Anterior Approach to Major Resection for Colorectal Liver Metastasis

Purpose

The aim of this study was to examine the merits of the anterior approach, if any, in colorectal liver metastasis (CRLM) resection.

Methods

Data of patients who underwent partial hepatectomy for CRLM were reviewed. Patients treated by the anterior approach were compared with patients treated by the conventional approach.

Results

Ninety-eight patients had right hepatectomy, extended right hepatectomy, or right trisectionectomy. Among them, 71 patients underwent the conventional approach (CA group) and 27 underwent the anterior approach (AA group). The two groups were comparable in demographic, pathological, and perioperative characteristics except that the AA group had higher levels of aspartate transaminase (median, 41 vs. 31 U/L; p?=?0.006) and alanine transaminase (median, 27 vs. 22 U/L; p?=?0.009), larger tumors (median, 7 vs. 4 cm; p?=?0.000), and more extensive resections (p <?0.001). The median overall survival was 40 months (range, 0.69–168.6 months) in the CA group and 33.7 months (range, 0.95–99.8 months) in the AA group (p?=?0.22), and the median disease-free survival was 9.7 months (range, 0.62–168.6 months) in the CA group and 6.2 months (range, 0.72–99.8 months) in the AA group (p?=?0.464). Univariate and multivariate analyses identified 4 independent prognostic factors for overall survival: lymph node status of primary tumor (HR 1.352, 95% CI 0.639–2.862, p =?0.034), intraoperative blood loss (HR 1.253, 95% CI 1.039–1.510, p =?0.018), multiple liver tumor nodules (HR 1.775, 95% CI 1.029–3.061, p =?0.039), and microvascular invasion (HR 2.058, 95% CI 1.053–4.024, p =?0.035).

Conclusions

The two approaches resulted in comparable survival outcomes even though the AA group had larger tumors and more extensive resections. The anterior approach allows better mobilization and easier removal of large tumors once the liver is opened up.

     

Comparison of Laparoscopy-Assisted and Open Donor Right Hepatectomy: a Prospective Case-Matched Study from China

Background

Laparoscopy-assisted hepatectomy is a new minimally invasive approach for graft harvesting in living donors. Only a few liver transplant centers have introduced this surgical procedure.

Methods

A prospective case-matched study was conducted on 25 consecutive donors who underwent laparoscopy-assisted donor right hepatectomy (LADRH) between July 2011 and March 2013 at our transplant center. These donors were matched 1:1 according to age, gender, and body mass index with 25 donors who underwent open donor right hepatectomy (ODRH).

Results

LADRH was successfully performed in all 25 of the donors. Donor complications, estimated blood loss, and operative time were similar between the groups. Hospital stay and periods of analgesic use were significantly shorter in the LADRH group [7.0?±?1.4 (LADRH) vs 8.7?±?2.4 (ODRH), p?=?0.003, and 2.4?±?1.0 (LADRH) vs 3.2?±?1.0 (ODRH), p?=?0.011, respectively). The total in-hospital cost is higher with LADRH, primarily due to the additional material costs for LADRH. Finally, there were no differences in graft size, graft survival, or recipient complications between the two groups.

Conclusion

The results of this study show that LADRH is a feasible and safe procedure compared with ODRH. Although higher material costs for laparoscopic assisted procedures are inevitable, LADRH may have an advantage over ODRH by causing less pain and facilitating earlier recovery. Efforts can be made to improve the technical success of LADRH for some overweight donors.     

Use of risedronate to prevent bone loss following a single course of glucocorticoids: findings from a proof-of-concept study in inflammatory bowel disease

Summary

We performed a randomised controlled trial (RCT) to determine whether risedronate 35 mg once weekly prevents bone loss following an 8-week reducing course of prednisolone given for an exacerbation of inflammatory bowel disease (IBD). The greatest change in bone mineral density (BMD) was at Ward’s triangle (WT), which fell by 2.2% in the placebo group, compared with a reduction of 0.8% in the risedronate group.

Introduction

Whether bisphosphonates can prevent bone loss associated with intermittent glucocorticoid (GC) therapy is unknown, reflecting the difficulty in performing RCTs in this context.

