Right Hepatic Lobectomy Using the Staple Technique in 101 Patients

Background Application of linear stapling devices for extrahepatic vascular control in liver surgery has been well-established. However, the technique for use of stapling devices in hepatic parenchymal transection is not well defined. Purpose To describe the safety and efficacy of our technique for use of vascular stapling devices in hepatic parenchymal transection during open right hepatic lobectomy is the purpose of this study. Methodology We reviewed our experience with 101 consecutive open right hepatic lobectomies performed by a single surgeon between January 2003 and July 2006, in which vascular staplers were utilized for the parenchymal transection phase. Results Of the 101 patients who underwent resection, 53 (52%) were female. The mean age was 58 years. Malignant disease was the indication for resection in the majority of patients (88%). Of those with cancer, 78% (69 of 89) had metastatic colorectal cancer, 6% (5 of 89) had metastatic neuroendocrine tumor, 4% (4 of 89) had hepatocellular carcinoma, 4% (4 of 89) had cholangiocarcinoma, and the remaining 8% were other metastatic cancers. Twelve patients (12%) underwent resection for hepatic adenoma or symptomatic benign disease (FNH or hemangioma). Forty-eight patients (48%) underwent a major ancillary procedure at the time of hepatic resection. Thirty-nine patients (39%) had a nonanatomic wedge resection of a left lobe lesion, 27 patients (27%) had one or more lesions treated with radiofrequency ablation (RFA), and 6 patients (6%) were treated with a synchronous bowel resection. The median total operative time was 336 min (range 155–620 min). A Pringle maneuver for temporary vascular inflow occlusion was utilized in all cases, with a median time of 9 min (range 4–17 min). Ten patients (10%) required blood transfusion during surgery or in the postoperative period. The maximum transfusion was 2 U of packed red blood cells (PRBC) in seven patients and 1 U of PRBC in three patients. The mean nadir postoperative hematocrit was 28.2. All patients with malignant disease had tumor-free margins at the completion of the procedure. The average hospital length of stay was 6.0 days. One patient (1%) developed a clinically significant bile leak requiring a postoperative endoscopic retrograde cholangiography (ERCP). No patient required reoperation. The 30 and 60-day postoperative survival was 100%. Conclusion These findings indicate that application of vascular stapling devices for parenchymal transection in major hepatic resection is a safe technique, with low transfusion requirements and minimal postoperative bile leak. The technique allows for rapid transection of the entire right hepatic lobe in under 10 min. Short video clips of the technique will be demonstrated. Presented at the 2007 American Hepato–Pancreato–Biliary Association, Las Vegas, Nevada, April 19–22, 2007 (oral presentation/video presentation).     

Antibiotics in 30 minutes or less for febrile neutropenic patients: a quality control measure in a new hospital

Infections are the most common complication in patients receiving treatment for cancer with neutropenia being the primary risk factor for the development of an infection. In the neutropenic patient, bacteremia remains a significant cause of mortality. Although the literature reports that prompt empiric antibiotic therapy to prevent death caused by virulent organisms is the standard of care, the literature fails to identify what prompt antibiotic administration means. Door/fever-to-patient antibiotic delivery was evaluated as a quality control measure in a new children's hospital. Initially, door/fever-to-patient time was significantly delayed. Collaboration between pharmacy, hospital bed control, medical, and nursing staff resulted in many changes in practice by all groups. As a result, the goal for prompt antibiotic delivery of thirty minutes or less is now achievable.     

Nonemergent ED patients referred to community resources after medical screening examination: characteristics, medical condition after 72 hours, and use of follow-up services.

INTRODUCTION: Limited access to medical care has resulted in large numbers of patients seeking primary care for non-emergent emergency conditions in emergency departments. This influx of patients is contributing to overcrowding and delays in care for patients with emergencies. In response, a system was implemented in which persons with non-emergent medical conditions, following a medical screening examination, did not receive further ED assessment or treatment and instead were referred to community resources. The purpose of this study was to describe the characteristics of individuals who were referred to community-based services, their condition after 72 hours, and their use of follow-up health care services. METHODS: All referred cases (n=225) were reviewed for chief complaint and demographics. Phone contact was attempted after 72 hours to determine the person's condition and if community resources were utilized. RESULTS: Of the 225 cases, 52% were female, with a mean age of 33 years. Their most common chief complaints were extremity problems (16%), toothache (9%), and medication refill (8%). Follow-up phone contact was successful with 82 people (37%) an average of 14 days after their ED visit. The majority (55%) reported their condition had improved; 39%were unchanged, and 6% were worse. Thirty-one people(40%) accessed community resources and 8 (26%) returned to another emergency department. No clinically significant associations were found between patient demographics and use of community resources. DISCUSSION: Most people who were successfully contacted for follow-up and who had come to the emergency department with non-emergent chief complaints did not access community resources and their condition frequently improved. Additional studies, with improved follow-up, are needed before suggesting that referring individuals to community resources is an acceptable practice.     

