Desmoid tumour following a distal radius fracture – a complication or a coincidence?

We describe a case of a desmoid tumour occurring 15 months following an uncomplicated fracture of the left distal radius. The occurrence of a desmoid tumour after fracture is extremely rare and a Medline search revealed only two previous reports. The correlation between the site of trauma and the tumour and the time interval between trauma and presentation strongly supports a causal role of the fracture in the occurrence of this tumour.     

Is a distal jejunojejunal pouch nutritionally ideal in total gastrectomy?

The question arises whether it is important to construct a gastric replacement reservoir, after a total gastrectomy. Creating a noncomplicated and easily constructed capacious antiperistaltic distal jejunojejunal pouch at the Roux-en-Y site should further improve nutritional satisfaction and weight gain, particularly in patients with gastric cancer.     

Laparoscopic distal pancreatomy: are we ready for a standardized technique?

This paper describes and discusses the surgical steps needed to perform a laparoscopic distal pancreatectomy. The current lack of standardization of the operative technique can account for the limited diffusion of this procedure. The issue of spleen preservation, which cannot be overemphasized, always demands an accurate surgical technique that results from proficiency both in open pancreatic surgery and advanced laparoscopy. The preservation of the splenic vessels or short gastric-vessel salvage is feasible, yet with different indications. Also, the splenic-vessels preservation procedure has two distinct technical options. The technique of occlusion of the pancreatic stump is crucial for reducing the risk of a postoperative fistula and should be tailored to the structural features of the gland at the transection line. Finally, the hand-assisted approach can provide distinctive advantages over the pure laparoscopic technique in selected circumstances.     

Primary menouria due to a congenital vesico–vaginal fistula with distal vaginal agenesis: a rarity

We present the case of a female aged 16 years, suffering from cyclical menouria for the last 3 years. Clinical examination revealed the absence of a vagina. Cystoscopy performed while the patient was having menouria revealed an orifice (10 × 8 mm) in the supratrigonal region; blood clots were entering the urinary bladder through this orifice. Magnetic resonance imaging of the pelvis depicted a fluid-filled longitudinal tract distal to the uterus (which was the upper vagina), between the cervix and the bladder. Diagnostic laparoscopy confirmed the presence of a uterus, both ovaries, and the tubal structures. Exploratory laparotomy, correction of the fistulous tract, and sigmoid vaginoplasty were performed. The distal part of the fistulous tract (urinary bladder end) was anastomosed to the proximal end of the sigmoid neo-vagina. The patient is doing well as per her last follow-up at 6 months. She has started menstruating per neo-vagina.     

Single-incision versus conventional laparoscopic distal pancreatectomy: a single-institution case–control study

Purpose

Laparoscopic distal pancreatectomy is becoming increasingly established at specialized surgical institutions worldwide. The purpose of this study was to compare single-incision laparoscopic distal pancreatectomy (panLESS) with conventional laparoscopic distal pancreatectomy (panLAP) to assess feasibility and 30-day morbidity.

Methods

Eight consecutive patients who underwent panLESS were matched with patients who underwent panLAP in the same time period. Matching criteria were age, body mass index, and American Society of Anesthesiologists score. Feasibility was based on tumor size, operative time, intraoperative bleeding, resection status, and hospital stay. Thirty-day morbidity was defined by the revised Accordion Classification system and the International Study Group on Pancreatic Fistula definition.

Results

Over a 19-month period, 8 and 16 patients were identified for panLESS and panLAP, respectively. There were no significant differences in tumor size, operative time, intraoperative bleeding, resection status, and hospital stay between the two groups. Surgical complications developed in four panLESS patients and five panLAP patients, and out of which, two patients from each group developed a postoperative pancreatic fistula (grade B).

Conclusions

This study indicates that panLESS is comparable to panLAP in terms of feasibility. More experience is needed to define what role single-incision distal pancreatectomy should have in minimal invasive pancreatic surgery.     

Is there a role of preservation of the spleen in distal pancreatectomy?