Method

To explore the feasibility of RCTs to examine this question, lumbar spine (LS; L2–4) and hip dual X-ray absorptiometry (DXA) scans were performed in 78 patients commencing a GC therapy course for a relapse of IBD. They were then randomised to receive placebo or risedronate 35 mg weekly for 8 weeks, after which the DXA scan was repeated.

Results

For LS BMD, there was no change in the placebo group (0.1?±?0.4, p?=?0.9), but there was an increase after risedronate (0.8?±?0.4, p?=?0.04; mean%?±?SEM by paired Student’s t test). There were small decreases in both groups at the total hip (?0.5?±?0.3, p?=?0.04; ?0.5?±?0.3, p?<?0.05, placebo and risedronate, respectively). At WT, BMD fell after placebo (?2.2?±?0.5, p?=?0.001) but not risedronate (?0.8?±?0.5, p?=?0.09; p?=?0.05 for between-group comparison).

Conclusion

RCTs can be used to examine whether bisphosphonates prevent bone loss associated with intermittent GC therapy, providing metabolically active sites such as WT are employed as the primary outcome.     

Preventive effects of conservative treatment with short-term teriparatide on the progression of vertebral body collapse after osteoporotic vertebral compression fracture

Summary

The progression of fractured vertebral collapse is not rare after a conservative treatment of vertebral compression fracture (VCF). Teriparatide has been shown to directly stimulate bone formation and improve bone density, but there is a lack of evidence regarding its use in fracture management. Conservative treatment with short-term teriparatide is effective for decreasing the progression of fractured vertebral body collapse.

Introduction

Few studies have reported on the prevention of collapsed vertebral body progression after osteoporotic VCF. Teriparatide rapidly enhances bone formation and increases bone strength. This study evaluated preventive effects of short-term teriparatide on the progression of vertebral body collapse after osteoporotic VCF.

Methods

Radiographs of 68 women with single-level osteoporotic VCF at thoracolumbar junction (T11–L2) were reviewed. Among them, 32 patients were treated conservatively with teriparatide (minimum 3 months) (group I), and 36 were treated with antiresorptive (group II). We measured kyphosis and wedge angle of the fractured vertebral body, and ratios of anterior, middle, and posterior heights of the collapsed body to posterior height of a normal upper vertebra were determined. The degree of collapse progression was compared between two groups.

Results

The progression of fractured vertebral body collapse was shown in both groups, but the degree of progression was significantly lower in group I than in group II. At the last follow-up, mean increments of kyphosis and wedge angle were significantly lower in group I (4.0°?±?4.2° and 3.6°?±?3.6°) than in group II (6.8°?±?4.1° and 5.8°?±?3.5°) (p?=?0.032 and p?=?0.037). Decrement percentages of anterior and middle border height were significantly lower in group I (9.6?±?10.3 and 7.4?±?7.5 %) than in group II (18.1?±?9.7 and 13.8?±?12.2 %) (p?=?0.001 and p?=?0.025), but not in posterior height (p?=?0.086).

Conclusions

In female patients with single-level osteoporotic VCF at the thoracolumbar junction, short-term teriparatide treatment did not prevent but did decrease the progression of fractured vertebral body collapse.     

Is laparoscopic surgery for recurrent Crohn’s disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study

Background

Patients undergoing abdominal surgery for Crohn??s disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn??s through midline laparotomy is controversial.

Methods

Patients with previous open resection for intestinal Crohn??s disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5?years), gender, body mass index (±2?kg/m²), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3?years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data.

Results

26 patients undergoing laparoscopic ileocolectomy (n?=?14), proctocolectomy (n?=?5), small bowel resection (n?=?4), abdominoperineal resection (n?=?1), extended right colectomy (n?=?1), and strictureplasty (n?=?1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12?%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158?min, p?=?0.94), estimated blood loss (222 versus 427?ml, p?=?0.32), overall morbidity (39 versus 69?%, p?=?0.051), reoperation rates (8 versus 0?%, p?=?0.5), postoperative return of bowel function (3.5?±?1.4 versus 3.9?±?1.7?days, p?=?0.3), mean length of hospital stay (6.4?±?6.2 versus 6.9?±?3.5?days, p?=?0.12), and readmission rates (8 versus 12?%, p?=?0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27?%, p?=?0.01).

