Spilled Gallstones: the Source of an Enigma

Spillage of gallstones may occur in the course of laparoscopic cholecystectomy. The incidence of this mishap and its consequences are variable. Ignored by many surgeons, stone spillage may be the source of significant morbidity many years after surgery. In this report, we describe the clinical course of a patient who presented with upper abdominal pain and swelling. The past history was positive for laparoscopic cholecystectomy 15 years earlier. After excision, the swelling was found to be a pseudocyst formed around spilled gallstones during a previous cholecystectomy. Apart from postoperative wound infection, the patient recovered well and remains so. Here, we discuss the problem and provide suggestions for spillage prevention and stone retrieval once spillage occurs.     

Ureteroscopic holmium laser lithotripsy in patients with renal impairment

Objectives In this study, we try to evaluate the efficacy and safety of holmium lasers for treatment of ureteric stones in patients with renal impairment or obstructive anuria. Patients and methods Twenty-six patients were included in this study, of which 20 patients presented with elevated blood urea and serum creatinine (2.1–7.6 mg%), and six patients presented with calcular anuria (mean serum creatinine 22 mg%). None of the patients had a ureteric stent or nephrostomy tube before the ureteroscopy. All patients were treated with holmium laser. A stone basket or grasper was used to remove significant stone fragments at the end of the procedure in seven patients. In these seven patients, ureteric stents were placed at the end of the procedure. Results All patients were free of any stone fragments at 1 week and at 3 months postoperatively. In all patients, including the six with obstructive anuria, the renal impairment resolved or improved as evidenced by normalization or fall in blood urea and creatinine. Thus, in this small group of uremic patients, the success rate for treatment of ureteral stone was 100%. Conclusions A holmium laser is a safe and effective modality of ureteroscopic lithotripsy in patients with significant renal impairment or even obstructive anuria. The use of holmium laser with ureteroscopy may be considered in this group of patients as long as the general condition of the patient permits the safe administration of anesthesia.     

Vulnerability of the spinal accessory nerve in the posterior triangle of the neck: a cadaveric study.

Injury to the accessory nerve results in an obvious shoulder droop, loss of shoulder elevation, and pain. Prevention of inadvertent injury to the accessory nerve is critical in neck dissection. No previous study, however, anatomically demonstrates the mechanism of the spinal accessory nerve traction injury. Anatomic determination of the location and course of the spinal accessory nerve may be helpful for a better understanding of the mechanism of the nerve injury. The accessory nerve courses obliquely across the posterior triangle on the surface of the levator scapula muscle and reaches the trapezius. The length of the spinal accessory nerve in the posterior triangle is 34.7+/- 6.3 mm. The nerve passes through the posterior border of the sternocleidomastoid muscle 50.7+/- 12.9 mm below the tip of the mastoid process and reaches the anterior border of the trapezius 49.8 +/- 5.9 mm above the clavicle. It makes a posterior angle of 73.1 degrees +/- 19.4 degrees, on average, relative to the posterior border of the sternocleidomastoid. When the shoulder is pulled down and the head is turned to the opposite direction, the spinal accessory nerve is stretched in the posterior triangle. In the posterior triangle, the nerve is vulnerable, since it is superficial and covered only by skin and subcutaneous fascia. Therefore, extreme caution should be taken with any surgical procedures in the posterior triangle. Traction injury of the spinal accessory nerve in the posterior triangle cannot be ignored.     

Ischemic preconditioning specifically restores complexes I and II activities of the mitochondrial respiratory chain in ischemic skeletal muscle

