Long-Term Effects of Extrinsic Denervation on VIP and Substance P Innervation in Circular Muscle of Rat Jejunum

Intestinal denervation contributes to enteric motor dysfunction after small bowel transplantation (SBT). Our aim was to determine long-term effects of extrinsic denervation on function of nonadrenergic, noncholinergic innervation with substance P and vasoactive intestinal polypeptide (VIP). Contractile activity of jejunal circular muscle strips from six age-matched, naive control rats (NC) and eight rats 1 year after syngeneic SBT was studied in tissue chambers. Spontaneous contractile activity did not differ between groups. Exogenous VIP inhibited contractile activity dose-dependently to a comparable degree in both groups. The VIP antagonist ([d-p-Cl-Phe⁶,Leu¹⁷]-VIP) and the nitric oxide synthase inhibitor l-N^G-nitro-arginine did not affect VIP-induced inhibition but increased contractile activity during electrical field stimulation (EFS) in both groups. Exogenous substance P increased contractile activity dose-dependently, greater in NC than SBT. The substance P antagonist ([d-Pro²,d-Trp^7,9]-substance P) inhibited effects of exogenous substance P and decreased the excitatory EFS response. Immunohistofluorescence showed tyrosine hydroxylase staining after SBT indicating sympathetic reinnervation. In jejunal circular muscle after chronic denervation, response to exogenous substance P, but not VIP, is decreased, whereas endogenous release of both neurotransmitters is preserved. Alterations in balance of excitatory and inhibitory pathways occur despite extrinsic reinnervation and might contribute to enteric motor dysfunction after SBT. Parts of this work were presented at the annual meeting of the Society for Surgery of the Alimentary Tract in Washington, DC, on May 21, 2007 and published in abstract form in Gastroenterology 2007;132:A890.     

A comparison between fibula and iliac crest in mandibular reconstruction

Nowadays the vascularized free fibula flap and the free iliac crest flap are the methods most frequently used to reconstruct the mandible. This is also the case in our clinic. A retrospective nonrandomized study was performed to compare both flaps. The vascularized fibula free flap and the iliac crest free flap were compared in terms of logistics, flap failure, revisionary surgery, donor site morbidity, and recipient site morbidity. No significant differences in flap failure and revision surgery were found between the fibula group and the iliac crest group. Recipient site and donor site complications (major and minor) were significantly less in the fibula group compared to the iliac crest group. In mandibular reconstruction, the free vascularized fibula flap appears to be superior to the free vascularized iliac crest flap in terms of both recipient site and donor site morbidity.     

Are drains required following a routine primary total joint arthroplasty?

The purpose of this study was to evaluate the benefits of suction drainage following primary total joint arthroplasty. We reviewed primary total hip and knee replacements separately and together in 126 consecutive patients. There were 63 patients each in the drainage and no drainage groups. Sex distribution and anticoagulant use were similar in the two groups. All patients underwent the same operative technique and method of closure. The mean postoperative fall in haemoglobin was 3.2 and 3.3 gm/dl in the drainage and no drainage groups respectively. There was no statistically significant difference between the two groups with regard to blood transfusion requirements, rehabilitation time, postoperative complications such as hypotension and wound infections (p>0.05). The average rehabilitation time in both groups was 8–9 days. The routine use of a suction drain is unnecessary after an uncomplicated total joint arthroplasty.

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Résumé Le sujet de cette étude était d’évaluer les bénéfices du drainage aspiratif après arthroplastie primaire. Nous avons revus 126 cas consécutifs d’arthroplastie totale de la hanche et du genou. Il y avait 63 patients dans chacun des groupes, drainés ou non drainés. La technique opératoire était la même chez tous les patients et le genre ainsi que le traitement anti-coagulant étaient similaires dans les deux groupes. La chute de l’hémoglobine était respectivement de 3,2 et 3,3 g/dl dans les groupes drainés et non drainés. Il n’y avait pas de différence significative entre les deux groupes pour la nécessité de transfusion, le temps de récupération, et les complications post-opératoires (p>0,05). Le temps moyen de récupération dans les deux groupes était de 8–9 jours. Le drainage aspiratif n’est pas nécessaire après une arthroplastie totale non compliquée.

     

Curative Laparoscopic Resection for Pancreatic Neoplasms: A Critical Analysis from a Single Institution

