Primary Stent Angioplasty of the Inferior Vena Cava After Liver Transplantation and Liver Resection

Purpose

This study evaluated technical efficacy and safety of stent angioplasty of the inferior vena cava (IVC) after liver transplantation or liver resection and analysis of changes in creatinine levels and patients’ weight.

Methods

Between October 2004 and February 2011, 16 patients (mean age, 52.6 years) with symptomatic IVC stenoses after liver transplantation (n = 10) or liver resection (n = 6) were subjected to stent angioplasty. Enrollment criteria included edema and/or ascites. The smallest diameter of the IVC, serum creatinine values, and patients’ weight were assessed before and after stent placement and respective values were compared. Technical and clinical success, patency rates, related complications, and patients’ survival were analyzed.

Results

Stent placement was technically successful in 16 patients (100 %). Clinical success was achieved in 13 patients (81.25 %), reflecting two patients with early restenosis and one patient suffering from thrombosis distal to the stent. Mean follow-up was 372 days. Primary patencies were 75 % (n = 12). Primary assisted patencies were 93.75 % (n = 15). Serum creatinine levels decreased significantly (p = 0.01) from 1.68 mg/dl before to 1.08 mg/dl after stent placement. Patients’ weight decreased (mean 2.1 %). No angioplasty-related complications occurred.

Conclusions

Stent angioplasty of the IVC is an effective and safe treatment of stenoses after liver transplantation and resection and has a positive effect on creatinine levels.     

Oral administration of antioxidants improves skin wound healing in diabetic mice

Oxidative stress aggravates several long‐term complications in diabetes mellitus. We evaluated the effectiveness of the oral administration of antioxidants (vitamins E and C, 40 and 100 mg/kg b.w., respectively) on skin wound healing acceleration in alloxan‐induced diabetic mice. Mice were wounded 30 days after the induction of diabetes. Antioxidants were effective in preventing oxidative stress, as assessed by TBARS. The enzymes catalase, glutathione reductase, glutathione peroxidase, and superoxide dismutase were increased in diabetics on the 3rd day post‐wounding; catalase and glutathione peroxidase remained still augmented in diabetics after 14th day postwounding, and the treatment with vitamins restored their activities to control. After 3 days, diabetic mice showed lower infiltration of inflammatory cells (including CD11b⁺ and Ly6G⁺ cells) and reduced levels of KC, TNF‐α, IL‐1β, and IL‐12 p40 when compared with control mice. The treatment restored cytokine levels. After 14 days, diabetic mice showed late wound closure, persistent inflammation and delayed reepithelialization, accompanied by an increase in MIG⁺/CD206^? macrophages whereas CD206⁺/MIG^? macrophages were decreased. Cytokines IL‐12p40, TNF‐α, IL‐1β, and KC were increased and normal levels were restored after treatment with antioxidants. These results suggest that oxidative stress plays a major role in diabetic wound healing impairment and the oral administration of antioxidants improves healing by modulating inflammation and the antioxidant system with no effect on glycemia.     

Late vertebral body fracture after lumbar transpedicular fixation. Report of three cases

Late-onset vertebral body (VB) fracture after lumbar transpedicular fixation has not been previously described in the literature. The authors present three cases in which VB fracture occurred several months after posterolateral fixation in patients with degenerative disease or traumatic injury. The authors suggest that postoperative osteopenia, modified load-sharing function, and intravertebral clefts were responsible for the fractures. Two women and one man were evaluated at a mean follow-up interval of 3 months. Two patients suffered recurrent lumbar pain. Radiography and magnetic resonance imaging revealed fracture of some of the instrumentation-treated VBs. These two patients underwent surgical superior or inferior extension of instrumentation. The third, an asymptomatic patient, received conservative management. The two patients who underwent reoperation made complete recoveries, and there was no evidence of further bone collapse in any case. The authors speculate that alterations in the VBs may occur following application of spinal instrumentation. In rare cases, the device can fracture and consequently lead to recurrent lumbar back pain. Recovery can be achieved by extending the instrumentation in the appropriate direction.     

Manometric study of the anal sphincter during haemorrhoidectomy using posterior perineal block

Minor anorectal diseases affect 4-5% of the adult western population. Operations are performed on an ambulatory or 24-hour-stay basis. The aim of our study was to assess the physiology of anal sphincter relaxation by anal manometry after posterior perineal block during haemorrhoidectomy. We recruited 15 patients with third and fourth degree hemorrhoids in a manometric study of the anal sphincter during haemorrhoidectomy with regional anaesthesia. The patients underwent anal manometry before and 15 minutes after the posterior perineal block to determine the resting and squeeze anal pressures. Differences were considered significant at p < 0.05. We observed mean reductions of 34.6% and 37.1% in resting and squeeze pressure values, respectively, after posterior perineal block (p < 0.005). Our manometric study demonstrated that anal sphincter relaxation after posterior perineal block correlates with a significant reduction in resting and squeeze pressures because the block anaesthesia not only the somatic, but also the sympathetic fibres. We believe that posterior perineal block allows the surgeon to perform radical haemorrhoidectomy in the overnight stay setting with optimal intra- and postoperative analgesia, safe sphincter relaxation, lower postoperative complications, and lower costs to the public health service.     

Comparison between CT and MR in perfusion imaging assessment of high-grade gliomas

Purpose

The aim of our study was to compare the relative cerebral blood volume (CBV) values obtained by first-pass dynamic susceptibility-weighted contrast-enhanced (DSC) T2-weighted magnetic resonance (MR) and perfusion computed tomography (P-CT) imaging in high-grade gliomas (HGG) in the same patient population.

Materials and methods

Sixteen patients with histologically proven HGG underwent P-CT and DSC-MR brain imaging. P-CT studies were obtained using a four-row multislice CT scanner and postprocessed with a commercial software package based on a deconvolution-based technique. DSC-MR images were obtained at 1.5 T with a first-pass dynamic susceptibility contrast-enhanced T2-weighted sequence. P-CT and DSC-MR images were obtained within 4 days of each another, always before surgery. Maximum CBV ratios normalised with contralateral white matter (rCBV) were calculated. Statistical analysis was performed with the classical parametric statistic procedure.

Results

A linear correlation between maximum rCBV values obtained with P-CT and DSC-MR imaging was evident. The best linear model is CT=slope×MR+error and provides a highly significant estimate of the slope equal to 1.08. Thus CT results can be predicted from MR values. Therefore, it is also possible to predict MR results from CT values by estimating the linear model MR=slope×CT+error. DSC-MR imaging gave lower rCBV average values (4.92±1.52) compared with P-CT (5.56±1.55).

Conclusions

In our population of patients, P-CT and DSC-MR imaging showed proportional results in rCBV assessment of HGGs, and thus both modalities may be used interchangeably in HGG of the brain.     

Rest-injected thallium-201 redistribution and resting technetium-99m methoxyisobutylisonitrile uptake in coronary artery disease: relation to the severity of coronary artery stenosis

To compare rest-injected thallium-201 (Tl) redistribution and resting technetium-99m methoxyisobutylisonitrile (^99mTc-MIBI) myocardial uptake in chronic coronary artery disease (CAD), 15 patients with angiographically proven CAD and left ventricular (LV) dysfunction (ejection fraction 34%±9%) were studied. All patients underwent rest-redistribution Tl and resting ^99mTc-MIBI cardiac imaging. Gated ^99mTc-MIBI images were also acquired to assess regional LV wall motion (WM). Myocardial segments (n=225) were divided into three groups on the basis of the degree of coronary artery stenosis: group 1 (total occlusion, n=82), group 2 (50%–99% of stenosis, n=84) and group 3 (<50% of stenosis, n=59). WM was significantly worse in groups 1 and 2 compared to group 3 (P<0.001), but no difference was observed between groups 1 and 2. TI and ^99mTc-MIBI uptake were significantly lower in groups 1 and 2 compared to group 3 (P < 0.001), and in group 1 compared to group 2 (P<0.001). When TI and ^99mTc-MIBI uptake were directly compared, TI uptake was higher than ^99mTc-MIBI uptake in group 1 (P<0.001), while no significant difference was observed in groups 2 and 3. Thus, both rest-injected TI redistribution and resting ^99mTc-MIBI uptake reflected the severity of coronary artery stenosis in CAD. However, in myocardial segments with total coronary occlusion T1 uptake was significantly higher than ^99mTc-MIBI uptake. Our data suggest that rest-injected Tl redistribution cardiac imaging may identify, more accurately than resting ^99mTc-MIBI imaging, the presence of viable myocardium in chronic CAD, particularly when the coronary blood flow is severely impaired.     

The effect of glossopexy on weight velocity in infants with Pierre Robin syndrome

Aim

In infants with Pierre Robin syndrome (PRS), mandibular distraction may be more advantageous than glossopexy as it not only relieves oropharyngeal airway obstruction but also reverses body growth retardation. Because no data are available on body weight velocity after glossopexy, we assessed longitudinally the body weight velocity in a cohort of children undergoing glossopexy.