OBJECTIVE: Defective mitochondrial function has been reported in patients presenting with peripheral arterial disease, suggesting it might be an important underlying mechanism responsible for increased morbidity and mortality. We therefore determined the effects of prolonged ischemia on energetic skeletal muscle and investigated whether ischemic preconditioning might improve impaired electron transport chain and oxidative phosphorylation in ischemic skeletal muscle. METHODS: Thirty rats were divided in three groups: the control group (sham, n = 9) underwent 5 hours of general anesthesia without any ischemia, the ischemia-reperfusion (IR) group (n = 11) underwent 5 hours ischemia induced by a rubber band tourniquet applied on the left root of the hind limb, and in the third group, preconditioning (PC group, n = 10) was performed just before IR and consisted of three cycles of 10 minutes of ischemia, followed by 10 minutes reperfusion. Maximal oxidative capacities (V(max)) of the gastrocnemius muscle and complexes I, II, and IV of the mitochondrial respiratory chain were determined using glutamate-malate (V(max)), succinate (V(s)), and N, N, N,'N'-tetramethyl-p-phenylenediamine dihydrochloride ascorbate as substrates. RESULTS: Physiologic characteristics were similar in the three groups. Ischemia reduced V(max) by 43% (4.5 +/- 0.4 vs 7.9 +/- 0.5 micromol O(2)/(min x g dry weight), P < .01) and V(s) by 55% (2.9 +/- 0.3 vs 6.3 +/- 0.4 micromol O(2)/min/g dry weight; P < .01) in the IR and sham groups, respectively, and impairments of mitochondrial complexes I and II activities were evident. Of interest was that preconditioning prevented ischemia-induced mitochondrial dysfunction. Both V(max) and V(s) were significantly higher in the PC rats than in IR rats (+32% and +41%, respectively; P < .05), and were not different from sham values. CONCLUSIONS: Ischemic preconditioning counteracted ischemia-induced impairments of mitochondrial complexes I and II. These data support that ischemic preconditioning might be an interesting approach to reduce muscular injuries in the setting of ischemic vascular diseases.     

A new patient classification for laser resurfacing and peels: predicting responses,risks, and results

Traditional classifications for skin treatment modalities are based on skin characteristics, the most important being skin color. Other factors are considered as well, such as oiliness, thickness, pathology, and sensitivity. While useful, these classifications are occasionally inadequate in predicting and explaining the outcome of some peels, dermabrasions, or laser resurfacing procedures. Why, for example, would a Korean patient with a light white skin inadvertently develop more hyperpigmentation than his darker skinned French counterpart? The new classification introduced here is based on the racial and genetic origins of patients. It suggests that racial genetic predisposition is the determining factor in human response to skin injury, including skin treatments. This classification takes into account both skin and features, rather than skin alone. It offers a new approach in evaluating patients scheduled for skin peels or laser resurfacing, in the hope of helping physicians to better predict reactions, select the appropriate type and intensity of the skin treatment and, ultimately, better control the outcome. Six categories (sub-races) are described: Nordics, Europeans, Mediterraneans, Indo-Pakistanis, Africans, and Asians. The reaction of each sub-race to peels, laser resurfacing, or dermabrasion is analyzed. The risks associated with each group are noted. This new classification provides physicians with a practical way to evaluate patients prior to treatment, with a view to determining each patient's suitability, postoperative reaction, the likelihood of complications, and likely result.     

Spontaneous and simultaneous complete bilateral rupture of the quadriceps tendon in a patient receiving hemodialysis: A case report and literature review

The spontaneous and simultaneous rupture of both quadriceps tendons is uncommon and has rarely been reported in the literature. The current case involves a 43-year-old man with end-stage renal disease requiring hemodialysis for the past 20 years. The patient experienced bilateral knee pain and swelling and was unable to bear weight. Physical examination revealed bilateral quadriceps tendon defect above the patella and loss of active extension. Although plain radiographs of both knees showed no fracture or widening of the joint space, an inferiorly positioned patella was observed. Ultrasonography of the knees revealed a quadriceps tendon defect at the upper edge of each patella, while MR imaging revealed a tear in each quadriceps tendon from the superior poles of the patella. The patient then underwent surgical correction wherein the tendons were repaired using sutures passed through drill holes in the patella. The knees were immobilized with splints for 4 wk before starting physiotherapy. The patient subsequently regained full functional activity within 1 year.     

Risk factors associated with local and in-transit recurrence of cutaneous melanoma

Background

Understanding the risk factors for local and in-transit recurrences (LR/ITR) may help facilitate methods of prevention, early detection, and treatment.

Methods

A retrospective review of a prospectively collected database was performed on patients diagnosed with single-lesion cutaneous melanoma. Clinical and pathologic characteristics of the tumors were evaluated.

Results

Of 225 patients, 10% had LR/ITR. Patients with LR/ITR were older (P = .0002), had thicker tumors (P = .018), and positive angiolymphatic invasion more frequently (P < .0001). An increased tumor mitotic rate (TMR) was more common in LR/ITRs (P = .051). On univariate logistic regression, age, thickness, TMR of 11/mm² or greater, and angiolymphatic invasion were all significant risk factors for LR/ITR. Multivariate logistic regression showed age, thickness, and angiolymphatic invasion were the only significant risk factors.

