Endoclip Closure of Jejunal Perforation after Balloon Dilatation

Endoscopy is commonly used in patients undergoing Roux-en-Y gastric bypass (RYGBP) for diagnosis and intervention. Stomal stricture at the gastrojejunostomy occurs in approximately 3% to 17% of patients after laparoscopic RYGBP. The incidence of iatrogenic perforation during stomal balloon dilatation is reported to be 3% to 12% among these patients. Surgery has typically been required for iatrogenic perforation. With the availability of the endoclip, endoscopists are able to manage iatrogenic perforation non-operatively. We report a patient who had jejunal perforation during balloon dilatation after RYBGP, who was successfully closed with endoclip applications and managed non-operatively.     

Multicenter assessment of ultrasound of the spermatic cord in children with acute scrotum

PURPOSE: Intravaginal or extravaginal spermatic cord torsion is a diagnostic challenge for the surgeon and radiologist. Color Doppler sonography can be inaccurate, leading to dangerous false-negative results. To date, no single reliable test has been able to provide 100% diagnostic accuracy. The direct visualization of the twisted cord during emergency high resolution ultrasonography has been proposed to avoid systematic and abusive surgical exploration. The aim of this multicenter study was to assess the validity and reproducibility of high resolution ultrasonography based management of acute scrotum in children. MATERIALS AND METHODS: A total of 919 patients from 11 European university hospitals underwent color Doppler sonography and high resolution ultrasonography for acute scrotum between 1992 and 2005. The spermatic cord was studied along its complete length to detect a spiral twist. The surgical findings were correlated with the preoperative results. RESULTS: A total of 208 patients had spermatic cord torsion proved at surgery. Intratesticular vascularization was absent in the affected testis in only 158 cases (76%). In contrast, high resolution ultrasonography detected the twist as a snail shell-shaped mass, measuring 7 to 33 mm, in 199 patients (96%). High resolution ultrasonography revealed a linear cord for all other causes of acute scrotum (711 patients) with a specificity of 99%. The radiologist training level was the best predictive factor of high resolution ultrasonography reliability (p <0.05). CONCLUSIONS: High resolution ultrasonography based management of acute scrotum is reliable and reproducible. Thanks to its high sensitivity and specificity for the diagnosis of spermatic cord torsion, high resolution ultrasonography can significantly improve the management of acute scrotum in children.     

Perioperative beta-blocker therapy and heart rate control during noncardiac surgery

BACKGROUND: Perioperative treatment with beta-blockade is a widely advocated practice. We assessed the preoperative, intraoperative, and postoperative control of heart rate (HR) in patients who received beta-blockade as recommended during preoperative medicine clearance. METHODS: We conducted a retrospective review of patients who underwent noncardiac surgery from 2002 to 2004 at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, with recommendations of beta-blockade as part of their risk stratification. Demographic data and comorbid risk factors were collected on patients undergoing general anesthesia. All data were presented as mean +/- SEM. The chi-square test and analysis of variance were used for statistical analysis. RESULTS: A total of 130 patients referred for preoperative medicine clearance, who were risk-stratified based on comorbid conditions and risk of procedure, had beta-blockade started before elective surgery. Sixty percent (78 of 130) of the patients underwent high-/intermediate-risk surgery. The mean preoperative HR was 74 +/- 1 beat per minute (bpm). The mean intraoperative HR was 69 +/- 1 bpm. The mean postoperative HR was 84 +/- 1 bpm. There was a significant difference in the preoperative and intraoperative HR when compared with the postoperative HR (P < .003). There were no deaths at 30 days postoperatively. Perioperative cardiac morbidity occurred in 5.4% (7 of 130) of all patients (high patient risk, 71%; low patient risk, 29%; P < .05), and did not correlate with procedure risk. CONCLUSIONS: Beta-blockade is achieved sufficiently in the preoperative and intraoperative settings. However, attention to postoperative HR may be warranted to maintain the benefits of beta-blockade.     

A comparison of stemmed and unstemmed components in revision knee arthroplasty

The purpose of the current study was to compare retrospectively the results of the Insall-Burstein constrained condylar knee implant used with and without intramedullary stems in 207 revision knee arthroplasties with the Insall-Burstein constrained condylar knee implant. One hundred sixty-one knees had either one or two stems placed. One hundred eight femoral stems and 76 tibial stems were placed. Fifty-five knees had no femoral or tibial stem. The average knee scores ranged from 52 preoperatively to 86 postoperatively. The average range of motion postoperatively was 4 degrees (range, 0 degrees -10 degrees ) to 106 degrees (range, 94 degrees -118 degrees ) in this group. The average postoperative knee score was 86 in the unstemmed group and 85 in the stemmed group with no difference in average range of motion. There were four (3%) cases of tibial loosening and two (2%) cases of femoral loosening in the unstemmed group. There were two (2%) cases of tibial loosening and two (2%) cases of femoral loosening at an average followup of 4.2 years (range, 2-6.2 years). Despite the higher constraint inherently designed in an Insall-Burstein constrained condylar knee component, the current study did not show a significantly higher loosening in implants without stems compared with implants used with stems. Therefore, the use of a semiconstrained component does not alone constitute a requirement for the use of an intramedullary stem.     

The new “dual osteotomy”: combined open wedge and tibial tuberosity anteriorisation osteotomies

The high frequency with which medial compartment osteoarthritis is associated with patellofemoral osteoarthritis makes the addition of tibial tuberosity anteriorisation to high tibial osteotomy an appealing solution, despite the discouraging previously reported long-term results when tubercle anteriorisation was combined with a Coventry closed wedge technique. We conducted a prospective study of a new osteotomy combination: “the dual osteotomy”. An open wedge high tibial osteotomy was combined with 1- to 1.5-cm Maquet-like tibial tuberosity anteriorisation. Thirty-four knees in 30 patients underwent surgery, including ten knees in nine male patients and 24 knees in 21 female patients with a mean age of 45 years (age range 34−58 years). All patients had varus medial compartment osteoarthritis and patellofemoral osteoarthritis with preoperative anatomical tibiofemoral angle exceeding 5°. Twenty-four months after surgery, final evaluation detected improvement in the Knee Society clinical rating system function score from a mean of 61.3 (range 30−80) preoperatively to a mean of 87.3 (range 50−100) postoperatively and in the knee pain score from 27.3 (range 10−30) to 47 (range 30−50) postoperatively. Based on the rating system, at final follow-up, 70% of patients experienced no pain, 13% had mild or occasional pain, 10% had pain on stairs only, and 7% had pain during walking and on stairs. Anatomical tibiofemoral angles from 0 to 10° valgus were achieved in 91% of operated knees, and union was achieved in all cases within six to twelve weeks after surgery. The dual osteotomy was effective in the short term in cases of medial compartment osteoarthritis associated with patellofemoral osteoarthritis.     

Microleakage of glass ionomer formulations after erbium:yttrium-aluminium-garnet laser preparation

The aim of this study was to investigate the microleakage in class V cavities restored with four conventionally setting glass ionomers (CGIs) and one resin-modified glass ionomer (RMGI) following erbium:yttrium–aluminium–garnet (Er:YAG) laser or conventional preparation. Four hundred class V cavities were assigned to four groups: A and B were prepared by an Er:YAG laser; C and D were conventionally prepared. In groups B and D, the surface was additionally conditioned with Ketac conditioner. Each group was divided into five subgroups according to the glass ionomer cement (GIC) used: groups 1 (Ketac Fil), 2 (Ketac Molar), 3 (Ionofil Molar), 4 (Ionofil Molar Quick) and 5 (Photac Fil Quick). After thermocycling, a 2% methylene blue solution was used as dye. Scanning electron microscope (SEM) photographs were taken to show the conditioner’s effect. Complete marginal sealing could not be reached. PhotacFil showed less microleakage than the conventionally setting glass ionomer cements (CGICs) investigated. Conditioning laser-prepared cavities did not negatively influence microleakage results except for Ionofil Molar Quick.     

Robot assisted laparoscopic partial nephrectomy: initial experience

PURPOSE: Advances in laparoscopy have made laparoscopic partial nephrectomy a technically feasible procedure but it remains challenging to even experienced laparoscopists. We hypothesized that robotic assisted laparoscopic partial nephrectomy may make this procedure more efficacious than the standard laparoscopic approach. MATERIALS AND METHODS: Ten patients with a mean age of 58 years and mean tumor size of 2.0 cm underwent robotic assisted laparoscopic partial nephrectomy and another 10 with a mean age of 61 years and mean tumor size of 2.18 cm underwent laparoscopic partial nephrectomy, as performed by a team of 2 surgeons (MS and ST) between May 2002 and January 2004. Demographic data, intraoperative parameters and postoperative data were compared between the 2 groups. RESULTS: There were no significant differences in patient demographics between the 2 groups. Intraoperative data and postoperative outcomes were statistically similar. In the 10 patients who underwent robotic assisted laparoscopic partial nephrectomy there were 2 intraoperative complications. There was 1 conversion in the laparoscopic partial nephrectomy group. CONCLUSIONS: Robotic assisted laparoscopic partial nephrectomy is a safe and feasible procedure in patients with small exophytic masses. The robotic approach to laparoscopic partial nephrectomy does not offer any clinical advantage over conventional laparoscopic nephrectomy.     

Human papillomavirus (HPV)-related oropharyngeal nonkeratinizing squamous cell carcinoma: characterization of a distinct phenotype.

We have recently shown that HPV-positive tonsillar carcinoma in young patients exhibits nonkeratinizing basaloid morphology and a characteristic immunophenotype. The purpose of this study was to review a large number of cases of oropharyngeal carcinomas, in all age groups, and to identify tumors with nonkeratinizing morphology. Using polymerase chain reaction (PCR) the prevalence and type of HPV DNA was determined in representative cases and in a control group of conventional keratinizing squamous cell carcinomas. The tumors were further characterized with a panel of immunohistochemical stains. A total of 235 carcinomas were reviewed; 141 of the tonsils and 94 in the base of tongue. Ninety (36%) of the tonsillar and 30 (32%) of the base of tongue carcinomas were nonkeratinizing (NKCa) with basal cell features; the rest were classical keratinizing squamous cell carcinomas (KSCC). HPV DNA, particularly type 16, was identified in 10 (100%) of 10 of NKCA and in only 2 (20%) of 10 of KSCC (P = .0014). NKCas were strongly reactive to p16 antibodies while KSCC showed weak and focal reactivity. Higher Ki67 and lower p53 staining scores were observed in NKCa as compared to KSCC. It is concluded that NKCa of the tonsils and base of tongue is a distinct subtype of squamous cell carcinoma of the head and neck with high prevalence of HPV DNA and a characteristic immunophenotype.     

Impact of a novel education curriculum on surgical training within an academic training program

BACKGROUND: The training of the 21st century surgeon has become increasingly complex with the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements and work-hour restrictions. Herein we report the two-year results of a novel problem-based learning education module at a large academic surgery program. METHODS: All data were prospectively collected from 2004 to 2006 on all categorical residents in the department of surgery (n = 42). Analysis was performed to identify any correlation between class attendance and American Board of Surgery In-Service Training Exam (ABSITE) score performance (percentile change). All data were reported as a mean with a standard error of the mean. Categorical variables were analyzed using a paired Student's t-test. A bivariate correlation was calculated using Spearman's rho correlation. RESULTS: When comparing the 2004 scores (pre-program) to 2006 scores, there was significant score improvement (P 相似文献