Methods

The records of 48 infants with PRS undergoing glossopexy after unsuccessful nonoperative treatment between 1981 and 2005 were reviewed. Weight measurements were analyzed at 4 time-points: at birth, on admission for glossopexy, on admission for lysis of lip-tongue adhesion (TLA), and at follow-up. Weight velocity was assessed using Tanner's tables.

Main Results

Adhesion dehiscence occurred in 9 patients (18.7%). Lip-tongue adhesion resolved airway compromise in 36 infants (75%). Release of TLA was accomplished in 34 patients. Data on weight velocity from birth to follow-up (mean, 5.57 ± 0.59 years) were available for 31 patients. After glossopexy, mean body weight increased from the 9.7 ± 2.6th to the 17.5 ± 4.6th percentile (P > .05), whereas mean weight velocity increased from the 19.1 ± 4.9th to the 74.2 ± 4.7th percentile (P < .001). No temporal correlation was found between glossopexy and oropharyngeal dysphagia.

Conclusion

In infants with PRS, glossopexy is a valid alternative to mandibular distraction because it does not cause decline in body growth.     

Circumumbilical pyloromyotomy in the era of minimally invasive surgery

Background/purpose

No studies have investigated the cosmetic outcome of current approaches to pyloromyotomy in infants with hypertrophic pyloric stenosis. The purpose of this study was to evaluate the final appearance of the scar in patients undergoing circumumbilical pyloromyotomy.

Methods

During a 16-year period, 86 infants underwent circumumbilical pyloromyotomy at our institution. A detailed questionnaire was created to document the family members' perceptions of the esthetic appearance of the scar. Data were collected by telephone interview and at clinic visit. In addition, cosmesis was assessed by 5 staff members who scored blindly the esthetic outcome of the scars with comparative photographs, using a categorical scale.

Results

Fifty-seven families were tracked by telephone contact. In the family questionnaire, 100% of families reported an excellent or good scar. Of these, forty-one (72%) were available for cosmetic assessment. Follow-up ranged between 5 months and 15 years (mean, 6 years). The panel members ranked the scar, on average, as excellent or good for 90% of the patients. No assessor stated that a scar was unacceptable. Intra- and interobserver agreement was 0.72 and 0.78, respectively.

Conclusions

Overall satisfaction with the cosmetic outcome of circumumbilical pyloromyotomy is very high.     

Renal and cardiovascular protection in type 2 diabetes mellitus: angiotensin II receptor blockers

Aggressive treatment of hypertension is effective in reducing both microvascular and macrovascular complications in type 2 diabetes, and target BP less than 130/85 or 130/80 mmHg are now recommended. Inhibition of renin angiotensin aldosterone system (RAAS) plays an essential role in the treatment of hypertension and diabetes-related complications. Studies focusing on renal end-points suggest that angiotensin-converting enzyme inhibitors (ACE-I) are more effective than other traditional agents in reducing the onset of clinical proteinuria in both type 1 and type 2 diabetic patients with incipient nephropathy, mainly in normotensive ones (secondary prevention). However, several small trials in type 2 diabetic patients with overt nephropathy (tertiary prevention) failed to demonstrate a specific renoprotective role for ACE-I, at variance with type 1 diabetes. Three recent large trials address the question of whether angiotensin II receptor blockers (ARB) prevent the development of clinical proteinuria or delay the progression of nephropathy in type 2 diabetes. The IRMA study showed that irbesartan is more effective than conventional therapy in preventing the development of clinical proteinuria and in favoring the regression to normoalbuminuria for comparable BP control in patients with incipient nephropathy. The IDNT and RENAAL trials showed that ARB are more effective than traditional antihypertensive therapies in reducing progression toward end-stage renal failure (ESRF) in type 2 diabetic patients with overt nephropathy independently of changes in BP. Moreover, a reduction in hospitalizations for heart failure was demonstrated for ARB-treated patients compared with placebo. Furthermore, the LIFE study showed that losartan is more effective than conventional therapy in reducing cardiovascular morbidity and mortality in a cohort of diabetic patients with hypertension and left ventricular hypertrophy. In conclusion, ARB seem to be effective in both preventing renal damage and reducing progression toward ESRF in type 2 diabetic patients. Thus, the guidelines for the prevention and treatment of diabetic nephropathy are now changed. In type 1 diabetes ACE-I are the first-choice drug; in type 2 diabetes, ARB are considered first-choice drugs in secondary prevention as well as ACE-I and have been now elected the unique first-choice drug in tertiary prevention of ESRF. Finally, ARB should be considered as the first-choice drug in cardiovascular prevention too, as well as ACE-I.