at 24 months postoperatively (P < 0.05). The gastric emptying half time (T1/2) accelerated significantly postoperatively from 86.50 (range 77.50–104.60) min, to 62.50 (range 46.30–80.00) min at 6 months and 60.80 (range 54.80–100.00) min at 24 months after SG (P < 0.05). The percentage of gastric emptying (%GE) increased significantly postoperatively, from 52 (range 43–58) % to 72 (range 57–97) % at 6 months and 74 (range 45–82) % at 24 months, following SG (P < 0.05). No differences in gastric emptying were observed, when values at 24 months were compared to those at 6 months postoperatively. When the whole group of 14 patients was studied, there were also no significant changes in T-lag, T1/2 and %GE between 6 and 24 months postoperatively. Conclusions  Our study indicates the constant effect of SG in the acceleration of gastric emptying of solids, which occurs faster, not only in short but also in long-term postoperatively. Such effects on gastric motility, in combination with the reported alterations in gut hormones, may explain how this ‘food limiting’ operation results in weight loss.