Pregnancy after TVT-O: case report and literature review

A 37-year-old woman previously treated with TVT-O developed recurrent symptoms of stress urinary incontinence during pregnancy. Symptoms started to develop later in the second trimester and progressed gradually to affect her quality of life at the end of pregnancy. In the event she had a very quick spontaneous vaginal delivery at 40 weeks’ gestation. Postnatal physiotherapy successfully controlled the incontinence symptoms and urodynamic studies demonstrated no incontinence with a stable bladder and a normal flow rate. The patient remains well 2 years following delivery with no further treatment.     

Radiotherapy for nonfunctioning pituitary adenomas: from conventional to modern stereotactic radiation techniques

The initial management of nonfunctioning pituitary macroadenomas (NFAs) is usually surgery; however, a significant proportion of NFAs may require further treatment. Radiotherapy is currently used in patients with residual tumour and achieves excellent long-term control, but there are concerns about potential late toxicity. Stereotactic radiotherapy, both in the form of radiosurgery or fractionated stereotactic radiotherapy, has been developed as a more accurate technique of irradiation with more precise tumour localization and consequently a reduction in the volume of normal tissue, particularly the brain, irradiated to high radiation doses. A review of the literature suggests that new radiation techniques offer safe and effective treatment for recurrent or residual pituitary adenomas; however longer follow-up is necessary to confirm the excellent tumour control and the potential reduction of long-term radiation toxicity. Currently, radiotherapy has an important role in patients with residual or progressive disease after surgery. Patients with small or no residual tumours after surgery may generally continue on a policy of surveillance without immediate irradiation, in order to avoid the potential toxicity of treatment.     

Bipedicle Orbicularis Oculi Flap in the Reconstruction of the Lower Eyelid Ectropion

Background Lower eyelid ectropion is conventionally reconstructed with a local flap or full-thickness skin graft. However, scar contracture and recurrence of ectropion often occur. This article describes an effective surgical technique for lower eyelid ectropion repair using a bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid. Methods This study prospectively analyzed collected data on the bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion between 1995 and 2004. The flap was used in 12 eyelid procedures for the correction of lower eyelid ectropion, in 10 cases with traumatic ectropion, and in 1 case with bilateral congenital ectropion. In these cases, a strip of orbicularis oculi muscle or a myocutaneous flap from the upper eyelid with two pedicles attached in the medial and lateral canthus was advanced to the lower eyelid to suspend the eyelid and repair the skin defect. Results No problem of flap viability was encountered in any of the patients, and all healed well. Deformities were corrected, and evaluation showed satisfactory function and appearance during 0.5 to 6 years (average, 2 years) of follow-up evaluation. Eyelid malposition and bulkiness of the lower eyelid occurred in the early stages, but disappeared gradually about 3 months after the operation. There was no flap contraction, recurrent deformity, or significant donor site morbidity in the follow-up period. The incision scars were almost invisible. Conclusions The application of bipedicle orbicularis oculi muscle or a myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion is effective and reduces postoperative morbidity.     

Resolution of Diabetes Mellitus and Metabolic Syndrome following Roux-en-Y Gastric Bypass and a Variant of Biliopancreatic Diversion in Patients with Morbid Obesity

Background Obesity is associated with increased prevalence of type 2 diabetes mellitus (DM2) and metabolic syndrome and increased morbidity and mortality. Bariatric surgery results in significant and long-term weight loss. Two of the most effective and popular bariatric procedures are Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD). The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2. Methods The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1±2.9 kg/m²) and 111 BPD-RYGBP (BMI 59.7±10.6 kg/m²). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean follow-up was 26.39±21.17 months. Results Excess weight loss was ∼70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose <110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups. Conclusions RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP.We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.     

