Three-dimensional ultrasonography before minimally invasive focused parathyroidectomy: The importance of coronal images

Purpose  To evaluate the usefulness of three-dimensional (3D) ultrasonography (US) as a noninvasive preoperative localization procedure before performing minimally invasive focused parathyroidectomy in patients with primary hyperparathyroidism (pHPT). Methods  Seventy-six patients with a solitary adenoma detected by US underwent minimally invasive focused parathyroidectomy. The value of 3D US was assessed by dividing patients into a 2D group and a 3D group. Age, the preoperative serum intact parathyroid hormone (PTH) level, operative time, length of skin incision, and weight of the resected specimen were compared between the groups, and multivariate analysis of the operative time was performed. Results  There were no significant differences between the 2D group and the 3D group in age, the preoperative intact PTH level, length of skin incision, or weight of the resected specimen, but the mean operative time was significantly longer in the 2D group (P < 0.01). Multivariate analysis revealed that 3D US and the weight of the resected specimen were correlated with the operative time (P < 0.05). Conclusion  The coronal images obtained by 3D US assist in the precise localization of parathyroid masses in patients with pHPT undergoing minimally invasive focused parathyroidectomy for a solitary adenoma.     

Lipofibromatous hamartoma of the median nerve in patients with macrodactyly: diagnosis and treatment of a rare disease causing carpal tunnel syndrome

Lipofibromatous hamartoma is a very rare benign peripheral nerve tumour. It is mostly encountered in the proximal extremities of young adults, involving the median nerve in the majority of cases. We present two patients with macrodactyly and carpal tunnel syndrome caused by lipofibromatous hamartoma of the median nerve and discuss diagnosis and treatment of the disease. A 10-year-old girl with a congenital progressive macrodactyly of her right index finger presented with a slowly growing mass in her right palm and pain and numbness, along with motor and sensory deficits in the median nerve distribution. Treatment consisted of carpal tunnel release, epineurolysis and partial excision of the fibrofatty tissue. The second patient, a 25-year-old man presented with a swelling in his left palm and findings compatible with carpal tunnel syndrome. Intraoperatively, the lesion presented as sausage-shaped enlargement of the median nerve by fibrofatty tissue. After carpal tunnel release, a partial excision of the mass with epineurolysis was performed. In both patients, histology showed nerve bundles separated by abundant fibrofatty tissue. In the girl, a proliferation of dysplastic perineurial cells could be observed. The suspected diagnosis for patients with macrodactyly and clinical signs of carpal tunnel syndrome should be lipofibromatous hamartoma. A carefully taken history, physical examination, X-ray, and MRI are important for its correct diagnosis. The surgical management remains controversial. Treatment should include decompression of the median nerve at points of compression, partial excision of the fibrofatty tissue, and debulking of soft tissue. In some cases, an epineurolysis can be additionally performed.     

Extracranial radiosurgery—applications in the management of benign intradural spinal neoplasms

Stereotactic radiosurgery has enabled the delivery of higher doses of radiation and decreased fractionation due to improved accuracy. Spinal radiosurgery has been increasingly utilized for the management of metastatic extradural spinal disease. However, surgical resection remains the primary treatment strategy for intradural spinal tumors. Preliminary evidence suggests that radiosurgical ablation with stereotactic radiation for intradural spinal lesions may be efficacious in certain clinical scenarios. Local tumor control, pain relief, and improvement in neurologic function with minimal morbidity have been reported in short-term follow-up. However, long-term efficacy of radiosurgery in the management of intradural spinal neoplasms necessitates further validation. As extracranial radiosurgery is a newly evolving modality, a continuative review of the current literature is appropriate. Until a standardized therapeutic window of safety and efficacy can be determined, the recommendation of radiosurgical applications for benign spinal tumors should be reserved for carefully selected cases.     

