Cuffed anastomosis for above-knee femoropopliteal bypass with a stretch expanded polytetrafluoroethylene graft

PURPOSE: To evaluate the patency and limb-salvage rates associated with cuffed anastomosis in above-knee femoropopliteal (FP) bypasses using prosthetic grafts. METHODS: Between January 1997 and December 2005, 96 patients (99 limbs) underwent above-knee FP bypass grafting for peripheral vascular disease, with disabling claudication in 81%. All grafts were 6-mm, thin-walled, ringed, expanded polytetrafluoroethylene (ePTFE) stretch grafts anastomosed to the above-knee segment of the popliteal artery in an end-to-side fashion, with a protruding area created around the anastomotic toe and an angle of less than 30 degrees between the graft and the artery. Postoperatively, graft patency was monitored by several objective methods. Patency and limb-salvage rates were calculated by actuarial methods and Kaplan-Meier analysis. RESULTS: The mean follow-up period was 40.4 months; 15 patients were lost to follow-up. The 1-, 3-, and 5-year primary graft patency rates were 94.5%, 88.2%, and 85.7%, respectively. The 1-, 3-, and 5-year secondary patency rates were 95.6%, 94.1%, and 90.8%. The 1-, 3-, and 5-year limb-salvage rates were 98.9%, 97.3%, and 97.3%. There were three graft infections. CONCLUSION: The use of a cuffed anastomosis in FP bypass with an ePTFE stretch prosthesis appears to increase graft patency rates.     

Use of “House” Advancement Flap in Anorectal Diseases

BACKGROUND: A retrospective review of 28 patients who had "house flap" anoplasty was carried out to evaluate the therapeutic effectiveness of the procedure. METHODS: House flap anoplasty was performed at Istanbul University Cerrahpasa Medical School, General Surgery Department, in 28 patients over 4 years. Indications were chronic anal fissure, anal stenosis, high transsphincteric fistula, low rectovaginal fistula, anal neoplasia, and obstetric third-degree perineal tear and incontinence. After rectangular excision of the anal or perianal lesion, the "walls" and "roof" of the house flap were incised to the depth of ischiorectal fat. The "base" of this house-shaped flap was then fixed to the top of the excised area. RESULTS: Median postoperative hospital stay was 4.86 (range = 2-12) days. Postoperative complications included three patients with minimal wound dehiscence and one with rectovaginal fistula recurrence. At a median follow-up of 26.4 (range = 1-46) months, excluding the patient with recurrence, all patients were satisfied with house flap anoplasty. CONCLUSION: House advancement flap anoplasty is a relatively simple procedure, combining the beneficial features of rectangular flaps and V-Y plasties. It can be used in nearly all types of anoderm deficiencies with a high rate of success and patient satisfaction.     

Retrorectal epidermoid cyst in an elderly woman: Report of a case

An epidermoid cyst is a common occurrence in the skin. Such a cyst occurring in the retrorectal space, however, is extremely rare. We herein present a case of retrorectal epidermal cyst in a 67-year-old Japanese woman. She reported no symptoms and a perirectal mass behind the lower rectum was accidentally detected by computed tomography (CT). Contrast CT and magnetic resonance imaging revealed a cystic mass (76 x 70 x 63 mm) with a slightly enhanced thin wall which was attached to the lower rectum. The patient underwent surgery via a posterior approach. The mass was exposed after an excision of subcutaneous fat and was firmly adhered to the anal sphincter muscle. The cystic mass was completely removed without a proctectomy. Histologically, the cyst was diagnosed to be an epidermoid cyst. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. A diagnosis of retrorectal cystic tumor is difficult, and a complete resection is necessary for the treatment of such tumors.     