Prevalence and Severity of Sleep Apnea in a Group of Morbidly Obese Patients

Background Obesity is the most important risk factor for obstructive sleep apnea. It is estimated that 70% of sleep apnea patients are obese. In the morbidly obese, the prevalence may reach 80% in men and 50% in women. The aim of this study was to determine the prevalence and severity of sleep apnea in a group of morbidly obese patients, leading to bariatric surgery. Methods In a cross-sectional study developed in Bahia, northeastern Brazil. 108 patients (78 women and 30 men) from the Obesity Treatment and Surgery Center - “Núcleo de Tratamento e Cirurgia da Obesidade” underwent standard polysomnography. Patients with an apnea-hypopnea index (AHI) ≥ 5 events/hour were considered apneic. Results Mean ± SD for age and BMI were 37.1 ± 10.2 years and 45.2 ± 5.4 kg/m2, respectively. The calculated AHI ranged widely from 2.5 to 128.9 events/hour. Sleep apnea was detected in 93.6% of the sample, wherein 35.2% had mild, 30.6% moderate and 27.8% severe apnea. Oxyhemoglobin desaturation was directly related to the AHI and was more severe in men. Conclusion There was a high frequency of sleep apnea in this group of morbidly obese patients, for whom it was very important to request polysomnography, thus enabling therapeutic management and prognostication.     

A reasonable mechanism for visible light-induced skin rejuvenation

In recent years, much research has been done in the field of non-ablative skin rejuvenation. This comes as a response to the continuous demand for a simple method of treating rhytides, UV exposure, and acne scars. Numerous researches involve visible light-pulsed systems (20–30 J/cm²). The mechanism of action is believed to be a selective heat-induced denaturalization of dermal collagen that leads to subsequent reactive synthesis (Bitter Jr., Dermatol. Surg., 26:836–843, 2000; Fitzpatrick et al., Arch. Dermatol., 132:395–402, 1996; Kauvar and Geronemus, Dermatol. Clin., 15:459–467, 1997; Negishi et al., Lasers Surg. Med., 30:298–305, 2002; Goldberg and Cutler, Lasers Surg. Med., 26:196–200, 2000; Hernandez-Perez and Ibeitt, Dermatol. Surg., 28:651–655, 2002). In this study, we suggest a different mechanism for photorejuvenation based on light-induced reactive oxygen species (ROS) formation. We irradiated collagen in vitro with a broadband of visible light (400–800 nm, 24–72 J/cm²) and used the spin trapping coupled with electron paramagnetic resonance spectroscopy to detect ROS. Irradiated collagen resulted in hydroxyl radicals formation. We propose, as a new concept, that visible light at the energy doses used for skin rejuvenation (20–30 J/cm²) produces high amounts of ROS, which destroy old collagen fibers, encouraging the formation of new ones. On the other hand, at inner depths of the skin, where the light intensity is much weaker, low amounts of ROS are formed, which are well known to stimulate fibroblast proliferation.     

Reconstruction of the coronoid process with iliac crest bone graft in complex fracture-dislocation of elbow

A 36-year-old man sustained posterior dislocation of left elbow joint with olecranon fracture, comminuted coronoid fracture and subluxation of proximal radioulnar joint. We reconstructed the coronoid process with autogenous iliac crest bone graft and reduced the olecranon fracture with internal fixation. In addition, we also repaired the medial collateral ligament, annular ligament and anterior capsule during the operation. He received immobilization of the left elbow for 3 weeks after surgery and started range of motion exercises. The radiographic bone union was found 2 months after operation. The range of motion of the elbow was full at 12 months after operation. The latest 2-year follow-up, the functional result of the elbow was excellent.     

