Carotid artery aneurysm secondary to cystic medial necrosis

Carotid artery aneurysm secondary to cystic medial necrosis is a rare clinical entity. We report a 59-year-old Chinese male patient who presented with a pulsatile right neck swelling for 2 months. Partial resection of the aneurysm with primary anastomosis of the internal carotid artery was performed. Histopathological examination of the aneurysmal wall demonstrated cystic degeneration of the media with accumulation of glycosaminoglycan material, consistent with the features of cystic medial necrosis. The pathogenesis of carotid artery aneurysm secondary to cystic medial necrosis is discussed.     

Do patients with obstructive sleep apnea have clinically significant proteinuria?

AIM: Previous studies report a high prevalence of proteinuria in patients with obstructive sleep apnea syndrome (OSAS). This common syndrome may therefore be an important cause ofproteinuria and renal failure in the general population. This study was undertaken to assess the prevalence of proteinuria among OSAS patients, and to identify the factors associated with urine protein excretion in these patients. METHODS: Overnight polysomnography, urine protein to creatinine ratio (PTCR), body mass index (BMI), mean arterial pressure (MAP), and hematocrit were assessed prospectively in 224 patients referred for evaluation of suspected OSAS. Sleep apnea was defined as apnea-hypopnea score (AHS) > or = 5 events/hour. Proteinuria was defined as PTCR > 0.2 mg/mg. RESULTS: Sleep apnea was present in 143 subjects (63.8%), and proteinuria in 10 (4.5%). The highest PTCR was 0.677 mg/mg. PTCR and AHS were weakly correlated (r = 0.12, p = 0.08). PTCR correlated (alpha = 0.05) with lowest oxygen saturation (r = -0.18, p = < 0.01), time spent with oxygen saturation below 90% (r = 0.19, p = < 0.01), and BMI (r= 0. 17, p = < 0.01). The mean PTCR was similar in subjects with and without sleep apnea. Proteinuria was present in 7 of 143 (4.9%) subjects with AHS > or = 5 and 3 of 81 (3.7%) subjects with AHS < 5, a relative risk of 1.34, 95% CI (0.34, 5.32). Predictors of LogPTCR in multiple linear regression (model R2 - 0.104) were: AHS (< 5 or > or = 5), baseline oxygen saturation, sex, and MAP. CONCLUSIONS: Clinically significant proteinuria is uncommon in OSAS. The prevalence and severity of proteinuria are similar in both OSAS patients and patients without sleep-disordered breathing. Sleep apnea severity is weakly associated with urine protein excretion, related more to hypoxemia than to frequency of apneic events.     

Subarachnoid lumbar drains: A case series of fractured catheters and a near miss

PURPOSE: Lumbar subarachnoid catheters for cerebrospinal fluid (CSF) drainage (lumbar drains) are indicated for several medical and surgical conditions. A number of complications can occur from the placement of this type of catheter, including catheter breakage from excessive traction or shearing over the Tuohy needle. CLINICAL FEATURES: Five cases of lumbar subarachnoid catheter breakage/shearing and catheter fragment retention, as well as one near miss, were identified over a one-year period at a single institution. All (n = 6) patients were undergoing neurosurgical procedures. Four patients required surgical retrieval of the catheter fragments. No patient experienced log-term neurological sequelae. DISCUSSION: From these experiences, the following risks factors for catheter rupture are identified: 1) intentional or accidental retraction of the catheter through the needle during placement; 2) faulty use of the guidewire; or 3) use of excessive force during removal of the catheter. Methods to prevent such complications are suggested, including minimal use, or complete avoidance of a guidewire.     

Neurointensive care; impaired cerebral autoregulation in infants and young children early after inflicted traumatic brain injury: a preliminary report

The objective of this report is to describe cerebral autoregulation after severe inflicted pediatric traumatic brain injury (iTBI). We examined cerebral autoregulation of both cerebral hemispheres (mean autoregulatory index; ARI) in children <5 years with Glasgow Coma Scale (GCS) score of <9 and no evidence of brain death within the first 48 h of pediatric intensive care unit (PICU) admission. Discharge and 6-month Glasgow Outcome Scale (GOS) scores were collected. GOS of <4 reflected poor outcome. All three iTBI and all seven noninflicted TBI (nTBI) patients had admission GCS score of <9. Eight of 10 patients had Autoregulatory Index (ARI) of <0.4 (impaired cerebral autoregulation) of at least one hemisphere. All children with iTBI had poor outcome, and none had intact cerebral autoregulation in both hemispheres. Children with nTBI had better overall outcome than those with iTBI. Two of the children with nTBI had intact autoregulation in both hemispheres and good outcome. Two of the three children with iTBI had differential effects on autoregulation between hemispheres despite bilateral injury. These are, to our knowledge, the first data on cerebral blood flow autoregulation in the unique setting of iTBI and provide a rationale for further study of their relationship to outcome and effects of therapy.     