Quantification of nuclear cardiac images: The Yale approach

Conclusion  Quantification of nuclear cardiac images provides a secondary support in reading myocardial perfusion images and improves the reproducibility in the diagnosis of cardiovascular diseases. The technology for the remote Web reading of nuclear cardiac images and the quantitative data allows for an easy and secured access to patient studies without the limitations of time and space. The recent increasing interests and applications in molecular targeted imaging have opened a new field in nuclear cardiology, and absolute image quantification of the focal tracer uptake in the myocardium is exceedingly critical for the quantitative analysis of molecular targeted images.     

Ruptured pediatric posterior cerebral artery aneurysm 9 years after the onset of Kawasaki disease: a case report

CASE REPORT: A 12-year-old boy who had a history of Kawasaki disease 9 years ago experienced a subarachnoid hemorrhage by ruptured right posterior cerebral artery aneurysm. On day 1 operation, as the aneurysm was very fragile and bled easily, two intraoperative ruptures, including a very premature rupture, were encountered. As a result, a left hemiparesis especially severe in the left hand was caused by the right anterior thalamic infarction due to the occlusion of a thalamo-perforating artery arising near the neck of the aneurysm. DISCUSSION: The histopathological examination of the intraoperative excised aneurysmal dome disclosed the thickening of the endothelial inner due to the endothelial hypertrophy and the invasion of inflammatory cells. This finding of the aneurysm was partially mimicking the finding of the coronary artery of the patients with Kawasaki disease. The combination of cerebral aneurysm and Kawasaki disease has never been reported until now, and the etiology of the aneurysm of this patient is unclear.     

<Emphasis Type="Italic">Bcl11b</Emphasis>mutations identified in murine lymphomas increase the proliferation rate of hematopoietic progenitor cells

Background  

The telomeric region of mouse chromosome 12 has previously shown frequent allelic loss in murine lymphoma. The Bcl11b gene has been identified and suggested as a candidate tumor suppressor gene within this region. In this study, we aimed to elucidate whether Bcl11b is mutated in lymphomas with allelic loss, and whether the mutations we detected conferred any effect on cell proliferation and apoptosis.     

Anatomical Course of the Superficial Branch of the Radial Nerve and Clinical Significance for Surgical Approaches in the Distal Forearm

Abstract 10 embalmed cadaver forearms and wrists were dissected to determine the anatomical course of the superficial branch of the radial nerve in the distal forearm. The superficial radial nerve bifurcated in two branches at a mean of 54,7 mm proximal to the radial styloid. From the styloid process of the radius, the mean distance to the closest dorsal branch of the superficial radial nerve was 3,5 mm and the mean distance to the closest volar branch was 9,8 mm. The mean distance between the closest branch of the superficial radial nerve and Lister?s tubercle was 16,4 mm. The crossing point between the nerve and the cephalic vein was located at a mean of 54,3 mm proximal to the styloid process. At the level of styloid process the mean distance between the closest dorsal branch of the superficial radial nerve and the first dorsal compartment was 15,2 mm and between the closest volar branch and the first dorsal compartment 4,4 mm. Detailed knowledge of anatomic characteristics of the superficial branch of the radial nerve may help prevent injury during operations and treat traumatic lesions of the nerve. Because of great variations in the course of the superficial radial nerve we could not define an absolute safe zone for surgical procedures on the distal forearm. Iatrogenic lesions of the superficial radial nerve are described complications of percutaneous procedures. Therefore open surgical approaches are recommended. Daniela Klitscher and Lars Peter Müller contributed equally to this work.     

Benign schwannoma of the pancreas

Reported cases of intrapancreatic schwannomas have recently increased in the literature. However, none of these cases were diagnosed clearly as schwannoma preoperatively. We herein describe the clinicopathologic findings of a solitary benign schwannoma occurring in the head of the pancreas. Additionally, the differential diagnosis versus other cystic- and solid-appearing pancreatic masses is briefly discussed.