Laparoscopic Common Bile Duct Exploration

Since the introduction of laparoscopic cholecystectomy, the management of common bile duct (CBD) stones has undergone significant change. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is now routinely done in cases where the diagnosis of choledocholithiasis is suspected preoperatively, with clearance of the bile ducts before laparoscopic cholecystectomy. Intraoperative discovery of CBD stones by cholangiography represents a challenge to the surgeon, who must make a decision about when to perform laparoscopic CBD exploration, convert to open surgery, or send the patient for ERCP during the postoperative period. Because ERCP has a definite failure rate, laparoscopic CBD exploration can be a treatment option. Among 2500 laparoscopic cholecystectomies done by our group from January 1991 to June 1997, 50 patients (2%) underwent laparoscopic CBD exploration, 13 by the transcystic technique and 37 by choledocotomy, with a conversion rate of 8% and a hospital stay of 4.3 days. One patient died from complicated pancreatitis following ERCP and unsuccessful extraction of a CBD stone. We obtained our goal of a CBD free of stones in 92% of the cases. We conclude that laparoscopic CBD exploration is an effective method for treating choledocolithiasis that allows management of this pathology in one stage, although it requires advanced laparoscopic skills and adequate equipment.     

Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study

Background. Minimally invasive aortic valve replacement reduces surgical trauma and, supposedly, postoperative pain, blood loss, and length of stay. A prospective, randomized study was designed to prove these theoretical advantages.

Methods. Forty patients undergoing isolated, elective aortic valve replacement were randomized into two equal groups. Patients in group M underwent aortic valve replacement through a ministernotomy (reversed or reversed ). In group S, a median sternotomy was used. The anesthetic and surgical protocol was identical for both groups. Pain was evaluated on a daily basis. Pulmonary function tests were performed preoperatively and before hospital discharge in all patients.

Results. There were two deaths in each group. Cross-clamp time was longer in group M: 70 ± 19 minutes versus 51 ± 13 minutes in group S (p = 0.005). There were no statistically significant differences between groups M and S in pump time (95 ± 20 minutes versus 83 ± 19 minutes), extubation time (9.9 hours in both groups), chest drainage (479 ± 274 mL/ 24 hours versus 355 ± 159 mL/ 24 hours), transfusion requirements (27% in both groups), pain evaluation (1.34 ± 1.3 versus 2.15 ± 1.5), length of stay (6.2 ± 2.3 days versus 6.3 ± 2.5 days), and cosmetic appraisal. Forced vital capacity decreased 26% from preoperative reference values in group M and 33% in group S (p = not significant). Forced expiratory volume in 1 second decreased 22% and 35%, respectively (p = not significant).

Conclusions. This study has failed to prove the theoretical advantages of minimally invasive aortic valve replacement. With this technique, cross-clamp time is longer than with a median sternotomy.     

The rs12594956 polymorphism in the NRF-2 gene is associated with top-level Spanish athlete's performance status

ObjectivesTo determine the association between the nuclear respiratory factor 2 (NRF-2) polymorphisms and elite athletic performance.DesignWe compared the genotype and allele frequencies of the NRF-2 A/C (rs12594956), NRF-2 A/G (rs7181866), and NRF-2 C/T (rs8031031) polymorphisms between world-class endurance athletes (n = 89), elite power-oriented athletes (n = 38), and non-athletic controls (n = 110) of the same Caucasian (Spanish) origin.MethodsGenomic DNA was extracted from peripheral EDTA-treated, anti-coagulated blood using a standard protocol. Genotyping was performed using polymerase chain reaction (PCR).ResultsThe frequency of the AA genotype of the NRF-2 A/C (rs12594956) polymorphism was significantly higher in endurance athletes compared with power athletes (P < 0.01) and controls (P < 0.01) (48% vs. 13% and 21%, respectively). The likelihood of having the AA (rs12594956) genotype was higher in elite endurance athletes compared with controls [odds ratio (OR): 3.536, 95% confidence interval (CI): 1.903–6.571] and elite power athletes (OR: 6.170, 95%CI: 2.206–17.253).ConclusionsOur results suggest that the NRF-2 A/C polymorphism might belong to a growing group of polymorphisms associated with endurance performance at the elite level. However, it is important to replicate these findings in other groups of elite athletes using larger sample sizes.     

