Clinical and user-friendly classification of traumatic digital nerve injuries of hand

INTRODUCTION: Surgical findings of traumatic neurapraxia and neurotmesis in digital nerve injuries of hand have significantly different prognosis and surgeons managing such injuries must be able to provide the expected incidence of these injuries along with decision on surgical exploration. There is a paucity of data in the literature defining the incidence of traumatic neurapraxia and neurotemesis in lacerated hand injuries with clinical features of digital nerve injury. MATERIALS AND METHODS: We carried out a study in an urban practice to understand this problem on 81 consecutive patients with 82 digital nerve injuries over 1.5 years. Seventy-two percent of the injuries were caused mainly in the domestic accidents by glass and knife. All patients had clinical features of digital nerve injury. RESULTS: Operative findings revealed nerve damage in 76 patients (confidence interval at 95% = 91-97). Seventy-one had severed nerves and underwent repair (CI at 95% = 80-95). There were 7% patients with operative findings of normal looking nerves and 6% of bruised but intact nerves. All of these 13% patients who did not require surgical repair were grouped as traumatic neurapraxia and showed complete clinical recovery. CONCLUSION: Traumatic neurapraxia in digital nerve injuries of the hand are not uncommon, as previously thought, following lacerated injuries to hand and have favourable prognosis. This information is important for clinicians in getting more informed consent and patient education. The classification of digital nerve injuries into traumatic neurapraxia and neurotemesis appears logical for its practical application in routine clinical practice.     

Significance of Ductal Margin Status in Patients Undergoing Surgical Resection for Extrahepatic Cholangiocarcinoma

OBJECTIVES: The objective of this study was to determine whether carcinoma in situ at the bile duct margin is prognostically different from residual invasive carcinoma in patients with extrahepatic cholangiocarcinoma. Although there are many reports that the ductal margin status at bile duct resection stumps is a prognostic indicator in patients with extrahepatic cholangiocarcinoma, some patients who undergo resection with microscopic tumor involvement of the bile duct margin survive longer than expected. METHODS: A retrospective clinicopathological analysis of 128 patients who had undergone surgical resection for extrahepatic cholangiocarcinoma was conducted. The status of the bile duct resection margin was classified as negative in 105 patients (82.0%), positive for carcinoma in situ in 12 patients (9.4%), and positive for invasive carcinoma in 11 patients (8.6%). RESULTS: Ductal margin status was an independent prognostic indicator by both univariate (p = 0.0022) and multivariate (p = 0.0105) analyses, along with lymph node metastasis. There was no significant difference between patients with a negative ductal margin and those with a positive ductal margin with carcinoma in situ (p = 0.5247). The 5-year survival rate of patients with a positive ductal margin with carcinoma in situ (22.2%) was significantly better (p = 0.0241) than with invasive carcinoma (0%). There was a significant relationship between local recurrence and ductal margin status (p = 0.0401). CONCLUSIONS: Among patients undergoing surgical resection for extrahepatic cholangiocarcinoma, invasive carcinoma at the ductal resection margins appears to have a significant relation to local recurrence and also a significant negative impact on survival, whereas residual carcinoma in situ does not. Discrimination whether carcinoma in situ or invasive carcinoma is present is important in clinical setting in which the resection margin at the ductal stump is positive.     

Sleep in rheumatic diseases and other painful conditions

Insufficient sleep is an under-recognized public health problem that is projected to increase in the next decade as the US population ages. Chronic insomnia alone impacts 10% to 15% of adults. Epidemiologic data indicate that pain, fatigue, and mood disturbance are common correlates of persistent insomnia. Rates of most sleep disorders are substantially elevated in rheumatologic diseases, with chronic insomnia impacting at least 50% of patients. Clinicians treating patients with rheumatologic disorders should screen for sleep disorders and possess a basic knowledge of sleep physiology and empirically based intervention approaches. Sleep disturbances occurring within the context of chronic medical illnesses, including rheumatologic diseases, do not typically respond to primary disease and/or pain management interventions. Identification of co-occurring sleep disorders followed by aggressive treatment is recommended and has the potential to improve quality of life, ameliorate pain, and improve psychosocial adaptation to the primary illness. In this report, we briefly highlight that sleep disturbance increases risk for both comorbidities and symptoms associated with rheumatologic diseases, we identify specific sleep disorders commonly encountered in rheumatologic populations, and we discuss pharmacologic and behavioral treatment approaches for the most common sleep disorder observed in rheumatologic conditions, chronic insomnia.     