Liver metastasis as an initial recurrence has no impact on the survival of patients with resectable pancreatic adenocarcinoma

Background  Prognosis of the patients with pancreatic adenocarcinoma is still poor due to a recurrence, and liver metastasis is a distant metastasis that is foreboded the short survival period. Methods  Between 1999 and 2005, 68 patients for pancreatic adenocarcinoma underwent a pancreaticoduodenectomy (n = 17), a pylorus-preserving pancreaticoduodenectomy (n = 27), distal pancreatectomy (n = 22), or total pancreatectomy (n = 2) with an extensive lymph node dissection. Results  A tumor recurrence occurred to 55 patients (13 of the liver, 21 of the local recurrence, 16 of peritoneal dissemination, three of the lymph node, and two of lung). The low tumor grade and female demonstrated a risk factor for a liver metastasis (P = 0.043, P = 0.031). A logistic regression analysis demonstrated female (P = 0.02) and low tumor grade (P = 0.04) as independent risk factors for recurrence with liver metastasis. The median survival time (MST) was 13.6 months, and MST of patients with a liver metastasis as an initial recurrent site was 13.7 months; the liver metastasis as an initial recurrent site has no impact on the MST after pancreatic resection. Conclusions  We concluded potentially supporting the hypothesis that even patients thought to be at higher risk of liver metastasis may still be given the chance of resection, considering the satisfying survival.     

The generation of osteoclasts from RAW 264.7 precursors in defined,serum-free conditions

Osteoclasts are the unique cell type capable of resorbing bone. The discovery of the TNF-ligand family member, RANKL, has allowed more reliable study of these important cells. The mouse monocytic cell line, RAW 264.7, has been shown to readily differentiate into osteoclasts upon exposure to recombinant RANKL. Unlike primary osteoclast precursors, there is no requirement for the addition of macrophage colony stimulating factor (M-CSF). However, to date, their differentiation has always been studied in the context of added foetal calf serum (FCS). FCS is a complex and largely undefined mixture of growth factors and matrix proteins, and varies between batches. For this reason, osteoclastogenesis would ideally be studied in the context of a defined, serum-free medium. RAW 264.7 cells were cultured in serum-replete α-MEM or serum-deprived medium (SDM) shown previously to support the growth of human osteoclasts in a co-culture with normal osteoblasts. In SDM, in the presence of recombinant RANKL, RAW 264.7 cells readily differentiated into tartrate resistant acid phosphatase (TRAP) positive multinucleated osteoclast-like cells, a process that was enhanced with the addition of 1α,25-dihydroxyvitamin D₃ (1,25D). While the osteoclasts grown in SDM were smaller in size compared with those derived in serum-replete media, their resorptive capacity was significantly increased as indicated by a twofold increase in average resorption pit size. In conclusion, we describe a defined model for studying osteoclast differentiation and activity in the absence of serum, which will be ideal for studying the role of agonistic and antagonistic molecules in this process.     

Preoperative Fasting of 2 Hours Minimizes Insulin Resistance and Organic Response to Trauma After Video-Cholecystectomy: A Randomized,Controlled, Clinical Trial

