Occipitocervicothoracic fixation using a hook and rod system for patients with rheumatoid cervical spine

Abstract

We retrospectively examined the outcomes of occipitocervicothoracic fixation using a hook and rod system for rheumatoid patients with cervical myelopathy in which decompression of the spinal cord and spinal fusion were performed simultaneously at multiple levels. There were 10 female patients with rheumatoid arthritis (ages 51–77 years, average 62.8 years; follow-up period 6 months to 3 years and 9 months, average 2 years and 8 months). Atlantoaxial subluxation was found in 5 patients, vertical subluxation in 4 patients, and subaxial subluxation in 8 patients. The progression of the disorder was assessed as class 4 stage 4 in 3 patients and class 3 stage 4 in 7 patients. The average time taken for surgery was 4?h 41?min, and the average volume of blood loss was 729?ml. There were no complications during surgery. One patient died of malignant lymphoma 1 month after surgery, and one patient died of heart failure 2 years and 3 months after surgery. The average Japanese Orthopaedic Association (JOA) score improved from 7.0 preoperatively to 9.5 postoperatively. Preoperative nuchal pain in 3 patients and difficulty in breathing on flexion of the cervical spine in 2 patients were improved after surgery. Good bony union was obtained in 9 patients. The exception being one patient who died of a disease unrelated to the surgery 1 month postoperatively. Occipitocervicothoracic fixation using a hook and rod system is an easy and safe procedure, and can facilitate not only good bony union, but also adequate decompression of the spinal cord with simultaneous laminoplasty because of the secure long fixation extending to the upper thoracic level and bilateral grafting of a considerable volume of bone.     

The surgical treatment of destructive forms of tuberculosis of the cervical spine

The paper analyzes the outcomes of surgical treatment in 19 patients with tuberculosis of the cervical part of the vertebral column. All the patients had surgical treatment: abscessotomy, sparing resection of a destruction area, decompression of the spinal cord, removal of kyphotic deformity by restoring the axis of the vertebral column. The existing defect was filled with an autograft in 7 cases, with a biocompatible implant by applying benemycin to its surface in 12 cases. Posterior fixation of the diseases part of the spinal apparatus was made in 8 cases. Good outcomes were followed up 8 months to 7 years after surgery. At X-ray study, the bony block formed between the resected vertebral bodies within 3 to 7 months. Neurological symptoms were arrested in all cases, except 4 ones. One patient was found to have a slight lower extremity weakness and 3 patients had correctable radicular symptoms.     

Gastric cancer in very young adults: apropos four patients and a review of the literature

Whether gastric cancer in young adults differs from gastric cancer in older patients has been a controversial issue. It has long been suspected that young patients with gastric cancer have different biological features with a more aggressive course of disease and a poorer prognosis than older patients. This, however, has not been firmly substantiated. We report on the clinical course of four patients (three female and one male) with locally advanced (n  =  1) or metastasized (n  =  3) non-resectable gastric cancer diagnosed under the age of 29 years (23, 25, 27, 28 years). Prior to diagnosis, all three women had recently been pregnant (1–22 months). Diagnosis was endoscopically biopsy-proven and staging work-up was performed by primary explorative surgery (n  =  1), laparoscopy and explorative surgery (n  =  1) or CAT scan and ultrasound (n  =  2). The delay between initial symptoms and diagnosis was 8–22 weeks (median, 10 weeks). The histology was signet-ring cell (n  =  2) or undifferentiated (n = 2) gastric cancer. All patients had the diffuse type of gastric cancer according to Lauren. Patients were treated with the FLAP polychemotherapy regimen consisting of leucovorin, 5-fluorouracil, doxorubicin and cisplatinum, as previously reported. The best response after chemotherapy was partial in two patients. Two patients showed progressive disease. Secondary surgery was performed in three responding patients (one of them responded only locally). One patient achieved no evidence of disease after complete tumor resection (R0). In two patients surgery was palliative (R2/exploration). Three patients died 6, 4 and 8 months after diagnosis. One patient is still alive. In our series, very young adults with gastric cancer had adverse clinical and pathological features. In accordance with other reports, we observed a predominance of female patients and a possible association with recent pregnancies. Though the delay between the first symptoms and diagnosis in our patients was no different from that reported for older patients, special emphasis should be given to prompt referral and diagnostic investigations, ensuring the diagnosis of gastric cancer early in the course of disease. Received: 3 August 1999 / Accepted: 8 September 1999     