Conclusions

Surgery for recurrent Crohn??s disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.     

Is it worthwhile to preserve adult spleen in laparoscopic distal pancreatectomy? Perioperative and patient-reported outcome analysis

Background

Despite the emphasis on its role, the spleen has commonly been removed in distal pancreatectomy. We designed this study to evaluate the efficacy of spleen salvage during laparoscopic distal pancreatectomy for patients with benign and borderline malignant tumors.

Materials and methods

From February 2005 to December 2010, 40 patients underwent spleen-preserving laparoscopic distal pancreatectomy (Sp-Lap DP) and 32 patients underwent laparoscopic distal pancreatosplenectomy (Lap DPS). Medical records were retrospectively reviewed, and a specially designed questionnaire was administered to the patients for the follow-up study.

Results

The demographics and final diagnoses were similar between the two groups. The operative time was significantly longer in the Sp-Lap DP group (303.9?±?136.0 versus 239.0?±?94.9?min, p?=?0.024). Patients in the Lap DPS group had more postoperative pancreatic fistulas of higher grade (p?=?0.026). A higher grade of postoperative complications occurred more frequently in the Lap DPS group (p?=?0.003). Consequently, postoperative hospital stay was significantly shorter for Sp-Lap DP than for Lap DPS patients (7.1?±?2.3 versus 12.5?±?10.8?days, p?=?0.004). On the follow-up survey, episodes of common cold or flu were apparently more frequent in the Lap DPS group (p?=?0.026). Despite the similar recovery period between the two groups, significantly more patients who underwent Lap DPS felt fatigue (p?=?0.014) and poorer health condition (p?=?0.042).

Conclusions

In addition to frequent higher-grade complications and prolonged hospital stays, Lap DPS appeared to impair patient quality of life based on follow-up survey. Even an effort to preserve adult spleen in distal pancreatectomy is worthwhile.     

Influence of Eating Profile on the Outcome of Laparoscopic Sleeve Gastrectomy

Background

The aim of this study was to assess the eating profile of patients after laparoscopic sleeve gastrectomy (LSG) and its impact on weight loss.

Methods

One hundred ten patients who underwent LSG were interviewed using Suter questionnaire and revised Questionnaire on Eating and Weight Patterns in follow-up visits. Eating patterns were assessed preoperatively and postoperatively. Patients were divided into six groups according to the timing point of assessment. Group 1 (n?=?10) included patients <3 months, group 2 (n?=?11) 3–6 months, group 3 (n?=?11) 6–12 months, group 4 (n?=?39) 1–2 years, group 5 (n?=?23) 2–3 years, and group 6 (n?=?16) >3 years. The excess weight loss (EWL) was correlated with the results.

Results

The total score of the Suter questionnaire was 15.0?±?5.87, 20.3?±?7.07, 26.2?±?1.54, 23.8?±?4.25, 24.65?±?2.8, and 23.43?±?4.14 for the groups 1–6, respectively (p?<?0.0001). No significant differences were denoted when long-term follow-up groups 3 to 6 were compared. No association was found between the preoperative eating pattern and EWL. Postoperatively, 91 patients modified their eating pattern. Postoperative eating pattern was significantly correlated with EWL (p?=?0.015). Patients with normal and snacking eating pattern achieve the best EWL (63.57?±?21.32 and 60.73?±?20.62, respectively). Binge eating disorder and emotional patterns had the worst EWL (42.84?±?29.42 and 34.55?±?19.34, respectively).

Conclusions

Better food tolerance is detected after the first postoperative year after LSG. The postoperative eating patterns seem to affect excessive weight loss.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm

Purpose

To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery.

Method

One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs.

Results

The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n?=?52) compared to the conventionally managed group (n?=?75); with values of 59?±?15 and 93?±?25?h (p?=?0.021), 9?±?3 and 16?±?5?days (p?=?0.001), respectively. The medical costs for the ERAS group were 92?% of the costs of the conventionally managed group.

Conclusion

Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.     

