Pulmonary Artery Access Embolization in Patients with Massive Hemoptysis in Whom Bronchial and/or Nonbronchial Systemic Artery Embolization Is Contraindicated

The objective of this paper is to present an alternative therapeutic approach for the treatment of patients with massive hemoptysis in whom bronchial and/or nonbronchial systemic arterial embolization is not possible. We describe a percutaneous procedure for pulmonary segmental artery embolization. Between May 2000 and July 2006, 27 adult patients with hemoptysis underwent percutaneous treatment at our department; 20 of 27 patients were embolized via bronchial and or nonbronchial systemic arteries and 7 patients were embolized via pulmonary artery. Femoral arterial access for systemic artery catheterization and femoral vein access for pulmonary arterial catheterization were used. Gelfoam particles and coils were used for embolization. In this study, we report on three cases of massive hemoptysis from a systemic arterial source in whom bronchial and/or nonbronchial arteries embolization was not possible. Percutaneous embolization via the pulmonary artery access was successful in all three patients. In conclusion, embolization via pulmonary artery is presented as an alternative approach for the management of hemoptysis in patients in whom bronchial arterial embolization is not possible.     

Perioperative management in children with sickle cell disease undergoing laparoscopic surgery.

OBJECTIVE: The aim of this study was to evaluate our experience with laparoscopic surgery in children with sickle cell disease. METHODS: A retrospective chart review was performed to analyze the indication for surgery, perioperative management, surgical technique, complications, duration of hospitalization, and outcome. One pediatric surgeon performed all procedures. RESULTS: Thirteen children underwent laparoscopic surgery for the following indications: symptomatic cholelithiasis/cholecystitis in 9; recurrent splenic sequestration in 3; and hypersplenism/symptomatic cholelithiasis in 1. The 7 boys and 6 girls had a median age of 7.8 years. Patients undergoing splenectomy only were younger than those undergoing cholecystectomy (median age, 3.6 years versus 11.5 years, respectively). Four children underwent endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy because of common bile duct dilatation and stones. Twelve patients received packed red blood cell transfusions prior to surgery. The median operative time was 150 minutes, and the median hospitalization was 3 days. Four patients suffered postoperative complications (2 with acute chest syndrome, 1 with recurrent abdominal pain, and 1 with priapism). The patient with abdominal pain was found to have a retained stone in the common bile duct, which was retrieved via endoscopic retrograde cholangiopancreatography and sphincterotomy. All complications resolved with medical management. CONCLUSIONS: Laparoscopic surgery is safe in children with sickle cell disease. Meticulous attention to perioperative management, transfusion guidelines, and pulmonary care may decrease the incidence of acute chest syndrome.     

Hyperhomocysteinemia in children with renal transplants

Many studies have demonstrated a strong association between elevated plasma total homocysteine (tHcys) levels and vascular disease. The aim of the present study was to determine the plasma levels of tHcys in pediatric recipients of renal transplants, to establish possible correlations with renal function, lipid profile, and folate and vitamin B12 status, and to assess whether the C677T and A1298C polymorphisms in the 5, l0-methylenetetrahydrofolate reductase (MTHFR) gene were associated with a particular risk. A total of 26 transplanted children and adolescents were investigated. tHcys levels were elevated in transplanted patients (12.9+/-4.8 micro mol/l) and 73% of these displayed values above the 97th percentile of healthy children. Plasma tHcys correlated negatively with creatinine clearance ( r=-0.58, P<0.001) and plasma vitamin B(12) ( r=-0.40, P<0.05) and positively with plasma triglycerides ( r=0.53, P<0.005). No significant correlations were found between plasma tHcys level and age, gender, time elapsed after transplantation and plasma values of glucose, insulin, folic acid, total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, apolipoprotein B, and apolipoprotein A-1. Plasma tHcys level was clearly increased in 3 patients with a MTHFR 677TT/1298AA genotype. In a multiple stepwise regression model plasma creatinine and triglyceride levels and MTHFR 677TT/1298 AA genotype accounted for 60% of the observed plasma tHcys variability. The MTHFR 677CT/1298 AC genotype was not a significant predictor of tHcys plasma levels. We conclude that a moderate degree of hyperhomocysteinemia is often present in renal transplant children and that folate supplementation must be considered in this population.     

Congenital and acquired mesocolic hernias presenting with small bowel obstruction in childhood and adolescence

Objective

The objective was to present a case series of pediatric patients presenting with small bowel obstruction secondary to both congenital and acquired internal mesocolic hernias, and the use of imaging technology in the management of this condition.

Methods

A retrospective review of patients treated at the Yale-New Haven Children's Hospital for small bowel obstruction from 1998 to 2008 (n = 6) who presented with acute small bowel obstruction secondary to internal mesocolic hernias was performed.

Results

We present 6 patients with small bowel obstruction caused by congenital (n = 4) and acquired (n = 2) mesocolic hernias after previous surgery. The median age at presentation was 13 years. Small bowel obstruction with a mesocolic hernia was identified by preoperative abdominal computerized tomography in 3 patients (50%) and at operation in the others. The mean length of stay was 6 days, with no recurrent episodes in the follow-up period.

Conclusion

Small bowel obstruction secondary to mesocolic hernias, although rare, may be considered in the differential diagnosis of patients with history of malrotation or abdominal wall defects owing to their association with congenital mesenteric anomalies. This condition requires special attention from the clinician because of its catastrophic consequences. Imaging studies are an important asset because of the difficulty in making an accurate clinical diagnosis and the rarity of internal hernias.     