Multivariate Analysis of Predictive Factors for Early Postoperative Death After Colorectal Surgery in Patients with Colorectal Cancer and Synchronous Unresectable Liver Metastases

Purpose Surgery of the primary tumor in patients with colorectal cancer and unresectable synchronous liver metastases remains controversial. This study was designed to evaluate predictive preoperative factors of early postoperative death (<3 months) in such patients. Methods This study included 80 patients who underwent colorectal resection (n = 56) or diversion stoma (n = 24) for colorectal cancer with unresectable liver metastases. Twenty-two patients (28 percent) died during the first three months after surgery with two (2.5 percent) in-hospital postoperative deaths. Analysis of predictive preoperative factors for three-month postoperative death risk was performed. Results In univariate analysis, age older than 75 years (P = 0.01), American Society of Anesthesiologists grade > II (P = 0.009), symptomatic patient (P = 0.01), bowel obstruction (P = 0.03), aspartate aminotransferase serum level >50 (1.5 N) IU/L (P = 0.008), and alkaline phosphatase >200 (2 N) IU/L (P = 0.02) were prognostic risk factors for three-month death after surgery. In multivariate analysis, age older than 75 years (relative risk = 7.9; P = 0.04) and aspartate aminotransferase serum level >50 IU/L (relative risk = 8.3; P = 0.03) were independent risk factors. Conclusions In patients with colorectal cancer and synchronous unresectable liver metastases, the three-month mortality rate was high (28 percent). Thus, better knowledge of risk factors could help select patients who could possibly benefit from surgery. The study suggested that age older than 75 years and liver cytolysis (>1.5 N) are associated with an increased three-month postoperative death risk. In these patients, surgery should be avoided. Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Pegylated doxorubicin for primary cutaneous T-cell lymphoma: a report on ten patients with follow-up

Purpose: Pegylated liposomal doxorubicin (PEG-DOXO) was found to be effective in primary cutaneous T-cell lymphomas (CTCL). The present observation reports on follow-up and relapse-free interval in patients with CTCL. Methods: Ten patients (one female, nine male) aged 50–78 years (mean 66.7 years) with relapsing or recalcitrant CTCL, stage I b (n=3), II a (2), II b (3), IV a (1), and IV b (1) were treated with PEG-DOXO 20 mg m⁻² once a month with an upper limit of 400 mg or eight infusions to induce a clinical response. There was one drop out after a single infusion because of a capillary leak syndrome. Results: In nine patients with PEG-DOXO the best response was a complete response (CR) in five patients and a partial response (PR) in four patients. The final outcome was CR in six, PR in two, stable disease (SD) in one, and progressive disease (PD) in another patient. The overall response rate (CR + PR) was 80% (of ten patients). The follow-up was 2–22 months (mean 12.8 ± 7.1 months). The overall survival was calculated as 19.8 ± 7.4 months with eight out of ten patients still alive. Response duration was 15.2 ± 3.9 months, disease-free survival 13.3 ± 6.1 months, event-free survival 16.7 ± 9.0 months, and progression-free survival 18.2 ± 6.5 months. Four patients (stage I b and II b) achieved 12–19 months of disease-free survival. The follow-up after the first course with PEG- DOXO was 2–22 months (mean 12.8 ± 7.1 months). The survival rate after 12 months of follow-up was 80% (n=5). One patient free of relapse died after 12 months because of pulmonary embolism not related to disease or treatment. Another patient died 1 month after a second course of PEG-DOXO in an advanced tumor stage of CTCL. The most frequent side effects of treatment were anemia and lymphopenia without the need of supportive treatment or dose-reduction. Only one patient developed toxicity of grade 4 (anemia). Conclusions: These results indicate that patients with relapsing or recalcitrant CTCL can achieve an 80% response rate with PEG-DOXO and long-term remissions. Received: 26 April 2000 / Accepted: 9 June 2000     

