Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications

Endoscopic ultrasonography (EUS) has gained wide acceptance as an important, minimally invasive diagnostic tool in gastroenterology, pulmonology, visceral surgery and oncology. This review focuses on data regarding risks and complications of non-interventional diagnostic EUS and EUS-guided fine-needle biopsy (EUS-FNB). Measures to improve the safety of EUS und EUS-FNB will be discussed. Due to the specific mechanical properties of echoendoscopes in EUS, there is a low but noteworthy risk of perforation. To minimize this risk, endoscopists should be familiar with the specific features of their equipment and their patients’ specific anatomical situations (e.g., tumor stenosis, diverticula). Most diagnostic EUS complications occur during EUS-FNB. Pain, acute pancreatitis, infection and bleeding are the primary adverse effects, occurring in 1% to 2% of patients. Only a few cases of needle tract seeding and peritoneal dissemination have been reported. The mortality associated with EUS and EUS-FNB is 0.02%. The risks associated with EUS-FNB are affected by endoscopist experience and target lesion. EUS-FNB of cystic lesions is associated with an increased risk of infection and hemorrhage. Peri-interventional antibiotics are recommended to prevent cyst infection. Adequate education and training, as well consideration of contraindications, are essential to minimize the risks of EUS and EUS-FNB. Restricting EUS-FNB only to patients in whom the cytopathological results may be expected to change the course of management is the best way of reducing the number of complications.     

Rupturen der tibiofibularen Syndesmose

The standard treatment of distal ruptures of the tibiofibular syndesmosis is an anatomical reduction of the fibula and fixation with one or two tibiofibular syndesmosis screws. The incidence of isolated distal rupture of the tibiofibular syndesmosis is rare. On the other hand 1 in 10 fractures of the ankle is associated with a relevant syndesmotic instability. The classification of Lauge Hansen is based on the analysis of the pathomechanism. A correct reduction and positioning of the screws is mandatory for a good clinical result. Injuries of the ankle combined with syndesmotic instability lead to worse outcome than those without, even after surgical treatment. This can be explained by many reasons, especially by the severity of the injuries but also by the quality of reduction and fixation. The syndesmosis screw fixation method is presented as a standard fixation and additionally the Ankle TightRope? is described as a valid treatment alternative.     

Techniques chirurgicales de traitement du carcinome ��pidermo?de de l��anus: amputation abdominop��rin��ale, colostomie p��rin��ale, reconstruction p��rin��ale par lambeaux

Although the treatment of anal squamous carcinoma is primarily medical, abdomino-perineal resection remains the only alternative treatment if primary chemoradiotherapy is contraindicated or is unsuccessful. Salvage surgery for anal squamous carcinoma requires wide excision of the anal sphincter and permanent abdominal colostomy. Such major surgery in an irradiated field is associated with significant morbidity from delayed wound healingm, but this can be reduced by the use of myocutaneous flaps, whilst perineal colostomy allows a permanent abdominal stoma to be avoided. These techniques have been employed in the management of low rectal cancer with good oncological and functional results. However, there is little data on perineal colostomy and its feasibility in squamous carcinoma is limited by the extent of the perineal surgical resection.     

Risk of graft fracture after dorso-ventral thoraco-lumbar spondylodesis: is there a correlation with graft size?

Study design

Retrospective clinical study in patients with dorso-ventral thoraco-lumbar spondylodesis.

Objective

To investigate whether the ratio between graft cross sectional area and the surface area of the adjacent endplates has any effect on the midterm stability of the spondylodesis.

Summary of background data

Dorso-ventral spondylodesis in the region of the thoraco-lumbar spine is one of the most frequent operations in orthopaedic surgery. Anterior stabilization with autologous iliac crest graft currently is a standard approach in many hospitals. Although numerous recommendations are given how to perform this technique, no clinical advice is available with regard to minimum graft size.

Methods

Sixty-four-slice CT-scans were obtained from 82 patients 4–12 months after posterior spondylodesis with anterior implantation of iliac crest graft and stabilization with an internal fixator. The scans were analyzed using image analysis software. First, the cross sectional area of the graft was calculated and then the surface area of the adjacent endplates. The ratio between graft cross sectional area and endplate surface area was then calculated from these two values. The grafts were then evaluated in sagittal reconstruction for signs of fracture.

Results

The probability for graft fracture in autologous tricortical grafts was >0.1% (p < 0.001) if the graft cross sectional area exceeded 23.9% of the surface area of the adjacent endplates. Patients with lower ratio values had a higher fracture risk and below a value of 10% all grafts fractured.

Conclusion

The relationship between graft cross sectional area and adjacent endplate area has an important effect on graft midterm stability in ventral spondylodesis of the thoraco-lumbar spine. In our opinion, the risk of graft fractures in dorso-ventral spondylodesis can be reduced by implantation of an appropriately sized graft without any additional procedures or instrumentation.     

Beurteilung von Residualtumoren nach Systemtherapie des metastasierten Seminoms

Background

Meta-analysis evaluating the accuracy and sensitivity of FDG (2-[¹⁸F]-fluoro-2-deoxy-D-glucose) positron emission tomography (PET) to predict viable residual tumours in patients with metastatic seminoma.