Acute abdomen in renal transplant recipients. Epidemiology and treatment in not referral transplantation centers

The incidence of gastrointestinal complications in renal transplant recipients is relatively high while about 10% is related to acute abdomen. Data concerning gastrointestinal (GI) complications were reported in literature mainly from referral center studies. A multicenter retrospectively survey was performed in Lazio, Italy, in order to evaluate the incidence of acute abdomen in renal transplant recipients observed to the emergency departments of not referral transplantation centers. Clinical and demographic findings regarding 14 patients who experienced acute abdomen between February 2005 and Dicember 2008 have been collected. The following data was investigated: etiology, diagnostic workup, duration of symptoms, elapsed time between admission and emergency operation if performed, morbility and mortality. The severity of disease at presentation was assessed by mean of the Acute Physiology and Chronic Health Evaluation score (APACHE II). Acute abdomen was due to pancreatitis in three patients (23.1%); to cholecystitis in three (23.1%); to acute diverticolitis with colon perforation in two patients (15.4%); to acute appendicitis in two (15.4%) and to intestinal obstruction in 2 patients (15.4%). Small bowel perforation was observed in two patients (15.4%) which one case, upon pathological examination, showed malignant lymphoma. The mean APACHE II score was 14.0 ± 5.9. Ten patients (71.4%) were submitted to surgery. Overall mortality and morbidity were 35% and 42% respectively. Statistical analysis showed admission APACHE II score (p<0.01), duration of symptoms (p<0.05), and total time elapsed between the onset of symptoms and treatment (p<0.04) as factors significantly related to mortality.     

Pancreaticogastrostomía versus pancreaticoyeyunostomía después de pancreaticoduodenectomía: análisis crítico de los ensayos prospectivos aleatorizados

This is a critical analysis of prospective randomised trials that compare pancreatic reconstruction techniques with the stomach and the intestine, after pancreaticoduodenectomy. A questionnaire with questions from the Evidence Based Medicine Centre of Oxford University (PICO analysis) was used, following the criteria for the evaluation of randomised prospective studies for surgical interventions of the McMaster University in Ontario. It was found that the studies differed in methodological aspects, the most important being the lack of a uniform definition of a pancreatic fistula. The techniques for performing pancreaticogastrostomy and pancreaticojejunostomy were not homogeneous. There were no differences in the percentage of pancreatic fistula in three of these studies; one which modified the pancreaticogastrostomy technique had more favourable results. New comparative studies should use new definitions of the complications of pancreaticoduodenectomy and standardise the pancreatic reconstruction technique.     

Lepidium meyenii （ Maca ） improved semen parameters in adult men

Aim: The present study was designed to determine the effect of a 4-month oral treatment with tablets of Lepidium meyenii (Maca) on seminal analysis in nine adult normal men aged 24 - 44 years old. Methods: Nine men received tablets of Maca (1500 or 3000 mg/day) for 4 months. Seminal analysis was performed according to guidelines of the World Health Organization (WHO). Serum luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (PRL), testosterone (T) and estradiol (E2) were measured before and after treatment. Results: Treatment with Maca resulted in increased seminal volume, sperm count per ejaculum, motile sperm count, and sperm motility. Serum hormone levels were not modified with Maca treamaent. Increase of sperm count was not related to dose of Maca. Conclusion: Maca improved sperm production and sperm motility by mechanisms not related to LH, FSH, PRL, T and E2.     

Microanatomy and surgical approaches to the infratemporal fossa: an anaglyphic three-dimensional stereoscopic printing study.

Objective: The infratemporal fossa (ITF) is a continuation of the temporal fossa between the internal surface of the zygoma and the external surface of the temporal bone and greater wing of the sphenoid bone that is sitting deep to the ramus of the mandible. The principal structure to understanding its relationships is the lateral pterygoid muscle. Other important structures are the medial pterygoid muscle, the maxillary artery, the pterygoid venous plexus, the otic ganglion, the chorda tympani nerve and the mandibular nerve. In this study, we describe the microsurgical anatomy of the ITF, as viewed by step-by-step anatomical dissection and also through the perspective of three lateral approaches and one anterior surgical approach. Methods: Eight cadaver specimens were dissected. In one side of all specimens, an anatomical dissection was done in which a wide preauricular incision from the neck on the anterior border of the sternoclidomastoid muscle at the level of the cricoid cartilage to the superior temporal line was made. The flap was displaced anteriorly and the structures of the neck were dissected followed by a zygomatic osteotomy and dissection of the ITF structures. On the other side were the surgical approaches to the ITF. The combined infratemporal and posterior fossa approach was done in two specimens, the subtemporal preauricular infratemporal fossa approach in two, the zygomatic approach in two, and the lateral transantral maxillotomy in two. The anatomical dissections were documented on the three-dimensional (3D) anaglyphic method to produce stereoscopic prints. Results: The lateral pterygoid muscle is one of the principal structures to enable understanding of the relationships into the ITF. The tendon of the temporal muscle inserts in the coronoid process at the ITF. The maxillary artery is the terminal branch of the external carotid artery that originates at the neck of the mandible and runs into the parotid gland. In our dissections the maxillary artery was lateral to the buccal, lingual, and inferior alveolar nerves. We found the second part of the maxillary artery superficial to the lateral pterygoid muscle in all specimens The anterior and posterior branches of the deep temporal artery supply the temporal muscle. In two cases we found a middle deep temporal artery. The different approaches that we used provided different views of the same anatomical landmarks and this provides not only safer surgery but also the best choice to approach the ITF according with the pathology extension. Conclusions: The ITF is a complex region on the skull base that is affected by benign and malignant tumors. The study through different routes is helpful to disclose the relationship among the anatomical structures. Although the authors have shown four approaches, there are a variety of approaches and even a combination of these can be used. This type of anatomical knowledge is essential to choosing the best approach to treat lesions in this area.