单侧开门外侧块螺钉固定植骨治疗颈脊髓压迫症

目的 探讨单侧开门外侧块螺钉固定植骨术治疗颈脊髓压迫症的临床疗效.方法 自2004-02～2008-06采用单侧开门外侧块螺钉固定植骨术治疗颈脊髓压迫症26例,男18例,女8例;年龄51～67岁,平均58岁.26例中有22例为多节段脊髓型颈椎病(3个或3个节段以上),其中10例合并发育性椎管狭窄症(6例合并动力性椎管狭窄症,3例合并后纵韧带骨化症,1例为外伤性);4例为颈椎管内肿瘤.随访9个月～2年2个月,平均1年8个月.结果 疗效评定标准参照日本整形外科协会(JOA)评分标准,优8例,良15例,可2例,差1例,优良率为88.5%.无一例出现血管损伤或内固定物断裂并发症,1例脊膜瘤因肿物过大术后出现脊髓再灌注损伤表现,经积极治疗好转,生活可自理.结论 该法适用于需要从后方入路进行减压的颈脊髓压迫症,疗效肯定.其优点是手术相对安全,在彻底减压的同时进行坚强的内固定,尤其适用于伴有节段性不稳的脊髓型颈椎病.     

Function and Quality of Life After Transanal Excision of Rectal Polyps and Cancers

Purpose The purpose of this study was to determine the functional outcomes and health-related quality of life of patients after transanal excision of rectal cancers or polyps and to assess the relationship between functional outcomes and health-related quality of life. Methods All patients having a transanal excision at the Mount Sinai Hospital from 1989 to 2002 were included if the indication for surgery was a benign or malignant neoplasm. Physician charts were reviewed, and patients and their physicians were contacted to obtain follow-up information. Continence was assessed by using the Continence Score described by Jorge and Wexner and the Fecal Incontinence Quality of Life instrument by Rockwood and Lowry. Results Eighty-two patients fit the inclusion criteria (42 males; mean age, 71 ± 13.7 years). Of these, 29 had villous adenomas, 2 had carcinoids, and 1 had a hyperplastic polyp. Fifty had cancers, including 34 with T1, 14 with T2, and 2 with T3 cancers. Seven patients had a low anterior resection or abdominoperineal resection within two months of transanal excision because of advanced features of cancer. Five patients had salvage abdominoperineal resections or low anterior resections for local recurrences. Five patients died of rectal cancer (including 3 who had salvage surgery) and an additional seven patients died of other causes. Functional results were assessed in 58 of 61 eligible patients. The mean Continence Score postoperatively was 3.5 ± 3.9 compared with 2.4 ± 3.7 preoperatively (P = 0.03). The mean Fecal Incontinence Quality of Life scores after surgery in all patients were 3.9 ± 0.3, 3.6 ± 0.6, 3.7 ± 0.3, 3.7 ± 0.6 in the domains of lifestyle, coping, depression, and embarrassment, respectively, after surgery, indicating high quality of life. Using Spearman’s correlation, we found that the continence scores after surgery correlated well with the Fecal Incontinence Quality of Life scores. In the domains of lifestyle (Spearman’s correlation = −0.69), coping and behavior (Spearman’s correlation = −0.7), and embarrassment (Spearman’s correlation = −0.61) but did not correlate well with the domain of depression (Spearman’s correlation = −0.17). Conclusions Although functional results are worsened in a minority of patients after transanal excision, quality of life is high in the majority of patients. Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Assessment of cervical pain and function in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by inflammation of the synovial membrane, which can lead to deformities and functional disability. Unlike the dorsal and lumbar spine, the cervical spine is often affected by RA. The objective of this paper is to assess cervical pain and function in patients with RA and correlate these variables with overall function, quality of life, and radiographic findings on the cervical spine. One hundred individuals aged 18 to 65 years were divided into study group (50 patients with rheumatoid arthritis) and control group (50 healthy individuals, paired for gender and age). Patients with prior surgery, prior trauma or other symptomatic cervical spine condition were excluded. The visual analogue pain scale (VAS), Neck Pain and Disability Scale (NPDS), SF-36, HAQ and X-rays were used for evaluation purposes. Mean disease duration was 11.1 years. The cervical VAS was 2.4 cm and 1.3 cm for the study and control groups, respectively (p = 0.074). Statistical differences were found in NPDS scores, mean = 26.7 and 6.9, and HAQ scores, mean = 1.1 and 0.1, for the study and control groups, respectively (p < 0.001). SF-36 scores were statistically worse in the study group, except for the vitality, social aspects and mental health subscales. There was a positive correlation between the NPDS and VAS (r = 0.54) and between the NPDS and HAQ (r = 0.67). There was a negative correlation between the NPDS and SF-36 functional capacity domain (r = −0.53) and physical limitation domain (r = −0.58). The radiographic findings revealed more prevalent anterior atlanto-axial subluxation (p = 0.030), listhesis in neutral posture (p = 0.037), listhesis in extension (p = 0.007), degenerative alteration of C4–C5 segment (p = 0.023), size of C2 spinal canal (p = 0.002) and C3 spinal canal (p = 0.029) in the study group. Patients with RA have poorer cervical function than healthy individuals, although there is no difference in cervical pain.     

