Combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic decompression of a giant pituitary adenoma: case report

Objective  This is the first report of the simultaneous combined use of trans-sphenoidal and trans-ventricular-endoscopic route for decompression of a giant pituitary adenoma. Method  A 38 year old man presented to us with symptoms of raised intracranial pressure along with visual and hypothalamic disturbances. The CT scan revealed destruction of the sella by a large (5 × 3.5 × 2.5 cm) well defined enhancing mass in the sella and suprasellar region extending laterally up to the cavernous sinuses and both carotid arteries and superiorly into the lumen of the 3rd ventricle producing obstructive hydrocephalus. On T2WI of the non-contrast MRI scan the mass was iso-intense to grey matter suggesting the possibility of a firm nature of the adenoma. The tumour was first approached by the standard trans-sphenoidal route and as predicted from the pre-operative MRI, the tumour was found to be firm and not amenable to suction. After decompression of the intra-sellar part of the tumour, the intracranial pressure was raised in an attempt to make the remainder of the tumour descend into the sella but without success. The suprasellar part of the tumour was then simultaneously addressed via a trans-ventricular-endoscopic route but the firm tumour did not yield to endoscopic instruments viz. biopsy forceps, angiographic catheter and electrosurgical probes. It was then gently pushed down towards the sella and decompressed piecemeal by using trans-sphenoidal instruments. The sellar cavity was reconstructed using fat, fascia lata graft and a piece of septal bone. Results  Post-operatively, the patient showed a remarkable improvement of his symptoms of raised intracranial pressure, hypothalamic dysfunction and visual disturbances. Follow-up imaging at 2 months and 1 year, did not show any residual or recurrent tumour. Conclusions  This novel technique of the combined trans-sphenoidal and simultaneous trans-ventricular-endoscopic approach is a viable option for patients with giant fibrous pituitary adenoma when the tumour is not yielding to the trans-sphenoidal route alone.     

Protective effect of resveratrol against renal oxidative stress in cholestasis

BACKGROUND/AIMS: This experimental study was designed to evaluate histological changes of the kidney and renal tissue levels of malondialdehyde (MDA), reduced glutathione (GSH), and nitric oxide (NO) and the effect of resveratrol on these metabolites after bile duct ligation in rats. METHODS: Secondary biliary cirrhosis was induced by bile duct ligation for 28 days. Swiss albino rats were divided into three groups. Group 1: Sham (n=7), Group 2: Bile duct ligation (n=7), Group 3: Bile duct ligation plus resveratrol (n=7). Bile duct ligation (BDL) plus resveratrol group received 10 mgr/kg dose of resveratrol intraperitoneally daily throughout 28 days. Kidney tissues were harvested to determine the tissue levels of MDA, GSH, and NO activity. Liver and kidney tissues were removed for light microscopic evaluation. RESULTS: Cholestasis was determined by biochemical and pathologic examination. In the resveratrol-treated rats, levels of MDA were significantly lower than those of the BDL group (p < 0.04). The levels of GSH in the resveratrol-treated rats were significantly higher than those in the BDL group (p < 0.01). The levels of NO in the resveratrol group were significantly lower than those in the BDL group (p < 0.01). CONCLUSION: The present study demonstrates that intraperitoneal administration of resveratrol in bile duct ligated rats maintains antioxidant defenses and reduces kidney oxidative damage. This effect of resveratrol may be useful in the preservation of renal oxidative stress in cholestasis.     

End-to-side nerve coaptation: is an additional proximal coaptation useful when available?

The aim of this experimental study was to evaluate the effects of end-to-side coaptation of the proximal end of a severed nerve to the same intact nerve, in addition to traditional end-to-side coaptation of the distal end, with an aim to use the intact nerve as a nerve conduit in a rat model and to compare the functional and histologic results of this modality to those obtained after nerve grafting and traditional end-to-side nerve coaptation. In group A, a peroneal nerve defect measuring 1 cm was created in the left hind limb, and a nerve graft 1 cm long was used to bridge the defect. In group B, only the distal stump of the peroneal nerve was coapted to the intact tibial nerve. In group C, both ends of the peroneal nerve defect were coapted to the intact tibial nerve in an end-to-side fashion 1.5 cm apart from each other, and in group D, the peroneal nerve defect was left unrepaired. Group E was consisted of nonoperated peroneal nerves that were used to obtain normative data. Although significantly higher myelinated axon densities were observed in groups B and C compared with group A and group E, total number of the myelinated axons was significantly higher only in group C. Peroneal functional index assessments demonstrated that nerve recovery in the peroneal nerve was similar in groups A and C, and both were better than those observed in groups B and D. Collectively, these results suggest that end-to-side coaptation of both ends of a severed nerve to an intact nerve, in case of a nerve defect in this length, may serve as an alternative for nerve grafting.     