Intragastric Injection of Botulinum Toxin A for the Treatment of Obesity

BACKGROUND: Botulinum toxin A (BTX-A) is a powerful and long-acting inhibitor of muscular contractions in both striated and smooth muscles. Hypothetically, BTX-A should inhibit the acetylcholine-mediated peristalsis, which is mainly responsible for gastric motility, and thereby induce slowed gastric emptying, earlier satiety and weight loss. The aim of this study was to observe the effects of endoscopic intragastric injections of BTX-A in obese patients. METHODS: After approval by the University Ethics Committee, 10 female patients with class I obesity (body mass index 30-35) were double-blind randomized into 2 groups (BTX-A and 0.9% Saline). In Group 1, 200 U BTX-A were injected endoscopically into the antrum and the distal gastric body. In Group 2, 0.9% saline was injected endoscopically into the antrum and the distal gastric body. Body weight and feeling of satiety were recorded monthly over a period of 6 months. RESULTS: Both groups (BTX-A and 0.9% Saline) showed no significant weight reduction (P>0.05). One patient in Group 1 and two patients in Group 2 reported a feeling of early satiety. No adverse effects related to BTX-A or complications resulting from the endoscopic procedure were observed. CONCLUSION: Intragastric injection of BTX-A for the treatment of obesity does not seem to reduce body weight.     

Smaller Hip Circumference is Associated with Dyslipidemia and the Metabolic Syndrome in Obese Women

BACKGROUND: There is great need for simple anthropometric measures that predict risk. The authors explored the relationship between body composition measures and features of the metabolic syndrome (MtS) in women aged between 20 and 50 years with class I obesity. METHODS:This is a cross-sectional study of 49 obese (BMI 30-35) women recruited into a weight management randomized trial. An analysis was conducted of the baseline weight, anthropometric measures, skin-fold thickness, bioelectrical impedance, whole body dual-energy x-ray absorptiometry (DEXA), and their relationships with the features of the MtS. RESULTS: All women but one (n=48) had a population risk waist circumference of >88 cm. 16 of the 49 (33%) fulfilled the criteria of the metabolic syndrome. Simple anthropometric measures provided the strongest correlations with the presence of the MtS. Cut-off values were selected using receiver operator characteristics. Waist circumference of >100 cm and hip circumference <115cm was associated with odds ratios of 5.2 (95% CI, 1.4-20) and 12.3 (95% CI, 3.0-51) respectively for the MtS. Regional DEXA analysis showed that lower leg fat mass rather than fat-free mass was associated with the MtS. The dyslipidemia of the MtS was associated with a lower leg fat mass, while higher HbAlc levels and HOMA, an indirect measure of insulin resistance, were seen with increased trunk fat. Percentage fat as measured by skin-fold thickness and bioelectrical impedance were not related to any features. Women with the metabolic syndrome were found to have lower bone mineral content as measured by DEXA. CONCLUSION: Weight distribution is highly predictive of metabolic risk. Smaller hip and larger waist circumference provided independent effect. BMI adjusted anthropometric measures may be of value.     

Arthroskopische Schulterstabilisierung mittels Fadenankern unter besonderer Berücksichtigung des tiefen anterior-inferioren Zugangs (5:30 Uhr)