Incidence and outcome of osteoporotic fractures in 2004 in Sado City,Niigata Prefecture,Japan

Osteoporotic fracture in elderly populations is increasing worldwide, but there are few data on the incidence and outcome of osteoporotic fractures, including upper extremity and vertebral fracture, during a certain period in a defined geographic area. The purpose of this study was to determine the incidence of osteoporotic fractures in a particular area: Sado City, Niigata Prefecture, Japan. From January to December 2004, osteoporotic fractures of the vertebra, hip, distal radius, and proximal humerus in Sado City were recorded. The incidence, age, gender, type of fracture (for hip fracture), right or left side (for distal radius, proximal humerus, and hip fracture), place of injury, cause of injury, outcome, hospitalization period, and patient status regarding taking of drugs for osteoporosis treatment were checked for each fracture. The incidence was calculated based on the whole population of Sado City. The incidence per 100,000 population was 232.8, 121.4, 108.6, and 37.1 for fractures of the vertebra, hip, distal radius, and proximal humerus, respectively. The total incidence of these four kinds of fracture was 499.9 per 100,000 persons per year. The average age at the time of injury was 81.4, 77.7, 75.7, and 60.2 years old for fractures of the hip, vertebra, proximal humerus, and distal radius, respectively. As the average age increased, the percentage of fractures that occurred indoors also increased; that is, a higher percentage of hip fractures occurred indoors, followed by fractures of the vertebra, proximal humerus, and distal radius. Most patients were not taking anti-osteoporosis drugs before fractures of the hip or vertebra. We determined the incidence of major osteoporotic fractures in 1 year in a defined geographic area. Our data showed that 81% of hip fracture patients also had a vertebral fracture and that the average age at the time of injury was higher for hip fractures than for vertebral fractures. Therefore, these results suggest that vertebral fracture leads to hip fracture, indicating that early fracture prevention and continuous prevention strategies through positive treatment are of importance in osteoporotic elderly people.     

Feasibility of Single-Stage Laparoscopic Resection After Placement of a Self-Expandable Metallic Stent for Obstructive Left Colorectal Cancer

BACKGROUND: The present study investigated the feasibility of a single-stage operation consisting of self-expandable metallic stent (SEMS) placement followed by laparoscopic surgery for obstructive left colorectal cancer. METHODS: From July 2002 to March 2007, 17 consecutive patients with primary obstructive left colorectal cancer underwent SEMS placement followed by laparoscopic surgery. Data were collected retrospectively regarding clinicopathological findings, SEMS placement, operative procedures, and perioperative outcomes. Technical success was defined as successful stent deployment across the obstructive lesion, and clinical success as the possibility of performing a single-stage operation without creating a stoma. RESULTS: In the laparoscopic group, the technical success rate was 100% (17/17) and there was no morbidity associated with SEMS placement. The median interval to laparoscopic surgery was 7 (range, 2-11) days, and the procedures included 11 anterior resections, 3 left hemicolectomies, 2 Hartmann's procedures, and 1 subtotal colectomy. All procedures were completed laparoscopically without conversion to open surgery. The median operating time was 178 (range, 93-377) minutes, and the median estimated blood loss was 100 (range, 50-400) ml with no cases requiring intraoperative transfusions. The clinical success rate was 82.4% (14/17), and there was no surgical morbidity other than two patients in whom chyloperitoneum and ileus were controlled by using conservative management. The median postoperative hospital stay was 9 (range, 7-49) days. CONCLUSIONS: A single-stage operation consisting of SEMS placement followed by laparoscopic surgery seems to be a feasible and safe treatment option for obstructive left colorectal cancer.     