BACKGROUND: The spleen may be preserved during distal pancreatectomy (DP) for benign disease. The aim of this retrospective study was to compare the postoperative course of DP with or without splenectomy. STUDY DESIGN: From June 1992 to June 1997, 40 adult patients without chronic pancreatitis underwent elective DP for benign lesions. Fifteen underwent spleen-preserving DP (Conservative Group) and 25 DP with splenectomy (Splenectomy Group). In spleen-preserving DP, we attempted to preserve the splenic artery and vein. RESULTS: Spleen-preserving DP was successfully performed in all 15 cases. Patient groups were comparable for clinical features, indication for DP, and surgical procedure. There were no postoperative deaths. The overall incidence of pancreatic fistula was 23%, but was significantly higher in the Conservative Group (40%) than in the Splenectomy Group (12%; p < 0.05). Subphrenic abscesses were more frequently observed in the Conservative Group than in the Splenectomy Group (p < 0.05). The mean duration of postoperative hospital stay was 19 days (range 6 to 46 days) in the Conservative Group and 12.5 days (range 7 to 45 days) in the Splenectomy Group (p < 0.05). At the end of mean followup of 30 months (range 8 to 40 months), no severe postsplenectomy sepsis was observed in the Splenectomy Group. CONCLUSIONS: In our experience, DP with splenectomy has a lower morbidity rate and we consider it to be the best procedure for benign pancreatic disease.     

The ski jump deformity of the distal phalanx: a new entity?

A case of a congenital hand anomaly is presented in which the distal phalanx of the little finger was curving dorsally in the sagittal plane. This may be the first reported case. A surgical approach to correct it is described.     

Brodie’s abscess following percutaneous fixation of distal radius fracture in a child

We report the case of a Brodie’s abscess presenting five and a half years following closed reduction and percutaneous pinning of a distal radius fracture. The index surgery was complicated by a pin site infection that was treated successfully with antibiotics. The patient represented with forearm pain years later, and radiological investigations revealed a Brodie’s abscess in the distal radius at the site of the previous Kirschner wires. The Brodie’s abscess was managed through surgical curettage and antibiotics. Staphylococcus aureus and diphtheroid organisms were cultured from the intraoperative specimens. A Brodie’s abscess is a form of localised subacute osteomyelitis, which usually occurs in the metaphysis of long bones and can mimic malignancy. Previous trauma or surgery has been implicated as predisposing factors. We have only identified one previously reported case of Brodie’s abscess following percutaneous pinning. Ours is the first reported case in an adolescent. The aim of this paper is to raise awareness of this rare complication and review the current literature.     

Laparoscopic versus open distal pancreatectomy in pancreatic tumours: a case–control study

Laparoscopic distal pancreatectomy has become an increasingly used procedure in the surgical treatment of benign or borderline cystic and endocrine tumours. The feasibility and safety of this technique is well known but its results when compared with open distal pancreatectomy were rarely reported in literature. Data from 22 consecutive patients who underwent laparoscopic distal pancreatectomy were recorded in a prospective database from January 2006 to January 2010. These patients were matched with 22 patients who underwent open distal pancreatectomy from January 2000 to December 2005, regarding age, gender, American Society of Anesthesiologists score, pancreatic pathology. Intraoperative parameters and postoperative outcome were compared between the two groups. Blood loss, amount of analgesic drugs administered, postoperative mortality and morbidity and pancreatic fistula rate were similar in laparoscopic and open groups. Tumour size was significantly smaller in laparoscopic group (2.0 ± 3.3 vs. 5.0 ± 4.2 cm; P = 0.038). Operative time was significantly shorter in open group (145 ± 49 vs. 225 ± 83 min, P = 0.045). Time to adequate oral intake and length of postoperative hospital stay were significantly better in laparoscopic group than in open group (3.0 ± 0.8 vs. 4.0 ± 0.7 days; P = 0.030 and 8.0 ± 1.3 vs. 11.0 ± 3.0 days; P = 0.011, respectively). Laparoscopic distal pancreatectomy is a feasible and safe surgical approach as well as open distal pancreatectomy.     

Abordaje del uréter distal en la nefroureterectomía laparoscópica

IntroductionNephroureterectomy is one of the procedures for which a laparoscopic approach is more clearly indicated. However, despite the long experience available, management of the distal ureter is still difficult.Materials and methodsThirty-two laparoscopic nephroureterectomies were performed from November 2004 to December 2008. The procedure used was endoscopic resection of distal ureter and earlier ligation of the ureter in the laparoscopic time in 13 patients, a laparoscopic bladder cuff in 13 patients, and an open bladder cuff in 3 patients.ResultsMean operating time was 221.53 min (125-315 min), and mean postoperative stay of 27 patients was 4.6 days. Conversion to open surgery and discontinuation of the procedure for local tumor progression were required in one patient each. Mean patient follow-up was 17.8 months. No local relapse or metastasis occurred in the ports.ConclusionThe most common procedures continue to be endoscopic resection and the open bladder cuff depending on indication. Any laparoscopic approach to upper urothelial tumors must strictly comply with oncological principles. The reported procedure is in our experience the fastest, most simple, and most effective for this purpose. In our opinion, the therapeutic algorithm provided is adequate for management of the distal ureter in laparoscopic nephroureterectomy.     

Is chronically dysfunctional yet viable myocardium distal to a severe coronary stenosis hypoperfused?

BACKGROUND: Controversy exists regarding the perfusion status of chronically dysfunctional yet viable myocardium. Studies investigating the pathophysiology of this condition have reached different conclusions, with some suggesting that myocardial blood flow (MBF) in these regions is normal at rest with regional dysfunction resulting from repetitive stress-induced ischemia (stunned myocardium), whereas others have proposed that MBF is chronically reduced at rest (hibernating myocardium). However, adequately powered experimental studies investigating this question in an appropriate animal model using clinically available techniques have not been performed. Based on the mixed results of prior studies, we hypothesized that these chronically dysfunctional yet viable regions may actually represent a mixture of hibernation and stunning. Consequently, the purpose of this study was to quantitatively determine the distribution of MBF in left ventricular regions with chronically impaired resting function but preserved viability in a large population of animals with single-vessel coronary stenosis in an attempt to further elucidate the mechanism(s) responsible for chronic, reversible myocardial dysfunction. METHODS: Fifty-two adult mini-swine with 90% proximal left circumflex (LCx) stenosis underwent dynamic positron emission tomography (PET) with 13N-ammonia and 18F-fluorodeoxyglucose and dobutamine stress echocardiography (DSE) (5 to 40 microg/kg/min) 1 month after stenosis creation. Values of MBF and FDG uptake by PET and wall motion score index (WMSI) by DSE were compared using a standard 16-segment model. RESULTS: Of 312 possible LCx segments seen on PET, 303 (97.1%) were visualized by DSE. Of the 303 LCx segments, 279 (92.1%) had rest dysfunction (WMSI > or = 2) by DSE. One hundred eighty-two segments (60.1%) had decreased (< 85% reference) MBF at rest with preserved to increased (> 60% reference) FDG uptake and were classified as hibernating. Ninety-two segments (30.4%) had preserved MBF (> or = 85% reference) and were classified as stunned. Five segments (1.7%) with reduced (< or = 60% reference) FDG uptake by PET and akinesis or dyskinesis at rest (WMSI > or = 3) and no contractile reserve were considered infarcted. Hibernating segments had significantly higher FDG uptake at rest (360.7+/-48.3 vs 212.3+/-17.7% septal values; p < 0.001) than stunned segments consistent with greater resting ischemia. Likewise, mean rest WMSI was also worse in hibernating versus stunned segments (2.35+/-0.04 vs 2.13+/-0.04; p < 0.001). There was no difference in the percentage of hibernating versus stunned segments exhibiting contractile reserve during dobutamine infusion (55.5 vs 63.7%; p = 0.4), indicating similar degrees of viability. CONCLUSIONS: Myocardial hibernation and stunning appear to frequently coexist in regions served by a stenotic coronary vessel. Hibernating regions appear to have greater resting ischemia based on higher values of FDG uptake and greater resting dysfunction. Reversible left ventricular dysfunction in the setting of chronic coronary artery disease is likely due to a combination of these two mechanisms.