OBJECTIVE: Arthroscopic (re)stabilization of the unstable shoulder by anatomic refixation of the detached capsulolabral complex with suture anchors or reduction of excessive capsule volume by capsule plication. INDICATIONS: Any type of shoulder instability (anterior, posterior, inferior, or multidirectional instability). Revision stabilization (even after primary open stabilization). Bone defects affecting < 25% of the glenoid surface. Lesions of the superior biceps tendon anchor complex (SLAP lesion). CONTRAINDICATIONS: Preexisting bone defects of the glenoid affecting > 25% of the glenoid surface. "Engaging" Hill-Sachs defects: osseous defects of the humeral head that engage with the anterior glenoid rim in extreme external rotation/abduction and consequently lead to shoulder dislocation. Bone-related etiology, e. g., clearly increased glenoid retroversion/anteversion or glenoid dysplasias (e. g., inverse pear shape). Voluntary shoulder dislocation in young patients until the end of the growth period. SURGICAL TECHNIQUE: Diagnostic arthroscopy and additional procedures based on clinical and intraoperative findings. For anterior-inferior instability, an anterior-superior approach is made with mobilization of the labrum and decortication of the glenoid. Creation of deep anterior-inferior portal and insertion of the anchors in 5.30, 4.30 and 3.00 o'clock position. The sutures are pulled through the capsulolabral complex and tied arthroscopically. Reconstruction of the inferior glenohumeral ligament is especially important. Lesions of the superior biceps tendon anchor and/or posterior labrum detachment can be treated by the same technique. Capsule plication with PDS sutures can be performed to decrease a large rotator interval or excessive capsule volume. The range of motion at the shoulder is limited for 6 weeks postoperatively (depending on the initial direction of the instability). RESULTS: At the authors' hospital over 600 arthroscopic shoulder stabilizations using the deep anterior-inferior portal have been completed so far. The redislocation rate for the first 147 patients (average follow-up of 3 years) treated with the technique described here is 6.1% and is slightly higher for arthroscopic revision stabilizations (n=43; of these, redislocation n=3 and reinstability n=3). There were no instances of axillary nerve lesion.     

Decision for salvage treatment after transanal endoscopic microsurgery

BACKGROUND: Transanal endoscopic microsurgery (TEM) has emerged as an alternative to classic radical operation for early rectal cancer. Early rectal cancer can be treated by adequate local excision such as TEM. If there are adverse risk factors, especially poor cellular differentiation, close resection margin, or positive lymphovascular invasion or incomplete excision, a radical resection is indicated. This study aimed to clarify the factors related to recurrence for patients required to undergo a salvage operation after TEM. METHODS: This retrospective study analyzed 167 patients who underwent TEM for rectal cancer between 1994 and 2004. Of these patients, 36 with poor differentiation, mucinous carcinoma, proper muscle invasion, lymphovascular invasion, and positive resection margin were included in the analysis. RESULTS: Of the 36 patients, 12 underwent a salvage operation, and the remaining 24 did not because of poor physical condition or refusal of radical surgery. There were a total of 6 (16.7%) recurrences. One (8.3%) of the 12 patients who underwent salvage surgery had systemic recurrence. Five (20.8%) of the 24 patients who did not receive surgery had recurrence (3 local recurrences, 2 distant recurrences). Analysis of the subgroups showed that 2 (28.6%) of 7 patients with lymphovascular invasion had recurrence, and that 1 patient (100%) had a T3 lesion. Three (17.6%) of 17 patients had T2 lesions. CONCLUSIONS: For high-risk patients, TEM followed by radical surgery is the most beneficial in preventing local recurrence. Radical salvage surgery is strongly recommended if pathologic results after TEM show T3 lesion or lymphovascular invasion.     

Prospective Study Comparing Two Brands of Cohesive Gel Breast Implants with Anatomic Shape: 5-Year Follow-Up Evaluation

