Rectal perforation after AxiaLIF instrumentation: case report and review of the literature

Background contextBowel perforation is an uncommon complication of posterior spinal surgery. The AxiaLIF transsacral instrumentation system has been used for the treatment of L5–S1 spondylolisthesis and degenerative disc disease since its introduction in 2005 as a potentially less invasive alternative to traditional anterior or posterior interbody fusion.PurposeIn this article, we report a case of a rectal perforation as a complication of placement of the AxiaLIF instrumentation system that was successfully treated without the removal of the device.Study designCase report.MethodsThe patient presented with progressive back pain and sepsis 3 weeks after an L5–S1 fusion done with the AxiaLIF technique at an outside facility. The patient was managed with antibiotic therapy and a diverting ileostomy, without the removal of the AxiaLIF device.ResultsOver the next year, she had symptoms indicative of nonunion of the operated level and breakdown at the adjacent level, which were confirmed with imaging. She underwent revision posterior spinal fusion without the removal of the AxiaLIF device. Eighteen months after the AxiaLIF device was placed, the patient continued to demonstrate no signs of infection recurrence.ConclusionsDelayed presentation of rectal perforation with a subsequent anaerobic sepsis is a potential complication of the presacral approach to the L5–S1 disc space. Recognition and treatment with fecal diversion and long-term intravenous antibiotics is an alternative to device removal and sacral reconstruction.     

Effect of the transdermal low-level laser therapy on endothelial function

The effect of low-level laser therapy (LLLT) on the cardiovascular system is not fully established. Since the endothelium is an important endocrine element, establishing the mechanisms of LLLT action is an important issue.The aim of the study was to evaluate the effect of transdermal LLLT on endothelial function.In this study, healthy volunteers (n?=?40, age?=?20–40 years) were enrolled. N?=?30 (14 female, 16 male, mean age 30?±?5 years) constituted the laser-irradiated group (LG). The remaining 10 subjects (6 women, 4 men, mean age 28?±?5 years) constituted the control group (CG). Participants were subjected to LLLT once a day for three consecutive days. Blood for biochemical assessments was drawn before the first irradiation and 24 h after the last session. In the LG, transdermal illumination of radial artery was conducted (a semiconductor laser λ?=?808 nm, irradiation 50 mW, energy density 1.6 W/cm² and a dose 20 J/day, a total dose of 60 J). Biochemical parameters (reflecting angiogenesis: vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), angiostatin; antioxidative status: glutathione (GSH) and the nitric oxide metabolic pathway: symmetric dimethylarginine (SDMA), asymmetric dimethylarginine (ADMA) and l-arginine) were assessed. In the LG, a significant increase in GSH levels and considerable decrease in angiostatin concentration following the LLLT were observed. No significant differences in levels of the VEGF, FGF, SDMA, ADMA were observed.LLLT modifies vascular endothelial function by increasing its antioxidant and angiogenic potential. We found no significant differences in levels of the nitric oxide pathway metabolites within 24 h following the LLLT irradiation.     

Two corticosteroid-free regimens-tacrolimus monotherapy after basiliximab administration and tacrolimus/mycophenolate mofetil-in comparison with a standard triple regimen in renal transplantation: results of the Atlas study

BACKGROUND: The side effects associated with corticosteroids have led to efforts to minimize their use in renal transplant patients. In this study we compared two corticosteroid-free tacrolimus-based regimens with a standard triple therapy. METHODS: This was a 6-month, phase III, open-label, parallel-group, multicenter study. The total analysis set comprised 451 patients, randomized (1:1:1) to receive tacrolimus (Tac) monotherapy following basiliximab (Bas) administration (n=153), Tac/mycophenolate mofetil (MMF) (n=151), or, Tac/MMF/corticosteroids triple therapy as a control (n=147). RESULTS: The study was completed by 91.2% (triple therapy), 94.7% (Tac/MMF), and 82.4% (Bas/Tac) of patients. Patient baseline characteristics were similar in all groups. The incidences of biopsy-proven acute rejection were 8.2% (triple therapy), 30.5% (Tac/MMF), and 26.1% (Bas/Tac), p<0.001 (multiple test for comparison with triple therapy); Bas/Tac vs. Tac/MMF, p=ns. The incidences of corticosteroid-resistant acute rejection were 2.0%, 4.0%, and 5.2%, p=ns. Graft survival (95.9%, 96.7%, and 94.7%, p=ns) and patient survival (100%, 99.3%, and 99.3%, p=ns) were similar in all groups. Median serum creatinine at month 6 was 123.0 micromol/L (triple therapy), 134.7 micromol/L (Tac/MMF) and 135.8 micromol/L (Bas/Tac). The overall safety profiles were similar; differences (p<0.05) were reported for anaemia (24.5% vs. 12.6% vs. 14.5%), diarrhoea (12.9% vs. 17.9% vs. 5.9%), and leukopenia (7.5% vs. 18.5% vs. 5.9%) for the triple therapy, Tac/MMF, and Bas/Tac group, respectively. The incidences of new-onset diabetes mellitus were 4.6%, 7.1%, and 1.4%, respectively. CONCLUSION: Corticosteroid-free immunosuppression was feasible with the Bas/Tac and the Tac/MMF regimens. Both corticosteroid-free regimens were equally effective in preventing acute rejection, with the Bas/Tac therapy offering some safety benefits.     

The loss and progressive recovery of voiding after spinal cord interruption in rats is associated with simultaneous changes in autonomous contractile bladder activity

Background

Autonomous contractile activity (ACA) is a well-known phenomenon in isolated bladders from different species and seems to be important in the physiology of both normal and dysfunctional voiding.

