Management of congenital tracheal stenosis

Objectives: Congenital tracheal stenosis is a rare disease. Various methods for treatment exist but there is still much debate as to the appropriate surgical procedure. We present our surgical experiences of patch tracheoplasty and slide tracheoplasty as viable methods for the treatment of congenital tracheal stenosis. Methods: From 1994 to 2002, 13 patients were diagnosed with congenital tracheal stenosis. Eight patients (7 symptomatic and 1 asymptomatic) had their stenosis corrected, three by means of pericardial patch tracheoplasty, four by slide tracheoplasty, and one by resection and anastomosis. Concomitant operations were performed on six patients to treat congenital cardiovascular disease. Five patients showing no significant symptoms did not undergo tracheal surgery and received only cardiac procedures. A retrospective review of the hospital course, complications, and long-term results was conducted. Results: Among the patch tracheoplasty group, every patient suffered from granulation tissue formation. One patient died of respiratory acidosis and one was hospitalized due to recurrent granulation tissue, which required frequent bronchoscopy. The third patient from this group is free of all symptoms. Among the slide tracheoplasty group, one patient died of anastomosis disruption. The three remaining patients are alive and well. The one patient who received resection and anastomosis is alive without symptoms. Conclusions: Surgical repair of long-segment congenital tracheal stenosis exhibited high mortality and morbidity rates. Every patient that underwent pericardial patch tracheoplasty suffered from troublesome granulation tissue. As slide tracheoplasty provided relatively good results in the short and mid-term follow-up periods, it seems to be a preferred method for the treatment of long-segment congenital tracheal stenosis.     

Chiari II malformation: MR imaging evaluation

The purpose of this study was to explore the value of high-detail MR imaging in the diagnosis of the Chiari II malformation. Twenty-four patients with known Chiari II malformation as diagnosed by CT scanning were evaluated with cranial MR scans. Two patients also had spine scans. The sagittal-plane images were the most informative, and abnormalities of the telencephalon, diencephalon, mesencephalon, rhomboencephalon, upper spinal cord, and mesencephalon were shown extremely well. We found MR to be an easy and accurate method for demonstrating the abnormalities of the Chiari II malformation, and it is our procedure of choice.     

Antibiotic prophylaxis for facial fractures. A prospective, randomized clinical trial

Although antibiotics are widely used in an attempt to decrease the incidence of infections after facial fractures, no systematic prospective study of their efficacy has been performed. In this study, all adult patients with facial fractures who had not received antibiotics were asked to participate in a clinical trial. There were 101 patients with facial fractures enrolled into the study and randomized prospectively into two groups. One group received no antibiotics. The other group received cefazolin sodium, 1 g intravenously, one hour prior to the surgical procedure, and a similar dose eight hours later. Of the 101 patients enrolled in the study, 79 had mandibular fractures, 18 had zygoma fractures, and four had Le Fort fractures. When all facial fractures were considered, perioperative intravenous cefazolin reduced the incidence of postoperative infections; 42.2% in the no-antibiotic group became infected, and 8.9% in the antibiotic group became infected. On the basis of this study, we conclude that cefazolin, used perioperatively, diminished the incidence of postoperative infections in facial fractures.     

Larger urethral catheter size leads to fossa navicularis stricture formation in robotic radical prostatectomy

Fossa navicularis strictures following radical prostatectomy are reported infrequently. We recently experienced a series of fossa strictures following robotic-assisted laparoscopic prostatectomy (RLP). We describe herein our experience to prevent fossa strictures and to determine its etiologic factors. From June 2002 to May 2006, 424 patients underwent robotic-assisted laparoscopic prostatectomy with the da Vinci surgical system. Fossa strictures were diagnosed based on the acute onset of obstructive voiding symptoms and bougie calibration. During our series, we switched from the intra-operative use of an 18 French (F) catheter to that of a 22 F one to avoid inadvertent stapling of the urethra when dividing the dorsal venous complex. After we observed a high incidence of fossa strictures, we reverted back to 18 F catheters during surgery. All patients had an 18 F catheter indwelling for 1 week after surgery. Parameters were evaluated using Fisher’s exact test and Student’s t-test for means. The 18 F catheter group of patients (n = 293) developed one fossa stricture, whereas the 22 F catheter group (n = 131) developed nine fossa strictures (P < 0.01). The fossa stricture rate in the 18 F group was 0.3% versus 6.9% in the 22 F group. The two groups had no differences in age, body mass index, cardiovascular disease, American Urological Association symptom score, urinary bother score, preoperative prostate-specific antigen, operative time, estimated blood loss, cautery use, prostate size, or catheterization time. Based on these results, a larger urethral catheter size – 20 F versus 18 F – during the intra-operative dissection would appear to increase the risk for fossa stricture by more than 20-fold. Statement of disclosure Dr. Thomas Ahlering is a meeting participant and lecturer for Intuitive Surgical Corp. The other authors have no direct or indirect commercial financial incentives associated with publishing the article. No research or project support funding was received.     

