Insular carcinomas of the thyroid exhibit poor prognosis and long-term survival in comparison to follicular and papillary T4 carcinomas

Background Insular thyroid carcinoma was described as a tumor with aggressive behavior, and patients usually present themselves with an advanced tumor stage. Whether the insular component is an independent factor for poor prognosis remains unclear. Therefore, in the present study, we compared the survival of patients with advanced insular, follicular, and papillary thyroid cancer. Materials and methods The clinical behavior of tumors in three groups of patients with T4 thyroid carcinoma—8 patients with insular, 11 patients with follicular, and 21 patients with papillary thyroid carcinomas—was compared. Disease-free survival and disease-specific death were analyzed statistically. Cox regression analysis was used to evaluate the influence of histotype and other prognostic factors. Results At 3 years, survival was 37.5% (mean 26 months) among patients with insular thyroid carcinoma, 80% (mean 59 months) among those with follicular, and 89% (mean 126 months) among those with papillary thyroid carcinomas (p = 0.007). Disease-free survival in patients without initial distant metastasis was worst in patients with insular thyroid carcinoma (20%) compared to those with follicular (75%) and those with papillary thyroid carcinomas (71%). Conclusion Patients with advanced insular thyroid carcinoma have a poorer outcome in comparison to patients with similar advanced stage who have follicular or papillary thyroid carcinoma.     

Potassium-titanyl-phosphate laser assisted robotic partial nephrectomy in a porcine model: can robotic assistance optimize the power needed for effective cutting and hemostasis?

A potassium-titanyl-phosphate (KTP) laser through robotic endo-wrist instrument has been evaluated as an ablative and hemostatic tool in robotic assisted laparoscopic partial nephrectomy (RALPN). Ten RALPN were performed in five domestic female pigs. The partial nephrectomies were performed with bulldog clamping of the pedicle. Flexible glass fiber carrying 532-nm green light laser was used through a robotic endowrist instrument in two cases. Power usage from 4 to 10 W was tested. The laser probe was explored both as a cutting knife and for hemostasis. The pelvicalyceal system was closed with a running suture. Partial nephrectomies using KTP laser were performed without complications. Mean operative times and warm ischemia times for laser cases were 96 and 18 min, respectively. Mean estimated blood loss was 60 ml compared with 50 ml for non-laser cases. Complete hemostasis with the laser alone could be achieved with a power of 4 W and was found to be effective. In our hands the laser fiber powered up to 10 W was not effective as a quick cutting agent. Histopathologic analysis of the renal remnant revealed a cauterized surface effect with average laser penetration depth less than 1 mm and minimal surrounding cellular injury. The new robotic endowrist instrument carrying flexible glass fiber transmitting 532-nm green light laser is a useful addition to the armamentarium of the robotic urologic setup. Its control by the console surgeon enables quicker and more complete hemostasis of the cut surface in renal sparing surgery using a porcine model. Histologically proven lased depth of less than 1 mm suggests minimal parenchyma damage in an acute setting. Laser application as a cutting agent, however, requires further investigation with interval power settings beyond the limits of this preliminary study. We estimate that effective cutting should be possible with a setting lower than traditionally recommended for solid organs.     

Prospective randomized study of azathioprine vs cyclosporine based therapy in primary haplo-identical living-donor kidney transplantation: 20-year experience

Background The achievements in short-term graft survival since the introduction of cyclosporine (CsA) have not been matched by improvements in long-term graft function. Chronic allograft nephropathy (CAN) remains the second most common cause of graft attrition over time, after patient mortality. We aimed to evaluate the long-term results of azathioprine vs CsA in live-donor kidney transplantation in a prospective randomized study. Methods We studied 475 renal transplant recipients who had had transplantations performed at the Urology and Nephrology Center, Mansoura University, before 1988 and who had received a primary immunosuppressive protocol consisting of either steroid and azathioprine (steroid/Aza; group 1, 300 patients) or steroid and CsA (steroid/CsA; group 2, 175 patients). Only adult primary renal transplant recipients aged between 18 and 60 years and with one haplotype HLA mismatch were included. All patients received kidneys from living-related donors, with previous donor nonspecific blood transfusions. The study was based on the long-term follow-up data of these renal transplant recipients. Comparative analyses included patient and graft survival rates, condition at last follow up, rejection (acute and chronic), and graft function (serum creatinine and creatinine clearance). Results The overall frequency of acute rejection episodes was not significantly different between the two groups. Graft survival rates were: group 1 vs group 2, 69% vs 58% at 5 years, and 52% vs 36% at 10 years, but at 20 years, graft survival rates had declined to 26% and 24%. No significant differences were encountered between the two groups regarding post-transplant malignancies, diabetes mellitus, hepatic impairment, or serious bacterial infections. Conclusions From this study we can conclude that the long-term result of historical conventional therapy (steroid/Aza) without induction therapy is effective for living-donor kidney transplants. In spite of the comparable graft function for the two groups, the steroid/CsA group experienced more hypertension, as well as many adverse reactions to CsA. Nowadays, since the introduction of induction therapy and the utilization of newer maintenance immunosuppressive agents – such as mycophenolate mofetil (MMF) and rapamycin – it is possible to achieve an excellent calcineurin inhibitors (CNI)-free regimen.     

