Long-term follow-up for superior vena cava filter placement

The short-term effectiveness and safety placement of superior vena cava (SVC) filter in the treatment of upper extremity deep venous thrombosis in patients with contraindication to anticoagulation have been well documented. However, as opposed to the numerous reported experiences with inferior vena cava filter placement and its complications, there has been no documented long-term follow-up on SVC filter placement. We, therefore, reviewed our experience with SVC filter placement. A retrospective review was performed of the 154 cases of patients who underwent SVC filter placement between January 1994 and August 2005 at our institution. Seven additional patients had unsuccessful SVC filter placement due to widespread deep venous thrombosis. The data were evaluated for both insertion complications (pneumothorax, hemorrhage, filter misplacement) and long-term complications (pulmonary embolism, migration, caval occlusion). The follow-up included review of serial chest radiographs to evaluate for filter migration in patients who lived at least 60 days after filter insertion and had chest radiography performed (n = 40), patients' charts, clinic visits, and telephone contacts, hospital databases, city death records, and national databases. There were 69 males and 85 females with a mean age of 73.6 years (range, 16-96 years; +/-15.3 [SD] years). Follow-up ranged from 1 day to 3750 days (256.3 +/- 576 days [mean +/- SD]) and 5 patients were lost to follow-up. Of the 154 patients, 58 survived longer than 60 days with mean follow-up of 628.4 days. All SVC filters (TrapEase, n = 38; Greenfield, n = 116) were successfully deployed in the 154 patients. During the follow-up, 114 (74.0% mortality) of the patients died of chronic illness or from cancer complications. There were three cases of pericardial tamponade (1.9%), and one case of misplaced filter in innominate vein. There were no known cases of symptomatic pulmonary embolism, caval occlusion, pneumothorax, or filter migration. SVC filter placement is associated with a low incidence of complications with long-term follow-up. These data help to reaffirm the safety and effectiveness of SVC filter placement. However, SVC perforation in young males remains a significant issue.     

Early and late outcomes of primary laparoscopic endorectal colon pull-through leaving a short rectal seromuscular sleeve for Hirschsprung disease

Aim

To report early and late outcomes of laparoscopic colon pull-through leaving a short rectal sleeve for Hirschsprung disease.

Methods

Laparoscopic endorectal colon pull-through was performed using 4 ports. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was carried out according to Georgeson's technique. However, we left a short rectal seromuscular sleeve of 1.5 to 2 cm above the dentate line.

Results

From January 2001 to December 2007, 200 patients were operated upon by the same surgeon. Ages ranged from 14 days to 36 months old. The aganglionic segment was located in the rectum in 112 patients, in the sigmoid colon in 80 children, and in the left colon in 8 patients. The median operating time was 152 minutes. There were no perioperative deaths. Conversion to open surgery was required in four patients. There was minimal blood loss during the surgery. Oral intakes of clear fluid were started 12 hours after surgery and advanced to formula on the second day. In 1 patient, a small intestinal perforation occurred 3 days after surgery, requiring a diverting ileostomy. The mean hospital stay was 6.6 days (range, 4-12 days). Follow-up ranging from 5 to 85 months was obtained in 157 patients; 124 patients (79%) had 1 to 4 defecations a day, 17 (11%) had 5 to 6, and 8 had more than 6. Fecal incontinence occurred in 3 patients (2.0%), constipation in 5 patients (3.0%), and enterocolitis in 15 patients (9.5%). Anastomotic fistula occurred in 2 patients.

Conclusion

Laparoscopic endorectal pull-through leaving a short rectal seromuscular sleeve is a safe and effective procedure for Hirschsprung disease.     

A Multi-institutional Analysis of Duodenal Neuroendocrine Tumors: Tumor Biology Rather than Extent of Resection Dictates Prognosis

Introduction

Duodenal neuroendocrine tumors (NETs) are rare neoplasms with poorly defined management. We sought to evaluate the outcomes of patients undergoing resection of duodenal NETs.

Methods

Using a multi-institutional database, 146 patients who underwent resection for duodenal NETs between 1993 and 2015 were identified. Data on clinicopathologic characteristics and outcomes were collected and analyzed.

Results

Local surgical resection (LR) was performed in 57 (39.0 %) patients, while 50 (34.3 %) patients underwent pancreaticoduodenectomy (PD) and 39 (26.7 %) patients an endoscopic resection (ER). Factors associated with worse RFS included advanced tumor grade and metastasis at diagnosis (both P?<?0.05) but not procedure type (P?>?0.05). Among patients who had at least one lymph node examined (n?=?85), 50 (58.8 %) had a metastatic lymph node; lymph node metastasis (P?=?0.04) and advanced tumor grade (P?=?0.04) were more common among patients with tumors >1.5 cm. Median length-of-stay was longer for PD versus LR (P?<?0.001). PD patients were at increased risk for severe postoperative complications (P?=?0.01).

Conclusion

Recurrence of duodenal NETs was dependent on tumor biology rather than procedure type. PD was associated with a longer hospital stay and higher risk of perioperative complications. For patients with tumors ≤1.5 cm, LR or ER may be appropriate with PD reserved for larger lesions and those not amenable to a more local approach.

     

Idiopathic sudden sensorineural hearing loss: a review

Idiopathic Sudden Sensorineural Hearing Loss (ISSHL) remains one of the major unsolved otologic emergencies. It is characterized by the onset of an unilateral sensorineural hearing loss developing within 24 hours, and averaging on pure tone audiogram at least 30 dB HL for three subsequent octave steps, with no marked vestibular symptoms and no identifiable cause. ISSHL is a syndrome covering several heterogeneous entities resulting from different pathogenetic mechanisms. At this time, the audiogram is the unique tool which may help clinicians to identify these entities and provide a classification based on 5 types of hearing loss. Numerous experimental and clinical studies have investigated the mechanisms by which infectious, ischemic, mechanic or immunologic insults may induce cochlear dysfunction. However, extrapolation to humans and rationale therapeutic approaches to ISSHL remain uncertain. SSHL being a diagnosis of exclusion, retrocochlear and neurologic etiologies should be eliminated. No argument allows to consider ISSHL a therapeutic emergency. More precisely, the experimental data presently available on cochlear physiology suggests that a treatment could have some chance to be effective if undertaken within minutes following the onset of ISSHL, a condition never encountered in daily practice. Conversely, it is not justifiable to impute the absence of hearing recovery to a delay in therapy. The various therapeutic strategies currently recommended are highly empirical and should be questionned in terms of cost-effectiveness, the most common being high-dose corticosteroids. New investigation tests are required for improving our approach to ISSHL.     

Is Hepatic Resection for Large or Multinodular Hepatocellular Carcinoma Justified? Results From a Multi-Institutional Database

Background The role of surgical resection in patients with large or multinodular hepatocellular carcinoma (HCC) remains unclear. This study evaluated the long-term outcome of patients with hepatic resection for large (>5 cm in diameter) or multinodular (more than three nodules) HCC by using a multi-institutional database.Methods The perioperative and long-term outcomes of 404 patients with small HCC (<5 cm in diameter; group 1) were compared with those of 380 patients with large or multinodular HCC (group 2). The prognostic factors in the latter group were analyzed.Results The postoperative complication rate (27% vs. 23%; P = .16) and hospital mortality rate (2.4% vs. 2.7%; P = .82) were similar between groups. The overall survival rates were significantly higher in group 1 than group 2 (1 year, 88% vs. 74%; 3 years, 76% vs. 50%; 5 years, 58% vs. 39%; P < .001). Among patients in group 2, five independent prognostic factors were identified to be associated with a worse overall survival: namely, symptomatic disease, presence of cirrhosis, multinodular tumor, microvascular tumor invasion, and positive histological margin.Conclusions Hepatic resection can be safely performed in patients with large or multinodular HCC, with an overall 5-year survival rate of 39%. Symptomatic disease, the presence of cirrhosis, a multinodular tumor, microvascular invasion, and a positive histological margin are independently associated with a less favorable survival outcome.     

