Posterior pelvic exenteration for ovarian cancer: surgical and oncological outcomes

ObjectivePosterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze morbidity, complete resection rate, and survival of PPE.MethodsNinety patients who underwent PPE in our Comprehensive Cancer Center between January 2010 and February 2021 were retrospectively identified. To analyze practice evolution, 2 periods were determined: P1 from 2010 to 2017 and P2 from 2018 to 2021.ResultsA 82.2% complete resection rate after PPE was obtained, with rectal anastomosis in 96.7% of patients. Complication rate was at 30% (grade 3 in 9 patients), without significant difference according to periods or quality of resection. In a binary logistic regression adjusted on age and stoma, only age of 51–74 years old was associated with a lower rate of complication (odds ratio=0.223; p=0.026). Median overall and disease-free survivals (OS and DFS) from initial diagnosis were 75.21 and 29.84 months, respectively. A negative impact on OS and DFS was observed in case of incomplete resection, and on DFS in case of final cytoreductive surgery (FCS: after ≥6 chemotherapy cycles). Age ≥75-years had a negative impact on DFS for new OC surgery. For patients with complete resection, OS and DFS were decreased in case of interval cytoreductive surgery and FCS in comparison with primary cytoreductive surgery.ConclusionPPE is an effective surgical measure to achieve complete resection for a majority of patients. High rate of colorectal anastomosis was achieved without any mortality, with acceptable morbidity and high protective stoma rate.     

How to tailor A "pi" graft for complex myocardial revascularization: a variant of the mammary loop technique

We present a new pattern for tailoring the “π” graft that uses the advantages of the mammary loop technique. The two internal thoracic mammary arteries are skeletonized. The free right mammary artery is anastomosed end-to-side to the proximal part of the in situ left mammary artery to make a “Y” graft. The distal end of the left mammary artery is anastomosed end-to-side to the middle portion of the right one to form a loop with the two arteries. The loop is severed at the appropriate level at the time of the coronary anastomosis to form a “π” graft. This technique allows a more rational use of the length of the two mammary arteries, because the branch leading to the left anterior descending artery is measured and cut precisely at the time of the anastomosis.     

Recurrence of aneurysmal bone cysts in young children: a multicentre study

Some authors have reported that the clinical and pathologic behaviour of aneurysmal bone cysts (ABCs) is more aggressive in younger patients and that younger patients have more tumour recurrence. The authors carried out a retrospective, multicentred paediatric population-based analysis of 21 patients (14 boys and seven girls), 5 years of age or younger, with primary ABCs. Only patients with a minimum follow-up of 2 years were included. The most common operation was curettage (14 cases). Methylprednisolone acetate injection was used in two cases (failure in the initial diagnosis before biopsy) with negative results. An Ethibloc (Ethnor Laboratories/Ethicon, Norderstedt, Germany) injection was employed in four cases. There were five recurrences. Three lesions recurred once, one lesion recurred three times and one recurred six times. These recurrences occurred in two cases after methylprednisolone acetate injection, after Ethibloc (Ethnor Laboratories/Ethicon) injection (one case) and, after curettage (two cases). ABCs in children, 5 years of age or younger, do not seem to be more aggressive than in older children. Curettage is a surgical procedure that can be used even in young children. Of course, recurrence is always possible but the recurrence rate is not unacceptable. More aggressive operative intervention does not appear to be indicated.     

Aseptic meningitis after intrathecal baclofen injection

StUDY DESIGN: Two case reports of aseptic meningitis after intrathecal baclofen injection. OBJECTIVES: To report an unusual complication of intrathecal baclofen injection during test injections. SETTING: Department of Neurological Rehabilitation, R Poincaré H?pital (Paris-Ile de France-Ouest University). CASE REPORTS: We present two cases of chemical meningitis after intrathecal baclofen injections by lumbar puncture. These cases presented with febrile meningeal syndromes during the 24 h following intrathecal baclofen injection. Direct cerebrospinal fluid (CSF) examination and CSF cultures were negative. An intense cellular reaction was observed with a marked predominance of neutrophils. Meningitis resolved spontaneously over 3-4 days. CONCLUSIONS: Chemical meningitis is a rare complication of intrathecal baclofen injections that must be recognized. It is a diagnosis of exclusion and its pathophysiological mechanism remains unclear.     

