Inhibition of Intra-Abdominal Adhesions: A Comparison of Hemaseel APR and Cryoprecipitate Fibrin Glue

Our previous studies demonstrated fibrin glue (FG) prepared from cryoprecipitate (cryo) inhibits intra-abdominal adhesions in rats. A new FG, Hemaseel APR, is Food and Drug Administration (FDA) approved for hemostasis during cardiac surgery and splenic trauma. This study was undertaken to determine if Hemaseel FG prevents intra-abdominal adhesions, and to compare it to cryo FG. Forty-five rats underwent laparotomy. Bilateral peritoneal-muscular defects were created. Polypropylene mesh was sewn into each defect with a running silk suture. The bowel was abraded with gauze. The rats were then randomized to mesh covered with Hemaseel FG, cryo FG, or control. On postoperative day 7, the severity of adhesions were graded by percentage of mesh covered by adhesion (0-100%) and degree of adhesion (0-3). The mean percentage of mesh covered by adhesion was 9% for Hemaseel FG, 43% for cryo FG (p = .005), and 65% for the controls (p < .0001). The mean density adhesion score was 0.5 for Hemaseel FG, 1.2 for cryo FG (p = .04), and 2.1 for the controls (p < .0001). In the Hemaseel FG group, 77% of patches had no adhesions, compared with 37% in the cryo FG group (p = .004) and 13% in the controls (p < .0001). Thus, Hemaseel FG significantly decreases intra-abdominal adhesions, and is more effective than cryo FG.     

Noninvasive monitoring of somatostatin receptor type 2 chimeric gene transfer.

Noninvasive monitoring of gene transfer will benefit basic research and patient care. Most gene-transfer imaging systems do not directly detect the gene of interest, and most do not exploit radiopharmaceuticals that have Food and Drug Administration approval for total-body use. (111)In-Octreotide is used clinically to locate tumors overexpressing primarily somatostatin receptor type 2 (SSTR2). We report the in vitro and in vivo detection of SSTR2 chimeric gene transfer with this radiopharmaceutical. METHODS: Full-length SSTR2A was ligated into a vector downstream of a 5' Igkappa leader sequence and the hemagglutinin A (HA) sequence. The vector plus insert was then introduced into HT1080 cells. Igkappa and HA domain functions were confirmed by immunologic methods. Receptor binding was studied in transfected cells incubated with (111)In-octreotide with and without somatostatin-28. Mice bearing tumors produced by transfected cells were injected with (111)In-octreotide for biodistribution and imaging studies. RESULTS: Cell-membrane localization by the amino-terminal Igkappa domain was confirmed by immunofluorescence. The HA domain was identified by enzyme-linked immunosorbent assay, immunofluorescence, and Western blotting analysis with anti-HA antibodies. (111)In-Octreotide detected the SSTR2 portion of the fusion protein in vitro (receptor-binding assay) and in vivo (biodistribution studies and gamma-camera imaging). In addition, in vitro studies using either the anti-HA antibody or (111)In-octreotide correlated with biodistribution and imaging studies when cell clones expressing different levels of the fusion protein were tested. This approach may be feasible clinically because we were able to discern chimeric gene transfer in tumor-bearing animals with (111)In-octreotide at doses similar to those already used in humans. CONCLUSION: With this method it may be possible to monitor transfer of a gene of interest directly and noninvasively.     

Relationship of femoral neck areal bone mineral density to volumetric bone mineral density, bone size, and femoral strength in men and women

Summary

Using combined dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography, we demonstrate that men matched with women for femoral neck (FN) areal bone mineral density (aBMD) have lower volumetric BMD (vBMD), higher bone cross-sectional area, and relatively similar values for finite element (FE)-derived bone strength.

Introduction

aBMD by DXA is widely used to identify patients at risk for osteoporotic fractures. aBMD is influenced by bone size (i.e., matched for vBMD, larger bones have higher aBMD), and increasing evidence indicates that absolute aBMD predicts a similar risk of fracture in men and women. Thus, we sought to define the relationships between FN aBMD (assessed by DXA) and vBMD, bone size, and FE-derived femoral strength obtained from quantitative computed tomography scans in men versus women.