Conclusions

Older patients with thicker tumors and angiolymphatic invasion appear to be at higher risk for LR/ITR. Such patients warrant consideration of preventative strategies and should receive close clinical follow-up evaluation for early recurrence.     

Single-stage medial plateau elevation and metaphyseal osteotomies in advanced-stage Blount’s disease: a new technique

PurposeSurgical treatment in advanced-stage infantile Blount’s disease with medial plateau (MP) depression is challenging. Several osteotomies and fixation methods have been described with no established benchmark. We conducted this study to evaluate the efficacy and safety of a new single-stage technique for acute medial condyle elevation and metaphyseal osteotomies with internal fixation.MethodsA prospective case series of 19 consecutive patients (21 knees) with severe infantile Blount’s disease underwent a single-stage MP elevation and metaphyseal osteotomies, with internal fixation. The mean age was 10.3 years (8.2 to 13.6) and the mean follow-up was 5.1 years (3.2 to 8.3). The outcome measures included clinical and radiological parameters and patient-reported pediatric outcomes data collection instrument (PODCI) score.ResultsThe mean PODCI score improved significantly from 50% to 88%. The mean internal tibial torsion improved from -27° to 11°. All cases maintained full knee extension, no limitation in flexion range of movement and no signs of instability or lateral thrust gait. All the radiographic parameters improved significantly; the mean tibiofemoral angle improved from -29° to 7°, the metaphyseal-diaphyseal angle improved from 33.4° to 4.7° and the angle of depressed MP improved from 38.3° to 2.4° (p < 0.001). At the latest follow-up, no cases of deformity recurrence were identified, the final limb-length discrepancy was < 1 cm in all patients.ConclusionSingle-stage MP elevation and metaphyseal osteotomies with internal fixation significantly improved the clinical and radiographic parameters and PODCI score in advanced infantile Blount’s disease and precluded the use of external immobilization, with no evidence of deformity recurrence.Level of evidenceIV     

Outcome of 234 pregnancies in 140 renal transplant recipients from five middle eastern countries

OBJECTIVE: To study the pregnancy and offspring outcomes in postrenal transplant recipients. METHODS: This is a retrospective case-note review study investigating the outcome of 234 pregnancies in 140 renal transplant recipients from five different Middle Eastern countries. RESULTS: Of the overall pregnancies 74.4% were successful albeit with high prevalences of preterm and Caesarean deliveries (40.8% and 53%, respectively). The mean serum creatinine did not rise significantly during pregnancy in the group as a whole but did so in patients who had serum creatinine of or above 150 micromol/L at the beginning of their pregnancies. The mean birth weight was (2,458 g) with 41.3% of the newborns being of low birth weight (<2,500 g). The prevalences of stillbirths were 7.3% and of spontaneous abortion was 19.3%. Preeclampsia and gestational diabetes were observed in 26.1% and 2% of pregnancies, respectively. CONCLUSIONS: In the presence of good allograft function, the majority of pregnancies in renal transplant recipients have a good outcome but with increased incidence of preeclampsia, reduced gestational age, and low birth weights. Patients with baseline serum creatinine of above 150 micromol/L have an increased risk of allograft dysfunction resulting from the pregnancy.     

Late-Onset Radial Nerve Palsy Associated with Conservatively Managed Humeral Fracture. A Case Report and Suggested Classification System

Radial nerve palsy can occur with humerus fracture, either at the time of injury (primary) or during reduction (secondary). Late-onset radial nerve palsy (not immediately related to injury or reduction) has been very seldom reported in the English literature. We describe a case of late-onset radial nerve palsy, which developed 9 weeks after an attempted closed management of a midshaft humerus fracture. Exploration of the nerve was performed. The radial nerve was found to be stretched over the ends of the fracture. Open reduction and external fixation of the fracture with mobilization of the nerve from the fracture site lead to complete return of radial nerve function occurring by 3 months. We recommend exploration of cases of late-onset radial nerve palsy in contrast to primary or secondary radial nerve palsy, which can be treated conservatively. Our experience suggests that the cause of the palsy is a continuous ongoing pathology and not a single time event as in primary or secondary cases. Radial nerve palsies associated with humeral fracture should be classified as either primary (at the time of injury), secondary (at the time of reduction), or late onset (not related to either injury or reduction).