Left ventricular hypertrophy and chronic fluid overload in peritoneal dialysis patients

Purpose

Cardiovascular disease is the leading cause of mortality in dialysis patients with left ventricular hypertrophy (LVH) being an important predictor of mortality. We wanted to determine the prevalence of LVH in peritoneal dialysis (PD) patients and factors contributing to it.

Methods

This is a cross-sectional study assessing LVH using echocardiogram in PD patients. Left ventricular mass index (LVMI) was calculated to determine LVH. Chronic fluid overload (overhydration) was assessed using the body composition monitor, and blood pressure (BP) was measured using 24-h ambulatory BP monitoring.

Results

Thirty-one patients (21 females:10 males, 48.97 ± 14.50 years and dialysis vintage 40.0 ± 28.9 months) were studied. More than two-thirds (77.4 %) were hypertensive, and a third (35.5 %) were diabetic. Baseline data included mean serum albumin (37.34 ± 4.43 g/l), weekly Kt/V (2.02 ± 0.23), residual renal function of 68 (0–880) ml and ultrafiltration of 1,606.9 ± 548.6 ml. Majority of patients (80.6 %) had LVH on echocardiogram with LVMI of 136.5 ± 37.8 g/m² and overhydration of 2.23 ± 1.77 l. Average systolic BP, diastolic BP and mean arterial pressure were 141.2 ± 23.3, 90.8 ± 19.7 and 107.6 ± 19.6 mmHg, respectively. Patients with LVH had a lower serum albumin (p = 0.003), were more overhydrated (p = 0.010) and were on higher number of anti-hypertensive agents (p ≤ 0.001). Predictors of LVMI were overhydration (p = 0.002), the presence of diabetes (p = 0.008) and the number of anti-hypertensive agents used (p = 0.026). However, overhydration (p = 0.007) was the main predictor of LVH on multivariate analysis.

Conclusion

Overhydration is strongly associated with LVH in PD patients.     

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

Introduction

Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation.

Methods

This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients.

Results

The average time to operation was 4 days. Average blood loss was 110 mL. Operative time averaged 95 min. Maximum fracture displacement averaged 10 mm preoperatively and 1.3 mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigné score, functional outcome was good to excellent in all patients.

Discussion and conclusion

Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.     

Factors Predicting the Oculomotor Nerve Palsy following Surgical Clipping of Distal Vertebrobasilar Aneurysms: A Single-Institution Experience

Background The aim of our study was to identify various clinical and radiologic factors that correlate with the oculomotor nerve palsy following clipping of distal vertebrobasilar aneurysms. Methods A total of 48 patients with 51 aneurysms were included in this retrospective study . Patient''s age, gender, size, location, and projection of the aneurysm, preoperative Hunt and Hess (H&H) grade, presence of subarachnoid hemorrhage (SAH), temporary clipping, preoperative third nerve palsy, and Glasgow Outcome Scale were included in the model for analysis. Results A total of 15 patients (31.25%) developed oculomotor nerve palsy following clipping of basilar apex aneurysms. 38 patients (79.2%) presented with SAH and 35 patients (72.9%) had poor H&H grades at presentation. The size of the aneurysm (p = 0.03), preoperative H&H grade (p = 0.04), preoperative oculomotor nerve dysfunction (p = 0.007), and projection of an aneurysm (p = 0.004) had shown a significant correlation with the oculomotor nerve palsy. The size of the aneurysm (p = 0.030, odds ratio: 0.381; 95% confidence interval, 0.175–0.827] was an independent predictor of postoperative nerve dysfunction. Conclusion The size of the aneurysm, clinical grade at presentation, and projection of the aneurysm correlated with the oculomotor nerve dysfunction following clipping. These clinical and radiologic parameters can be used to predict the oculomotor nerve outcome.     