Background  Studies showing the improvement of insulin sensitivity by reducing the term of preoperative fasting are mostly done in patients undergoing major operations. More information about the role of shortened preoperative fasting in perioperative metabolism is needed for such elective minor/moderate abdominal procedures as laparoscopic cholecystectomy. We investigated the influence of a carbohydrate-rich drink given 2 h before laparoscopic cholecystectomy on insulin resistance and the metabolic response to trauma. Methods  A group of 21 female candidates (18–65 years old) for elective laparoscopic cholecystectomy were randomized to either an 8 h fasting group (control group: n = 10) or to a group receiving 200 ml of a carbohydrate beverage containing 12.5% (25 g, 50 kcal per 100 ml and approximately 285 mOsm) of maltodextrine 2 h before operation (CHO group: n = 11). Blood samples for various biochemical assays were collected both at induction of anesthesia and after the 10th postoperative hour. Insulin resistance was assessed by the HOMA-IR equation (Insulin (μU/ml) × blood glucose (mg/dl)/405). Results  There were no postoperative complications. Seventy percent (7/10) of the controls and 27.3% (3/11) of the CHO group experienced at least one episode of vomiting (RR = 2.42, 95% Confidence Interval [CI] = 0.88–6.68; P = 0.08). Biochemical analysis showed that serum glucose (P < 0.01), insulin (P < 0.01), lactate/pyruvate ratio (P = 0.03), and triglycerides (P < 0.01) for the control group were higher than for the CHO group. The value of HOMA-IR was significantly greater (P = 0.03) in the conventionally fasted patients than in the CHO group. Conclusions  Abbreviation of the period of preoperative fasting and administration of a carbohydrate beverage diminishes insulin resistance and the organic response to trauma.     

Evisceration Following Abdominal Stab Wounds: Analysis of 66 Cases

Background  Abdominal stab wounds with evisceration remain an indication for emergency laparotomy. The purpose of this study was validate a policy of mandatory laparotomy for organ evisceration and a policy of selective nonoperative management with serial physical abdominal examination for omentum evisceration. Methods  The charts of 379 patients with abdominal stab wounds who presented to our Level I trauma center over a 3-year (January 2005 to December 2007) period were retrospectively reviewed. Altogether, 66 (17.4%) patients with evisceration were identified and included in the study. Indications for mandatory laparotomy were peritonitis, hemodynamic instability, organ evisceration, and a high spinal cord or severe head injury with an abdominal stab wound. Further data gathered included the organ eviscerated, intraabdominal organs injured, and complications. Injury severity was categorized using the revised trauma score (RTS), injury severity score (ISS), and penetrating abdominal index (PATI). Results  Organ and omentum evisceration occurred in 35 (53%) and 31 (47%) patients, respectively. Organs eviscerated were as follows (number of patients): small bowel in 27 (40.9%), stomach in 2 (3%), colon in 1 (1.5%), small bowel and stomach in 2 (3%), and small bowel and colon in 3 (4.5%). The mean RTS, ISS, and PATI scores were 7.71, 13.74, and 8.26, respectively. Only two (5.7%) patients with organ evisceration underwent a negative laparotomy. In total, 23 patients with omentum evisceration (21 with peritonitis, 1 with a head injury, 1 who failed abdominal observation) underwent therapeutic laparotomy. Six patients with omentum evisceration were managed successfully nonoperatively. Two patients with left thoracoabdominal omentum evisceration underwent delayed laparoscopy, which revealed a diaphragm injury in one patient. Overall, 57 (86.4%) patients with evisceration had an intraabdominal injury that required repair. Conclusions  Evisceration should continue to prompt operative intervention. An exception can be made to a select few patients with omentum evisceration with benign abdominal findings.     

Fusion versus Bryan Cervical Disc in two-level cervical disc disease: a prospective,randomised study

In this prospective study, our aim was to compare the functional results and radiographic outcomes of fusion and Bryan Cervical Disc replacement in the treatment of two-level cervical disc disease. A total of 65 patients with two-level cervical disc disease were randomly assigned to two groups, those operated on with Bryan Cervical Disc replacement (31) and those operated on with anterior cervical fusion with an iliac crest autograft and plate (34). Clinical evaluation was carried out using the visual analogue scale (VAS), the Short Form 36 (SF-36) and the neck disability index (NDI) during a two year follow-up. Radiological evaluation sought evidence of range of motion, stability and subsidence of the prosthesis. Substantial reduction in NDI scores occurred in both groups, with greater percent improvement in the Bryan group (P = 0.023). The arm pain VAS score improvement was substantial in both groups. Bryan artificial cervical disc replacement seems reliable and safe in the treatment of patients with two-level cervical disc disease.