一期前路病灶清除并钛笼肋骨植骨加钉棒系统内固定治疗胸椎结核(附21例报告)

目的 分析一期前路病灶清除并钛笼肋骨植骨加钉棒系统内固定治疗胸椎结核的临床效果。方法 2009年9月至2016年12月采用一期前路病灶清除并钛笼肋骨植骨加钉棒系统内固定术治疗胸椎结核28例,获得随访21例,男14例,女7例,其中胸5、6椎体结核1例,胸6、7椎体结核3例,胸7、8椎体结核3例,胸9、10椎体结核 2例,胸10、11椎体结核4例,胸11、12椎体结核2例;胸6、7、8椎体结核1例,胸7、8、9椎体结核3例,胸9、10、11椎体结核2例;根据术前、术后随访的Frankel脊髓损伤分级、视觉模拟评分法(VAS)评分结果,以及脊柱后凸Cobb角矫正和植骨融合情况评价临床治疗效果。结果 随访10个月至7年,Frankel分级,术前B级1例,C级5例,D级6例,E级9例;末次随访时D级4例,E级17例。VAS评分术前平均为(6.29±1.27)分,术后1周平均为(2.81±0.87)分,末次随访时平均为(1.24±0.89)分。术前测量患者的Cobb角平均为(19.81±11.08)°,术后1周平均为(3.81±2.77)°,末次随访时平均为(4.52±3.23)°;21例患者均获骨性融合,融合时间5~11个月,平均(6.93±1.33)个月,至末次随访未发现内固定钉棒系统松动、脱落及断裂。结论 一期前路病灶清除并钛笼肋骨植骨加钉棒系统内固定术治疗胸椎结核,能有效清除病灶,解除神经压迫,矫正后凸畸形,重建脊柱稳定性,可获得良好的临床效果。     

Vincristine as salvage treatment for refractory thrombotic thrombocytopenic purpura

 Vincristine (1.4 mg/m² on day 1, followed by 1 mg on days 4 and 7) was given to eight patients with thrombotic thrombocytopenic purpura (TTP) who were refractory to plasma exchange (n=4) or plasma infusion (n=4). Seven of eight patients (87%) achieved a complete response; one was refractory to treatment and died within a few weeks. After a median follow-up of 50 months, all responding patients are alive and well. Two patients relapsed and were successfully retreated with vincristine. Toxicity was mild, consisting of two episodes of leukopenia and one of autonomic neuropathy leading to paralytic ileus in a patient aged 70 years. We conclude that vincristine is highly effective in the treatment of patients suffering from refractory TTP, with negligible toxicity. Received: March 24, 1999 / Accepted: May 5, 1999     

Prospective,Five-Year Follow-up Study of Patients with Symptomatic Uncomplicated Diverticular Disease