Laparoscopic pancreatic surgery (LPS) has seen significant development but much of the knowledge refers to small and benign pancreatic tumors. This study aims to evaluate the feasibility, safety, and long-term outcome of the laparoscopic approach in patients with benign, premalignant, and overt malignant lesions of the pancreas. This study, currently, is the largest single center experience worldwide. One hundred twenty-three consecutive patients underwent laparoscopic pancreatic surgery from April 1998 to April 2007, 20 patients with cysts or pseudocysts for acute and chronic pancreatitis, laparoscopic pancreatic drainage was performed, and were excluded from the analysis. The 103 patients were divided based on preoperative diagnosis: group I, inflammatory tumors for chronic pancreatitis (eight patients); group II, cystic pancreatic neoplasms (29 patients); group III, intraductal papillary mucinous neoplasms (10 patients); group IV, neuroendocrine pancreatic tumors (NETs) (43 patients); and group V ductal adenocarcinoma (13 patients). The median tumor size was 5.3 cm. Pathologic data include R ₀ or R ₁ resection (transection margins on the specimen were inked). Perioperative data, postoperative complications, and resection modalities were compared using statistical analysis. Long-term outcomes were analysed by tumor recurrence and patient survival. The overall conversion rate was 7%. Laparoscopic distal pancreatic resection was performed in 82 patients (79.6%). Laparoscopic spleen-preserving distal pancreatectomy (Lap SPDP) was performed in 52 patients (63.7%), but with splenic vessels preservation in 22% and without splenic vessels preservation in 41.5%. Laparoscopic en-bloc splenopancreatectomy (Lap SxDP) was performed in 30 patients (36.6%) and laparoscopic enucleation (Lap En) in 20 patients (19.4%). There was no mortality. The overall complication rate was 25.2, 16.7, and 40% after Lap SPDP, Lap SxDP, and Lap En, respectively. The overall morbidity rate was significantly higher (p > 0.05) in the group of Lap SPDP without splenic vessels preservation comparing with Lap SPDP with splenic vessels preservation because of the occurrence of splenic complications (20.6%). The overall pancreatic fistulas was 7.7, 10, and 35% after Lap SPDP, Lap SxDP, and Lap En, respectively; the severity of fistula was significantly higher in the Lap En group (p > 0.05). The mean hospital stay was within 1 week in all groups, except in the group of ductal adenocarcinoma, which is 8 days. In this series, 27 patients (26.2%) had malignant disease. R ₀ resection was achieved in 90% of ductal adenocarcinoma and 100% for other malignant tumors. The median survival for ductal adenocarcinoma patients was 14 months. This series demonstrates that LPS is feasible and safe in benign-appearing and malignant lesions of the pancreas.     

Extremity Soft Tissue Sarcoma: Adding to the Prognostic Meaning of Local Failure

Background We explored the prognostic meaning of local relapse and surgical margins in adult soft tissue sarcoma of the extremities. Methods Out of a series of 1017 patients with extremity soft tissue sarcoma treated over 20 years, we picked a group of 238 patients operated on at our institution for their first local relapse: 88 after their primary operation performed at the same center and 150 elsewhere. At operation for relapse, margins were microscopically negative in 77% and 75% of patients, respectively. Median follow-up was 107 months. Results The 10-year mortality rate was 22% in the absence of local relapse, whereas in locally relapsing patients it was 54% and 43%, respectively, for patients first operated on at our institute and for those who were not. The hazard ratio of positive versus negative surgical margins was 1.7 for cause-specific death and 2.1 for distant metastases in patients first operated on at our institute, as opposed to 1.2 and 1.3 for the others. Conclusions Local relapse was an unfavorable prognostic factor. In the face of a consistent surgical policy for local relapse in a single-institution setting, patients relapsing after the first operation performed at our institution received rescue treatment less frequently than those previously operated on outside a referral center. This is likely due to an inherently higher tumor aggressiveness. In the presence of such a higher aggressiveness, the adequacy of surgical margins at operation for first relapse seemed more critical prognostically. This may have clinical and speculative implications. Presented at the Annual Meeting of the American Society of Clinical Oncology, June 2–6, 2006, Atlanta, GA (USA) (abstract 9565).     

Treatment Failure After Percutaneous Radiofrequency Ablation for Nonsurgical Candidates With Pulmonary Metastases From Colorectal Carcinoma

Background This study critically evaluated the local and overall treatment failure rates after percutaneous radiofrequency ablation (RFA) of pulmonary metastases from colorectal carcinoma. Methods Fifty-five nonsurgical candidates underwent RFA of colorectal pulmonary metastases. The primary end points of this study were local progression-free survival (PFS) and overall PFS. Univariate and multivariate analyses were performed to identify significant prognostic parameters for local and overall PFS. Results The local recurrence rate was 38%. For local PFS, univariate analysis demonstrated that the largest size of lung metastasis, the location of lung metastases, the post-RFA carcinoembryonic antigen level at 1 month, and the post-RFA carcinoembryonic antigen level at 3 months were significant prognostic indicators. In multivariate analysis, a largest size of lung metastasis of >3 cm and a post-RFA carcinoembryonic antigen level of >5 ng/mL at 1 month were independently associated with a reduced local PFS. The overall recurrence rate was 66%. For overall PFS, univariate analysis demonstrated that sex and the largest size of lung metastasis were significant prognostic indicators. In multivariate analysis, a largest size of lung metastasis of >3 cm was independently associated with a reduced overall PFS. Conclusions RFA of colorectal pulmonary metastases may have a useful role in local disease control for nonsurgical candidates, but its efficacy in patients with a lung metastasis of >3 cm is limited.     