Effects of nicardipine-induced hypotension on cerebrovascular carbon dioxide reactivity in patients with diabetes mellitus under sevoflurane anesthesia

Purpose The purpose of this study was to examine the effects of nicardipine-induced hypotension on cerebrovascular CO₂ reactivity in patients with diabetes mellitus under sevoflurane anesthesia. Methods Nineteen diabetic patients, and 11 nondiabetic patients (serving as controls), undergoing elective orthopedic, cardiovascular, or thoracic surgery were included in the study. The diabetic patients were divided into three groups according to the antidiabetic therapy they were receiving, i.e., diet therapy (n = 6), oral antidiabetic drugs (n = 7), and insulin (n = 6). Anesthesia was maintained with 1.0 minimum alveolar concentration of sevoflurane. Absolute and relative cerebrovascular CO₂ reactivity was calculated using a 2.5-MHz pulsed transcranial Doppler (TCD) probe for the continuous measurement of mean blood flow velocity in the middle cerebral artery (Vmca). The cerebrovascular CO₂ reactivity was measured both at baseline and during hypotension by increasing the ventilatory frequency by 4 to 7 breaths·min⁻¹. Nicardipine was used to induce hypotension. Results We found that values for the Bispectral index (BSI), baseline mean blood pressure, endtidal CO₂ (Pet_{CO 2}), and Vmca were essentially identical in all patients, irrespective of the type of antidiabetic treatment being taken. Values for absolute and relative CO₂ reactivity in insulin-dependent patients, at both baseline blood pressure and during hypotension, were lower than those in patients in the antidiabetic drug, diet, and control groups (during hypotension, absolute CO₂ reactivity: diet group: 3.2 ± 0.9; oral antidiabetic drug group: 3.2 ± 0.7; insulin group: 1.5 ± 0.6; control group: 3.4 ± 0.8 cm·s⁻¹·mmHg⁻¹, [P < 0.05 insulin group vs the other groups]; relative CO₂ reactivity: diet group, 6.3 ± 1.0; oral antidiabetic drug group, 6.5 ± 0.8; insulin group, 3.5 ± 0.8; control group, 6.5 ± 0.7%·mmHg⁻¹, [P < 0.05 insulin group vs the other groups]. Conclusion We concluded that cerebrovascular CO₂ reactivity in insulin-dependent patients is impaired during nicardipine-induced hypotension under sevoflurane anesthesia.     

Type B aortic dissection associated with <Emphasis Type="Italic">Salmonella</Emphasis> infection

A 59-year-old man with a long history of hypertension and diabetes was admitted to our hospital with acute type B aortic dissection 14 days after the sudden onset of back pain. The dissecting descending thoracic aorta was enlarged to 5.2 cm in diameter, and laboratory tests showed an elevated white blood cell count (15 530/mm³) and an increased C-reactive protein level (19.2 mg/dl). Computed tomography performed 2 days after admission revealed rapid growth of the aortic dissection. Blood cultures obtained upon admission were positive for Salmonella. Impending rupture of the aortic dissection complicated by Salmonella infection was strongly suspected, and the patient underwent emergency surgery consisting of debridement and prosthetic graft placement covered by an omental flap. In this case, it is believed that insidious Salmonella aortitis caused acute type B aortic dissection.     

PEG “Rescue”: a practical NOTES technique

Dislodged percutaneous endoscopic gastrostomy (PEG) tubes occur commonly and may require urgent surgical intervention in a susceptible patient population. Natural orifice translumenal endoscopic surgery (NOTES) may facilitate PEG rescue and avoid the morbidity associated with contemporary surgical techniques. We report a case of a dislodged PEG tube in the early post-operative period with evidence of incomplete gastrocutaneous tract formation and intra-abdominal leakage. Bedside transgastric NOTES exploration facilitated peritoneoscopy, evacuation of intra-abdominal fluid, and re-establishment of the PEG tube through the original gastrotomy tract. Tube feeds were resumed and postoperative contrast fluoroscopy demonstrated no intra-abdominal leakage from the replaced PEG tube. No postoperative complications related to the NOTES procedure were noted at 30 days of follow-up. PEG rescue represents a unique, practical, and empowering application of the burgeoning experience of NOTES. Electronic Supplementary Material The online version of this article (doi: ) contains supplementary material, which is available to authorized users