Management of Vascular Complications following Femoral Artery Catheterization with and without Percutaneous Arterial Closure Devices

Percutaneous arterial closure devices allow earlier mobilization and discharge of patients after arterial catheterization than with manual compression for puncture site hemostasis. We reviewed our recent experience managing the complications of femoral artery catheterization with and without these devices on the vascular surgery service at a tertiary hospital. Thirty-one patients presenting over an 18-month period with complications after femoral artery catheterization with manual compression (n = 21) or percutaneous arterial closure devices (n = 10) were retrospectively reviewed.     

Surgical sympathectomy for reflex sympathetic dystrophy syndromes

PURPOSE: The purpose of this study was the assessment of the efficacy of thoracoscopic cervicodorsal and open lumbar sympathectomy for the reduction of pain severity and disability associated with reflex sympathetic dystrophy (RSD). METHODS: From 1992 to 2000, 73 patients with RSD underwent 46 video-assisted thoracoscopic (first to fourth thoracic ganglion) or 37 surgical lumbar (first to fourth lumbar ganglion) sympathetic chain resections. The patients were referred from multidisciplinary pain clinics with documented sympathetically maintained pain syndrome on the basis of reproducible more than 50% reduction in pain severity score (0, no pain; 10, most severe pain imaginable) for more than 2 days after sympathetic block therapy. The mean duration of the RSD symptoms before sympathectomy was 26 plus minus 14 months (range, 6 to 100 months). Postoperative pain severity score, limb disability, and overall patient satisfaction were assessed by an independent third-party observer at a mean follow-up period of 30 months. RESULTS: No operative mortality or serious morbidity (Horner's syndrome, bleeding that needed transfusion, wound infection) occurred. Transient (<3-month) postprocedural sympathalgia developed in one third of the patients for cervicodorsal sympathectomy and 20% of the patients for lumbar sympathectomy and was treated effectively with trigger point/proximal ganglion block therapy or transcutaneous electrical nerve stimulation. At 3 months after sympathectomy, 10% of the patients had conditions that were judged treatment failures with no reduction in pain severity or limb disability. The remaining patients testified to more than 50% pain reduction, with pain severity scores decreasing from a mean of 8.7 before surgery to 3.4 after sympathectomy. At 1 year, one quarter of the patients had continued significant pain relief (pain severity score, <3) and an additional 50% of the patients indicated continued but reduced pain severity and an increase in daily/work activities. Overall, patient satisfaction (willingness to have procedure again, benefit from sympathectomy) was 77% and was not significantly influenced by patient age, RSD duration/stage, or extremity involvement (lumbar, 84%; cervicodorsal, 72%). CONCLUSION: Patients with RSD with a confirmed sympathetically maintained pain syndrome can realize long-term benefit from surgical sympathectomy. Procedural efficacy was similar for both upper limb and lower limb RSD syndromes, although the level of pain reduction did deteriorate with time. After sympathectomy, the patients with RSD had a low incidence rate (7%) of "new" complex regional pain or disabling compensatory sweating syndromes.     

Outpatient Laparoscopic Adjustable Gastric Banding in Super-obese Patients

Background Laparoscopic adjustable gastric banding (LAGB) is a safe and effective treatment for morbid obesity that is well suited to outpatient surgery. Super-obese patients (BMI ≥50) are often viewed as higher risk patients, with their surgical procedures limited to hospital operating-rooms. We report our experience performing LAGB for super-obese patients in a freestanding ambulatory surgery center and describe the program elements that make this feasible and safe. Methods Database records containing 1,780 consecutive patients from program inception (November 2002 to November 2006) were searched for patients with a BMI >49.9 undergoing an outpatient LAGB and reviewed to identify complications. Results 320 super-obese patients underwent an outpatient LAGB.Mean preoperative weight was 155.2 kg (range 112.3–220.5 kg), and mean BMI was 55.4 kg/m² (range 50.0–71.1 kg/m²). 53 patients (16.6%) had BMI >60. There were no deaths, significant cardiopulmonary complications, significant intraoperative bleeding, conversion to open laparotomy, or hospital admissions. 3 patients (0.1%) developed gastric edema causing transient obstruction, and 1 developed a delayed colon perforation from electrocautery incurred during adhesiolysis. No complication arose or was more difficult to manage as a result of the procedure being done on an outpatient basis. Conclusions Outpatient LAGB can be safely performed in super-obese patients with a complication rate similar to lower BMI patients. Patient selection and preoperative preparation are essential to achieve excellent outcomes. The decision to offer an outpatient LAGB should rest on the overall physiological condition rather than BMI or weight alone.     