Sleeve Gastrectomy Improves Glucose Homeostasis in Zucker Diabetic Fatty Rats

Background

Bariatric surgery improves glucose homeostasis, but the mechanism of action is poorly understood. The aim of this study was to assess the effect of sleeve gastrectomy (SG) on glucose homeostasis in two obese populations of rats.

Methods

Two strains of rats [Zucker fatty (ZF) and Zucker diabetic fatty (ZDF)] were each divided into two groups: sham and SG. Food intake was measured daily, and weight was measured bi-weekly. Oral glucose tolerance testing (OGTT) was performed before and 45?days after surgery.

Results

In both strains of rats, there was no statistical difference in food intake and weight gain between the sham and SG rodents before and after surgery. In ZF rats, there was no change in fasting glucose or OGTT area under the curve (AUC) before or 45?days after surgery. In the ZDF rodents, the mean preoperative fasting glucose and OGTT AUC was 204?±?25 and 25,441?±?2,648, respectively. At 45?days after surgery, mean fasting glucose significantly increased in the sham (sham?=?529?±?26, p?=?0.0003) but not in the SG rodents (SG?=?289?±?46, p?=?0.1113). In ZDF sham animals, OGTT at 45?days showed a higher AUC compared to before surgery (44,983?±?6,338, p?=?0.006), whereas in ZDF SG rodents, the increase in AUC glucose approached but did not reach statistical significance (35,553?±?3,925, p?=?0.06).

Conclusions

In ZF and ZDF rodents, SG did not influence food intake and weight evolution. In ZDF rodents, diabetes progressed in the sham group but not in the SG group.     

Predictive factors of excess body weight loss 1?year after laparoscopic bariatric surgery

Background

Bariatric surgery (BS) is widely accepted for the treatment of patients with morbid obesity (MO). We aimed to determine presurgical predictors of and surgical technique-related differences in excess weight loss (EWL) 1?year after BS.

Methods

This retrospective study included 407 subjects (F/M 3:1, median age?=?44?years) who underwent laparoscopic Roux-en-Y gastric bypass (RYGB, n?=?307) or sleeve gastrectomy (SG, n?=?100) at our University Hospital and were evaluated 1?year after surgery.

Results

Baseline median (min–max) body mass index (BMI) was 47?kg/m² (range?=?36–71). BMI was higher in the SG than in the RYGB group (53 vs. 46?kg/m², p?p?p?=?0.2), was lower in diabetic than in nondiabetic subjects (71?±?17% vs. 79?±?17%, p?p?p?=?0.4) after taking into account baseline BMI. Multiple regression and logistic analysis showed that younger individuals with lower BMI but higher WC, and lower HbA1c and TG, had higher EWL and a higher rate of successful (EWL?≥?60%) weight loss.

Conclusions

Our data indicate that some of the characteristics that would have subjects referred early for BS were associated with higher weight loss. Therefore, the timing of laparoscopic BS might be an important factor for MO individuals in which medical weight loss intervention has failed.     

Heat loss during carbon dioxide insufflation: comparison of a nebulization based humidification device with a humidification and heating system

Introduction

This study compared the heat loss observed with the use of MR860 AEA Humidifier? system (Fisher & Paykel Healthcare, New Zealand), which humidifies and heats the insufflated CO₂, and the use of the AeronebPro? device (Aerogen, Ireland), which humidifies but does not heat the insufflated CO₂.

Methods

With institutional approval, 16 experiments were conducted in 4 pigs. Each animal, acting as its own control, was studied at 8-day intervals in randomized sequence with the following four conditions: (1) control (C) no pneumoperitoneum; (2) standard (S) insufflation with nonhumidified, nonheated CO₂; (3) Aeroneb? (A): insufflation with humidified, nonheated CO₂; and (4) MR860 AEA humidifier? (MR): insufflation with humidified and heated CO₂.

Results

The measured heat loss after 720L CO₂ insufflation during the 4?h was 1.03?±?0.75?°C (mean?±?SEM) in group C; 3.63?±?0.31?°C in group S; 3.03?±?0.39?°C in group A; and 1.98?±?0.09?°C in group MR. The ANOVA showed a significant difference with time (p?=?0.0001) and with the insufflation technique (p?=?0.024). Heat loss in group C was less than in group S after 60?min (p?=?0.03), less than in group A after 70?min (p?=?0.03), and less than in group MR after 150?min (p?=?0.03). The heat loss in group MR was less than in group S after 50?min (p?=?0.04) and less than in group A after 70?min (p?=?0.02). After 160?min, the heat loss in group S was greater than in group A (p?=?0.03).

