Accuracy of magnetic resonance imaging for preoperative detection of portal vein thrombosis in liver transplant candidates.

The detection of main portal vein thrombosis (PVT) on preoperative imaging of liver transplant candidates has important technical implications for the transplantation procedure. Data are scarce regarding the accuracy of magnetic resonance imaging (MRI) at detecting PVT. The aim of our study was to compare preoperative findings of the portal vein on MRI to operative findings at liver transplantation. Abdominal MRI and clinical records of 172 consecutive patients who received liver transplants between January 1999 and September 2004 were reviewed. Two radiologists independently evaluated the last abdominal magnetic resonance examinations obtained before liver transplantation, blinded to the original reading, operative findings, and clinical data. Findings on MRI were compared with intraoperative findings at transplantation. Main PVT was detected in 12 patients, in whom 8 were found to have thrombus at surgery, with 6 requiring a jump graft or thrombectomy. Sensitivity and specificity of MRI for detecting main PVT were 100% and 98%, respectively. The cause of discordance between findings on MRI and at transplantation in 2 cases was a diminutive caliber of the main portal vein that was interpreted as recanalized chronic thrombosis on MRI. In conclusion, in our study group MRI detected PVT in all liver transplant recipients requiring jump grafts at transplantation. The major reason for a false-positive MRI was a diminutive but patent portal vein.     

Surgical correction of pinna malformations.

BACKGROUND: Auricle reconstruction is a surgical procedure described in the medical literature as early as 600 BC. The aim of the present paper is to review these attempts and their results. METHODS: Literature search and medical history books were used as scientific sources. RESULTS: More than 40 different cartilagenous, osseous or other alloplastic frame materials (autogenous tibial bone, iliac bone, mastoid bone, maternal auricular cartilage, autogenous nasoseptal cartilage, allogenous meniscus, autogenous meniscus and many more) have been used since 1891. From approximately 40 reconstruction procedures that had been proposed, only eight were still in use in the 1980s. The reason for abandoning the majority of these surgical techniques was the unacceptable aesthetic result. However, at the end of the 20th Century two new techniques were introduced. These techniques were designed by Satoru Nagata and Burt Brent. Both techniques provide cosmetic and functional results that are acceptable both to the patient and to the surgeon. CONCLUSIONS: Although the outcome of surgical auricle reconstruction was in general disappointing through the centuries, at the end of the 20th Century new surgical methods were established and at the present time auricle reconstruction can be attempted with acceptable results.     

Feasibility study and pharmacokinetics of low-dose paclitaxel in cancer patients with severe hepatic dysfunction

The aim of this study is to investigate the feasibility and determine the pharmacokinetics of low-dose paclitaxel in cancer patients with severe hepatic dysfunction. This was a prospective study. Patients with liver metastases who had either transaminase serum levels higher than 10 times the upper normal limit or bilirubin serum levels higher than 5 times the upper normal limit were eligible. All patients underwent pharmacokinetic evaluation during the first course of treatment. Pharmacokinetics in severe hepatic dysfunction patients were compared with data from a reference group of patients with normal hepatic function who participated in a phase I study. Nine severe hepatic dysfunction patients were treated with paclitaxel 70 mg/m administered as a 1-h infusion every 2 weeks. They received a median three treatment courses (range 1-9) without clinically relevant toxicity. The area under the concentration-time curve of paclitaxel was markedly higher in severe hepatic dysfunction patients when compared with the normal hepatic function control group treated with the same dose (98% increase, P<0.001). Area under the concentration-time curve and the time above 0.1 micromol/l (T>0.1) concentration threshold in the severe hepatic dysfunction patients who received paclitaxel 70 mg/m approximated pharmacokinetics of paclitaxel in patients with normal liver function who received 130 mg/m. Maximum plasma concentration (Cmax) did not differ between the two groups. In conclusion, paclitaxel 70 mg/m was safely delivered every 2 weeks in patients with severe hepatic dysfunction and resulted in adequate plasma concentrations. Paclitaxel at this dosage can be taken as an option for severe hepatic dysfunction patients who are expected to get clinical benefits from taxanes.     

Third-line hormonal treatment with exemestane in postmenopausal patients with advanced breast cancer progressing on letrozole or anastrozole. A phase II trial conducted by the Hellenic Group of Oncology (HELGO)

AIMS AND BACKGROUND: The understanding of hormonal therapies in postmenopausal women with metastatic breast cancer has advanced greatly in the past several decades. With the introduction of orally active, potent and selective third-generation aromatase inhibitors (anastrozole, letrozole and exemestane), approaches to the treatment of hormone-sensitive advanced breast cancer are undergoing reevaluation. For treatment of advanced or metastatic disease that has progressed on tamoxifen, all three agents are active. The purpose of the study was to assess the antitumor efficacy and tolerance of exemestane administered as third-line hormonal therapy to postmenopausal women with metastatic breast cancer refractory to letrozole and anastrozole. STUDY DESIGN: Sixty postmenopausal women with stage IV hormone receptor-positive carcinoma of the breast were enrolled in the study. All patients had received two prior hormonal manipulations and had measurable or assessable disease. All adverse events were monitored. RESULTS: Objective tumor response was achieved in 12 (20%) patients (95% CI, 9.6-30.4). The overall clinical benefit was 38.3% (95% CI, 21.2-49.3), and the median duration of objective tumor response was 20 months (range, 9-26). The median time to death was 17.4 months (95% CI, 16.14-18.66). CONCLUSIONS: Exemestane represents an active and well-tolerated treatment option in pretreated patients with advanced breast cancer who have received standard first- and second line hormonal therapies. By extending the sequence of hormonal therapy, disease progression and the need for chemotherapy may be significantly delayed.     

Fenofibrate: metabolic and pleiotropic effects

Disturbances of lipoprotein metabolism represent one of the most important risk factors for vascular events. However, dyslipidaemic patients often have a number of additional abnormalities (such as endothelial dysfunction, hypertension, low-grade inflammation, haemostatic abnormalities and hyperuricaemia) that may accelerate the atherosclerotic process. Thus, the ideal lipid-modifying drug, along with exerting beneficial effects on lipoprotein metabolism, should also improve these coexisting disturbances. Fibric acid derivatives (fibrates) are a class of lipid-modifying drugs mainly used in patients with elevated triglyceride levels. These drugs mainly exert their actions via the activation of specific nuclear receptors called peroxisome proliferator-activated receptors alpha (PPARalpha). In this review, we summarize the current evidence suggesting that fenofibrate, one of the most widely used fibric acid derivatives, along with its well established actions on lipids also exerts several other antiatherogenic actions. Based on recently published studies, fenofibrate is a useful option for patients with primary combined dyslipidaemias or secondary dyslipidaemias, such as those associated with diabetes mellitus, metabolic syndrome or HIV infection. Additionally, in cases of refractory dyslipidaemia, the combination of fenofibrate with statins is a therapeutic option.     

Surgery insight: Current advances in percutaneous heart valve replacement and repair

Several advances have been made in interventional cardiology, particularly in the field of valvular heart disease. Among the procedures for which technologies are available, percutaneous replacement of the pulmonary and aortic valves, and percutaneous repair of the mitral valve, via annuloplasty or the Alfieri method, are the best known. Along with the excitement generated by these new subspecialties, however, there has also been skepticism. In this article we focus on the current innovations that have been applied to the procedures in humans, and discuss the advantages and disadvantages of the different strategies.     

Management of a ruptured bile duct cyst

A case of a ruptured bile duct cyst in a 25-year-old male patient is presented. The initial management of the clinical presentation of acute abdomen consisted of an exploratory laparotomy and a T-tube cystostomy of a choledochal cyst. Two months later, he was admitted to our surgical department. Preoperative evaluation showed a type IV-A choledochal cyst. The patient underwent excision of the choledochal cyst, cholecystectomy, and the construction of a Roux-en-Y end-to-side hepaticojejunostomy.     

Surgical Techniques and Treatment for Hepatic Hydatid Cysts

Purpose Hepatic hydatid cysts (HHCs) are a parasitic infestation caused by several species of Echinococcus. We examined the clinical features of HHCs and evaluated the results of various surgical procedures. Methods One hundred and sixty-nine patients aged between 17 and 84 years underwent surgery for HHCs within a 12-year period. We recorded the demographic data, location of the cysts, surgical procedures used, morbidity, recurrences, and hospital stay. Results Most (90.5%) of the patients presented with symptoms, but 16 (9.5%) patients reported no symptoms. The most common symptom was abdominal pain. The overall number of cysts was 216 HHCs and 9 concomitant hydatid cysts in other abdominal organs. The surgical treatments consisted of hepatic resection in 8 (4.7%) patients, cystostomy with drainage in 43 (25.5%), cystostomy with capitonnage in 22 (13%), cystostomy with omentoplasty in 72 (42.6%), and cystectomy in 24 (14.2%). Splenectomy or nephrectomy was also performed in nine patients. Postoperative complications developed in 36 (21.3%) patients, and three suffered recurrences. The postoperative mortality rate was 1.2%. Postoperative complications were more frequent after cystostomy with capitonnage than after cystostomy with omentoplasty (P < 0.001) or cystectomy (P = 0.0037). The additional procedures prolonged the hospital stay. Conclusions Current surgical techniques combined with antiscolicidal therapy using albendazole are effective and safe treatments for HHCs, associated with low morbidity, mortality, and recurrence rates.     

Primary Resection With Anastomosis vs. Hartmann’s Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review

Purpose This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. Methods Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. Results Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. Conclusions Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.