New parameter of flexion after posterior stabilized total knee arthroplasty: posterior condylar offset ratio on X-ray photographs

In cruciate-retaining (CR) type TKA, the increase in posterior condylar offset (PCO) is considered to be correlated to flexion angle acquired postoperatively according to the article reported by Bellemans (J Bone Joint Surg Br 84:50–53, 2002). However, the significance of PCO seems to differ according to the size of joints. We therefore have defined a new parameter of posterior condylar offset ratio (PCOR) on the lateral view of plain X-ray photographs and studied the relationship between PCOR and postoperative flexion status in posterior-stabilized (PS) type TKA. Flexion status includes two parameters, such as postoperative flexion angle (FA) and flexion achievement rate (AR). The subjects of this study were 160 knees (16 males and 144 females, average 75 years.) with PS type TKA for osteoarthritic knees between 1999 and 2003 at our institution, more than at least 1 year postoperative follow-up. In the study of FA, patients with FA of less than 100° were divided into Group L (n = 28), patients with FA of 130° and greater were divided into Group H (n = 58). In the study of AR, patients with AR of less than 100% were divided into Group P (n = 46), patients with AR of 120% and greater were divided into Group G (n = 22). PCOR was statistically compared in each group, respectively. In FA, PCOR in Group L (0.385) was significantly lower (P = 0.027) than that in Group H (0.428). In AR, PCOR in Group P (0.376) was significantly lower (P = 0.0018) than that in Group G (0.456). We have concluded, though there are many factors influencing the range of movement after TKA, our newly defined PCOR could possibly serve as a parameter of postoperative flexion status of PS type TKA on plain X-ray photographs. No benefits or funds were received in support of the study.     

Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results

Introduction Laparoscopic repair of inguinal hernias is usually achieved by totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) techniques. The intraperitoneal onlay mesh (IPOM) could be an interesting alternative as it is much easier to perform and faster to execute. This technique is subject to correct selection of indications and to demonstration of its safety. Materials and methods From January 2003 to January 2006 we performed 61 laparoscopic hernia procedures on 60 selected patients (60 males with a mean age of 60 and mean weight of 76 kg) with an IPOM technique combining the Parietex composite mesh (12 cm circular model) and a fibrin glue (Tissucol) for its fixation. The glue was diluted to increase fixation time and applied to the mesh prior to positioning on the hernia defect. Results Mean operative time was 10 minutes. Mean hernia diameter was 2.5 cm (± 0.8 cm). 10 hernias were direct, 51 were indirect and 10 out of 61 were recurrent. We did not convert any of the laparoscopic procedures. Mean hospital stay was one day; mean recovery time for working and general physical activities was five days. Patients were checked after one week, 1-3-6 months and 1-2 years. Average follow up time was 23.7 months. 1.6 % of patients showed short-term complications: one trocar site haematoma. No additional complications were reported; particularly, we had no recurrence, no seroma, no mesh migration, and no bowel obstruction or fistula. Conclusion Results of this study show intraperitoneal (IP) tolerance to this kind of mesh and the safety of its fixation with Tissucol. The absence of recurrence and complications could be a good reason to extend the indication of IPOM hernia repair. However, these preliminary results should be confirmed by longer follow-up.     

Post streptococcal acute glomerulonephritis secondary to sporadic <Emphasis Type="Italic">Streptococcus equi</Emphasis> infection

Streptococcus equi subspecies zooepidemicus infection is rare in humans, but a well-known cause of pyogenic disease in cows and horses. S. zooepidemicus uncommonly causes post-strep glomerulonephritis (PSGN) in humans via epidemic outbreaks. We present a sporadic case of post S. zooepidemicus glomerulonephritis in a child most probably contracted from a horse. The 14-year-old girl presented with the typical signs of PSGN, with S. equi zooepidemicus isolated from a blood culture, together with a low C3 and raised anti-DNAse B. This is the first known report of a sporadic case of PSGN in a child caused by this organism.     

Facial Fractures in Kajang Hospital,Malaysia: A 5-Year Review

Abstract Objective: The objective of this study was to determine the demographic data as well as other relevant data pertaining to the management of patients with maxillofacial injury in a Malaysian government regional hospital. Study Design: Medical records of 313 patients who sustained maxillofacial injury treated in Kajang Hospital, Selangor, Malaysia over a 5-year period (1998–2002) were collected. Data regarding age, gender and race, etiology of injury, site of injury, other associated injuries and treatment undertaken were analyzed. Results: Two hundred and forty-nine male (79.6%) and 64 female patients (20.4%) were treated for maxillofacial trauma. The patients' age range from 1 to 67 years old, with a median age of 23 years old. A high number of Malays (60.1%) sustained maxillofacial injury, followed by Indians (16%), Chinese (13.4%) and other races (10.5%). Road traffic accident was the main etiology for maxillofacial injury with 230 cases (73.5%), followed by fall (16.6%), assault (5.4%), industrial accident (2.6%), sports injuries (0.6%) and others (1.3%). Mandibular fractures were the most common, occurring in 83.1% of the cases while the midfacial fractures accounted for 16.9%. Majority of patients were treated with closed reduction and intermaxillary fixation (88.1%) and 11.9% underwent open reduction and internal fixation. Conclusion: Road traffic accident involving motorcyclists was the main cause of maxillofacial trauma in Malaysia. The most common facial fracture was the mandibular fracture. Non-surgical manipulation of fracture was the most common treatment carried out in this hospital.