ERα signaling regulates MMP3 expression to induce FasL cleavage and osteoclast apoptosis

The benefits of estrogens on bone health are well established; how estrogens signal to regulate bone formation and resorption is less well understood. We show here that 17β‐estradiol (E2)‐induced apoptosis of bone‐resorbing osteoclasts is mediated by cleavage and solubilization of osteoblast‐expressed Fas ligand (FasL). U2OS‐ERα osteoblast‐like cells expressing an EGFP‐tagged FasL at the C‐terminus showed decreased fluorescence after E2 treatment, indicative of a cleavage event. Treatment of U2OS‐ERα cultures with a specific MMP3 inhibitor in the presence of E2 blocked FasL cleavage and showed an increase in the number of EGFP‐FasL⁺ cells. siRNA experiments successfully knocked down MMP3 expression and restored full‐length FasL to basal levels. E2 treatment of both human and murine primary osteoblasts showed upregulation of MMP3 mRNA expression, and calvarial organ cultures showed increased expression of MMP3 protein and colocalization with the osteoblast‐specific RUNX2 after E2 treatment. In addition, osteoblast cell cultures derived from ERαKO mice showed decreased expression of MMP3 but not MMP7 and ADAM10, two known FasL proteases, demonstrating that ERα signaling regulates MMP3. Also, conditioned media of E2‐treated calvarial osteoblasts showed an approximate sixfold increase in the concentration of soluble FasL, indicating extensive cleavage, and soluble FasL concentrations were reduced in the presence of a specific MMP3 inhibitor. Finally, to show the role of soluble FasL in osteoclast apoptosis, human osteoclasts were cocultured with MC3T3 osteoblasts. Both a specific MMP3 inhibitor and an MMP inhibitor cocktail preserved osteoclast differentiation and survival in the presence of E2 and demonstrate the necessity of MMP3 for E2‐induced osteoclast apoptosis. These experiments further define the molecular mechanism of estrogen's bone‐protective effects by inducing osteoclast apoptosis through upregulation of MMP3 and FasL cleavage. © 2013 American Society for Bone and Mineral Research     

The Metabolic Syndrome in Patients Undergoing Knee and Hip Arthroplasty : Trends and In-Hospital Outcomes in the United States

We evaluated the impact of metabolic syndrome (MetS) on perioperative outcomes in patients undergoing total joint arthroplasty. Using the Nationwide Inpatient Sample, patients with MetS were identified if they had at least 3 of 4 component comorbidities (obesity, dyslipidemia, hypertension, and diabetes). Patient demographics, in-hospital outcomes, and cost were compared between patients with and patients without MetS. Trends were studied for 3-year periods between 2000 and 2008. The prevalence of MetS increased over time, reaching 14% (total knee arthroplasty) and 8.7% (total hip arthroplasty) most recently. Metabolic syndrome was overproportionately prevalent among female total knee arthroplasty recipients, male total hip arthroplasty recipients, and patients in the minority race group. In the regression analysis, MetS was an independent risk factor for the development of major complications, nonroutine discharge, and increased hospital cost. Given the increasing rates of MetS and its association with higher risk for major complications among total joint arthroplasty recipients, further research into the impact of this disease complex is warranted.     

Laparoscopic approach in complicated diverticular disease

AIM: To analyze the results of laparoscopic colectomy in complicated diverticular disease.METHODS: This was a retrospective cohort study conducted at an academic teaching hospital. Data were collected from a database established earlier, which comprise of all patients who underwent laparoscopic colectomy for diverticular disease between 2000 and 2013. The series was divided into two groups that were compared: Patients with complicated disease(abscess, perforation, fistula, or stenosis)(G1) and patients undergoing surgery for recurrent diverticulitis(G2). Recurrent diverticulitis was defined as two or more episodes of diverticulitis regardless of patient age. Data regarding patient demographics, comorbidities, prior abdominal operations, history of acute diverticulitis, classification of acute diverticulitis at index admission and intra and postoperative variables were extracted. Univariate analysis was performed in both groups.RESULTS: Two hundred and sixty patients were included: 28%(72 patients) belonged to G1 and 72%(188 patients) to G2. The mean age was 57(27-89) years. The average number of episodes of diverticulitis before surgery was 2.1(r 0-10); 43 patients had no previous inflammatory pathology. There were significant differences between the two groups with respect to conversion rate and hospital stay(G1 18% vs G2 3.2%, P = 0.001; G1: 4.7 d vs G2 3.3 d, P < 0.001). The anastomotic dehiscence rate was 2.3%, with no statistical difference between the groups(G1 2.7% vs G2 2.1%, P = 0.5). There were no differences in demographic data(body mass index, American Society of Anesthesiology and previous abdominal surgery), operative time and intraoperative and postoperative complications between the groups. The mortality rate was 0.38%(1 patient), represented by a death secondary to septic shock in G2.CONCLUSION: The results support that the laparoscopic approach in any kind of complicated diverticular disease can be performed with low morbidity and acceptable conversion rates when compared with patients undergoing laparoscopic surgery for recurrent diverticulitis.     