The importance of submalleolar deformity in determining leg length discrepancy

Background and purposeThe association of leg length discrepancy (LLD) with a number of clinical disorders has made its determination a significant part of the physical examination. We believe that submalleolar causes of LLD may be under-acknowledged. The most common clinical method used to measure LLD is by tape from the anterior superior iliac spine (ASIS) to medial malleolus which disregards the potential for LLD arising from asymmetry in the foot distal to the tibiotalar joint.MethodsThe present pilot study involves a group of 5 volunteers (experimental group) and a group of 3 patients with flexible flat feet (clinical study). The differences in tibial tubercle height from the ground between full pronation and full supination were measured using the CODA MPX 30^® system (Charnwood Dynamics Limited, Leicestershire, England). Correlations of the patterns within each group were produced.ResultsA significant relationship with leg lengths was found in the experimental group when they induced maximum pronation (R-squared = 0.62, p = 0.007) while an inverse relationship occurred with supination, although marginally significant (R-squared = 0.37, p = 0.064).ConclusionsWe have demonstrated that significant leg length discrepancy can occur in patients who do not have obvious deformity when non weight bearing. We recommend using the blocks method routinely. Appropriately measuring LLD is of vital importance to properly diagnosing and treating patients with unequal leg lengths or related symptoms.     

Minilaparoscopic appendectomy using a new spiral needle

Background

Acute appendicitis is the most frequent abdominal disease and requires urgent surgery. At the present time, laparoscopic appendectomy is a well-accepted emergency procedure at most centers. In this study, we used a new spiral needle to facilitate the procedure, making it easy, minimally invasive, and cost effective.

Methods

The study included 70 patients of both sexes with acute appendicitis that was treated by laparoscopic appendectomy using a new spiral needle. These cases were treated at the General Surgery Department, Zagazig University, Egypt, from May 2012 to August 2013. In the procedure we used only two ports (a 10-mm port directly below the umbilicus for the camera and a 5-mm port at the left iliac fossa at the midclavicular line). The new spiral needle was used to hold the appendix during the procedure and was inserted into the right iliac fossa depending on the site of the appendix.

Results

The mean age of the patients was 27.3 years, mean operative time was 40 min, and mean hospital stay was 1.3 days. Ten patients (14 %) had minimal bleeding at the site of needle passage into the mesoappendix. Wound infection at the site of umbilical port occurred in four patients (5.7 %) postoperatively.

Conclusion

Laparoscopic appendectomy using our new spiral needle is easy, minimally invasive, and cost effective.     

Volume of Resected Stomach as a Predictor of Excess Weight Loss After Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of obesity. The objective of this study was to evaluate the volume of the resected stomach (VRS) as a predictor of the percentage of excess weight loss (%EWL) 1 year after LSG.

Methods

This was a single-surgeon study of prospectively collected data of patients who underwent LSG at Jordan University Hospital (February 2009 to February 2012). The VRS was measured using a standardized technique. The %EWL was calculated at 3, 6, and 12 months postoperatively. The correlation between the VRS and %EWL was statistically evaluated.

Results

Ninety patients underwent LSG during the study period. Of these, 73 patients (57 female) completed at least 1 year of follow-up and were analyzed; their body mass index was 45?±?7.6 kg/m² (33–81). The VRS was 1,337.4?±?435.2 ml (600–2,800). The %EWL was 33.6?±?11.1 % at 3 months, 48.6?±?15.5 % at 6 months, and 56.8?±?18.9 % at 12 months. A significant correlation was observed between the VRS and %EWL at 1 year (p?=?0.003). Patients with a VRS of >1,100 ml (n?=?43) achieved significantly greater %EWL at 12 months than did those with a VRS of ≤1,100 (n?=?30). Removal of >1,100 ml of gastric volume was associated with a sensitivity and specificity of 75.5 and 46.2 %, respectively, for achieving a %EWL of ≥50 %.

Conclusion

The VRS can be used as an indicator of excess weight loss 1 year after LSG.     

In reply: Apneic oxygenation during emergency airway management

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -