Kyphoplastie in Kombination mit intraoperativer Radiotherapie

Background

Operative and radiotherapeutic procedures are available for the treatment of symptomatic vertebral metastases. The method for treatment of vertebral metastases presented in this article involves a combination of intraoperative radiotherapy (IORT) and kyphoplasty.

Methods and results

Kyphoplasty-IORT allows treatment of symptomatic vertebral metastases between vertebrae T3 and L5. With the patient under intubation narcosis an extrapedicular or bipedicular access to the vertebra is selected as for conventional kyphoplasty. This is followed by insertion of special sheaths of the radiation applicator and radiation therapy is intraoperatively administered via a radiation generator (Intrabeam®, Carl Zeiss Surgical, Oberkochen, Germany). The radiation dose is 8 Gy at a depth of 5–10 mm depending on the study protocol (50 kV X-radiation). Following radiation a conventional kyphoplasty procedure (Medtronic, USA) is carried out and the vertebra stabilized with cement.

Conclusions

The procedure presented demonstrates a new approach to treatment of vertebral metastases and represents a valuable alternative to previously established methods.     

Validation of the English Severe Respiratory Insufficiency Questionnaire

Assessment of health-related quality of life in patients with respiratory failure on home ventilation requires appropriate and highly specific measurement tools. We attempt to validate the English version of the Severe Respiratory Insufficiency Questionnaire (SRI). Psychometric properties of the SRI in 152 patients established on home ventilation were assessed. Cronbach's alpha ranged between 0.77 and 0.89 for the seven subscales and and was 0.93 for the summary scale. Principal components analysis revealed a one-factor solution for four and two factors for three subscales. Confirmatory factor analysis revealed a two-factor solution for six subscales, but these factors were dependent on each other. One factor was extracted out of the subscales confirming one summary scale accounting for 70% of the total variance. Correlation analysis between scales of the SRI and the Medical Outcome Study 36-item short-form health survey demonstrated highest correlations between comparable subscales. Chronic obstructive pulmonary disease patients had lower summary scale scores than patients with restrictive chest wall diseases, neuromuscular disorders and obesity hypoventilation syndrome. The English SRI has high internal consistency reliability, clearly established construct and concurrent validity, and is capable of differentiating between different diseases. It is now validated for use in research involving patients receiving home ventilation.     

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis

AIM:To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients. METHODS:Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n= 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were:technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney Utest and the χ 2 test as appropriate. RESULTS:No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P= 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival. CONCLUSION:RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.     

Improved laparoscopic treatment of symptomatic urachal anomalies

Purpose

Remaining urachal anomalies are seldom found but can result in long-standing recurrent symptoms and repeated surgery. In this single-centre study, we evaluated the laparoscopic approach of excision of the urachus leaving the umbilicus untouched.

Methods

Twenty-one patients were operated on for persisting symptomatic urachal anomalies between 1998 and 2011. Patients included 8 males and 13 females (mean 28.5 years, range 15–72 years). Patients’ histories, surgical data and demographic data were prospectively collected and analysed. During follow-up, patients were evaluated using the total body image and cosmesis questionnaire (BIQ).

Results

Excision of the urachus was carried out in 18 cases in a laparoscopic three-trocar technique and in 3 cases using single-site surgery. In all cases, the infected umbilicus was left untouched. Mean surgical time of all procedures was 55.7 min (31–106 min). Histopathology confirmed an urachal anomaly in all cases. The former discharging or infected umbilicus healed without any complications. Sixteen patients could be included for the BIQ. Total body image score after surgery was 5.49 with a score of 5.0 being the most satisfactory result possible. The total cosmetic score was 21.37 close to the maximum score of 24.

Conclusions

The laparoscopic treatment of urachal anomalies using a three-trocar technique or the single-site surgery technique is both safe and effective. In our opinion, the excision of the umbilicus should be avoided. It simplifies the procedure and leads to satisfactory cosmetic results.     

Randomized placebo‐controlled human pilot study of cold atmospheric argon plasma on skin graft donor sites

Cold atmospheric plasma has already been shown to decrease the bacterial load in chronic wounds. However, until now it is not yet known if plasma treatment can also improve wound healing. We aimed to assess the impact of cold atmospheric argon plasma on the process of donor site healing. Forty patients with skin graft donor sites on the upper leg were enrolled in our study. The wound sites were divided into two equally sized areas that were randomly assigned to receive either plasma treatment or placebo (argon gas) for 2 minutes. Donor site healing was evaluated independently by two blinded dermatologists, who compared the wound areas with regard to reepithelialization, blood crusts, fibrin layers, and wound surroundings. From the second treatment day onwards, donor site wound areas treated with plasma (n = 34) showed significantly improved healing compared with placebo‐treated areas (day 1, p = 0.25; day 2, p = 0.011; day 3, p < 0.001; day 4, p < 0.001; day 5, p = 0.004; day 6, p = 0.008; day 7, p = 0.031). Positive effects were observed in terms of improved reepithelialization and fewer fibrin layers and blood crusts, whereas wound surroundings were always normal, independent of the type of treatment. Wound infection did not occur in any of the patients, and no relevant side effects were observed. Both types of treatment were well tolerated. The mechanisms contributing to these clinically observed effects should be further investigated.     

Are Mammographic Changes in the Tumor Bed More Pronounced After Intraoperative Radiotherapy for Breast Cancer? Subgroup Analysis from a Randomized Trial (TARGIT‐A)

Intraoperative radiotherapy (IORT) with low‐energy x‐rays is increasingly used in breast‐conserving therapy (BCT). Previous non‐randomized studies have observed mammographic changes in the tumor bed to be more pronounced after IORT. The purpose of this study was to reassess the postoperative changes in a randomized single‐center subgroup of patients from a multicenter trial (TARGIT‐A). In this subgroup (n = 48) 27 patients received BCT with IORT, 21 patients had BCT with standard whole‐breast radiotherapy serving as controls. Overall 258 postoperative mammograms (median follow‐up 4.3 years, range 3–8) were retrospectively evaluated by two radiologists in consensus focusing on changes in the tumor bed. Fat necroses showed to be significantly more frequent (56% versus 24%) and larger (8.7 versus 1.6 sq cm, median) after IORT than those in controls. Scar calcifications were also significantly more frequent after IORT (63% versus 19%). The high incidence of large fat necroses in our study confirms previous study findings. However, the overall higher incidence of calcifications in the tumor bed after IORT represents a new finding, requiring further attention.     

Thoracoscopic lobectomy: is a training program feasible with low postoperative morbidity?

Objective

To evaluate the feasibility of training program in video assisted thoracic surgery (VATS) lobectomy comparing intraoperative and postoperative data of patients operated on by an established consultant and trainees.

Methods

Retrospective analysis of 100 consecutive patients who underwent VATS lobectomies between May 2008 and May 2012. 66 patients were operated on by an established consultant (Group A) and 34 by trainees (Group B).

Results

The groups were comparable for clinical characteristics and pathological staging. The mean operating time in Group A was 125 ± 30 min and in Group B was 133 ± 26 min (p = 0.18). The rate of conversion was similar in both groups: 9.1 % in Group A and 8.8 % in Group B (p = 0.6). The complication rate was comparable (p = 0.4): 36.3 % in Group A and 32.3 % in Group B. Median time to drain removal and median length of hospital stay was 3 and 5.5 days in Group A and 3 and 5 days in Group B, showing no statistical differences between the two groups (p = 0.3 and 0.5). There were no differences in term of long-term complications between the two groups.

Conclusion

Our study showed that a training program in VATS lobectomy is feasible, without increasing the operative time, conversion rate, postoperative complication, time to drain removal, and length of hospital stay.