The orally bioavailable met inhibitor PF‐2341066 inhibits osteosarcoma growth and osteolysis/matrix production in a xenograft model

Osteosarcoma (OS) is the most common primary bone tumor in children and adolescents. Ninety percent of patients who present with metastatic and 30% to 40% of patients with nonmetastatic disease experience relapse, creating an urgent need for novel therapeutic strategies. The Met receptor tyrosine kinase and its ligand, hepatocyte growth factor (HGF), are important for mitosis, motility, and cell survival. Upregulation of Met/HGF signaling via receptor overexpression, amplification, or mutation drives the proliferation, invasiveness, and metastasis of a variety of cancer cells, including OS, prompting the development of Met/HGF inhibitors. OS cells depend on Met overexpression because introduction of dominant‐negative Met inhibits in vivo tumorigenicity. Despite the importance of Met/HGF signaling in the development and maintenance of OS, the potential efficacy of pharmacologic Met inhibition in OS has been addressed only in in vitro studies. PF‐2341066 is an orally bioavailable, selective ATP‐competitive Met inhibitor that showed promising results recently in a phase I clinical trial in non–small cell lung cancer (NSCLC) patients. We tested the ability of PF‐2341066 to inhibit malignant properties of osteosarcoma cells in vitro and orthotopic xenograft growth in vivo. In vitro, PF‐2341066 inhibited osteosarcoma behavior associated with primary tumor growth (eg, proliferation and survival) as well as metastasis (eg, invasion and clonogenicity). In nude mice treated with PF‐2341066 via oral gavage, the growth and associated osteolysis and extracortical bone matrix formation of osteosarcoma xenografts were inhibited by PF‐2341066. PF‐2341066 may represent an effective new systemic therapy for localized and potentially disseminated osteosarcoma. © 2011 American Society for Bone and Mineral Research.     

Radial shortening following a fracture of the proximal radius

Background and purpose

The Essex-Lopresti lesion is thought to be rare, with a varying degree of disruption to forearm stability probable. We describe the range of radial shortening that occurs following a fracture of the proximal radius, as well as the short-term outcome in these patients.

Patients and methods

Over an 18-month period, we prospectively assessed all patients with a radiographically confirmed proximal radial fracture. Patients noted to have ipsilateral wrist pain at initial presentation underwent bilateral radiography to determine whether there was disruption of the distal radio-ulnar joint suggestive of an Essex-Lopresti lesion. Outcome was assessed after a mean of 6 (1.5–12) months using clinical and radiographic results, including the Mayo elbow score (MES) and the short musculoskeletal function assessment (SMFA) questionnaire. One patient with a Mason type-I fracture was lost to follow-up after initial presentation.

Results

60 patients had ipsilateral wrist pain at the initial assessment of 237 proximal radial fractures. Radial shortening of ≥ 2mm (range: 2–4mm) was seen in 22 patients (mean age 48 (19–79) years, 16 females). The most frequent mechanism of injury was a fall from standing height (10/22). 21 fractures were classified as being Mason type-I or type-II, all of which were managed nonoperatively. One Mason type-III fracture underwent acute radial head replacement. Functional outcome was assessed in 21 patients. We found an excellent or good MES in 18 of the 20 patients with a Mason type-I or type-II injury.

Interpretation

The incidence of the Essex-Lopresti lesion type is possibly under-reported as there is a spectrum of injuries, and subtle disruptions often go unidentified. A full assessment of all patients with a proximal radial fracture is required in order to identify these injuries, and the index of suspicion is raised as the complexity of the fracture increases.The Essex-Lopresti lesion is the eponym given to radio-ulnar instability caused by sequential injury to the distal radio-ulnar joint, the interosseous membrane, and fracture of the proximal radius (Essex-Lopresti 1951). The original paper by Essex-Lopresti suggested that this is a rare injury, with subsequent literature indicating that the lesion is present in approximately 1% of all radial head fractures (Essex-Lopresti 1951, Trousdale et al. 1992). A varying degree of force, in order to sustain such an injury, has been reported (Hotchkiss et al. 1989, Wallace et al. 1997).The diagnosis and treatment are challenging, with further imaging used when an unstable lesion is suspected (Starch and Dabezies 2001, Wallace 2002). When there is instability, open reduction and internal fixation or radial head replacement with added longitudinal stabilization of the forearm bones is recommended (Lewin 1973, Edwards and Jupiter 1988, Bruckner et al. 1996).A recent study has shown that the incidence of associated injuries following radial head fractures is high on MRI (Kaas et al. 2010). The purpose of our study was to describe the spectrum of radial shortening suggestive of an Essex-Lopresti lesion that occurs following a radial head or neck fracture, along with determining the short-term outcome in these patients.     