Methods

We studied men and women aged 40 to 90?years and not on osteoporosis medications.

Results

In 114 men and 114 women matched for FN aBMD, FN total cross-sectional area was 38% higher (P?P?Conclusions In this cohort of young and old men and women from Rochester, MN, USA who are matched by FN aBMD, because of the offsetting effects of bone size and vBMD, femoral strength and the load-to-strength ratio tended to be relatively similar across the sexes.     

Patient-perspective quality of life after laparoscopic and open hernia repair: a controlled randomized trial

Background

Laparoscopic hernia repair accounts for 10% of all hernia surgery. Potential benefits include reduction in postoperative pain, rapid recovery, lower recurrence rate, and fewer complications. The outcomes of health-related quality of life and patient perspective after hernia repair are our aim.

Methods

Consecutive patients treated for unilateral uncomplicated groin hernia were enrolled after evaluation for inclusion. Participants were randomly distributed to receive either laparoscopic transabdominal preperitoneal repair (TAPP) (group I) or Lichtenstein repair (group II). Operative and postoperative complications, operative time, hospital stay, and late complications were assessed early postoperatively, at 4?weeks, and every 6?months thereafter. Quality of life was assessed using Short Form-36 questionnaire in the first visit (after 4?weeks).

Results

One hundred and eighty-five patients of unilateral uncomplicated groin hernia were included; 88 patients (group I) were treated by TAPP, and 97 patients were treated by Lichtenstein repair (group II) with median follow-up of 17.9?months. Mean hospital stay, mean operative time, operative and postoperative complications were similar in the two groups. Quality of life showed better and significant outcomes in group I for physical function (p?≤?0.001), role physical (p?≤?0.011), bodily pain (p?≤?0.017), general health (p?≤?0.047), and total physical health (p?≤?0.008). However, mental health showed no statistical significance in its four scales, but with better outcomes in group I. Total quality outcomes showed significantly better outcomes in group I (p?≤?0.031).

Conclusions

TAPP hernia repair technique is a safe technique with low complication rate, less postoperative body pain, and better quality-of-life outcomes compared with open technique, being well accepted from the patient’s perspective for quality of life.     

Anatomic bifurcated reconstruction of chronic bilateral innominate-superior vena cava occlusion using the Y-stenting technique

This article presents the case of a 42-year-old man who presented with superior vena cava (SVC) syndrome due to fibrosing mediastinitis with multiple failed attempts at recanalization. We initially treated him with unilateral sharp needle recanalization of the right innominate vein into the SVC stump followed by stenting. Although his symptoms improved immediately, they did not completely resolve. Six months later, he returned with worsening symptoms, and venography revealed in-stent restenosis. The patient requested simultaneous treatment on the left side. The right stent was dilated, and a 3-cm-long occlusion of the left innominate vein was recanalized, again using sharp needle technique, homing into the struts of the right-sided stent. Following fenestration of the stent, a second stent was deployed from the left side into the SVC, and the two Y limbs were sequentially dilated to allow a true bifurcation anatomy (figure). The patient had complete resolution of his symptoms and continues to do well 6 months later.     

Use of blocking screws in intramedullary fixation of subtrochanteric fractures

Intramedullary fixation is the mainstay of treatment for femur fractures in the adult trauma population. With subtrochanteric fractures, accurate reduction and stable fixation become technically challenging. Adjuvant blocking screws in the proximal fragment can effectively be used to prevent varus and apex anterior malalignment when intramedullary nails are used in these fractures. Blocking screws decrease the canal volume, thereby allowing the intramedullary device to control the proximal segment. This aids in improving alignment between the proximal and distal fragments during reduction. We review the cases of six patients with proximal femur fractures who were treated with intramedullary nailing in conjunction with the placement of blocking screws.     

Laparoscopic management of paratubal and paraovarian cysts.

OBJECTIVES: To define the proportion, methods of diagnosis, and a simplified laparoscopic technique for treating paratubal and paraovarian cysts. METHODS: We conducted a prospective cross-sectional study in the Gynecologic Endoscopy Unit of Assiut University Hospital in Assiut, Egypt in 1853 patients undergoing video-assisted laparoscopy. Transvaginal ultrasonography (TVS) was performed to detect paratubal or paraovarian cysts. Tubal shape and patency were evaluated with hysterosalpingography (HSG) in the infertile group. Diagnostic laparoscopy was performed to confirm the diagnosis of paratubal or paraovarian cysts. Small cysts were punctured and coagulated, and larger cysts required cystectomy and extraction of the cysts by using bipolar electrosurgery. Cystectomy was preceded by endocystic visualization in all cases. The primary outcomes measured included (1) correlation of the preoperative TVS, HSG, or both of these, with the laparoscopic diagnosis; (2) estimation of the success of the laparoscopic management of paratubal cysts; (3) assessment of the value of endocystic visualization prior to cystectomy; and (4) evaluation of tubal patency after laparoscopic management. RESULTS: Laparoscopically, only 118 patients (15.7%) were proved to have paratubal or paraovarian cysts. Preoperatively, TVS confirmed paratubal or paraovarian cysts in 52 (44%) patients. Cysts less than 3 cm in size (34 cases) were treated with simple puncture and bipolar coagulation of the cyst wall, whereas larger cysts (84 cases) were treated by cystectomy. Endocystic visualization using the 4-mm rigid hysteroscope was performed in 84 (71%) patients with large cysts. Statistically significant improvement occurred in tubal patency after laparoscopic management. CONCLUSIONS: Sonographic diagnosis of not uncommon paratubal and paraovarian cysts is not always feasible and requires greater awareness and accuracy. The characteristic laparoscopic differentiation of ovarian cysts is the crossing of vessels over them. Endocystic-endoscopic visualization is a simple, valuable step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy, not time-consuming, and should be routinely performed in all cases following microsurgical laparoscopic principles.     

15 Years in surgical management of pulmonary hydatidosis.

OBJECTIVES: Echinococcosis remains an endemic surgical problem in countries where sheep and cattle raising is carried out, particularly in many Mediterranean countries. This study aims to evaluate the management of different presentations of pulmonary hydatidosis and their outcome over 15 years. DESIGN: Retrospective study.Setting: Thoracic surgical department, Chest Diseases Hospital, Kuwait. PATIENTS: Sixty patients operated upon for hydatid disease were evaluated pre- and post- operatively; 35 males, 25 females with a mean age of 28.4 years. Most patients were investigated by laboratory, serological and radiological studies. Different surgical techniques were used to remove the hydatid cyst from the lung. RESULTS: The most common presenting symptoms were cough (41 patients), and 12 patients were asymptomatic. Chest X-ray showed a rounded shadow in 42 patients; 19 cases were of vigorous size >10 cm. Thoracotomy was done in 57 patients; two chest wall cases were managed by minimal skin incision and enucleation, one hydatid cyst of the heart was approached through a median sternotomy. The mean hospital stay was 9 days. Postoperative complications occurred in 9 patients; prolonged air leak in 4 patients, pleural effusion in 3, pneumothorax, and wound infection in one patient each. One patient (65 years old) died on the 6th post-operative day most probably from pulmonary embolism. In a follow-up period of 2-15 years, 4 recurrences have been noted. CONCLUSION: Surgical excision of pulmonary hydatidosis with maximum preservation of the lung parenchyma is the main stay of treatment.     

Cough and paradoxical vocal fold motion

OBJECTIVES: The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause. STUDY DESIGN AND SETTING: We conducted a review of the literature. METHODS: We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion. RESULTS: The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patient's reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists. CONCLUSION: Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients.