Extremity Soft Tissue Sarcoma: Adding to the Prognostic Meaning of Local Failure

Background We explored the prognostic meaning of local relapse and surgical margins in adult soft tissue sarcoma of the extremities. Methods Out of a series of 1017 patients with extremity soft tissue sarcoma treated over 20 years, we picked a group of 238 patients operated on at our institution for their first local relapse: 88 after their primary operation performed at the same center and 150 elsewhere. At operation for relapse, margins were microscopically negative in 77% and 75% of patients, respectively. Median follow-up was 107 months. Results The 10-year mortality rate was 22% in the absence of local relapse, whereas in locally relapsing patients it was 54% and 43%, respectively, for patients first operated on at our institute and for those who were not. The hazard ratio of positive versus negative surgical margins was 1.7 for cause-specific death and 2.1 for distant metastases in patients first operated on at our institute, as opposed to 1.2 and 1.3 for the others. Conclusions Local relapse was an unfavorable prognostic factor. In the face of a consistent surgical policy for local relapse in a single-institution setting, patients relapsing after the first operation performed at our institution received rescue treatment less frequently than those previously operated on outside a referral center. This is likely due to an inherently higher tumor aggressiveness. In the presence of such a higher aggressiveness, the adequacy of surgical margins at operation for first relapse seemed more critical prognostically. This may have clinical and speculative implications. Presented at the Annual Meeting of the American Society of Clinical Oncology, June 2–6, 2006, Atlanta, GA (USA) (abstract 9565).     

Treatment Failure After Percutaneous Radiofrequency Ablation for Nonsurgical Candidates With Pulmonary Metastases From Colorectal Carcinoma

Background This study critically evaluated the local and overall treatment failure rates after percutaneous radiofrequency ablation (RFA) of pulmonary metastases from colorectal carcinoma. Methods Fifty-five nonsurgical candidates underwent RFA of colorectal pulmonary metastases. The primary end points of this study were local progression-free survival (PFS) and overall PFS. Univariate and multivariate analyses were performed to identify significant prognostic parameters for local and overall PFS. Results The local recurrence rate was 38%. For local PFS, univariate analysis demonstrated that the largest size of lung metastasis, the location of lung metastases, the post-RFA carcinoembryonic antigen level at 1 month, and the post-RFA carcinoembryonic antigen level at 3 months were significant prognostic indicators. In multivariate analysis, a largest size of lung metastasis of >3 cm and a post-RFA carcinoembryonic antigen level of >5 ng/mL at 1 month were independently associated with a reduced local PFS. The overall recurrence rate was 66%. For overall PFS, univariate analysis demonstrated that sex and the largest size of lung metastasis were significant prognostic indicators. In multivariate analysis, a largest size of lung metastasis of >3 cm was independently associated with a reduced overall PFS. Conclusions RFA of colorectal pulmonary metastases may have a useful role in local disease control for nonsurgical candidates, but its efficacy in patients with a lung metastasis of >3 cm is limited.     

New parameter of flexion after posterior stabilized total knee arthroplasty: posterior condylar offset ratio on X-ray photographs

In cruciate-retaining (CR) type TKA, the increase in posterior condylar offset (PCO) is considered to be correlated to flexion angle acquired postoperatively according to the article reported by Bellemans (J Bone Joint Surg Br 84:50–53, 2002). However, the significance of PCO seems to differ according to the size of joints. We therefore have defined a new parameter of posterior condylar offset ratio (PCOR) on the lateral view of plain X-ray photographs and studied the relationship between PCOR and postoperative flexion status in posterior-stabilized (PS) type TKA. Flexion status includes two parameters, such as postoperative flexion angle (FA) and flexion achievement rate (AR). The subjects of this study were 160 knees (16 males and 144 females, average 75 years.) with PS type TKA for osteoarthritic knees between 1999 and 2003 at our institution, more than at least 1 year postoperative follow-up. In the study of FA, patients with FA of less than 100° were divided into Group L (n = 28), patients with FA of 130° and greater were divided into Group H (n = 58). In the study of AR, patients with AR of less than 100% were divided into Group P (n = 46), patients with AR of 120% and greater were divided into Group G (n = 22). PCOR was statistically compared in each group, respectively. In FA, PCOR in Group L (0.385) was significantly lower (P = 0.027) than that in Group H (0.428). In AR, PCOR in Group P (0.376) was significantly lower (P = 0.0018) than that in Group G (0.456). We have concluded, though there are many factors influencing the range of movement after TKA, our newly defined PCOR could possibly serve as a parameter of postoperative flexion status of PS type TKA on plain X-ray photographs. No benefits or funds were received in support of the study.     

Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results

Introduction Laparoscopic repair of inguinal hernias is usually achieved by totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) techniques. The intraperitoneal onlay mesh (IPOM) could be an interesting alternative as it is much easier to perform and faster to execute. This technique is subject to correct selection of indications and to demonstration of its safety. Materials and methods From January 2003 to January 2006 we performed 61 laparoscopic hernia procedures on 60 selected patients (60 males with a mean age of 60 and mean weight of 76 kg) with an IPOM technique combining the Parietex composite mesh (12 cm circular model) and a fibrin glue (Tissucol) for its fixation. The glue was diluted to increase fixation time and applied to the mesh prior to positioning on the hernia defect. Results Mean operative time was 10 minutes. Mean hernia diameter was 2.5 cm (± 0.8 cm). 10 hernias were direct, 51 were indirect and 10 out of 61 were recurrent. We did not convert any of the laparoscopic procedures. Mean hospital stay was one day; mean recovery time for working and general physical activities was five days. Patients were checked after one week, 1-3-6 months and 1-2 years. Average follow up time was 23.7 months. 1.6 % of patients showed short-term complications: one trocar site haematoma. No additional complications were reported; particularly, we had no recurrence, no seroma, no mesh migration, and no bowel obstruction or fistula. Conclusion Results of this study show intraperitoneal (IP) tolerance to this kind of mesh and the safety of its fixation with Tissucol. The absence of recurrence and complications could be a good reason to extend the indication of IPOM hernia repair. However, these preliminary results should be confirmed by longer follow-up.     

Post streptococcal acute glomerulonephritis secondary to sporadic <Emphasis Type="Italic">Streptococcus equi</Emphasis> infection

Streptococcus equi subspecies zooepidemicus infection is rare in humans, but a well-known cause of pyogenic disease in cows and horses. S. zooepidemicus uncommonly causes post-strep glomerulonephritis (PSGN) in humans via epidemic outbreaks. We present a sporadic case of post S. zooepidemicus glomerulonephritis in a child most probably contracted from a horse. The 14-year-old girl presented with the typical signs of PSGN, with S. equi zooepidemicus isolated from a blood culture, together with a low C3 and raised anti-DNAse B. This is the first known report of a sporadic case of PSGN in a child caused by this organism.     

Facial Fractures in Kajang Hospital,Malaysia: A 5-Year Review

Abstract Objective: The objective of this study was to determine the demographic data as well as other relevant data pertaining to the management of patients with maxillofacial injury in a Malaysian government regional hospital. Study Design: Medical records of 313 patients who sustained maxillofacial injury treated in Kajang Hospital, Selangor, Malaysia over a 5-year period (1998–2002) were collected. Data regarding age, gender and race, etiology of injury, site of injury, other associated injuries and treatment undertaken were analyzed. Results: Two hundred and forty-nine male (79.6%) and 64 female patients (20.4%) were treated for maxillofacial trauma. The patients' age range from 1 to 67 years old, with a median age of 23 years old. A high number of Malays (60.1%) sustained maxillofacial injury, followed by Indians (16%), Chinese (13.4%) and other races (10.5%). Road traffic accident was the main etiology for maxillofacial injury with 230 cases (73.5%), followed by fall (16.6%), assault (5.4%), industrial accident (2.6%), sports injuries (0.6%) and others (1.3%). Mandibular fractures were the most common, occurring in 83.1% of the cases while the midfacial fractures accounted for 16.9%. Majority of patients were treated with closed reduction and intermaxillary fixation (88.1%) and 11.9% underwent open reduction and internal fixation. Conclusion: Road traffic accident involving motorcyclists was the main cause of maxillofacial trauma in Malaysia. The most common facial fracture was the mandibular fracture. Non-surgical manipulation of fracture was the most common treatment carried out in this hospital.     

Comparison of Functional and Surgical Outcomes of Laparoscopic-Assisted Colonic J-Pouch Versus Straight Reconstruction After Total Mesorectal Excision for Lower Rectal Cancer

Background To compare the functional and surgical outcomes of colonic J-pouch and straight anastomosis in the context that both reconstruction procedures were performed laparoscopically. Methods The present study was a randomized prospective clinical trial. Patients with lower rectal cancer requiring laparoscopic total mesorectal excision were equally randomized to either laparoscopic-assisted colonic J-pouch reconstruction or laparoscopic straight end-to-end anastomosis. The techniques of the laparoscopic-assisted colonic J-pouch reconstruction are shown in the attached video. The primary end point was the comparison of functional results in both reconstruction methods. The secondary end points included the safety (surgical morbidity and mortality), surgical efficiency, and postoperative recovery. Results A total of 48 patients were recruited within 2-year periods, in consideration of statistical power of 90% for comparison. There was no marked difference between patient groups undergoing colonic J-pouch surgery (n = 24) and straight anastomosis (n = 24) in various demographic and clinicopathogic parameters. The anorectal function of patients by colonic J-pouch were better than those by straight anastomosis in 3 months after operation, as evaluated by stool frequency (mean ± standard deviation: 4.0 ± 2.0 vs. 7.0 ± 2.4 times/day, P < .001); use of antidiarrheal agents (29.2% [n = 7] vs. 75.0% [n = 18], P = .004); and perineal irritation (45.8% [n = 11] vs. 79.2% [n = 19], P = .037). Because of the relatively better bowel function in immediate postoperative period, patients by colonic J-pouch reconstruction were less disabled after surgery and had quicker return to partial activity (P = .039), full activity (P < .001), and work (P < .001). Both reconstruction methods were performed with similar amounts of blood loss, complication rates, and postoperative recovery. However, the operation time was significantly longer in the colonic J-pouch group (274.4 ± 34.0 vs. 202.0 ± 28.0 minutes, P < .001). Conclusions Because laparoscopic-assisted creation of a colonic J-pouch achieved better short-term functional results of the anorectum and did not increase surgical morbidity, as compared with laparoscopic straight anastomosis, this reconstruction procedure could be recommended to patients with lower rectal cancer requiring laparoscopic total mesorectal excision. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Development of a Simple Model of Extrinsic Denervation of the Small Bowel in Mouse

Small bowel transplantation (SBT) is associated with poorly understood enteric dysfunction. The study of SBT in mice is hindered by the technical difficulty of orthotopic SBT in the mouse. Our aim was to develop an easy preparation of extrinsic denervation of the entire jejunoileum in mice as a model of orthotopic SBT. All neurolymphatic tissues accompanying the superior mesenteric artery (SMA) and vein (SMV) were ligated just distal to the middle colic vessels. The SMA and SMV were then stripped of investing adventitia, and the mesentery to jejunum and colon were transected radially. Jejunum and colon were not transected and reanastomosed. To confirm extrinsic denervation 1, 3, and 6 months later, segments of small bowel were stained for protein gene product 9.5 (PGP9.5) and tyrosine hydroxylase (TH). Tyrosine hydroxylase immunoreactive intensity was then quantified using a semiquantitative analysis. Immunohistochemical fluorescence showed persistence of PGP9.5 immunoreactivity confirming enteric nerves in jejunoileum; however, there was no TH immunoreactivity in jejunoileum in denervated mice despite the expected preservation of TH immunoreactivity in the still-innervated duodenum at 1 month. At 3 months, sparse immunoreactivity for TH was present, and by 6 months, reinnervation of TH-containing nerves appeared similar to controls. Quantification of intensity at each time-point further confirmed this trend. This technique in the mouse accomplishes a complete extrinsic denervation of jejunoileum early postoperatively (1 and 3 months); reinnervation occurs by 6 months. This is an easily learned murine model of orthotopic SBT. Presented at the American Gastroenterological Association during Digestive Disease Week in Los Angeles, CA, as a poster presentation on May 23 2006. Abstract published in GastroenterologyE 2006; 130:A604.     

Radiofrequency (RF)-Assisted Hepatectomy May Induce Severe Postoperative Liver Damage

Background Radiofrequency (RF) ablation for the treatment of the section line prior to liver resection has been proposed as a way to reduce blood loss during hepatectomy. Our group compared hepatectomy with and without RF ablation to determine whether this technique actually reduces blood loss during liver resection and whether it affects the perioperative outcome. Method Of 151 patients who underwent a hepatectomy between January 2002 and October 2005 at the Division of Gastrointestinal Surgery in the Department of Surgery of Saitama Medical University, 48 who had a partial hepatectomy or resection of a portion of liver smaller than a single Couinaud segment were included in the study. Twenty patients who had RF-assisted hepatectomy [RF (+) group] and 28 patients who had hepatectomy without ablation [RF (-) group] were studied to compare the rates of intraoperative blood loss and the effects of RF ablation on the perioperative outcome. Results Intraoperative blood loss was significantly reduced in the RF (+) group. In contrast, the alanine aminotransferase activity in the RF (+) group was significantly elevated immediately after the operation. There was no significant difference in the incidence of postoperative complications between the groups, although bile leakage did occur in three RF (+) patients. Conclusions Our results demonstrate that the RF ablation technique can be a useful way to reduce surgical blood loss. In view of its association with severe postoperative liver damage, the technique must be applied with caution. The danger may be especially relevant to patients with chronic liver disease and decreased liver reserve.     

Prospective randomized study of azathioprine vs cyclosporine based therapy in primary haplo-identical living-donor kidney transplantation: 20-year experience

Background The achievements in short-term graft survival since the introduction of cyclosporine (CsA) have not been matched by improvements in long-term graft function. Chronic allograft nephropathy (CAN) remains the second most common cause of graft attrition over time, after patient mortality. We aimed to evaluate the long-term results of azathioprine vs CsA in live-donor kidney transplantation in a prospective randomized study. Methods We studied 475 renal transplant recipients who had had transplantations performed at the Urology and Nephrology Center, Mansoura University, before 1988 and who had received a primary immunosuppressive protocol consisting of either steroid and azathioprine (steroid/Aza; group 1, 300 patients) or steroid and CsA (steroid/CsA; group 2, 175 patients). Only adult primary renal transplant recipients aged between 18 and 60 years and with one haplotype HLA mismatch were included. All patients received kidneys from living-related donors, with previous donor nonspecific blood transfusions. The study was based on the long-term follow-up data of these renal transplant recipients. Comparative analyses included patient and graft survival rates, condition at last follow up, rejection (acute and chronic), and graft function (serum creatinine and creatinine clearance). Results The overall frequency of acute rejection episodes was not significantly different between the two groups. Graft survival rates were: group 1 vs group 2, 69% vs 58% at 5 years, and 52% vs 36% at 10 years, but at 20 years, graft survival rates had declined to 26% and 24%. No significant differences were encountered between the two groups regarding post-transplant malignancies, diabetes mellitus, hepatic impairment, or serious bacterial infections. Conclusions From this study we can conclude that the long-term result of historical conventional therapy (steroid/Aza) without induction therapy is effective for living-donor kidney transplants. In spite of the comparable graft function for the two groups, the steroid/CsA group experienced more hypertension, as well as many adverse reactions to CsA. Nowadays, since the introduction of induction therapy and the utilization of newer maintenance immunosuppressive agents – such as mycophenolate mofetil (MMF) and rapamycin – it is possible to achieve an excellent calcineurin inhibitors (CNI)-free regimen.