Incidence and clinical significance of distal embolization during percutaneous interventions involving the superficial femoral artery

OBJECTIVE: Distal embolization of plaque or thrombus may cause organ ischemia following percutaneous peripheral interventions. The purpose of this study was to evaluate the incidence and clinical significance of particulate embolization during percutaneous superficial femoral artery (SFA) intervention by monitoring with continuous Doppler ultrasound. The rate and timing of embolization at various phases of intervention such as guidewire crossing, balloon angioplasty, stent deployment, and directional atherectomy were analyzed and compared. METHODS: Sixty patients underwent SFA intervention. Of these 60 patients, 10 patients underwent percutaneous transluminal angioplasty (PTA) alone, 40 patients underwent PTA with stenting, and 10 patients underwent plaque excision with the SilverHawk atherectomy device (8) or Spectranetics excimer laser (2) with or without additional PTA or stent placement. A 4-MHz Doppler probe was used for continuous monitoring in the ipsilateral popliteal artery. Distal embolization was registered as embolic signals (ES). ES were quantitatively assessed during critical portions of the procedure including guidewire crossing, balloon angioplasty, stent deployment and/or atherectomy. ES during different phases of intervention were compared using analysis of variance (ANOVA). RESULTS: ES was noted in every patient during wire crossing, angioplasty, stent deployment and atherectomy. The average number of ES noted during guidewire crossing was 8, PTA was 12, stent deployment was 28, SiverHawk atherectomy was 49, and Spectranetics excimer laser was 51. The frequency of ES was statistically higher during stent deployment vs wire crossing or balloon angioplasty but equivalent to that generated by plaque excision. ES was observed more frequent during balloon angioplasty than during wire crossing. In one patient who was treated with the excimer laser, a single runoff vessel was occluded with embolic debris but patency was restored angiographically after thrombolysis. The patient went on to require below knee amputation. During follow-up, all patients with claudication reported improved symptoms and those with ulcers or gangrene demonstrated healing. The average increase in ankle-brachial index following intervention was 0.31. CONCLUSION: While ES were recorded at each step of SFA intervention, the frequency was greatest during stent deployment. Despite the frequency of these events, only one patient developed angiographically and clinically significant embolization. Thus, our findings do not support the routine use of protection devices during percutaneous SFA intervention.     

Systematic Review and Meta-analysis of Laparoscopic Versus Open Distal Gastrectomy

Background

Laparoscopic distal gastrectomy has been increasingly utilized in the treatment of gastric adenocarcinoma. This study aims to compare the morbidity/mortality and postoperative outcomes of laparoscopic-assisted versus open distal gastrectomy since 2000.

Methods

A comprehensive search of MEDLINE and EMBASE was conducted including studies published between 2000 and present.

Results

Seventeen studies with a total of 7,109 distal gastrectomies (3,496 lap vs 3,613 open) were included. Across all studies, postoperative morbidity rates for laparoscopic gastrectomy were lower than that of open [median (range) 10 (0–36)?% vs 17 (0–43)?%]. Meta-analysis of postoperative morbidity rates in prospective studies only yielded pooled odds ratio of 0.52 (95 % CI 0.33–0.81) (P?=?0.004). In-hospital mortality rates were comparable between the two (range: laparoscopic 0–3.3 vs open 0–6.7 %). The long-term oncological outcomes of resection were difficult to analyze given variable reporting but appeared similar between the two. Meta-analysis of prospective studies showed that laparoscopic-assisted distal gastrectomy was associated with significantly shorter hospital length of stay [standard mean difference (SMD)?=??0.78 (95 % CI?=??1.0 to ?0.56)], comparable intraoperative bleeding [SMD?=?0.64 (95 % CI?=??1.3–0.0430) P?=?0.066] and longer operative time compared to open gastrectomy [1.9 (95 % CI 0.05–3.8) P?=?0.045, with P?<?0.001].