Radiological and Pathological Assessment of Hepatocellular Carcinoma Response to Radiofrequency. A Study on Removed Liver after Transplantation

BACKGROUND: The real efficacy of radiofrequency ablation (RFA) in destroying hepatocellular carcinoma is not completely known, nor is the ability of computed tomography (CT) to precisely assess response. Our aims were to analyze pathological response, tumor size influence, and CT response evaluation. MATERIALS AND METHODS: This was a retrospective study of 30 hepatocellular carcinoma nodules treated by RFA before liver transplant (LT) in 28 patients. Pathological study of the whole removed liver was then performed and the tumor response was classified as complete, incomplete, or absent. The biggest nodule diameter was estimated by CT or ultrasound. The procedure was carried out percutaneously in all but 3 patients, and in those 3 it was done surgically. RESULTS: The pathological response was complete in 14 nodules (46.7%) and incomplete in 16 (53.3%). The differences in mean preoperative diameter between cases with complete and incomplete response were not significant (p = 0.3). We found that small tumors were not always completely destroyed, whereas bigger tumors could be successfully deleted. There was no clear association between any location and better or poorer response. The detection of RFA incomplete response by means of CT scan had 50% sensitivity and 100% specificity. CONCLUSIONS: In our experience, RFA can achieve some degree of tumor destruction in every treated case of hepatocellular carcinoma, the complete response rate being slightly lower than half. We have not found any association of response with tumor size or interval RFA-transplant. Second, CT had not enough sensitivity to assess RFA response of hepatocellular carcinoma.     

The comparative effects of sevoflurane versus isoflurane on cerebrovascular carbon dioxide reactivity in patients with previous stroke

PURPOSE: The use of volatile anesthetics is reportedly related to altered cerebrovascular carbon dioxide (CO2) reactivity. We examined the comparative effects of sevoflurane versus isoflurane on cerebrovascular CO2 reactivity in patients with previous stroke. METHODS: Twenty-four patients with previous stroke and 20 patients without previous stroke (serving as controls) were studied. Anesthesia was maintained with either end-tidal 1.0 minimum alveolar concentration (MAC) sevoflurane or 1.0 MAC isoflurane in 33% oxygen and 67% nitrous oxide. A 2.5-MHz pulsed transcranial Doppler (TCD) probe was attached to the patient's head at the right or left temporal window for continuous measurement of mean blood flow velocity in the middle cerebral artery (Vmca). After establishing baseline values of Vmca and cardiovascular hemodynamics, we increased end-tidal CO2 by decreasing the ventilatory frequency by 2-5 breaths x min(-1). RESULTS: We found that values for absolute and relative CO2 reactivity in the sevoflurane groups were lower than those in the isoflurane groups (absolute CO2 reactivity in the sevoflurane groups: control, 3.3 +/- 0.4*; previous stroke, 3.4 +/- 0.4*; absolute CO2 reactivity in the isoflurane groups: control, 4.2 +/- 0.3; previous stroke, 4.5 +/- 0.4, cm x s(-1) x mmHg(-1); *P < 0.05 compared with isoflurane group). There were no significant differences in the values for absolute and relative CO2 reactivity between the controls and the previous-stroke patients within each of the sevoflurane and isoflurane groups. CONCLUSION: Our findings suggest that, in patients with previous stroke, cerebrovascular CO2 reactivity under sevoflurane anesthesia was lower than that under isoflurane anesthesia.     

A new approach to the diagnosis of children’s urolithiasis based on the Bonn Risk Index

Published data on the association between calcium oxalate (CaOx) crystallization and kidney stone disease in children are scarce. The aims of this study were to determine CaOx crystallization using the Bonn Risk Index (BRI) in children with urolithiasis in comparison to healthy controls, to evaluate the relationships between BRI and urinary parameters, such as pH, calciuria, oxaluria and citraturia, and to assess the association between BRI and the size of renal stones. We compared the BRI in 142 Caucasian children and adolescents (76 girls, 66 boys) aged 3-18 years with kidney stones and 210 healthy age- and sex-matched controls without urolithiasis. Urinary ionized calcium ([Ca2+]) was measured using a selective electrode, while the onset of spontaneous crystallization was determined using a photometer and titration with 40 mmol/L ammonium oxalate (Ox2-). The calculation of the BRI value was based on the Ca2+:Ox2- ratio. High-resolution renal ultrasonography was carried out to estimate the size of the renal stones. The BRI values were 15-fold higher in children with renal stones than in healthy children without stones. The same trend was shown by BRI/kg body weight (tenfold greater in children with renal stones than in healthy children without stones), BRI/per 1.73 m2 body surface (13-fold greater) and BRI/body mass index (23-fold greater). No association was observed between BRI and the diameter of stones. Children with kidney stones, both males and females, had an increased BRI compared with subjects without urolithiasis. High BRI suggests an association with lower urinary pH, hypercalciuria, hyperoxaluria or hypocitraturia, which are all risk factors of kidney stones. An increased BRI in children, although unrelated to renal stone size, reflects the risk of calcium oxalate crystallization and may indicate early metabolic disorders leading to urolithiasis.     