Discussion

As far as heat loss is concerned, for laparoscopic procedures of less than 60?min, there is no benefit of using any humidification with or without heating. However, for procedures greater than 60?min, use of heating along with humidification, is superior.     

A comparative North American experience of robotic thyroidectomy in a thyroid cancer population

Purpose

This study seeks to explore the efficacy of robotic thyroidectomy in treating a North American population with differentiated thyroid cancer (DTC) as compared with the conventional cervical approach.

Methods

A retrospective analysis of our prospectively collected thyroid surgery database was performed. We included all consecutive patients that underwent thyroidectomy for the treatment of well-differentiated thyroid cancer, performed by a single surgeon.

Results

Twenty-four robotic transaxillary and 35 conventional thyroidectomy procedures were performed. Average size of the tumor was 1.1?±?0.2 cm in the robotic group and 1.7?±?0.3 cm in the cervical group (p?=?0.16). Average total operative time for the robotic group was 133?±?65.4 and 119.7?±?22.5 min in the cervical group (p?=?0.34). No robotic cases required conversion. One patient required reoperation for recurrent disease at 24 months follow-up. Both groups had similar blood loss (p?=?0.37) and all margins were negative for malignancy on permanent pathology. All patients were discharged home within 24 h. Postoperative stimulated thyroglobulin levels were similar for the two groups (p?=?0.82).

Conclusions

Our experience with robotic transaxillary thyroidectomy confirms this technique is feasible. It is possible to achieve a safe and effective oncologic result in a select group of North American patients with DTC.     

Right Hepatectomy in Patients over 70 Years of Age: An Analysis of Liver Function and Outcome

Background

As a consequence of the increase in life expectancy, hepatobiliary surgeons have to deal with an emerging aged population. We aimed to analyze the liver function and outcome after right hepatectomy (RH) in patients over 70?years of age.

Methods

From January 2006 to December 2009, we prospectively collected data of 207 consecutive elective hepatectomies. In patients who had RH, cardiac risk was assessed by a dedicated preoperative workup. Liver failure (LF) was defined by the “fifty–fifty” criteria at postoperative day 5 (POD) and morbidity by the Clavien–Dindo classification. Liver function tests (LFTs) and short-term outcome were retrospectively analyzed in patients over (elderly group, EG) and younger (young group, YG) than 70?years of age.

Results

Eighty-seven consecutive RH were performed during the study period. Indication for surgery included 90?% malignancy in 47?% of patients requiring preoperative chemotherapy. ASA grade?>?2 (44 vs. 16?%, p?=?0.027), ischemic heart disease (17 vs. 5?%, p?=?0.076), and preoperative cardiac failure (26 vs. 2?%, p?n?=?23) than in the YG (n?=?64). Both groups were similar regarding rates of normal liver parenchyma, chemotherapy and intraoperative parameters. The overall morbidity rates were comparable, but the serious complication (grades III–V) rate was relatively higher in the EG (39 vs. 25?%, p?=?0.199), particularly in patients with diabetes mellitus (100 vs. 29?%, p?=?0.04) and those who had additional nonhepatic surgery (67 vs. 35?%, p?=?0.110) and transfusions (44 vs. 30?%, p?=?0.523). The 90-day mortality rate was similar (9?% in the EG vs. 3?% in the YG, p?=?0.28) and was related to heart failure in the EG. LFTs showed a similar trend from POD 1 to 8, and patients ≥70?years of age had no liver failure.

Conclusions

Age ≥70?years alone is not a contraindication to RH. However, major morbidity is particularly higher in the elderly with diabetes. This high-risk group should be closely monitored in the postoperative course. Liver function is not altered in the elderly patient after RH.     

Investigation of anal sphincter function following Mainz pouch type II urinary diversion after radical cystectomy

Purposes

Our aim was to evaluate the anal sphincter function following cystectomy with urinary diversion of Mainz pouch II.

