Postbiopsy renal transplant arteriovenous fistulas: color Doppler US characteristics

Color Doppler ultrasound (US) with point-spectral analysis was performed on eight patients with postbiopsy renal transplant arteriovenous fistulas. Waveform analysis of the supplying artery documented decreased resistive indices in all cases and increased flow velocities in seven. The peak-systolic flow velocity in the arteries supplying the fistulas ranged from 55 to 180 cm/sec (mean, 92 cm/sec), while the range in normal arteries was 20-52 cm/sec (mean, 32 cm/sec). The resistive indices of the arteries supplying the fistulas ranged from 0.31 to 0.50 (mean, 0.45), while the resistive indices of the normal arteries ranged from 0.60 to 0.92 (mean, 0.74). Arterialization of the venous waveform from the draining vein was also documented in all cases. In six cases, the increased flow velocities resulted in increased color saturation toward white in the supplying artery (n = 2) or in both the artery and the draining vein (n = 4), which was detectable on the realtime image. In six cases, flow turbulence resulted in localized tissue vibration, which appeared as random color assignment in extravascular renal parenchyma adjacent to the fistula. Knowledge of these imaging and Doppler characteristics should aid in the identification of renal transplant arteriovenous fistulas with color Doppler US.     

A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery

This quantitative systematic review compared the efficacy and safety of ephedrine with phenylephrine for the prevention and treatment of hypotension during spinal anesthesia for cesarean delivery. Seven randomized controlled trials (n = 292) were identified after a systematic search of electronic databases (MEDLINE, EMBASE, The Cochrane Controlled Trials Registry), published articles, and contact with authors. Outcomes assessed were maternal hypotension, hypertension and bradycardia, and neonatal umbilical cord blood pH values and Apgar scores. For the management (prevention and treatment) of maternal hypotension, there was no difference between phenylephrine and ephedrine (relative risk [RR] of 1.00; 95% confidence interval [CI], 0.96-1.06). Maternal bradycardia was more likely to occur with phenylephrine than with ephedrine (RR of 4.79; 95% CI, 1.47-15.60). Women given phenylephrine had neonates with higher umbilical arterial pH values than those given ephedrine (weighted mean difference of 0.03; 95% CI, 0.02-0.04). There was no difference between the two vasopressors in the incidence of true fetal acidosis (umbilical arterial pH value of <7.2; RR of 0.78; 95% CI, 0.16-3.92) or Apgar score of <7 at 1 and 5 min. This systematic review does not support the traditional idea that ephedrine is the preferred choice for the management of maternal hypotension during spinal anesthesia for elective cesarean delivery in healthy, nonlaboring women. IMPLICATIONS: Phenylephrine and ephedrine to manage hypotension during spinal anesthesia for elective cesarean delivery were compared in this systematic review. Women given ephedrine had neonates with lower umbilical cord blood pH values compared with those given phenylephrine. However, no differences in the incidence of fetal acidosis (pH value of <7.2) or neonatal Apgar scores were found.     

Preference for donor site scar orientation in pedicled latissimus dorsi breast reconstruction

A survey was carried out to ascertain the preference for donor site scar orientation in patients undergoing pedicled latissimus dorsi breast reconstruction and their views on breast reconstruction in general. One hundred twelve women (59 Chinese, 53 Western) completed the questionnaire. Participants were asked to state their preferred scar orientation (i.e., oblique, horizontal, or vertical) based on photographs showing the position of the scars. Demographic information and views on issues surrounding breast reconstruction in general were also collected. Data was analyzed non-parametrically with chi-square test and t test. The mean age of participants was 39.5 years (20–73 years). Seventy-seven percent of the participants would opt for an immediate breast reconstruction if offered (p < 0.001). Eighty-six percent would have objection to the use of silicone implant as a whole or part of a reconstruction (p < 0.001). Vertical and horizontal scars were the preferred orientation, with no women choosing the oblique orientation as their first choice (p < 0.001). The non-Chinese of 40 years or older, as well as Chinese women from all age groups, preferred the horizontal scar (p < 0.05). We demonstrated that both culture and age impact on the preferred scar orientation in breast reconstruction. Women in the age group we commonly reconstruct favored the horizontal scar. However, the younger women of non-Chinese origin tended to favor the vertical scar.     

Multicenter Study of Robotic Thyroidectomy: Short-Term Postoperative Outcomes and Surgeon Ergonomic Considerations

Background  

Robotic thyroidectomy (RT) has recently emerged as a viable approach to thyroid surgery, resulting in better functional and cosmetic outcomes than afforded by open thyroidectomy (OT). The present multicenter study assessed the perioperative outcomes of RT and compared physician perspectives on the musculoskeletal ergonomic parameters associated with OT, endoscopic thyroidectomy (ET), and RT.     