Left ventricular systolic and diastolic function and carotid intima-media thickness in pediatric dialysis patients

Background  Cardiovascular complications are common in patients with end-stage renal disease (ESRD). We aimed to investigate left ventricular (LV) function and carotid intima-media thickness (cIMT) in children and adolescents with ESRD. Methods  This study included 38 ESRD patients (15 hemodialysis and 23 peritoneal dialysis) and 17 age- and sex-matched healthy subjects. Results  The ESRD patients had significantly lower mean mitral E/A ratio, and higher left ventricular mass index (LVMI) and cIMT than the control group. Compared with PD patients, HD patients had worse LV diastolic function. In stepwise linear regression analysis, LVMI (P = 0.043) and hemoglobin (P = 0.015) turned out to be independent variables for predicting diastolic dysfunction (reduced E/A ratio), and the only significant predictor of cIMT was indexed diastolic blood pressure (DBP) (P = 0.035). Conclusion  Cardiovascular structure and function abnormalities are also common in pediatric dialysis patients, as in adults. Furthermore our data indicated that hemodialysis was disadvantageous for preserving LV diastolic function as compared with peritoneal dialysis.     

Kotz and Ganz osteotomies in the treatment of adult acetabular dysplasia

In hips with acetabular dysplasia, we performed Kotz osteotomy (group 1) in 22 hips (20 patients; mean age 24.3 years) and Ganz osteotomy (group 2) in 23 hips (22 patients; mean age 23.1 years). Group 1 was followed 83.3 (56-112) months and group 2 40.9 (24-66) months. In group 1, Harris hip score improved from average 74.9 to 86.9, mean center edge (CE) angle from -4.5 degrees to 30.3 degrees, and mean vertical center edge (VCE) angle from 5.3 degrees to 36.2 degrees. In group 2, Harris hip score improved from average 76.6 to 91.1, mean CE angle from -5.9 degrees to 32.0 degrees, and mean VCE angle from 5.0 degrees to 41.3 degrees. Using Pauwels criteria, regression was observed in 12 hips in group 1 and one progressed. In group 2, 15 hips showed regression and three progressed. In patients treated with Ganz osteotomy, the complication rate was higher and the complications more serious than in patients treated with Kotz osteotomy. Most complications were, however, seen among the first ten patients treated with Ganz osteotomy. Although we detected no significant difference between the two groups in terms of clinical and radiological findings, we believe the outcome to be slightly better after a properly performed Ganz osteotomy.     

Management of stiff hypertrophic nonunions by distraction osteogenesis: a report of 16 cases

OBJECTIVE: Hypertrophic nonunions can be managed successfully with distraction. Hypertrophic changes indicate that the tissue at the nonunion site has a biologic healing potential. The missing component is an appropriate mechanical environment to transform a hypertrophic nonunion into solid bone. DESIGN: At our institution, the records of 10 male and 6 female patients treated for stiff hypertrophic nonunion with the Ilizarov distraction method were retrospectively analyzed. The average age of the patients was 42.3 years (range 15-69 years). The nonunion time ranged from 8-48 months. All patients had at least 1 cm shortening, 3 patients had a deformity in one plane, and 13 had a deformity in two planes. The pathology was localized to the upper extremity in 5 patients, to the lower extremity in 11 patients, with a periarticular localization in 11 patients. An Ilizarov-type circular external fixator was applied in all patients to correct shortening, to correct deformity, and to achieve a solid union. RESULTS: All nonunions healed at an average follow-up of 38.1 months (range 24-95 months). The average time spent in the external fixator was 7.1 months (range 5-10 months). The average preoperative length discrepancy was 2.25 cm (range 1-8 cm), which was eliminated in all patients at the time of frame removal. The average coronal plane angulation of 19.7 degrees (range 15-37 degrees) and sagittal plane angulation of 20.8 degrees (range 5-45 degrees), together with translation in one patient, also were corrected to normal anatomic alignment. Complications included minor pin tract infections and hardware problems; recurrence of deformity was observed in one patient who refused to wear a protective brace after frame removal. CONCLUSIONS: Hypertrophic nonunions can be managed successfully with distraction. The Ilizarov device can address every aspect of a stiff hypertrophic nonunion, including shortening and deformity.     