Endoscopic Evaluation of the Quality of the Anastomosis After Esophagectomy with Gastric Tube Reconstruction

BACKGROUND: The morbidity and mortality of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux continue to burden patients jeopardizing their quality of life. In the present study we performed endoscopic evaluation of the outcomes of esophagogastrostomy by analyzing the presence of anastomotic stenosis and reflux esophagitis. METHODS: A retrospective analysis was carried out on 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. Fifty-three patients had an endoscopic examination during follow-up (29 +/- 23.6 months, range = 5-111 months). Reflux esophagitis and stenosis at the anastomostic site were analyzed according to the surgical technique used and the location of the esophagogastrostomy. RESULTS: The mean age at the time of repair was 60.3 +/- 8.87 (range = 39-81) years. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in the frequency of anastomotic stenosis was observed between the two groups (p = 0.829); reflux esophagitis was noted in three patients in the cervical anastomosis group and in 14 patients in the intrathoracic anastomosis group (p = 0.041). For all patients, 23 received a hand-sewn esophagogastric anastomosis and 30 a circular stapled one. There was no significant statistical difference in anastomotic stenosis (p = 0.689) and reflux esophagitis (p = 0.879) in comparisons between the two groups. CONCLUSION: Cervical anastomosis resulted in a better outcome for esophagogastrostomy by lowering the risk of reflux esophagitis; this outcome might improve the patient's quality of life.     

Prognostic Factors and Availability of D2 Lymph Node Dissection for the Patients with Stage II Gastric Cancer: Comparative Analysis of Subgroups in Stage II

BACKGROUND: According to the fifth edition of the UICC TNM classification, stage II gastric cancer has three subgroups: T1N2M0, T2N1M0, and T3N0M0. This study was designed to investigate the prognosis of stage II gastric cancer according to the T and N category to verify the accuracy of TNM staging for stage II and to determine the prognostic factors for patients with stage II gastric cancer by subgroup. METHODS: Clinicopathologic data from 326 patients with stage II gastric cancer were studied. We stratified the patients into T2N1 and T3N0 groups and performed comparative analysis between the two groups as well as univariate and multivariate survival analyses for each group. RESULTS: The five-year survival rate for patients with T2N1 disease was 75.6%, whereas for patients with T3N0 disease it was 68.3%. There was no significant difference in survival between T2N1 and T3N0 groups (p = 0.174). Univariate survival analysis showed that age, gender, histological type, and the extent of lymph node dissection were significant prognostic factors for stage II gastric cancer. However, multivariate analysis demonstrated that only gender and the extent of lymph node dissection were significant variables. Among these variables, gender was an independent prognostic factor for survival only in the T2N1 group. On the other hand, the extent of lymph node dissection was an independent prognostic factor in the T3N0 group, not in the T2N1 group. CONCLUSIONS: There was no significant difference in survival between the T2N1 and the T3N0 groups. Thus, our data support the accuracy of the TNM staging classification for stage II gastric cancer. We found a significant survival benefit with D2 dissection for T3N0 but not T2N1. However, before recommending limited lymph node dissection for T2N1 stage disease, development of a preoperative method for prediction of depth of invasion and lymph node status is needed.