Objective

To determine whether ACA is changed in bladders from paraplegic rats at different periods post–spinal cord injury (post-SCI).

Design, setting, and participants

ACA was studied in bladders (at least six per group) from normal and paraplegic female Wister rats at different times post-SCI (2 h, 24 h, 1 wk, and 3 wk). A group of normal rats was used as a control group. For measurements bladders were incubated in organ baths under standardised conditions.

Measurements

ACA was measured as pressure change, which was defined as either a transient change or a spiked change according to its characteristics. The effects of intravesical volume load and muscarinic agonists were studied.

Results and limitations

Following spinal cord injury (SCI) a clear evolution in ACA was observed. In bladders from SCI rats in the acute areflexive voiding phase (1 wk post-SCI), we observed decreased ACA associated with a highly increased compliance and a changed response to muscarinic agonists. ACA in bladders from SCI rats with renewed voiding reflexes (3 wk post-SCI) was increased, together with a moderately increased compliance and a (moderately) changed response to muscarinic agonists.

Conclusions

From these observations it is apparent that SCI leads to alterations in the behaviour and muscarinic response of ACA in the isolated bladder. These changes in ACA may play an important role in the pathophysiology of overactive bladder disease (OAB), and interacting with changed ACA might be promising in the search for newer treatments for OAB.     

Renovascular hypertension – simultaneous aortic and renal artery reconstruction

Despite the enormous progress that has been madein the fields of vascular surgery and intensive care, reconstructive surgery of renal arteries in the presence of arteriosclerosis of the abdominal aorta remains a serious therapeutic problem and is associated with a high rate of complications. The purpose of this study was to analyze the results of treatment of patients with renovascular hypertension and so-called difficult aorta. Surgery was carried out in 68 patients with a critically stenosed renal artery and severe arteriosclerosis of the abdominal aorta. In 53 patients an aortobifemoral prosthetic graft was implanted together with endarterectomy of the renal artery in 23 patients, an aortorenal venous graft in 23 patients and a prosthetic graft in 7 patients. In the remaining 15 patients extra-anatomic anastomoses were performed between the splenic artery and the renal artery (7 patients), hepatic artery and renal artery (6) and between the superior mesenteric and renal artery (2). Postoperatively, the hypertension was cured in 55% of patients, improved in 38% and remained unchanged in 7%. After 1 year the results were respectively 47, 36, and 17%. The patients with an aortorenal prosthetic graft demonstrated a greater tendency for hypertension to recur.     

Arthroscopic verification of meniscus repair]

The purpose of this study was to verify the arthroscopic meniscus repair by second-look arthroscopy. From November 2001 to October 2005, 28 meniscus (18 medial and 10 lateral) were repaired in 26 patients (two patients had both menisci in one knee repaired). There were 11 females and 15 males. The average age at surgery was 25.5 (range, 13 to 52 years of age). The indication for repair was a full-thickness, vertical tear > or = 8 mm. Meniscus repair was combined with partial meniscectomy of posterior horn because of horizontal tear in 3 cases. In 1 zone 14 meniscus were injured and in 2 zone--also 14 meniscus, according to Cooper's classification. All patients had anterior cruciate ligament rupture. The average time interval between the injury and the repair was 22 weeks (range, 2 weeks to 2 years). The inside-out suture was used in 18 repairs, all inside--3 repairs, outside-in--2 repairs and a mixed technique--5 repairs. Arthroscopic evaluation of meniscus repair was performed on average after 15 weeks (range, 2 months to 37 weeks) since the suture. That was done during the second stage of treatment--ACL reconstruction. There were 78.6% of completely healed repairs, 10.7% of incompletely healed and 10.7% were not healed.     

Diffuse Parenchymal Urine Leak After Kidney Transplantation Following Degloving Injury During Donor Nephrectomy

Laparoscopic donor nephrectomy can result in trauma to the kidney which may affect recipient graft function. In this case, the kidney sustained a complete degloving of the capsule during extraction. The kidney was transplanted and had immediate, good renal function, but postoperative course was complicated by a large urinoma that drained through the wound. Exploration was negative for a defined urine leak, but the surface of the denuded kidney was leaking a significant amount of unconcentrated urine. The patient was successfully treated with tissue glue treatment to the kidney surface and peritoneal window.     

Carcinoma, a fibrolamellar variant--immunohistochemical analysis of 4 cases

BACKGROUND/AIMS: To analyze, by means of immunocytochemistry, the cases of fibrolamellar variant of hepatocellular carcinoma (FLC), diagnosed in our Department. METHODOLOGY: The material comprised 4 FLC cases of tumors resected surgically. Besides the routine morphological assessment, we used a panel of immunohistochemical stainings including: hepatocellular cytokeratin, CK7, CK19, Ki67, PCNA, chromogranin A, synaptophysin, NSE, insulin, calcitonin, parathormon, CD34, EBV (LMP), Bcl2, cyclin D1. RESULTS: In 3 out of 4 cases, we observed co-expression of CK7 with hepatocellular CK. In addition, there was positive staining with some endocrine markers in the majority of patients. In one case, we found strong cyclin D1 immunoreactivity which correlated with EBV (LMP) immunoreactivity, in the same patient. The score of PCNA positivity varied between 15 and 90%. In all cases Ki67 was negative. CONCLUSIONS: The incidence of FLC, among all hepatocellular carcinomas diagnosed in our Department was 5.1%. In accordance with other reports, all our FLC cases were young patients without underlying liver disease. We were unable to find a correlation between FLC cellular immunophenotype, and histological and clinical markers of malignancy. In addition, it appears that PCNA is a better marker of cell-proliferation in FLC than Ki67. The significance of EBV infection in FLC requires further study.