An evaluation of quality of life of mothers of children with enuresis nocturna

The aim of this study was to evaluate the impact of enuresis nocturna on quality of life of the mothers. Mothers who have a child with monosymptomatic nocturnal enuresis (n = 28) and mothers who have a child without any health problems (n = 38) were enrolled in the study. Groups were in balance for background variables (child’s age, gender, and number of siblings; mother’s age, marital status, highest year of education completed, and occupation; presence of health insurance; and type of residence). Short-Form Health Survey (SF-36) Questionnaire, the Beck Depression Inventory (BDI), and Spielberg’s State-Trait Anxiety Inventory (STAI) were applied to all mothers. The mothers of children with enuresis had significantly lower quality-of-life scores in the SF-36 for the bodily pain (p = 0.015) and role emotional (p = 0.014) subscales. We observed significant difference between groups according to BDI; mean score was higher in mothers who have a child with enuresis nocturna (p = 0.017). There was no significant difference between groups according to the STAI. Significant differences according to bodily pain and role emotional subscales of SF-36, and the BDI scores, show that the mothers were negatively affected by having a child with monosymptomatic nocturnal enuresis.     

Free nerve endings and morphological features of the ligamentum capitis femoris in developmental dysplasia of the hip

A conflict exists on whether the ligamentum capitis femoris has the neuro-morphological structures required for nociception or proprioception of the hip joint. Therefore, we investigated the morphological features and the presence of mechanoreceptors in 24 ligamentum capitis femoris biopsies obtained at open reduction in patients with developmental dysplasia of the hip. Of these 24 hips, 16 were completely dislocated and eight were subluxated. The mean age was 33.8 months (range 13-52 months) at the time of surgery. En bloc ligamentum capitis femoris and pulvinar were taken for biopsy specimen. Ligamentum capitis femoris was dissected and the weight of each ligament was determined using a highly sensitive balance. Specimens were stained with hematoxylin and eosin and Masson trichrome for routine histolopathological evaluation and examined immunohistochemically using monoclonal antibody against S-100 protein. All specimens were graded on a four-grade system according to the amount of coarse-thick collagen bundles and hyalinization. The mean number and type of mechanoreceptors of each specimen were recorded. When the mean age, the patient's weight and the ligamentum capitis femoris weight of each group (completely dislocated vs. subluxated) were compared, there were no significant differences. In the ligamentum capitis femoris of the dislocated hips, the cells were irregularly distributed, had different shapes, and appeared to be in different stages of functional activity. The collagen fiber bundles were thicker than in the subluxated hips, distributed and of varied thickness. The elastic fibers of the dislocated hips were thicker and more numerous than those in the subluxated hips. We found a significant difference between the two groups with regard to the grade of collagen and hyalinization of ligamentum capitis femoris (P<0.004). We found type IVa, free nerve endings in 16 of 24 samples of ligamentum capitis femoris. The 66.6% presence of free nerve endings in the ligamentum capitis femoris suggests a role in nociception/proprioception of the hip in developmental dysplasia of the hip. Interestingly, the percentage and the mean numbers of free nerve endings containing ligamentum capitis femoris were similar in completely dislocated hip group and the subluxated group (62.5 vs. 75%, 12.13+/-9.07 vs. 9.37+/-9.24, respectively). We conclude that the morphological features of ligamentum capitis femoris are influenced by the severity of developmental dysplasia of the hip, whereas the distribution of free nerve endings are not influenced.     

Interpleural versus epidural analgesia with ropivacaine for postthoracotomy pain and respiratory function

STUDY OBJECTIVE: To evaluate the impact of interpleural analgesia (IP) on postthoracotomy pain and respiratory function as an alternative to thoracic epidural analgesia (TEA). DESIGN: Prospective, randomized study. SETTING: Tertiary-care military hospital. PATIENTS: Sixty young patients scheduled for elective thoracic surgery (correction of aorta coarctation and patent ductus arteriosus). INTERVENTIONS: Patients were randomized into two groups to receive either IP or TEA for postthoracotomy pain management. MEASUREMENTS: Patients in the IP group (n = 30) had a catheter inserted between the parietal and visceral pleura by a surgeon, and 0.2% ropivacaine was given through this catheter. In the TEA group, ropivacaine was administered through a thoracic epidural catheter. The impact of both methods on pain control, respiratory function, and pulmonary complications was analyzed and compared. MAIN RESULTS: The frequency of atelectasis and pleural effusion was also significantly high in the IP group (P < 0.01). Respiratory function and postoperative pain scores were better in the TEA group (P < 0.01). Arterial blood gas analysis on the fifth postoperative day was significantly better in the TEA group. CONCLUSION: Thoracic epidural analgesia has more beneficial effects on respiratory function and postoperative pain after thoracotomy than does IP.