Combined devascularization and proximal splenorenal shunt: is this a better option than either procedure alone?

Background/Purpose We aimed to determine the rationality of pericardial devascularization (PCDV) plus proximal splenorenal shunt (PSRS) for cirrhotic patients with portal hypertension with variceal bleeding, using a duplex sonography study of the effects of the different surgical procedures (PCDV, PSRS, and PCDV + PSRS) on the hemodynamics of the portal system.Methods Ninety-nine patients with cirrhotic portal hypertension and a history of bleeding esophageal varices were studied. These patients were divided into three groups (PSRS group, PCDV group, and PCDV + PSRS group). The hemodynamic parameters of the portal systems of all patients were measured by Doppler color-flow imaging perioperatively.Results In the PSRS group, the postoperative portal venous flow (PVF) and free portal pressure (FPP) decreased by 57 ± 9% and 52 ± 5%, respectively (P < 0.01). In the PCDV group, the postoperative PVF lessened by 8 ± 5% (P > 0.05), and the postoperative FPP was reduced by 19 ± 7% (P < 0.05). In the PCDV + PSRS group, the postoperative PVF and FPP were lowered by 36 ± 8% and 34 ± 10%, respectively (P < 0.05). The postoperative decreases of PVF and FPP in the PCDV + PSRS group were between those of the PSRS and PCDV groups. The differences among these groups were statistically significant (P < 0.05).Conclusions Combined devascularization and splenorenal shunt (PCDV + PSRS) significantly decreases portal venous flow and portal pressure, as well as maintaining hepatopedal flow, thus entailing fewer complications compared to either PCDV or PSRS.     

Ottawa versus Bernese: which is better?

Purpose

Trauma of the foot and ankle is commonly seen in the emergency service. For most patients, fractures cannot be ruled out without radiography. The aim of this study is to consider these injured patients in the light of the Ottawa ankle rules and the Bernese ankle rules.

Methods

Our study is a randomized, prospective clinical study. This study was performed during a 24-month period in the Süleyman Demirel University Emergency Medicine Service. A total of 962 adult patients with foot and ankle pain or tenderness following trauma incurring within the previous 10 days were included in the study. Patients were examined only by physicians who had been trained in the correct application of the Ottawa ankle rules and the Bernese ankle rules. All patients were X-rayed with standardized anterior-posterior and lateral radiographs of the ankle and foot, regardless of whether the Ottawa ankle rules and the Bernese ankle rules were positive or negative. The sensitivity and specificity of the Ottawa and Bernese ankle rules according to the study results regarding the correlation between physical examination and radiography were calculated.

Results

For the Ottawa ankle rules, the sensitivity was 74.8 %, specificity was 68.6 %, false-negative ratio was 15.1 %, and the false-positive ratio was 46.3 %. For the Bernese ankle rules, the sensitivity was 55.7 %, specificity was 79 %, false-negative was ratio 21.4 %, and the false-positive ratio was 43.7 %.

Conclusion

These data suggest that the Ottawa ankle rules are more sensitive than the Bernese ankle rules to accurately identify the fracture, but they are still not 100 % reliable.     

Varicocele surgery or embolization: Which is better?

Introduction:

Varicocele remains the most commonly identified correctable cause of male factor infertility. Surgical correction is the most commonly performed technique to treat varicoceles with a technical failure rate of less than 5%. An attractive alternative to surgery is the selective catheterization and embolization of the gonadal vein. This data are limited by small series.

Methods:

We reviewed a total of 158 patients. These patients underwent embolization for clinical varicoceles and male factor infertility between 2004 and 2008. Of these, 56% underwent attempted bilateral embolization, 43% unilateral left-sided embolization and 1.3% unilateral right-sided embolization.

Results:

Of these patients who underwent attempted bilateral embolization, 19.3% did not experience a successful obliteration of the right gonadal vein and 2.3% (2/88) experienced a failure rate in the embolization of the left gonadal vein. Of the 2 attempts at unilateral right-sided embolization, there were no failures. Of the 68 unilateral left-sided embolization attempts, there was a 4.4% failure rate. Of all of the right-sided embolization attempts, 18.9% failed, while 3.2% of the left-sided attempts failed.

Conclusion:

This review represents the largest contemporary series of varicocele embolization outcomes currently in the literature. Our 19.3% technical failure rate for bilateral varicocele embolization is higher than the current published rate of 13% and is largely related to failure to successfully occlude the right gonadal vein. This supports our belief that bilateral varicoceles are best managed with a primary microsurgical approach, where technical failure rates are expected to be less than 5% based on published data. Men with unilateral left-sided varicoceles should be offered both options as they have similar failure rates, but with embolization offering some clear advantages to the patient.     

Sodium chloride intake: is lower always better?

Current treatment of kidney disease is not completely satisfactory, particularly when initiated in the late stages of renal progression. There is an urgent need for additional interventions, especially reduction of salt intake, which is rather high in the Western world. In this commentary we provide a critical assessment of post hoc analyses of recent interventional and observational studies on the effect of salt intake on renal and cardiovascular outcomes. To evaluate the mechanisms and safety of reduced salt intake, studies specifically designed to assess salt intake as an endpoint are needed. This approach will have implications for health care policies and labeling of the salt content of purchased foods.     

Outpatient laparoscopic sterilization: is local anaesthesia better?

A prospective, randomized study comprised 125 outpatient laparoscopic sterilization patients who had received either general anaesthesia or local anaesthesia together with intravenous sedation. The patients who had received local anaesthesia suffered significantly less postoperative pain and sore throat. Recovery and discharge were similar in the two groups, but those given a general anaesthetic were more drowsy in the evening on the day of operation. The time spent in the operating theatre was significantly shorter for the group given local anaesthesia, and the costs were lower. The majority of patients from both groups would prefer local anaesthesia for a similar procedure in the future. We conclude that local anaesthesia together with intravenous sedation is the method of choice for laparoscopic sterilization.     

Tubeless percutaneous nephrolithotomy: is it really less morbid?

PURPOSE: To prospectively evaluate and study the role, relative safety, and effectiveness of "tubeless" percutaneous nephrolithotomy (PCNL) and whether it is really less morbid vis-à-vis PCNL with a nephrostomy tube; to compare the postoperative pain, analgesia requirement, hospital stay, return to work time, and other parameters in patients undergoing tubeless PCNL and standard PCNL. PATIENTS AND METHODS: Sixty selected patients underwent PCNL. A single urologist (IS) was the surgeon, and a resident administered random chit numbers, and recorded pain scores and results of all the chosen parameters. Patients who fulfilled the entry criteria for a tubeless PCNL protocol were randomized to either the omission of a nephrostomy tube (tubeless PCNL with Double-J stent) or to the placement of a 22F nephrostomy tube. The recorded data were analyzed with respect to several parameters. RESULTS: The mean age, stone burden, and preoperative hemoglobin, blood urea, and serum creatinine values were not significantly different between the two groups. However, the operative time (P < 0.001), analgesia requirement (P < 0.001), and hospital stay and time to return to normal activity (P < 0.001) were significantly lower in the tubeless PCNL group. CONCLUSIONS: Significantly less pain, lower analgesia requirement, and shorter hospital stay with early return to normal activities were observed in the tubeless PCNL group v the primary nephrostomy tube PCNL group. Tubeless PCNL in selected patients is a secure, effective, and less morbid procedure that does not compromise patient safety and concerns. We recommend that tubeless PCNL be the preferred procedure in selected patients for management of nephrolithiasis.     

Incision length for standard thyroidectomy and parathyroidectomy: when is it minimally invasive?

HYPOTHESIS: Current techniques for open conventional thyroidectomy or parathyroidectomy have evolved to enable a shorter incision (main proposition), and the length of the incision is influenced by objective factors. DESIGN: Case series. SETTING: University referral center.Patients and INTERVENTION: Retrospective study of the most recent 200 primary consecutive routine thyroid and parathyroid operations (excluding neck dissections). MAIN OUTCOME MEASURES: The length of incision was routinely measured with a ruler before the incision. Univariate and multivariate analysis was performed to distinguish variables affecting length of incision. RESULTS: Mean length of the incision was 5.5 cm for total thyroidectomy, 4.6 cm for lobectomy, and 3.5 cm for parathyroidectomy (P<.001). It was 4.1 cm for bilateral parathyroid exploration, but was reduced to 3.2 and 2.8 cm for unilateral (P<.001) and focal (P<.001) explorations, respectively. By multiple regression analysis, thyroid specimen volume and patient body mass index were independent predictors of incision length in thyroidectomy. Extent of exploration and resident training level were independent predictors of incision length in parathyroidectomy. CONCLUSIONS: Current techniques for open conventional thyroidectomy or parathyroidectomy have evolved to enable a shorter incision. Thyroid volume, patient body mass index, extent of the planned parathyroid exploration, and the resident clinical training stage are important variables for incision length in open operation and should be taken into account when minimally invasive thyroidectomy and parathyroidectomy are evaluated.