BACKGROUND : The new generation of breast implants has an anatomic shape. These implants are made with a textured shell and filled with a cohesive silicone gel. Available since 1993 except in the United States, these implants are gaining in popularity for breast enlargement and reconstruction. This prospective, randomized, controlled, and blinded study was designed to compare mid- and long-term results with the use of cohesive gel-filled implants from two different manufacturers: Style 410 of the McGhan brand (MG) made by Allergan and Vertex made by Eurosilicone (ES). METHODS: From May 1997 to May 1999, 80 women underwent breast augmentation: 40 with Style 410 implants (MG) and 40 with Vertex implants (ES). All surgeries were performed by the same surgeon (I.N.). Another physician (G.J.) interviewed and examined 64 of these women (80%) 4 to 6 years (median, 5 years) after implantation. In addition, 10 patients responded to the same questionnaire and were interviewed by phone, bringing the follow-up rate to 92.5%. RESULTS: Overall, satisfaction was high, with 98.6% of the patients evaluated after 4 to 6 years "very satisfied" or "satisfied" with the result in general. Approximately 20% of the patients who responded judged their breasts to be firmer than desirable. Breast augmentation classification (BAC) was used to grade the breast firmness of the 64 patients examined by G. J. At examination, 24% of patients had soft breasts, 53% had slightly firm breasts, and 23% had moderately firm breasts. That last category also was classified as capsular contracture. No patient was graded as having very hard breasts (BAC 4). Skin sensitivity of the breast adjacent to the incision was altered for 25% of the patients. The implant rotated in four patients (5%). Breast firmness, implant palpability, nipple sensitivity, and skin sensitivity were further analyzed by implant location (submuscular vs subglandular) and implant size (volume). Frequency of the breast asymmetries and the impact of augmentation on asymmetric breasts also was studied. All these analyses were performed with the entire pool of examined patients who answered the follow-up questionnaire. Data also were analyzed by distinguishing between results of the two each implant manufacturers. The results showed no difference between the Eurosilicone and McGhan implants except for the self-evaluation of "breast consistency" by the patient. A higher percentage of patients with the Vertex implants than with the McGhan implants reported that their breast was "firmer than desired." CONCLUSIONS: Breast augmentation with anatomic, textured, cohesive silicone gel-filled implants is a reliable procedure with consistently good results. The results also show that candidates for breast enlargement should be informed that their implanted breast may feel firmer than their natural breasts. They also may experience reduced sensation of their nipple or breast skin.     

Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection

BACKGROUND: Large colonic polyps or polyps that lie in anatomical locations that are difficult to access at endoscopy may not be suitable for endoscopic resection and therefore may require partial colectomy. This approach eradicates the polyp and allows an oncologic resection should the polyp prove to be malignant. The purpose of this study was to assess outcomes of a laparoscopic approach for the management of these polyps. METHODS: Patients referred for laparoscopic colectomy for colonic polyps were identified from the prospective colorectal laparoscopic surgery database. Demographics, operative details, and final pathology were reviewed. RESULTS: Fifty-one consecutive patients (27 male) with a mean age of 68 +/- 11.4 years, ASA classification (1/2/3/4) of 0/21/27/3, and body mass index (BMI) of 26.5 +/- 4.9 were identified. Right (RHC) and left (LHC) colectomy was performed for 39 right and 12 left colonic polyps. Mean operating time (OT) was 87 +/- 30 min (81 for RHC, 105 for LHC) and mean hospital stay was 3.1 +/- 1.9 days. There were six complications (17.7%), including anastomotic leak (n = 1), small bowel obstruction (n = 2), abscess (n = 1), and exacerbation of preexisting medical conditions (n = 2). Four patients were readmitted (7.8%); one required CT scan-guided abscess drainage (1.9%) and two required reoperation (3.9%). Five patients (9.8%) were converted because of adhesions (n = 3), obesity (n = 1), and inability to identify the area that was tattooed at colonoscopy (n = 1). Mean polyp size was 3.1 cm, and pathology revealed tubular (n = 14), tubulovillous (n = 33) and villous adenoma (n = 2), pseudopolyp (n = 1), and prolapse of the appendix into the cecum mimicking an adenoma (n = 1). High-grade dysplasia was seen in four tubular (33%) and five tubulovillous adenomas (15.5%). Adenocarcinoma not identified at colonoscopy was found in 11 polyps (20%), 9 tubulovillous (27.8%) and both villous adenomas (100%). CONCLUSIONS: Large colonic polyps unresectable at colonoscopy are associated with a high rate of unsuspected cancer. This requires a formal colectomy rather than transcolonic polypectomy. Laparoscopic colectomy offers safe and effective management of these polyps with the benefits of accelerated postoperative recovery.