Conclusion

This study supports the use of laparoscopic-assisted distal gastrectomy for treatment of gastric adenocarcinoma with evidence of comparable, if not better, short-term postoperative parameters when compared to open distal gastrectomy. The long-term oncological outcomes appear similar but may require more evaluation.     

European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update

Context

The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.

Pancreaticoduodenectomy with En Bloc Portal Vein Resection for Pancreatic Carcinoma with Suspected Portal Vein Involvement

Pancreaticoduodenectomy combined with portal vein resection is increasingly accepted as a viable treatment option for pancreatic carcinoma with suspected involvement of the portal vein.However, its clinical benefit remains controversial. This study evaluated the outcomes of pancreaticoduodenectomy with portal vein resection for pancreatic carcinoma in a group of Chinese patients operated on by a specialized team in a center with a low case volume of pancreatic cancer. The perioperative and long-term outcomes of 12 patients with portal vein resection for suspected involvement of the portal vein and 38 patients who underwent pancreaticoduodenectomy without portal vein resection during the same period were compared. In the former group, eight patients underwent segmental resection, and four patients underwent wedge resection of the portal vein. There were no significant differences in operative blood loss (median 0.8 vs. 0.8 liter, p = 0.313), hospital mortality (0% vs. 2.6%, p = 1.000), or operative morbidity (41.7% vs. 42.1%, p = 0.979) between the two groups. Patients who required portal vein resection had higher frequencies of microscopic lymphatic permeation (58.3% vs. 18.4%, p = 0.023) and vascular invasion (50.0% vs. 15.8%, p = 0.025). Long-term survival was comparable between patients with portal vein resection and those without it (median 19.5 vs. 20.7 months, p = 0.769). These findings suggest that pancreaticoduodenectomy combined with portal vein resection can be performed safely by a specialized team in a center with a low case volume of pancreatic carcinoma and that it may offer survival benefit in patients with suspected portal vein involvement.     

Delayed portal vein thrombosis after experimental radiofrequency ablation near the main portal vein

BACKGROUND: Portal venous blood flow may protect adjacent tumour cells from thermal destruction with radiofrequency ablation (RFA). This study aimed to investigate the local effect of RFA on the main portal vein branch, and the completeness of cellular ablation in its vicinity, with or without a Pringle manoeuvre using a porcine model. METHODS: This was an in vivo study on 23 domestic pigs. RFA using a cooled-tip electrode was performed 5 mm from the left main portal vein branch under ultrasonographic guidance for 12 min with (n = 10) or without (n = 10) a Pringle manoeuvre. Ten pigs were killed 4 h after the procedure to study the early effects of RFA and ten others were killed 1 week later to determine any delayed effect. As a control, sham operations with a Pringle manoeuvre for 12 min were performed on three pigs. The flow velocity changes of portal vein and hepatic artery were measured using Doppler ultrasonography, and the completeness of cellular ablation around the portal vein was assessed qualitatively by histochemical staining and quantitatively by measuring intracellular levels of adenosine 5'-triphosphate (ATP). RESULTS: In the absence of the Pringle manoeuvre, there was no significant change in mean(s.d.) portal vein flow velocity before RFA (20.0(3.5) cm/s) and at 4 h (18.5(2.5) cm/s) (P = 0.210) and 1 week (19.5(2.2) cm/s) (P = 0.500) after the procedure. Gross and histological examination of the portal vein branches showed no damage without the Pringle manoeuvre. In all pigs that underwent RFA with a Pringle manoeuvre, the portal vein was occluded 1 week after the operation; histological examination of the affected portal vein showed severe thermal injury and associated venous thrombosis. The local effect of RFA on the hepatic artery was similar. With intact portal blood flow during RFA, complete ablation of liver tissue around the pedicle was demonstrated by histochemical staining and measurement of the intracellular ATP concentration. CONCLUSION: RFA was safe when applied close to the main portal vein branch without a Pringle manoeuvre, with complete cellular destruction. Use of the Pringle manoeuvre resulted in delayed portal vein and hepatic artery thrombosis and injury to the hepatic artery and bile duct.