Transvaginal organ extraction: potential for broad clinical application

Background

Natural orifice transluminal endoscopic surgery procedures have evolved over the past few years. A transvaginal approach is a promising alternative for intraperitoneal procedures. Our objective was to evaluate the safety and feasibility of transvaginal organ extraction.

Methods

This institutional review board-approved protocol involved retrospective review of an ongoing prospective study. Female subjects who presented to our hospital for elective cholecystectomy, appendectomy, or sleeve gastrectomy were offered participation in the study. Eligible patients met the following criteria: age between 18 and 75, diagnosis of gallbladder disease, acute appendicitis, or morbid obesity who desired surgical treatment. A hybrid transvaginal natural orifice approach was used in this series.

Results

Thirty-four women underwent transvaginal organ extraction between September 2007 and January 2012. The mean age was 40 ± 12.1 years (range 23–63 years). The mean body mass index was 27 ± 6.4 kg/m² (range 16–43 kg/m²). All patients had an American Society of Anesthesiologists classification of two or below. The mean operative time for cholecystectomy, appendectomy, and sleeve gastrectomy was 90, 71, and 135 min, respectively. There were no conversions to open operation and no intraoperative complications. The mean hospital stay was 2 days for all cases. Patients were followed for a mean of 24 months (range 1–61 months). There were two pregnancies and two successful vaginal deliveries. Six patients (18 %) had minor complaints of spotting or heavy menses in the immediate postoperative period that resolved with conservative measures. There were no abdominal wall complications. There were no long-term complications and no mortalities.

Conclusions

This initial experience suggests that this surgical approach is safe, does not increase length of stay, and has no long-term vaginal complications. Given this attractive profile, a transvaginal approach may prove to be a superior mode of organ extraction, although randomized studies and long-term follow-up are needed.     

Outcomes after total hip replacement based on patients' baseline status: What results can be expected?

Objective

We evaluated patient satisfaction with total hip replacement (THR) to establish cut points of sufficient improvement based on the patient acceptable symptom state (PASS) and receiver operating characteristic (ROC) curves, and compared them with measures derived from the minimum clinically important difference (MCID), taking into account patients' baseline status.

Methods

Two cohorts of prospectively recruited patients on waiting lists for THR were studied. Sociodemographic data and comorbidities were recorded. Patients completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and other patient‐reported outcomes questionnaires before THR and 6 months afterward. Cut points of sufficient improvement were established by the PASS, ROC, and MCID and were compared.

Results

Patients satisfied with THR had, by preintervention WOMAC tertiles, gains of 19.4, 34.1, and 49.3 in the WOMAC pain domain and 17.8, 30.8, and 41.4 in the WOMAC functional limitation domain. The PASS cut points determined were 20, 25, and 25 for postintervention WOMAC pain and 28, 35, and 42 for functional limitation. ROC cut points were 19, 25, and 25 for postintervention pain and 26.4, 39, and 40 for functional limitation. Agreement among cut points classifying patients as responders to THR was 1.0 for pain with both PASS and ROC, and 0.85 for functional limitation; 0.6 for pain between MCID and PASS or ROC, and 0.58 and 0.60 for functional limitation.

Conclusion

Cut points of expected gain after THR can help clinicians, researchers, and managers to identify suitable candidates for THR, although such measures must be used with caution.     

Diabetic retinopathy screening with non-mydriatic retinography by general practitioners: 2-year results

AimsTo ascertain in real practice the diagnosis rate of diabetic retinopathy (DR) in patients considered to have positive screening test by general practitioners (GPs) and what are the reasons for the false positive diagnosis.MethodsFour GPs previously instructed in the interpretation of retinal photographs evaluated the digital retinography images of patients with diabetes obtained during a 2-year period. When the images were considered normal, a new appointment was scheduled for 1 year later and a report was emailed to the referring physician. Patients with any sign of DR or other suspicious retinal alterations and those whose images were considered difficult or impossible to assess were referred to an ophthalmologist.ResultsA total of 2750 patients were referred for screening. The images of 2036 (74%) patients were considered normal, and the images of 714 (26%) patients were sent to ophthalmologists. Among the referred patients, 392 (55%) did not have DR, 244 (34%) had DR, and 78 (11%) had unreadable images. The retinal images of 240 patients whose fundi were considered normal were read again by ophthalmologists to evaluate false negatives. Of them, 16 patients (7%) had DR but only two patients (1%) had treatable DR.ConclusionsAfter adequate training, GPs can screen for DR with a high level of accuracy using non-mydriatic retinography. There is a need to strengthen the training of GPs in order to recognize non-visual threatening abnormalities.     

Platelet-rich plasma,a source of autologous growth factors and biomimetic scaffold for peripheral nerve regeneration

Introduction: In mammals, axons of injured peripheral nerves (PNI) can and do regenerate, but often the functional recovery is incomplete or suboptimal. In recent years, in vivo tissue engineering approaches through molecular intervention and scaffolding are offering promising outcomes. Evidence is accumulating in both preclinical and clinical settings indicating that Platelet-rich plasma (PRP) and fibrin scaffolds obtained from this technology hold an important adjuvant therapeutic potential.

Areas covered: This review addresses current molecular and cellular data in intrinsic nerve repair processes and describes different strategies to harness and enhance these processes by using biochemical and biomechanical cues. It focuses on autologous fibrin, plasma and platelet-derived growth factors as filler or scaffolds that can synergize with the gold standard therapy and other nerve guidance conduits.

Expert opinion: PRP is applied as a filler of nerve conduits or vein-muscle grafts across nerve gaps post trauma by infiltrating the nerve stumps perineurally and intraneurally in neuropathies, or as scaffolds to bridge or wrap nerve stumps, with significant neurological recovery and pain reduction. The application of PRP at the injured nerve site might be considered as an ‘off the shelf’ alternative.