A case of primary omental torsion presenting as an acute abdominal pain]

Torsion of greater omentum is a rare cause of acute abdomen. However, it should be included in the differential diagnoses in addition to acute cholecystitis, acute appendicitis, cecal diverticulitis, and other variable causes of acute abdomen. Diagnosis is usually made at laparotomy for suspected appendicitis. In some cases, computed tomography demonstrates a successful preoperative detection of omental torsion. We report a case of surgically and pathologically proven torsion with subsequent infarction of greater omentum presented as an acute abdominal pain.     

Suppression of acute lymphoblastic leukemia by the human wild-type p53 gene.

Independent mutations in both alleles of the p53 tumor suppressor gene are a frequent finding in human T-cell acute lymphoblastic leukemia (T-ALL) cell lines and in the cells of some T-ALL patients in relapse. One major goal of studying the status of p53 (and other tumor suppressor genes) in human cancer is to facilitate the suppression of the tumorigenic phenotype through the restoration of the expression of the wild-type allele. While the efficient insertion of a suppressor into all cells of solid/metastatic human tumors may at present be impossible, insertion into leukemia cells may be feasible due to the accessibility of the leukemia cells in the body. To examine the feasibility of suppressing the tumorigenicity of human T-leukemia cells, the human T-ALL cell line Be-13, which lacks endogenous p53 protein, was infected with a recombinant retrovirus encoding the wild-type allele of human p53 (hwtp53). Expression of p53 reduced the growth rate of infected Be-13 cells in vitro, suppressed colony formation in methylcellulose cultures, and abrogated their tumorigenic phenotype in nude mice in vivo. These results suggest that suppression of the leukemic phenotype of relapse T-ALL-derived Be-13 cells is feasible. Acute leukemia cell suppression via high-efficiency infection with retroviruses encoding wtp53 may be feasible and beneficial in T-ALL cases as part of a bone marrow transplantation regimen in an effort to reduce the frequency of posttransplantation relapse.     

Parathyroid hormone regulation of proline uptake by cultured neonatal mouse osteoblastlike cells

Regulation of proline uptake by the synthetic amino-terminal fragment of bovine parathyroid hormone [bPTH-(1-34)] has been studied in confluent primary cultures of osteoblastlike cells isolated from neonatal mouse calvaria. The initial velocity of proline transport was increased by 85% in cultures treated with 24 nM bPTH-(1-34) for 6 h. Cycloheximide, at a concentration that inhibited protein synthesis by 97%, did not prevent this effect. However, adding the inhibitor during the first 1-2 h of hormone treatment did significantly reduce its magnitude. Exposure of cells to the inhibitor alone caused a time-dependent decrease in the basal rate of proline uptake. In the absence of protein synthesis, the maximal velocity (Vmax) of transport was 60% greater in cultures treated with 24 nM bPTH-(1-34) than in controls. The concentration of proline at which half-maximal transport occurred (Km) was unchanged. In cultures treated with cycloheximide alone, proline transport decreased as a first-order exponential with a half-life of 250-280 min. Parathyroid hormone significantly reduced this decline, increasing the half-life of proline transport activity about fourfold. These effects were duplicated by 1 mM DBcAMP. It is concluded that bPTH-(1-34) increases proline transport in osteoblastlike cells by decreasing the degradation of amino acid transport system A proteins. The hormone may also affect the synthesis of these molecules. These effects appear to be mediated by cAMP.