High molecular weight hyaluronan promotes repair of IL-1 beta-damaged cartilage explants from both young and old bovines

OBJECTIVE: The addition of exogenous high molecular weight hyaluronic acid (HA) reverses cartilage damage caused by fibronectin fragments (Fn-fs) added to explant cultures of bovine and human cartilage and by Fn-fs in an experimental in vivo model of rabbit knee joint damage. Our objective was to test whether HA was also effective in an IL-1 damage model and whether this repair was stable and occurred in older bovine cartilage. DESIGN: Bovine cartilage explants from 18-month-old or 6-year-old bovines in 10% serum/Dulbecco's modified Eagle's medium were exposed to Fn-f or to IL-1 and the ability of 1mg/ml HA of 800 kDa to block damage or promote restoration of proteoglycan (PG) after the damage was measured. The damage phase as well as the exposure to HA were varied. RESULTS: Exposure of exogenous HA decreased Fn-f-mediated damage, but did not decrease IL-1 beta-induced cartilage damage. If explants from 18-month-old bovines were damaged by a 7-day exposure to Fn-f or IL-1 beta and then exposed for 7 days to HA, PG was restored. This reparative activity persisted up to 4 weeks after the removal of HA from the culture medium. The restoration of PG did not occur in 0.1% serum-free cultures, was less when the exposure to the Fn-f was doubled and failed when exposure to IL-1 beta was doubled. In explants from 6-year-old bovines damaged with IL-1 beta for 7 days, HA fully restored PG content to normal levels. CONCLUSIONS: The reparative activities of HA occur not only in a Fn-f damage model, but also in an IL-1 damage model and occur with older bovine cartilage.     

Off-pump multivessel coronary artery surgery in high-risk patients

BACKGROUND: Coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality, which may be more marked in high-risk patients. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. METHODS: A total of 1,075 patients who underwent OPCAB between October 1996 and June 2001 and who had one or more of the following risk factors were included in the study: poor left ventricular function (EF < or = 30%), advanced age (> 70 years), left main stenosis, acute myocardial infarction, and redo coronary artery surgery. These patients were compared with 2,312 similar patients who underwent coronary artery bypass grafting on cardiopulmonary bypass during the same period. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups. RESULTS: The average number of grafts was 3.0 +/- 0.4 and 3.2 +/- 0.3 in the off-pump (OPCAB) and on-pump (CCAB) groups, respectively. Hospital mortality was 3.2% and 4.5% in OPCAB and CCAB groups respectively (p = 0.109). Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time (19 +/- 5 vs 24 +/- 6 hours, p < 0.001), mean blood loss (362 +/- 53 vs 580 +/- 66 mL, p < 0.001), atrial fibrillation (14.3 vs 19.7%, p < 0.001), and prolonged ventilation (4.6 vs 7.6%, p = 0.002) were less in OPCAB group. Intensive care unit stay (20 +/- 8 hours) and hospital stay (6 +/- 3 days) were significantly less in the OPCAB group (p < 0.001). CONCLUSIONS: Off-pump coronary artery surgery can be safely performed in high-risk patients with multivessel coronary artery disease. Operative mortality is comparable to that associated with on-pump surgery, and avoidance of cardiopulmonary bypass is associated with reduced postoperative morbidity in these patients.     

Perineal burn contractures: An experience in tertiary hospital of a Himalayan State

Perineal burn contracture is a rare burn sequel. We conducted a retrospective analysis of cases with perineal burn contractures managed in a tertiary care centre of a Himalayan state. We found that all cases sustained burn injury from burning firewood and the time of presentation was two to six years after the burn injury. We analyzed our treatment method and have classified these contractures into two types.     

Laparoscopic Management of a Retroperitoneal Duodenal Perforation Following ERCP for Periampullary Cancer

Introduction:

Endoscopic retrograde cholangiopancreatography (ERCP) is a fairly common procedure being performed in several centers worldwide. Although it is proven to be efficient and relatively safe, complications do occur (1.8%). We present a patient with ERCP-induced retroperitoneal perforation of the duodenum treated laparoscopically at our institution.

Case Report:

The patient is a 60-year-old female who underwent ERCP for obstructive jaundice due to periampullary carcinoma, during which the perforation occurred. Laparoscopy was performed 5 hours later and the perforation sutured primarily.

Results:

The operating time was 125 minutes. On the fourth postoperative day, the patient developed a retroperitoneal collection, confirmed by computed tomographic scan. Re-look laparoscopy was performed and the fluid drained. She recovered completely and was discharged on the eighth postoperative day.

Conclusion:

Duodenal perforation following ERCP is rare, with an incidence of 1.8%. Both surgical and non-surgical management have been reported, each with its specific indications. Our patient needed surgery, because the perforation was large and a retroperitoneal collection was present. Laparotomy is the preferred approach, though now laparoscopy is a viable and effective alternative, because it provides the benefits of minimal access, such as reduced pain and early ambulation.     

Limb conservation in extremity soft tissue sarcomas with vascular involvement

Background:

The major neurovascular involvement and large primary tumors are indication of amputation. The present study is an attempt to explore the feasibility of a limb salvage surgery in extremity sarcoma cases with major vessel involvement. Oncological outcomes and surgery-related morbidities are compared with those reported in literature.

Materials and Methods:

A retrospective review of all limb salvage surgeries done in our department between 2005 and 2008 was done and four cases of extremity sarcoma of lower limb involving femoral vessels analyzed. Interpretation of data from these cases, along with review of literature, is done.

