Carotid stenosis: Endarterectomy or angioplasty and stenting?

Opinion statement Atherosclerotic narrowing of the proximal internal carotid artery is an important mechanism in ischemic stroke. Optimal medical management of internal carotid stenosis includes antiplatelet agent and statin administration, blood pressure reduction, weight control, and smoking cessation. Decisions regarding the use of invasive procedures to treat carotid disease—specifically carotid endarterectomy and carotid angioplasty and stenting—must weigh the long-term risk reduction in ipsilateral ischemic stroke against the immediate intervention risks. Clinical trials evaluating the benefits of carotid endarterectomy were conducted before widespread use of statins and newer blood pressure-lowering agents such as angiotensin-receptor blockers; it is unclear what impact this may have had on trial results. Regardless, carotid endarterectomy is clearly superior to medical therapy for patients with symptomatic severe stenosis. Conversely, the benefit from endarterectomy is muted in individuals with symptomatic moderate stenosis or asymptomatic stenosis, and decisions regarding surgical intervention must incorporate surgeon proficiency and patient comorbidity. Currently, there is a lack of evidence to support the use of carotid artery angioplasty and stenting in the routine management of carotid disease. Selected patients with severe symptomatic stenosis for whom endarterectomy cannot be safely performed may still benefit from endovascular management. However, it is unlikely that asymptomatic patients or symptomatic patients with moderate stenosis considered at high risk for endarterectomy would benefit from any intervention.     

Infrared analysis of bones in magnesium-deficient rats treated with vitamin K<Subscript>2</Subscript>

In this study, we compared the effects of vitamin K₂ menatetrenone on bone mechanical properties in rats fed a low-magnesium (Mg) diet. In addition, the mechanism of bone quality was examined using Fourier transform infrared imaging (FTIRI). Thirty 4-week-old male Wistar rats were divided into three groups: intact, low-Mg-control, and low-Mg-MK-4 groups. Rats in the low-Mg groups were given a diet containing 6 mg/100 g Mg (intact, 90 mg/100 g). After an 8-week-treatment, the cortical bone mineral content (CtBMC), outer perimeter, and endo perimeter of the femoral diaphysis in the low-Mg-control group were significantly higher, while the maximum load (ML) and elastic modulus (EM) were 81% and 50% of those in the intact group, respectively (respectively, P < 0.05). In the low-Mg-MK-4 group, ML and EM were significantly higher than in the low-Mg-control group (P < 0.05), with no differences in CtBMC. The mineral/matrix ratios for the periosteal and central regions in the low-Mg-control group were 162% and 120% of those in the intact group (both, P < 0.05), respectively. MK-4 significantly inhibited these increases (P < 0.05). We found that the mineral/matrix ratios for the periosteal region of the femoral diaphysis were negatively correlated with EM, suggesting that an increase in the mineral/matrix ratio may be involved in the reduction of EM and that MK-4 may improve EM by improving the mineral/matrix ratio.     

CCAAT/enhancer-binding protein-d is induced in mesangial area during the early stages of anti-Thy1.1 glomerulonephritis and regulates cell proliferation and inflammatory gene expression in cultured rat mesangial cells

Background Interleukin (IL)-6, cyclooxygenase (COX)-2, and monocyte chemoattractant protein (MCP)-1 contribute to renal injury. The promoter regions of these genes contain CCAAT/enhancer-binding protein (C/EBP)-binding sites. In this study, we investigated the role of C/EBP-δ in mesangial cells (MCs). Methods In an in vivo study, anti-Thy 1.1 glomerulonephritis rats were generated and C/EBP-δ, IL-6, COX-2, and MCP-1 expressions were assessed by immunohistochemistry. In an in vitro study, cultured MCs were transfected with non-silencing (NS) short interfering RNA (siRNA) or C/EBP-δ siRNA. Subsequently, after stimulation with IL-1β, C/EBP-δ, IL-6, COX-2, and MCP-1 mRNA expression levels were evaluated using real-time polymerase chain reaction (PCR). IL-6 concentration in the culture medium was determined by enzyme-linked immunosorbent assay. In addition, cell proliferative activity against IL-1β or platelet-derived growth factor-BB was assessed by bromodeoxyuridine incorporation. Results In the in vivo study, C/EBP-δ, IL-6, COX-2, and MCP-1 were expressed in the mesangial region of anti-Thy 1.1 glomerulonephritis rats on day 1. In the in vitro study, IL-1β increased C/EBP-δ mRNA levels in NS siRNA-transfected MCs (7.3-fold), but no increase was evident in C/EBP-δ siRNA-transfected MCs. IL-6, COX-2, and MCP-1 mRNA levels in C/EBP-δ siRNA-transfected MCs were all lower than those in NS siRNA-transfected MCs (decreases of 57.7%, 85.7%, and 69.3%, respectively). The IL-6 concentration in the culture medium from C/EBP-δ siRNA transfected MCs (7.37 ± 4.3 pg/ml) was also lower than that in the culture medium from NS siRNA-transfected MCs (25.2 ± 3.4 pg/ml). Cell proliferative activity in C/EBP-δ siRNA-transfected MCs was lower than that in NS siRNA transfected MCs. Conclusions C/EBP-δ was induced in the mesangial region during the early stages of anti-Thy1.1 glomerulonephritis. C/EBP-δ contributes to inflammatory gene expression and MC proliferation.     