Management of increase in spasticity in patients with intrathecal baclofen pumps]

INTRODUCTION: The incidence of complications after baclofen pump implantation is relatively high. Diagnosis of these complications can be difficult. A diagnostic tree would be a useful tool in cases of suspected malfunctioning of the intrathecal bacolfen infusion system and would standardise the diagnostic procedure. METHOD: From results in the literature and the experience of our department, we designed a diagnostic tree to aid in finding the cause of a recrudescence of spasticity in patients with implanted baclofen pumps. RESULTS: The potential causes of recrudescence of spasticity are described and a diagnostic pathway is proposed. DISCUSSION: The aim of a standardised hierarchical method of diagnosis of the cause of increased spasticity in patients with intrathecal baclofen pumps is to gain time in the diagnosis and treatment. Such diagnosis should improve patient care by permitting rapid restoration of an adequate level of baclofen infusion as well as decreasing the length of hospital stay and, as a consequence, the cost relating to malfunctioning pumps.     

Ventricular arrhythmias after left ventricular assist device implantation

Background: Left ventricular assist devices (LVADs) have been used as a bridge to cardiac transplantation and as destination therapy in patients with advanced heart failure. The period after LVAD support is associated with ventricular arrhythmias (VAs) despite ventricular unloading and such VAs can have a detrimental effect on survival. Despite the increasing use of LVAD, little is known regarding post‐LVAD VAs at the molecular level and in vivo. Methods: Forty‐two patients who received LVAD over a 24‐month period were evaluated and grouped on the basis of the presence or absence of VAs during LVAD support. We completed a comparative microarray analyses between six patients who developed ventricular tachycardia (VT) or ventricular fibrillation (VF) after LVAD support and six patients who did not develop VAs after LVAD. Results: VAs occurred in 15 patients (35.7%) during LVAD support at a median post‐LVAD day of 25.2. VAs were strongly associated with nonusage of a β‐blocker post‐LVAD (odds ratio of 7.04, P‐value = 0.001). Analysis of a subset of patients who had VT or VF after LVAD placement showed a decrease in the expression of connexin 43 (0.48 ± 0.07), Na+/K+–ATPase (0.60 ± 0.05), and voltage‐gated K+ channel Kv4.3 (0.42 ± 0.04), and an increase in Na+/Ca2+ exchanger (2.2 ± 0.4) and the structural genes: Titin (2.1 ± 0.2), laminin (1.7 ± 0.4), calsequestrin (1.8 ± 0.5), skeletal muscle isoform of troponin T (5.1 ± 0.9), and skeletal muscle isoform of troponin I (3.9 ± 0.7). Conclusion: After LVAD, the increased risk of VAs is strongly associated with nonusage of β‐blocker postoperatively.     

Deactivation of alveolar macrophages in septic neutropenic ARDS

STUDY OBJECTIVES: Neutrophils often have been involved in the pathophysiology of ARDS. However, authentic ARDS has been described in patients with severe neutropenia, suggesting the presence of other potential mechanisms that are responsible of this syndrome. Alveolar macrophages (AMs) could be involved in the development of ARDS, and so we decided to study AM activation in neutropenic patients. PATIENTS: We designed a prospective study and enrolled two subgroups of consecutive patients (group A, 18 patients; group B, 22 patients) with septic ARDS. In the first period, 7 of 18 patients were neutropenic, and in the second period 10 of 22 patients were neutropenic. All neutropenic patients were treated with granulocyte colony-stimulating factor (G-CSF). Measurements and results: In group A, BAL fluid samples were analyzed for differential and total cell counts, and alveolar activation marker expression (ie, human leukocyte antigen [HLA]-DR locus) was determined. Basal and lipopolysaccharide (LPS)-stimulated production of tumor necrosis factor, interleukin (IL)-1 beta, IL-6, and IL-10 was evaluated in group B. In neutropenic patients, the BAL fluid total cell count and the neutrophil absolute count was significantly lower compared to those in nonneutropenic patients (p = 0.029 and p = 0.046, respectively). HLA-DR expression on AMs was significantly decreased (p = 0.016), and the percentage of AMs expressing HLA-DR was also significantly lower (p = 0.041). In neutropenic patients, the mean percentage of AMs expressing HLA-DR was significantly lower in deceased patients compared to survivors (30 +/- 7 vs 43 +/- 1, respectively; p = 0.047). Basal AMs released cytokines was comparable between the two groups; however, LPS stimulation yielded a deactivation of AMs in neutropenic patients. CONCLUSION: These results suggest a deactivation and/or hypoactivation of AMs in septic ARDS patients. This deactivation/hypoactivation could be linked to the use of G-CSF as this molecule has been shown to generate a down-regulation of HLA-DR expression.