Purpose The natural history of diverticular disease is largely unknown. Most studies are retrospective and treatment recommendations are derived from outdated literature. This study was a prospective, long-term assessment of the development of complications in patients with symptomatic diverticular disease. Methods All patients with a confirmed diagnosis of symptomatic diverticular disease between August 1999 and April 2001 were followed up prospectively for an average of five years. Hospital computerized discharges were assessed for any subsequent elective or emergency admission for diverticular disease-related complications, including surgical intervention. A telephone questionnaire was conducted on all patients and/or their family physician looking specifically for symptoms, complications, and surgical intervention. Results A total of 163 patients (106 females) were identified (median age, 74 (interquartile range, 64–80) years). The diagnosis was confirmed through colonoscopy (n = 106), flexible sigmoidoscopy (n = 57), and barium enema (n = 31). Nineteen were lost to follow-up and a further 19 died from unrelated causes. Twenty-five were excluded. After the initial diagnosis, two patients (1.7 percent) subsequently presented with an episode of diverticulitis, which was treated conservatively. A single patient (0.8 percent) required surgery for chronic symptoms. One hundred sixteen patients (97 percent) had no or mild symptoms after a median follow-up of 66 months. Conclusions In this prospective long-term study, symptomatic uncomplicated diverticular disease seems to run a long-term benign course with a very low incidence of subsequent complications. Symptomatic disease, acute diverticulitis, and complicated diverticular disease seem to constitute distinct clinical entities with little crossover between groups. Presented at the meeting of the Association of Surgeons of Great Britain and Ireland, Edinburgh, Scotland, May 3 to 5, 2006. Presented at the meeting of the European Association of Endoscopic Surgeons, Berlin, Germany, September 13 to 16, 2006.     

Long-Term Outcome After Operative Intervention for Rectal Cancer in Patients Aged Over 80 Years: Analysis of 9,501 Patients

Introduction Perceptions of poor outcome may detract caregivers from offering standard therapies to patients over 80 years who have been diagnosed with rectal cancer. We evaluate the effect of operative intervention on their survival. Methods Demographics, tumor characteristics, treatment, and survival for patients over 80 years with rectal and rectosigmoid cancer from 1993 to 2002 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute were examined. Survival was determined by using the Kaplan-Meier method. Patients who underwent operation (Group A) were compared with those who did not undergo surgery (Group B). Fisher's exact, chi-squared, analysis of variance, and log-rank tests were used as appropriate, and P < 0.05 was considered statistically significant. Results A total of 9,501 patients (19 percent) were aged older than 80 years. Mean age was 85 years, and median survival was 24 months. Stage of disease was unknown for 2,915 patients. Median survival was 58, 53, 39, 27, and 5 months for Stages 0 (n=163), I (n=1,878), II (n=1,796), III (n=1,536), and IV (n=1,213), respectively. A total of 6,900 patients (81 percent) underwent surgery. Median survival for operated patients was significantly longer for all stages (36 vs. 5 months, P < 0.00001), Stage 0 (60 vs. 7 months, P < 0.01), Stage I (55 vs. 11 months, P < 0.0001), Stage II (41 vs. 13 months, P < 0.0001), Stage III (28 vs. 14 months, P < 0.05), and Stage IV (8 vs. 3 months, P < 0.0001). For patients with rectal cancer, local therapy also significantly improved median survival compared with nonoperated patients (P < 0.0001). Conclusions Operative intervention provides sustained benefit in terms of survival to patients aged >80 years with rectal cancer at all stages who are assessed to be a good operative risk. Age older than 80 years should not detract surgeons from offering optimal therapy to good-risk patients. Reprints are not available.     

Autologous hematopoietic stem cell transplantation—what determines the outcome: an experience from North India