Internal Hernia with Strangulation Through a Mesenteric Defect After Laparoscopy-Assisted Transverse Colectomy: Report of a Case

A 58-year-old woman underwent laparoscopy-assisted transverse colectomy for transverse colon cancer. On postoperative day 7, she experienced sudden abdominal pain accompanied by vomiting and fever. Computed tomography showed a small bowel obstruction caused by an internal hernia. Laparotomy revealed an internal hernia through the mesenteric defect at the anastomotic colonic stumps, which had not been closed in the previous operation. Almost the entire small bowel protruding through the mesenteric defect was found in the omental bursa. We resected part of the jejunal loop, which was strangulated and congested by an adherent band. Our experience suggests that if the mesenteric defect is relatively small, it should be closed completely during laparoscopy-assisted colectomy; however, more studies are required to determine the indications for closure of the mesenteric defect to prevent this complication.     

Role of Centchroman in Regression of Mastalgia and Fibroadenoma

Objectives Centchroman (Ormeloxifene) is a novel non-steroidal, selective antiestrogen. Because of its selective antiestrogen action, centchroman has been used for treatment of mastalgia and fibroadenoma. Materials and Methods Benign breast disease patients up to 35 years of age attending our surgery outpatient department from August 2003 to September 2004 and fulfilling the inclusion criterion were included in this study. They were started on centchroman 30 mg on alternate days for a period of 3 months and were followed up for 6 months. Results were recorded as per clinical examination, visual analog scale (VAS) for pain, and ultrasonography for breast lump size. Results A total of 60 patients were included in this pilot study, 42 (70%) of whom had mastalgia with or without nodularity, and 18 (30%) had fibroadenoma. Noncyclical pain was recorded in 38 patients (90%), and cyclical pain was recorded in only 4 (10%) patients. A VAS score of 10 was recorded by 33 (80%) patients (severe pain), and the remaining 9 patients (20%) had VAS scores from 7 to 10. Fibroadenoma size ranged from 1.5 to 5 cm., single or multiple in one or both breasts. There was a good response in the mastalgia group, with a decrease in the VAS scoring from 10 to 3 in 90 % of the patients in the first week. Almost all of the patients were painless at the end of one month, with complete disappearance of the nodularity. In the fibroadenoma group there was a mixed response, with complete disappearence in 40%, partial regression in 20%, and no response at all in the remaining 40%. There were very few side effects. Conclusions Centchroman is a safe nonsteroidal drug for the treatment of mastalgia and fibroadenoma. It has shown good results in mastalgia and is a safe drug as compared to the drugs of choice used at present (danazole and bromocriptine). Further randomized studies are in progress and are needed to determine its definitive role in this patient group. Presented at the BSI Prize Session, International Surgical Week “ISW2005,” 41st World Congress of Surgery of ISS/SIC, 21–25 August 2005, Durban, South Africa     

Anterior lumbar instrumentation improves correction of severe lumbar Lenke C curves in double major idiopathic scoliosis

Fifteen skeletally immature patients with double major adolescent idiopathic scoliosis with large lumbar curves and notable L4 and L5 coronal plane obliquity were retrospectively studied. Seven patients who underwent anterior release and fusion of the lumbar curve with segmental anterior instrumentation and subsequent posterior instrumentation ending at L3 were compared with eight patients treated with anterior release and fusion without anterior instrumentation followed by posterior instrumentation to L3 or L4. At 4.5 years follow-up (range 2.5-7 years), curve correction, coronal balance and fusion rate were not statistically different between the two groups; however, the group with anterior instrumentation had improved coronal plane, near normalangulation in the distal unfused segment compared with the group without anterior instrumentation. In cases involving severe lumbar curvatures in the context of double major scoliosis, when as a first stage anterior release is chosen, the addition of instrumentation appears to restore normal coronal alignment of the distal unfused lumbar segment, and may in certain cases save a level compared with traditional fusions to L4.     