Liver transplantation for chronic hepatitis B with lamivudine-resistant YMDD mutant using add-on adefovir dipivoxil plus lamivudine.

Lamivudine treatment in patients with chronic hepatitis B virus (HBV) infection may improve clinical state and suppress viral replication before liver transplantation. Emergence of lamivudine-resistant YMDD mutant is common. We report the results of liver transplantation in 16 patients with pretransplantation YMDD mutants after receiving lamivudine treatment for a median of 738 days (range, 400-1799 days). Adefovir dipivoxil (10 mg daily) was added on to lamivudine for a median of 20 days (range, 8-271 days) before (n = 11) or at (n = 5) liver transplantation, and the combination was continued indefinitely thereafter. Eight patients received additional intravenous hepatitis B immune globulin (HBIG) for a median of 24 months. Fifteen patients with known pre-adefovir HBV DNA levels had a median titer of 14,200 x 10(3) copies/mL (2 x 10(3) to 4,690,000 x 10(3) copies/mL), and 14 had HBV DNA >10(5) copies/mL. All but 1 patient remained positive for HBV DNA (by quantitative polymerase chain reaction [qPCR]) at the time of liver transplantation, and the titer was greater than10(5) copies/mL in 8 patients. The median follow-up after liver transplantation was 21.1 (range, 4.4-68.9) months. One patient (6%) died of an unrelated cause 12.2 months after transplantation, and 15 patients (94%) were alive with the original graft. All patients cleared HBV DNA and had no detectable HBV DNA by qPCR at the latest follow-up. Fourteen patients had cleared hepatitis B surface antigen (HBsAg), but 2 patients who received only adefovir dipivoxil and lamivudine without HBIG remained HBsAg positive after 7.7 and 9.5 months. Serum HBV DNA, however, was negative, and there was no biochemical or histological evidence of recurrence. Adefovir dipivoxil was well tolerated with no significant renal toxicity. In conclusion, a combination of add-on adefovir dipivoxil plus lamivudine therapy provides effective prophylaxis in patients with pretransplantation YMDD mutant that may be actively replicating. The cost effectiveness of additional passive immunoprophylaxis remains to be defined.     

不同施灸距离对人体体表皮肤温度的影响——论施灸的安全距离

目的:观察不同施灸距离对人体施灸局部皮肤温度的影响,为临床提供安全的施灸距离参数。方法:健康成年志愿者3名,用无药清艾条在足三里(右)和关元分别施行艾条温和灸和温灸盒灸,施灸距离分别为2cm、3cm和4cm。每次以艾条3cm燃尽为度。用红外热像仪系统记录储存热像图并进行分析处理,同样的试验第2天重复1次,将每穴每次测得的皮肤温度的平均值作为结果进行分析。结果:①关元温灸盒灸:施灸距离为4cm时,局部皮肤温度超过44℃[(44.1±1.3)～(46.7±1.5)℃)]的时间为7min;施灸距离为3cm时,局部皮肤温度超过44℃[(44.1±1.3)～(49.3±2.0)℃]的时间约为10min,超过49℃[(49.0±2.1)～(49.3±2.0)℃]的时间为2min;施灸距离为2cm时,因局部灼痛而不能进行观察。②足三里穴温和灸:施灸距离为4cm时,皮肤温度在(40.0±2.0)～(44.9±2.3)℃之间;距离足三里穴3cm处施灸时,皮肤温度在1min内即可上升超过44℃,并持续稳定在(45.9±3.0)～(47.8±2.0)℃之间;施灸距离为2cm时,同样因局部灼痛而不能进行观察。结论:施灸时,艾条距离皮肤越近,皮肤温度越高。在施行温和灸和温灸盒灸时,以艾条距皮肤的距离为3～4cm为宜。