Material and methods

Altogether 5 studies with 130 patients were identified. Both FDG PET and the size of the residual lesions on conventional computed tomography (CT; lesions either ?? or > 3 cm) were correlated with the presence or absence of viable residual tumour.

Results

The specificity (92 vs 59%), sensitivity (72 vs 63%), positive (70 vs 28%) and negative (93 vs 86%) predictive value of FDG PET were superior to data obtained by assessing residual tumour size (either ?? or > 3 cm) applying CT scans alone.

Conclusion

In view of the data currently available, FDG PET seems to be a clinically useful predictor of viable tumour in post-chemotherapy residuals of pure seminoma.     

Langzeitergebnisse in der Knieendoprothetik

Background

Total knee arthroplasty (TKA) is one of the most common procedures in orthopedic surgery and clinical success can be characterized by the revision rate and improvement of function. To quantify both characteristics two independent meta-analyses have been performed.

Materials and methods

A search in Medline provided a total of 96 studies on revision rates and 63 studies with functional results with a minimum follow-up of 5 years.

Results

A total of 911 revisions among 20,873 TKAs were identified corresponding to a meta-revision rate of 4.4% after a mean follow-up of 10.7 years. Most common causes for revision were aseptic loosening (31%), infection (23%), polyethylene wear (16%) and patellar problems (14%). Revision rates were higher in younger patients (7.0% <60 years at time of operation, 5.0% between 60 to 70 years and 2.2% >70 years), after cementless TKA (8.3% cementless versus 3.6% cemented) and in studies with a higher rate of patients with rheumatoid arthritis. The second meta-analysis revealed a meta-improvement based on the Knee Society Knee Score of 51.3%, for the Knee Society Function Score of 30.6%, for the Hospital for Special Surgery Score of 36.1% and for the New Jersey Orthopedic Hospital Knee Evaluation System of 33.6%.

Conclusion

TKA is a successful treatment for osteoarthritis of the knee with an expectable revision rate of less than 5% within 10 years and a long-lasting functional improvement of more than 30% in any assessment score.     

Kontinuierliche lokale Wundinfusion mit Lokalan?sthetika

Wound infusion with local anesthetics is a nearly 100 years old proven and secure analgesic method. Recently special wound infusion catheters have become available which can be placed intraoperatively into the wound under direct supervision of the surgeon to infuse local anesthetics and optimize postoperative analgesia. For thoracotomy this method was modified to improve its efficacy and the catheters are used to establish a continuous paravertebral intercostal nerve block (PVB). Many studies have confirmed the analgesic power of PVB which results in a pain reduction comparable to thoracic epidural analgesia (TEA) but without TEA-specific side-effects, in particular hypotension. The efficacy of continuous local wound infusion (CLWI) is less obvious for laparotomy. If fundamental preconditions for this loco-regional method are considered (indications, choice of catheter, local anesthetic dose) the laparotomy wound could also be suitable for the use of CLWI. According to the literature currently available CLWI is not associated with an increased risk of wound infections.     

Patellofemoraler Schmerz nach prim?rer Knieendoprothetik

Total knee arthroplasty (TKA) is an operation with a high gain in quality of life. However, some patients suffer from pain, limited range of motion, instability, infections or other postoperative complications. Patellofemoral pain (PFP) in particular is a common complication after TKA and is often responsible for revision surgery. In particular increasing and localized contact pressure and patella maltracking are held accountable for patellofemoral pain but the reasons are various. Diagnostics and therapy of patellofemoral pain is not easy to handle and should be treated following a clinical pathway. We suggest that patients with patellofemoral pain should be classified into four groups according to the suspected diagnosis after basic diagnostic measures as 1) tenidinosis, 2) mechanical reasons, 3) intraarticular non-mechanical reasons and 4) neurogenic psychogenic reasons. Efficient application of special diagnostic measures and further therapy is facilitated by this classification.     

Are abductor muscle quality and previous revision surgery predictors of constrained liner failure in hip arthroplasty?

Dislocation is one of the most common complications of total hip arthroplasty. The use of constrained liners is an option for the management of chronic hip instability, typically used after other methods have failed. The purposes of this study were to evaluate the overall clinical outcomes and failure rates of a tripolar constrained liner design, to assess the radiographic outcomes of its use, and to examine whether various factors such as abductor mechanism quality and history of previous revision surgeries were associated with an increased risk of failure. Forty-three hips in 39 patients who had a mean follow-up of 51 months (range, 24–110 months) were reviewed. Ninety-one percent of the hips (39 of 43 hips) did not need any revisions over the study period. A new liner was implanted in all four failed hips with concurrent revision of the acetabular cup in three cases. No further dislocations occurred in this group. The mean hip score for surviving hips was 82 points (range, 38–100 points) at final follow-up. Radiographic evaluation revealed stable, well-fixed acetabular components in all surviving hips without progressive radiolucencies. No association was found between abductor muscle quality and the incidence of failure, but patients who experienced a constrained liner failure were more likely to have undergone at least one previous hip revision operation. Tripolar constrained acetabular liners can provide successful outcomes in patients with hip instability, although it is important not to rely on the use of a constrained liner alone in an attempt to compensate for other correctable factors such as component positioning.