Limited information is available from developing countries about complications, pattern of infections, and long-term outcome of patients following high-dose chemotherapy (HDCT) and autologous blood stem cell transplantation (ASCT). Between April, 1990 and December 2009, 228 patients underwent ASCT. Patients’ median age was 48 years, ranging from 11 to 68 years. There were 158 males and 70 females. Indications for transplant included multiple myeloma, n = 143; lymphoma, n = 44 (Hodgkin’s, n = 25 and non-Hodgkin’s, n = 19); leukemia, n = 22; and solid tumors, n = 18. Patients received HDCT as per standard protocols. Following ASCT, 175 (76.7%) patients responded; complete, 98 (43%); very good partial response, 37 (16.2%); and partial response, 40 (17.5%). Response rate was higher for patients with good Eastern Cooperative Oncology Group (ECOG) performance status (0–2 vs. 3–4, p < 0.001), pretransplant chemo-sensitive disease (p < 0.001) and those with diagnosis of hematological malignancies (p < 0.003). Mucositis, gastrointestinal, renal, and liver dysfunctions were major nonhematologic toxicities, 3.1% of patients died of regimen-related toxicities. Infections accounted for 5.3% of deaths seen before day 30. At a median follow-up of 66 months (range, 9–234 months), median overall (OS) and event-free survival (EFS) were 72 months (95% CI 52.4–91.6) and 24 months (95% CI 17.15–30.9), respectively. For myeloma, OS and EFS were 79 months (95% CI 52.3–105.7) and 30 months (95% CI 22.6–37.4), respectively. Pretransplant good performance status and achievement of significant response following transplant were major predictors of survival. Our analysis demonstrates that such procedure can be successfully performed in a developing country with results comparable to developed countries.     

Clinical and radiological results of treating lumbar spondylosis with cortical bone trajectory screws

The cortical bone trajectory screws technique (CBTT) is a popular minimally invasive spine surgery. Few studies have reported long-term outcomes. We aimed to evaluate the complication profile and long-term follow-up results of patients with lumbar degenerative disease treated with the CBTT.This retrospective analysis included the first 40 consecutive patients that underwent the CBTT. The indication for surgery was critical stenosis of the intervertebral foramen, which required removal of the entire intervertebral joint, on at least 1 side, during decompression.The last follow-up showed minimal clinically important differences in the numerical rating scale of leg pain, the numerical rating scale of back pain, and the Oswestry Disability Index, in 97%, 95%, and 95% of patients, respectively. Thirty-nine patients completed long-term radiological follow-up. Computed tomography demonstrated solid bone union on 47 (92%) operated levels, collapsed union on 2 (4%) levels, nonunion on 1 (2%) level, and 1 (2%) patient was lost to follow-up. Seven patients experienced complications (4 hardware-related). Three patients required 4 revision surgeries.The CBTT effectively achieved spinal fusion; over 90% of patients achieved clinical improvement at a mean follow-up of 4.4 years (range: 3–5.75 years).     

Long-term results of concurrent chemoradiotherapy followed by high dose rate brachytherapy for T2-3 N0-1 M0 esophageal carcinoma

Background To assess the long-term efficacy and the pattern of failure of concurrent chemoradiotherapy followed by high dose rate (HDR) brachytherapy for stage T2-3 N0-1 M0 esophageal carcinoma. Methods Forty-six patients with clinical stage T2-3 N0-1 M0 esophageal cancer received concurrent chemoradiotherapy followed by HDR brachytherapy. The chemotherapy regimen was a combination of cisplatin 60 mg/m² on day 1 and fluorouracil 600 mg/m² continuous infusion from days 1 to 4 during the first and last week of external-beam irradiation. Radiotherapy consisted of external beam to a total dose of 40–60 Gy (median, 50 Gy) and high dose rate brachytherapy to 8–24 Gy (median, 16 Gy) in 2–4 fractions. External beam was delivered to a field of the primary lesion and the involved nodal lesions. All patients were followed up for at least 5 years. Results The 5-year overall survival rate was 28%. The median survival duration was 22 months. The 5-year cause-specific survival rate was 34% and the median was 22 months. Persistent disease was found in 7 of 46 patients (15%). Of the 39 patients with initial complete tumor disappearance, locoregional failure occurred ultimately in 13 patients. The ultimate local control rate was 57% (26/46). Three patients were salvaged successfully with surgery. Four patients (9%) had regional recurrence out of the irradiated fields as first failure site. Four patients (9%) had recurrence 3 years or longer after treatment. Twelve patients had transient ulcers, which healed spontaneously within a few months. Massive esophageal bleeding, thought to be treatment related, occurred in 2 patients, leading to death. Severe late toxicity with esophageal ulceration was found in patients receiving a dose of 16–24 Gy via brachytherapy. Conclusions Concurrent chemoradiotherapy followed by HDR brachytherapy achieved long-term effective and curative results for stage T2-3 N0-1 M0 esophageal carcinoma. However, severe late toxicity was observed with 16–24 Gy via brachytherapy. We recommend a dose via HDR brachytherapy should be 12 Gy or less following concurrent chemoradiotherapy.     

Etanercept 25 mg/week is effective enough to maintain remission for ankylosing spondylitis among Korean patients

Specific antagonists of tumor necrosis factor (TNFα) have rapidly gain popularity for the treatment of ankylosing spondylitis (AS). The dose of etanercept has not been determined in Asia, especially in Korea. This study was designed to investigate the maintaining effect of low-dose (25 mg/week) etanercept in Korean patients with AS and after discontinuation, the duration to be aggravated. Patients who had active AS [Bath AS Disease Activity Index (BASDAI) ≥4] were treated with 50 mg of etanercept per week for 3 months. After that, for 6 months, the patients were treated with 25 mg of etanercept per week. We evaluated the serum erythrocyte sediment rate (ESR), C-reactive protein (CRP), and BASDAI every 1 month for 3 months and every 2–3 months during the remaining 6 months. After all schedules of treatment were finished, we reevaluated ESR, CRP, and BASDAI every 4 months until recurrence. Twenty-seven AS patients received etanercept. Twenty-three patients completed treatment for 3 months with a dose of 50 mg/week. Among them, 18 completed for 6 months with a dose of 25 mg/week and discontinued. Mean age was 30.0 ± 5.4 years and mean disease duration was 7.5 ± 6.5 years. These 18 patients were evaluated for BASDAI, ESR, and CRP every 4 weeks. After discontinuation, mean duration to recur was 9.2 ± 6.1 weeks. Twenty-five milligrams of etanercept per week is effective enough to maintain remission in AS. After discontinuation, this effect was maintained by using a dose of 50 mg of etanercept per week.     

What is the Optimal Time of Surgical Intervention After an Acute Attack of Sigmoid Diverticulitis: Early or Late Elective Laparoscopic Resection?

Purpose This prospective study was designed to check the ideal time of surgical intervention by comparing the results of early elective laparoscopic sigmoid resection after an inflammatory attack with those of late elective resection during the inflammation-free interval. Methods A total of 210 patients (114 males) underwent laparoscopic resection for acute sigmoid diverticulitis between 1999 and 2005. They were prospectively divided into two groups: Group I with an early elective sigmoid resection (5–8 days after initial antibiotic treatment); Group II in the inflammation-free interval (4–6 weeks after initial hospitalization). Results There was no difference between the groups with regard to age (55.7 years), American Society of Anesthesiologists score (1.86), previous diseases, and extent of inflammation. After surgery, 156 patients (74.3 percent) were complication-free. There was a total of ten conversions (Group I, 9; Group II, 1; P < 0.05). Minor complications developed in 42 patients (abdominal wall abscess = 24, intestinal atony = 6, hematoma = 9, urinary tract infection = 2). Eight patients in Group I (P < 0.05) developed anastomotic leaks. None of the patients died. Conclusions In the majority of patients, laparoscopic sigmoid resection in sigmoid diverticulitis can be performed without conversion. Patients who underwent surgery in the inflammation-free interval had a lower complication rate than those submitted to early elective resection. In our patient population, we were able to show that surgery in the inflammation-free interval significantly reduces postoperative morbidity. It is thus preferable for patients with sigmoid diverticulitis to receive initial antibiotic treatment and then undergo late elective laparoscopic sigmoid resection. Presented at the Congress of the German Society of Surgery, Munich, Germany, April 5 to 8, 2005.     