Clinical analysis of thoracic ossified ligamentum flavum without ventral compressive lesion

The aim of this study was to analyze the clinical characteristics of thoracic ossified ligamentum flavum (OLF) and to elucidate prognostic factors as well as effective surgical treatment modality. The authors analyzed 106 thoracic OLF cases retrospectively from January 1999 to December 2008. The operative (n = 40) and the non-operative group (n = 66) were diagnosed by magnetic resonance imaging (MRI) and/or computed tomography (CT) imaging. We excluded cases exhibiting ventral compressive lesions causing subarachnoid space effacement in thoracic vertebrae as well as those with a coexisting cervical compressive myelopathy. Those in the operative group were treated with decompressive laminectomy as well as resection of OLF. The preoperative neurologic status and postoperative outcomes of patients, as indicated by their modified Japanese Orthopedic Association (mJOA) scores and recovery rate (RR), Modic changes, the axial (fused or non-fused) and sagittal (omega or beak) configurations of OLF, and the ratios of the cross-sectional area (CSA) and anteroposterior diameter (APD) of the most compressed level were studied. The most commonly affected segment was the T10–11 vertebral body level (n = 49, 27.1%) and the least affected segment was the T7–8 level (n = 1, 0.6%). The ratios of the CSA in non-fused and fused types were 77.3 and 59.3% (p < 0.001). When Modic changes were present with OLF, initial mJOA score was found to be significantly lower than those without Modic change (7.62 vs. 9.09, p = 0.033). Neurological status improved after decompressive laminectomy without fusion (preoperative vs. last mJOA; 7.1 ± 2.01 vs. 8.57 ± 1.91, p < 0.001). However, one patient exhibited transient deterioration of her neurological status after surgery. In the axial configuration, fused-type OLF revealed a significant risk for a decreased postoperative mJOA score (0–7, severe and moderate) (Odds ratio: 5.54, χ² = 4.41, p = 0.036, 95% CI: 1.014–30.256). The results indicated that the new categorization of axial-type of OLF is a helpful predictor of postoperative patient outcome and fused type was related with poor prognosis. In OLF cases free from ventral lesions compressing the spinal cord, decompressive laminectomy is enough for successful surgical outcome. Therefore, early surgical treatment will be considered in cases with fused-type OLF compressing spinal cord even though they do not have myelopathic symptoms.     

Diagnostic yield of MR-guided liver biopsies compared with CT- and US-guided liver biopsies

PURPOSE: To compare diagnostic yield and complication rates of magnetic resonance (MR)-guided versus computed tomography (CT)- and ultrasound (US)-guided liver biopsies. MATERIALS AND METHODS: MR-, CT-, and US-guided liver biopsies performed between 9/96 and 9/98 were compared. Sixty patients (21 men and 39 women, mean age 60 years) underwent MR-guided biopsy of liver lesions. Thirty patients (16 men and 14 women, mean age 59 years) underwent CT-guided biopsy. Eighteen patients (seven men and 11 women, mean age 50 years) underwent US-guided biopsy. MR procedures were performed in an open-configuration 0.5-T Signa SP MR unit. Lesion localization used standard T1 and T2 sequences, whereas biopsies were performed with multiplanar spoiled gradient recalled echo and fast gradient recalled echo sequences. A coaxial system with an MR-compatible 18-gauge stabilizing needle and a 21-gauge aspiration needle was used to obtain all samples. In CT and US procedures, a 19-gauge stabilizing needle and a 21-gauge aspiration or a 20-gauge core biopsy needle were used. A cytotechnologist was present to determine the adequacy of samples. RESULTS: MR had a diagnostic yield of 61%. CT and US had diagnostic yields of 67% and 61%, respectively. No serious complications were reported for MR and US procedures. Two CT biopsies resulted in postprocedural hemorrhage. One patient required surgical exploration and died. CONCLUSIONS: MR-guided biopsy of liver lesions with use of a 0.5-T open-configuration magnet is safe and accurate when compared with CT and US. No statistical difference was observed between the diagnostic yield of biopsies performed with MR, CT, and US guidance. MR enabled biopsy of a number of lesions in the hepatic dome and lesions with low contrast, which would normally be difficult to sample safely with use of CT or US.     

Management of misplaced or migrated endovascular stents.

PURPOSE: To report experience with techniques for management of misplaced or migrated endovascular stents. MATERIALS AND METHODS: During a 5-year period, percutaneous management of 27 misplaced or migrated endovascular stents (16 Palmaz, 11 Wallstents) in 25 patients was attempted. The 17 venous and 10 arterial stents were rescued from the aorta (n = 9), inferior vena cava (IVC) (n = 4), transjugular intrahepatic portosystemic shunt/IVC (n = 2), right atrium (n = 3), right ventricle (n = 2), pulmonary artery (n = 2), iliac vein (n = 2), iliac artery (n = 1), superior vena cava (n = 1), and superior mesenteric vein (n = 1). RESULTS: Stent management was successful in 26 of 27 cases (96%). Eleven stents were removed percutaneously, two were repositioned and removed with a minor surgical procedure, and 13 were repositioned and deployed in a stable alternate location. The only complication was the development of tricuspid insufficiency in the single case in which the procedure failed (4% complication rate). This patient's stent was eventually surgically removed from the right ventricle. CONCLUSION: Misplaced or migrated endovascular Palmaz and Wallstents can be effectively managed with few complications by using a variety of percutaneous techniques.     