Methods

Seventy-six patients were involved in our survey, and the cohort was for two groups divided. The first group was a retrospective review of 40 patients with examination of the state of continence. Comparative examinations on anal sphincter function and the quality of life survey were carried out. The second group consisting of 15 patients underwent a prospective investigation including rectal manometry in both the pre- and postoperative periods. Measurements of resting anal sphincter pressure (RASP), maximal anal closing pressure (MACP) and the function of the recto anal inhibitions reflex were taken.

Results

In the first part of our investigation, 80% of the patients were considered as continent. There were no significant differences observed between RASP values in the cases of continent as well as of incontinent patients (79.2?±?2 vs. 73.6?±?68.4?mmHg, p?=?0?C53); however, the MACP values of the continent patients were significantly higher (204.3?±?22.8 vs. 117.3?±?14?mmHg, p?=?0.001). In the course of the second experiment, both the RASP (86.3?±?18.7 vs. 76.1?±?13.9?mmHg p?=?0.0049) and the MACP (232.2?±?53.8 vs. 194.1?±?74.5?mmHg, p?=?0.0054) were detected as decreasing in the case of the incontinent group.

Conclusions

A decrease in rectal sphincter function is responsible for incontinence following Mainz pouch type II diversion, and this dysfunction can be correlated with the surgery. Ureterosigmoideostomy is therefore considered as a useful method of urinary diversion only in selected cases with proven good sphincter function.     

Sclerostin and Pref-1 have differential effects on bone mineral density and strength parameters in adolescent athletes compared with non-athletes

Summary

Excessive exercise can have detrimental effects on bone; however, the mechanisms leading to bone loss are not well understood. Sclerostin and preadipocyte factor (Pref)-1 are two hormones which inhibit bone formation. The present study demonstrates that these hormones may have differential effects in athletes as compared to non-athletes.

Introduction

Exercise activity is common in female adolescents, however, excessive exercise can have detrimental effects on bone mineral density (BMD). Mechanisms underlying this decrease in bone mass are not well understood. We investigated the effects of sclerostin, a potent inhibitor of bone formation via WNT signaling inhibition, and Pref-1, a suppressor of osteoblast differentiation, on BMD, bone turnover markers and bone strength in adolescent athletes.

Methods

We studied 50 adolescents between 15–21 years of age: 17 amenorrheic athletes (AA), 17 eumenorrheic athletes (EA), and 16 nonathletic controls (NA). We measured spine and hip BMD by dual energy x-ray absorptiometry and estimated failure load and stiffness at the distal radius and tibia using micro-finite element analysis. We also measured fasting sclerostin, Pref-1, N-terminal propeptide of type 1 procollagen, and C-terminal collagen cross-links levels.

Results

Sclerostin levels were higher in AA and EA compared with NA (AA: 0.42?±?0.15 ng/mL, EA: 0.44?±?0.09 ng/mL, NA: 0.33?±?0.14 ng/mL; p?=?0.047). In EA, sclerostin was positively associated with lumbar spine (LS) BMD and its Z-score (R?=?0.52, p?=?0.03 and R?=?0.55, p?=?0.02, respectively) whereas in NA, sclerostin was inversely associated with LS BMD (R?=??0.61, p?=?0.01). Pref-1 levels were similar in all three groups and there were significant inverse associations between Pref-1, BMD, and estimated bone strength in NA.

Conclusions

Sclerostin and Pref-1 may have differential effects on bone in adolescent athletes compared to non-athletes.     

The Role of Gender in Primary Hyperparathyroidism: Same Disease, Different Presentation

Background

Hyperparathyroidism is much more common in women and therefore may represent different diseases in men and women. In order to understand the role of gender in hyperparathyroidism, we reviewed our experience.

Methods

We analyzed a prospective database of 1309 consecutive patients with primary hyperparathyroidism who underwent parathyroidectomy at our institution between March 2001 and August 2010.

Results

The female-to-male ratio was 3.3:1, and female patients were older at presentation (60?±?0 vs. 57?±?1?years, p?p?=?0.005) and the most common symptom for men was kidney stones (23?% vs. 13?%, p?p?p?=?0.03), higher parathyroid hormone level (140?±?7 vs. 124?±?4?pg/ml, p?=?0.04), higher urinary calcium level (376?±?10 vs. 314?±?5?mg/24?h, p?p?p?=?0.004). The operative approach as well as the number of glands involved and their location did not significantly differ between the groups. The mean gland weight for a single adenomas was higher in male patients (1123?±?128 vs. 636?±?32?mg, p?=?0.001). No significant difference was identified in the immediate and remote postoperative course.

Conclusions

Hyperparathyroidism appears to present differently depending on gender. Male patients more often present without symptoms, present with vitamin D deficiency, and have larger parathyroid glands. Importantly, surgical outcomes were equivalent between men and women.     

The Deleterious Effect of Bariatric Surgery on Cortical and Trabecular Bone Density in the Femurs of Non-obese, Type 2 Diabetic Goto-Kakizaki Rats

Background

The effects of type 2 diabetes on bone mass and microstructure are not clear. The aim of this study was to evaluate bone microstructural properties and volumetric bone mineral density (vBMD) in type 2 diabetic Goto-Kakizaki non-obese rats after gastrojejunal bypass and their relationship with hormonal parameters.

Methods

We designed an experimental study in Goto-Kakizaki rats with and without gastrojejunal bypass, performing densitometric and microstructural studies of the distal femur using X-ray computed microtomography (micro-CT). Levels of insulin, glucagon, leptin, and glucagon-like peptide-1 (GLP-1) were also determined.

Results

We observed reduced cortical (1,488.92?±?98.2 vs. 1,727.92?±?133.45?mg/cm³, p?=?0.028) and trabecular (180.8?±?9 vs. 261.23?±?45.54?mg/cm³, p?=?0.036) vBMD in operated rats. Bone volume fraction (BV/TV) and trabecular connectivity were reduced in operated rats, while there was a reduction in cortical thickness and an increase in rod-like trabeculae at the expense of plate-like trabeculae. Leptin was reduced (1,042?±?549 vs. 2,447?±?1,035?pg/ml, p?=?0.05) and GLP-1 increased (1.62?±?0.32 vs. 0.96?±?0.1?ng/ml, p?=?0.008) but only leptin showed a significant association with vBMD

Conclusions

In type 2 diabetic Goto-Kakizaki rats, gastrojejunal bypass produces a reduction in cortical and trabecular bone mineral density and a deterioration in bone quality that could be explained, in part, by the reduction in leptin levels.     

Effects of single dose methylprednisolone on patient recovery after cardiopulmonary bypass

Background

Ischaemic reperfusion injury, systemic inflammatory response and multi-organ dysfunction are not infrequent following Cardiopulmonary Bypass (CPB). We investigated the role of methylprednisolone in minimizing this state.

Subject and Methods

Hundred consecutive patients undergoing elective single heart valve replacement surgery were randomized to receive methylprednisolone 30?mg/kg (M group) or placebo (P group) after induction of anaesthesia. Data were analyzed using the??t?? test and Fischer test.

Results

The cardiac indices in the M and P group were 2.79?±?0.13?L/min/m² and 2.52?±?0.26?L/min/m² respectively (p?<?0.0001). The amount of blood loss in the test versus control group was 268.3?±?65.78?ml/24 hours versus 318.7?±?55.5?ml/24?h respectively (p?<?0.0001) and the amount of blood transfused in the test versus control group was 1.26?±?0.57 units versus 1.76?±?0.8 units respectively (p?=?0.005). Patients in the test group had a lower incidence of early postoperative fever and new-onset atrial fibrillation during the first 3?days postoperatively. There was a statistically significant reduction in the intensive care unit stay (3.52?±?1.16?days versus 4.14?±?1.29?days in the M versus P group, p?=?0.01) but not in hospital length of stay (13.7?±?1.78?days versus 14.2?±?1.52?days in the M versus P group, p?=?0.13), or in overall morbidity and mortality.

Conclusions

The use of methylprednisolone prior to initiation of CPB is associated with a more stable postoperative course with a higher cardiac index, shorter duration of Intensive Care Unit (ICU) stay and fewer blood transfusions. Methylprednisolone use also appears to be associated with a lower incidence of early postoperative fever and new-onset atrial fibrillation.