An Unusual Complication of Gastric Bypass: Perforated Duodenal Ulcer

Peptic ulcer in the excluded segment of a gastric bypass has been reported in the literature in only 17 cases.We report a 54-year-old woman with a perforated duodenal ulcer, who had undergone laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity 15 months previously. She was successfully treated by a laparoscopic repair of the perforated duodenal ulcer.     

Primary Cardiac Liposarcoma Causing Cardiac Tamponade: Report of a Case

The intracardiac growth and extension of liposarcoma was observed in a 60-year-old woman. The epicardial tumor was identified to originate from the anterior wall of the right ventricle. She initially showed symptoms associated with cardiac tamponade. A surgical operation was performed but it resulted in incomplete resection due to massive invasion and dissemination. The recurrence of the tumors led to congestive heart failure. Finally, she died of heart failure and liver dysfunction as a result of tumor metastasis and invasion. An autopsy detected the primary cardiac liposarcoma. Only a few cases of cardiogenic liposarcoma have so far been reported. A further elucidation of cardiac liposarcoma could reveal mechanisms of the disease, and thus contribute to development of complementary therapies after surgical intervention.     

Internal Mammary Nodal Chain Drainage Is a Prognostic Indicator in Axillary Node-Positive Breast Cancer

Background Internal mammary (IM) nodes are a potential site of breast lymphatic drainage. We examined the relationship between lymphoscintigraphic evidence of IM drainage and survival in early-stage breast cancer patients (pts). Methods From a prospective database of 855 consecutive sentinel node mapping procedures using peritumoral radiocolloid injection from 1996–2004, we analyzed the 604 cases with stage I–III breast cancer. Overall survival and recurrence-free survival (OS, RFS) rates were compared in pts with (IM+) and without (IM-) IM drainage on lymphoscintigraphy using Kaplan-Meier plots and Cox proportional hazards models. Results: 100 of 604 pts (17%) showed IM drainage. Five-year OS and RFS were 92% vs 88% and 88% vs 85% in IM- vs IM+ pts. In the 186 pts with axillary metastases (node+), 5-year OS and RFS were 91% vs 71% and 84% vs 69% in IM- vs IM+ pts. Univariate analysis of node+ pts estimated increased mortality risk for IM+ (hazard ratio, HR 2.9, P = .04), ≥4 positive nodes (HR 3.2, P = .02), tumors that were ER-negative (HR 3.4, P = .02), or had high Ki-67 (HR 6.8, P = .01). Multivariate analysis estimated similar increased risks [≥4 nodes (HR 4.0, P = .02), IM+ (HR 3.3, P = .06), and ER negativity (HR 2.6, P = .09)]. Conclusions IM nodal drainage predicted a nearly 3-fold increased mortality risk in node+ pts. Peritumoral radiocolloid injection provides a clinically relevant assessment of IM drainage and should be prospectively tested for its value in tailoring treatment strategies for axillary node-positive pts. Presented at the 29th Annual San Antonio Breast Cancer Symposium, December 14–17, 2006.     

Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer

Background and aims The aim of this study is to evaluate the predictive accuracy of different scoring systems on surgery for perforated peptic ulcer referred to an academic department of general surgery in a tertiary reference center. Patients and methods Seventy-five consecutive patients (Male/female ratio = 64:11; mean age, 44 years; range, 16–85) with perforated peptic ulcer disease were investigated. Disease severity scores and mortality predictions were calculated using the collected data during admission. Discrimination and calibration characteristics of each system, namely, the acute physiology and chronic health evaluation II and III, the simplified acute physiology score II, and the mortality probability models (MPM) II, were determined by using the area under receiver operating characteristics curve and the Hosmer–Lemeshow goodness-of-fit test, respectively. Results Among the 75 patients included, there were eight (10.6%) mortalities. All systems had a reliable power of discrimination and calibration. Among the systems tested, MPM II was the best performing as far as discrimination and calibration characteristics were considered. The parameters of MPM II system that were related to systemic perfusion of the patient were significantly positive in patients who died compared to those who survived. Conclusions MPM II that predicted mortality at admission is better than the other systems in predicting mortality. Results also indicate the importance of maintenance of systemic perfusion of the patient at the early phases of peptic ulcer perforation.