Randomized controlled study of colloid preload before spinal anaesthesia for caesarean section

We randomized women having elective Caesarean section to receiveeither no preload (control group, n=33) or 4% gelatin solution(Gelofusine) 15 ml kg^–1 (colloid group, n=35)i.v. before spinal anaesthesia. Intravenous metaraminol wastitrated at 0.25–0.75 mg min^–1 to maintainsystolic arterial pressure (SAP) in the target range 90–100%of baseline after the spinal injection. The control group requiredmore vasopressor in the first 10 min [median 1.7 (range 0–2.9)mg vs 1.4 (0–2.8), P=0.02] at a greater maximum infusionrate [0.5 (0–0.75) vs 0.25 (0–0.5) mg min^–1,P=0.0005] and had a lower minimum SAP [90 (51–109) vs101 (75–127) mm Hg, P=0.006] than the colloid group. Nauseawas less frequent in the colloid group (6 vs 24%) but neonataloutcome was similar in the two groups. Colloid preload improvedhaemodynamic stability but did not affect neonatal outcome whenarterial pressure was maintained with an infusion of metaraminolduring spinal anaesthesia for Caesarean section. Br J Anaesth 2001; 87: 772–4     

Risk of developing metachronous colon neoplasm after polypectomy: comparison of one-stage versus two-stage polypectomy

Background

The impact of one-stage polypectomy (removal of all neoplasms during diagnostic colonoscopy) versus two-stage polypectomy (removal of all neoplasms during therapeutic colonoscopy following the initial diagnostic colonoscopy) on the development of metachronous neoplasms is poorly understood. Our aim was to compare the effects of one- versus two-stage polypectomy on the development of metachronous neoplasms

Methods

We retrospectively reviewed the medical records of 249 patients in a tertiary center who underwent one-stage polypectomy, which was followed by one or more surveillance colonoscopy. The development of metachronous neoplasm in this group was compared with that of an age- and sex-matched two-stage polypectomy group consisting of 498 patients

Results

In total, 346 (46.3 %) patients developed any metachronous neoplasm and 29 (3.9 %) patients developed advanced metachronous neoplasm. The 5 years cumulative incidences of any and advanced metachronous neoplasm were 46.2 and 5.0 %, respectively, in the one-stage group, which are not significantly different from the rates of 50.7 and 3.3 % in the two-stage group (p = 0.94 and 0.30, respectively). The only significant risk factor for developing any metachronous neoplasm was ≥3 neoplasms at the baseline polypectomy [hazard ratio (HR) 1.75; 95 % confidence interval (CI) 1.41–2.17; p < 0.001]. The only significant risk factor for developing advanced metachronous neoplasm was advanced neoplasm at the baseline polypectomy (HR 2.37; 95 % CI 1.16–4.84; p = 0.01). One- and two-stage polypectomy did not affect the development rates of metachronous neoplasm

Conclusions

The risks of developing metachronous neoplasm may be similar following one- and two-stage polypectomy.     

Atypical femoral fractures after anti-osteoporotic medication: a Korean multicenter study

Purpose

Increasing numbers of atypical femoral fractures have been reported among long-term bisphosphonate users. We evaluated clinical characteristics of atypical femoral fractures throughout Korean multicenter studies.

Methods

We retrospectively analysed the bone mineral density, prodromal symptoms before femoral fracture, and medication history of osteoporosis in 76 cases of atypical femoral fracture.

Results

The mean age of cases was 71.4 ± 8.8 (range, 43–89) years old. The mean follow-up period after the fracture operation was 24.5 ± 12.9 (range, 12–79) months. BMI was 23.2 ± 3.0 on average. The mean BMD of femur was −1.9 ± 1.4 (range, −4.8 to 1.3). Prodromal symptoms including thigh pain before femoral fracture appeared in 22 (28.9 %) of 76 patients. All patients included in the study used bisphosphonate. The duration of taking bisphosphonate before fracture was 36.8 ± 50.8 (one–204 months) months. Fifty-seven (75 %) of 76 patients were taking the medication for more than three years. Delayed union occurred in 43 (56.5 %) of 76 patients. Delayed union was defined as a fractured bone that did not completely heal within six months of injury. The group of having taken anti-osteoporotic medication for more than three years showed relatively longer union period compared to that for a shorter period medication group (4.8 ± 2.5 months vs 9.3 ± 3.7 months, p = 0.017). The delayed union developed in 43 (56.5 %) of 76 patients and showed a significantly higher incidence in the group with long-term therapy (five/43 vs 38/43, p = 0.021). The bilateral femoral fractures developed in 23 (30.2 %) of 76 patients and showed a high incidence in the group medicated more than three years (two/23 vs 21/23, p = 0.039).

Conclusions

The longer bisphosphonates are used, the more the cases of delayed union and the more frequent the development of bilateral fractures following unilateral fractures. With regard to the delayed union, the methods of the acceleration of fracture healing may be beneficial in atypical femoral fracture patients who had been receiving long-term bisphosphonates therapy. Careful observation is required for contra-lateral femurs due to a high incidence of bilateral atypical femoral fractures.