Risk factors for the need of surgical treatment of a first recurrent lumbar disc herniation

Purpose

A recurrent lumbar disc herniation (RLDH) is the most prevalent cause for new radicular pain after surgery for disc herniation-induced sciatica. Reported risk factors include age, gender and smoking, while its surgical treatment is associated to a higher rate of complications and costs. The purpose of this study is to identify factors that increase the risk of requiring surgical treatment for a first RLDH in workers’ compensation patients.

Methods

Nested case–control: 109 patients operated for an RLDH (cases) between June 1st 1994 and May 31st 2011 (minimum follow-up 1 year) and 109 randomly selected patients operated for a first disc herniation with no recurrence during the study period (controls). Age, gender, smoking status, type of work and MRI characteristics of the index herniation were statistically evaluated as potential risk factors.

Results

Patient’s age of less than 35 years (p = 0.001) and a subligamentous herniation (p < 0.05) at the time of the index surgery were identified as risk factors for requiring surgical treatment of a first RLDH. No statistical differences were observed between both groups regarding the other evaluated variables.

Conclusion

A subligamentous disc herniation and patient’s age inferior to 35 years at the time of the first surgery are risk factors for requiring surgical treatment of a first RLDH among workers’ compensation patients.

     

Is the levator–urethra gap helpful for diagnosing avulsion?

Introduction and hypothesis

Levator avulsion is a risk factor for female pelvic organ prolapse (POP) and recurrence after POP surgery. Imaging diagnosis requires the observation of an abnormal muscle insertion on tomographic ultrasound imaging (TUI). This study was designed to compare the diagnostic performance of the qualitative diagnosis (visual qualitative assessment) to measurement of the distance between muscle insertion and urethra [levator–urethra gap; (LUG)].

Methods

This was a retrospective analysis of data obtained in a tertiary urogynecological unit. All patients presented with symptoms of pelvic floor dysfunction and underwent 4D translabial pelvic floor ultrasound (US), supine, and after voiding. Avulsion was defined qualitatively as abnormal muscle insertion and quantitatively as LUG ≥25 mm on at least three consecutive central axial plane slices, with one examiner using both methods. We examined the correlation between both methods and validated them against clinical prolapse, significant organ descent on US, and hiatal ballooning.

Results

Between January and July 2013, 233 patients were seen, of whom 202 had complete volume data sets. The qualitative method diagnosed avulsion in 22 % and the quantitative method in 24.3 %. Agreement was good, with a kappa of 0.79 (0.70–0.87). Avulsion diagnosed by either method was associated with clinical and sonographic prolapse and hiatal ballooning, with odds ratios nonsignificantly higher for the quantitative method.

Conclusion

Qualitative analysis of slices on TUI and a method using LUG measurement show good agreement for the diagnosis of avulsion. The LUG method is at least equally as valid in its capacity to predict significant prolapse on clinical examination and US, as well as ballooning of the levator hiatus.

     

Maffucci's syndrome. Case reports and literature review

Maffucci syndrome is a rare, congenital disease, which is associated with the appearance of multiple enchondromas (possibility of malignant transformation in 20 to 100%), soft tissue hemangiomas and other mesenchymatous injuries. Case 1 is a 33-year-old female who presented with multiple nodules predominantly in upper extremities. Upon examination, there was deformity in articulation and nodules on the hands, which were soft and moveable. There were bony shavings in the second and fourth fingers of the left hand (enchondromas and atypical cells associated with hemangioma esclerosante). Maffucci syndrome was diagnosed. Later, excision of subcutaneous nodules in superior extremities was performed along with excision of nodules in both hands and hypochondrium (enchondroma injuries of left hand and hypochondrium, hemangioma in right hand). There was dysarticulation of the second finger at the metacarpal level of the phalanges of the left hand (chondrosarcoma). The patient is being followed up currently. Case 2 is a 26-year-old female. The patient had a history of subcutaneous abdominal tumor, exostosis, nodules and nodule in right breast. Upon examination, a tumor was found in the right breast, exostosis of right tibia, injury to the right wrist and left thyroid nodule. A simple mastectomy and axillary dissection was performed (fibroadenoma to intracanalicular and 14 negative lymph nodes). Later, left thyroidectomy and lumpectomy in right wrist were performed (hyperplasia to nodular thyroid and hemangioma cavernous). There was injury in the carpus of the right hand and elbow (hemangioma cavernous and synovial tissue with fibrosis and enchondroma). A diagnosis was made of Marffucci syndrome associated with mesenchymatous tumors. The patient was in poor general health and did not survive this hospitalization.