Obstructive Complications of Laparoscopically Created Defunctioning Ileostomy

Purpose  The use of defunctioning ileostomy is a common practice to reduce the septic complications after anastomotic leakage in colorectal surgery. In open surgery, the fashioning of ileostomy is a straightforward procedure. However, in the laparoscopic approach, this can be a difficult task and obstructive complications can occur postoperatively. Methods  A retrospective review was undertaken for all patients who underwent laparoscopic colorectal resection and defunctioning loop ileostomy over a 15-year period. Results  In this period, 161 patients underwent laparoscopic colorectal surgery with defunctioning ileostomy. Eight patients developed obstructive complications in the early postoperative period requiring surgical intervention (5 percent). All patients presented with intestinal obstruction from the fourth to the sixth postoperative day. The median time to reoperation was 9.5 days (range, 5 to 19). The causes of obstructive complications were twisting of the ileostomy (n = 3), adhesive kinking proximal to the ileostomy (n = 3), tight fascia (n = 1), and both tight fascia and twisting of ileostomy (n = 1). Six patients underwent laparotomy for diagnosis and refashioning of ileostomy. The seventh patient had endoscopic decompression of small bowel and refashioning of ileostomy. The last patient was successfully managed with combined endoscopic and laparoscopic approach. Conclusions  Various pitfalls can occur in laparoscopically created defunctioning ileostomy. Measures can be taken to minimize these technical errors. Various surgical reinterventions can be attempted to determine the cause. With combined uses of enteroscope and laparoscope, a laparotomy can be avoided.     

Occurrence of adenomas in the pouch and small intestine of FAP patients after proctocolectomy with ileoanal pouch construction

Purpose Proctocolectomy with ileoanal pouch construction is the standard therapy for patients with familial adenomatous polyposis coli (FAP) to prevent the genesis of colorectal carcinomas. In our patient population, we observed the postoperative development of adenomas not only in the pouch but also in the remaining small intestine. The exact incidence of these ileal polyps is still unknown, since the diagnostic possibilities of examining the small intestine are limited. Methods We performed wireless capsule endoscopy (CE) in patients who developed postoperative pouch adenomas (PA) to record the simultaneous occurrence of small bowel adenomas and PA. We operated on 46 patients with FAP (m:f 17:10, age 33 ± 9 years). Thirty-five patients underwent proctocolectomy with ileoanal pouch creation. Pouch endoscopy was performed in regular intervals at 3 months and then annually after proctocolectomy. Capsule endoscopy was additionally carried out in all patients with PA. Results Ileal PA occurred in 22.8% (n = 8) of the patients with proctocolectomy (n = 35) after a mean of 5 years after surgery. Eight PA patients (all with PA) also had adenomas in the small intestine diagnosed by CE. Conclusions Since jejunal and ileal adenomas occur in all patients with PA, we recommend regular follow-up examinations, which include pouch endoscopy at 3 months and annually after surgery in the presence of PA after proctocolectomy and pouch creation. On the basis of our observations, we recommend adding CE or double-balloon enteroscopy to the follow-up examination.     

Ineffectiveness of interferon-γ in the treatment of idiopathic myelofibrosis: a pilot study

 It has been proposed that interferon-γ (IFN) inhibits collagen synthesis in myeloproliferative disorders through an inhibitory effect on PDGF and TGF-β. We therefore evaluated the role of IFN-γ on bone marrow fibrosis in idiopathic myelofibrosis (IMF). After a 3-month observation period, nine patients (five female, four male), median age 64 years (range 43–72 years), received 3×3 mU IFN-γ/week over 6 months and were monitored after withdrawal of IFN-γ for further 3 months. Three out of nine patients have completed the study according to the protocol. Six patients had to be withdrawn from IFN-γ due to the following reasons: bacterial infection (three patients), splenic infarction or deterioration of splenomegaly (one patient, each) and refusal to continue IFN-γ (one patient). Results from seven patients treated for at least 8 weeks were considered measurable. Leukopenia, initially present in one of the evaluated patients, deteriorated during IFN-γ treatment. This patient died during the observation period shortly after withdrawal of the therapy as a result of septicemia. Transfusion-dependent anemia, initially observed in two of the evaluated patients, deteriorated during the IFN-γ treatment. Bone marrow fibrosis increased in three patients, whereas it remained unchanged in another and improved in a further patient. Splenomegaly improved in two patients but deteriorated markedly in one. Taking these observations together, four patients had disease progression during IFN-γ treatment, two had stable disease and one could be qualified as a partial responder. According to these data IFN-γ cannot be considered as a treatment option for patients with IMF. Received: 7 February 2000 / Accepted: 14 July 2000