Results:

In all these cases a wide monobloc excision was done adhering to oncological principles. This required resection of superficial femoral artery alone in two cases, resection of superficial femoral artery along with common femoral vein and femoral nerve in another, and of common femoral vein alone in yet another. Reconstruction was done in all these cases with reversed long saphenous vein graft. Histopathology of resected margins was free of tumor in all the four patients. One patient developed local recurrence and one developed distant metastsis. Two were disease free for one year with good functional limb, one has been disease-free for three years and another was disease-free at two years, after which he defaulted further follow-up. One patient developed arterial blowout which required ligation of common femoral artery which resulted in gangrene of the limb. He underwent amputation.

Conclusion:

Major neurovascular involvement in extremity sarcoma is not considered a contraindication for limb salvage surgery. Review of literature also supports our view. Post-operative wound related complications are more in this group of patients. However, long term functional outcome is good. Literature suggests a good long term local control after vascular resection and reconstruction.     

Custom prosthetic replacement for distal radial tumours

We analysed the results of 24 cases of aggressive benign and malignant tumours of the distal radius treated by resection and prosthetic replacement between 1995 and 2006. Patient ages ranged from 18 to 74 years, averaging 33 years; 18 were males. Recurrent giant cell tumour was the most common tumour. The prosthesis used was a bipolar hinge custom mega prosthesis manufactured locally. Average follow-up was 78 months. The average Musculoskeletal Tumor Society (MSTS) functional score achieved was 75%. The ten-year prosthesis survival was rate 87.5%. Infection was the most common complication.

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Resume  Prothèses sur mesure dans les tumeurs du radius distal. Indications de remplacement. Nous avons analysé les résultats de 24 cas de tumeurs malignes et bégnines agressives de l’extrémité distale du radius traitées par résection et prothèses entre 1995 et 2006. Les patients étaient agées de 18 à 74 ans avec un age moyen de 33 ans dont- 18 étaient des hommes. La cause la plus fréquente a été la récidive de tumeur à cellules géantes. La prothèse utilisée était une prothèse bipolaire à charnière sur mesure fabriquée localement. Le suivi moyen a été de 78 mois. Le score moyen MSTS après traitement était de 75%, la courbe de survie à 10 ans de 87,5%. La complication la plus fréquente a été l’infection.

     

Targeted mesenchymal stem cell and vascular endothelial growth factor strategies for repair of nerve defects with nerve tissue implanted autogenous vein graft conduits

Peripheral nerve gaps exceeding 1 cm require a bridging repair strategy. Clinical feasibility of autogenous nerve grafting is limited by donor site comorbidity. In this study we investigated neuroregenerative efficacy of autogenous vein grafts implanted with tissue fragments from distal nerve in combination with vascular endothelial growth factor (VEGF) or mesenchymal stem cells (MSCs) in repair of rat peripheral nerve defects. Six‐groups of Sprague‐Dawley rats (n = 8 each) were evaluated in the autogenous setting using a 1.6 cm long peroneal nerve defect: Empty vein graft (group 1), Nerve graft (group 2), Vein graft and nerve fragments (group 3), Vein graft and nerve fragments and blank microspheres (group 4), Vein graft and nerve fragments and VEGF microspheres (group 5), Vein graft and nerve fragments and MSCs (group 6). Nerve fragments were derived from distal segment. Walking track analysis, electrophysiology and nerve histomorphometry were performed for assessment. Peroneal function indices (PFI), electrophysiology (amplitude) and axon count results for group 2 were ?9.12 ± 3.07, 12.81 ± 2.46 mV, and 1697.88 ± 166.18, whereas the results for group 5 were ?9.35 ± 2.55, 12.68 ± 1.78, and 1566 ± 131.44, respectively. The assessment results did not reveal statistical difference between groups 2 and 5 (P > 0.05). The best outcomes were seen in group 2 and 5 followed by group 6. Compared to other groups, poorest outcomes were seen in group 1 (P ≤ 0.05). PFI, electrophysiology (amplitude) and axon count results for group 1 were ?208.82 ± 110.69, 0.86 ± 0.52, and 444.50 ± 274.03, respectively. Vein conduits implanted with distal nerve‐derived nerve fragments improved axonal regeneration. VEGF was superior to MSCs in facilitating nerve regeneration. © 2015 Wiley Periodicals, Inc. Microsurgery 36:578–585, 2016.     

A prospective randomized trial of endoscopic versus open saphenous vein harvesting technique for coronary artery bypass graft surgery

Purpose

The great saphenous vein harvested with a traditional open technique often results in leg wound complications. An endoscopic harvesting technique may decrease incidence of these complications.

Methods and material

Fifty consecutive patients having elective primary coronary artery bypass surgery were prospectively and randomly assigned to either endoscopic great saphenous vein harvesting (EVH—group A) or open great saphenous vein harvesting (OVH—group B). Both groups were demographically similar and received identical management. Leg wound healing was evaluated at discharge, 1 week, 1 month and 6 months for evidence of complications.

Result

The patient in endoscopic vein harvesting group had increased harvest time and an insignificant increase in vein injuries at the time of harvesting but decreased incision closure times when compared with traditional longitudinal open vein harvesting. Conversion from endoscopy to a traditional longitudinal open vein harvest occurred in 5 % of patients. Leg wound complications were significantly reduced postoperatively in the endoscopic vein harvesting group in comparison with the open vein harvesting group. Histological evaluation of structural integrity of vein samples shows that there is no significant difference between both the groups. No patient was readmitted to the hospital for leg wound complications in either group.

Conclusion

EVH is a safe, reliable method for saphenous vein harvesting. The best indication for EVH may be in patients who are in increased risk for wound infection and in whom cosmetics is a major concern.