Loss of primary cilia upregulates renal hypertrophic signaling and promotes cystogenesis

Primary cilia dysfunction alters renal tubular cell proliferation and differentiation and associates with accelerated cyst formation in polycystic kidney disease. However, the mechanism leading from primary ciliary dysfunction to renal cyst formation is unknown. We hypothesize that primary cilia prevent renal cyst formation by suppressing pathologic tubular cell hypertrophy and proliferation. Unilateral nephrectomy initiates tubular cell hypertrophy and proliferation in the contralateral kidney and provides a tool to examine primary cilia regulation of renal hypertrophy. Conditional knockout of the primary cilia ift88 gene leads to delayed, adult-onset renal cystic disease, which provides a window of opportunity to conduct unilateral nephrectomy and examine downstream kinetics of renal hypertrophy and cyst formation. In wild-type animals, unilateral nephrectomy activated the mTOR pathway and produced appropriate structural and functional hypertrophy without renal cyst formation. However, in ift88 conditional knockout animals, unilateral nephrectomy triggered increased renal hypertrophy and accelerated renal cyst formation, leading to renal dysfunction. mTOR signaling also increased compared with wild-type animals, suggesting a mechanistic cascade starting with primary ciliary dysfunction, leading to excessive mTOR signaling and renal hypertrophic signaling and culminating in cyst formation. These data suggest that events initiating hypertrophic signaling, such as structural or functional loss of renal mass, may accelerate progression of adult polycystic kidney disease toward end-stage renal disease.     

Selective approach to use of upper gastroesophageal imaging study after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Many institutions routinely perform upper gastroesophageal imaging (UGI) studies on their laparoscopic Roux-en-Y gastric bypass (LRYGB) patients after surgery. We had routinely studied our patients with UGI on postoperative day 1 to rule out an anastomotic leak or obstruction, until recently when we abandoned this practice. As previously reported, we found that routine UGI did not contribute significantly to patient care. The purpose of this study was to determine whether patient outcomes were affected by this change in protocol. METHODS: From March 2004 to September 2005, 508 LRYGB cases were performed at our institution. Linear cutting staplers were used to create both the gastrojejunostomy and the jejunojejunostomy. In each case, the Roux limb was brought up in an antecolic, antegastric configuration. Before changing our protocol, 194 LRYGB cases were performed, and each patient underwent a routine UGI study (group 1). After abandoning this practice, 314 LRYGB cases were performed (group 2), and an UGI study was obtained only if clinical indicators (e.g., tachypnea, tachycardia, nausea, vomiting, low urine output, and/or abdominal pain) were present. The patient demographics, including gender, age, body mass index, length of hospital stay, and complications were recorded in our bariatric database and reviewed retrospectively. RESULTS: A postoperative UGI study was obtained in 204 patients--in 194 patients routinely (group 1) and in 10 patients because of clinical indications (group 2). No obstructions or leaks were found in any of these 204 patients. In group 2, 304 patients were discharged without an UGI series and did well without any leak or obstruction, except for 1 patient who returned 3 months postoperatively with a stricture at his jejunojejunostomy. No statistically significant differences were found between the 2 groups. CONCLUSION: The results of our study have shown that routine UGI studies after LRYGB do not contribute significantly to postoperative patient care at our institution. We now perform them selectively according to clinical indications, without this change adversely affecting our clinical outcomes.     

Duplex scan surveillance after carotid angioplasty and stenting: a rational definition of stent stenosis

OBJECTIVE: A duplex ultrasound (DUS) surveillance algorithm used after carotid endarterectomy (CEA) was applied to patients after carotid stenting and angioplasty (CAS) to determine the incidence of high-grade stent stenosis, its relationship to clinical symptoms, and the outcome of reintervention. METHODS: In 111 patients who underwent 114 CAS procedures for symptomatic (n = 62) or asymptomatic (n = 52) atherosclerotic or recurrent stenosis after CEA involving the internal carotid artery (ICA), DUS surveillance was performed 300 cm/s, diastolic velocity >125 cm/s, internal carotid artery stent/proximal common carotid artery ratio >4) involving the stented arterial segment prompted diagnostic angiography and repair when >75% diameter-reduction stenosis was confirmed. Criteria for >50% CAS stenosis was a PSV >150 cm/s with a PSV stent ratio >2. RESULTS: All 114 carotid stents were patent on initial DUS imaging, including 90 (79%) with PSV <150 cm/s (94 +/- 24 cm/s), 23 (20%) with PSV >150 cm/s (183 +/- 34 cm/s), and one with high-grade, residual stenosis (PSV = 355). During subsequent surveillance, 81 CAS sites (71%) exhibited no change in stenosis severity, nine sites demonstrated stenosis regression to <50% diameter reduction, and five sites developed velocity spectra of a high-grade stenosis. Angiography confirmed >75% diameter reduction in all six CASs with DUS-detected high-grade stenosis, all patients were asymptomatic, and treatment consisted of endovascular (n = 5) or surgical (n = 1) repair. During the mean 33-month follow-up period, three patients experienced ipsilateral, reversible neurologic events at 30, 45, and 120 days after CAS; none was associated with severe stent stenosis. No stent occlusions occurred, and no patient with >50% CAS stenosis on initial or subsequent testing developed a permanent ipsilateral permanent neurologic deficit or stroke-related death. CONCLUSION: DUS surveillance after CAS identified a 5% procedural failure rate due to the development of high-grade in-stent stenosis. Both progression and regression of stent stenosis severity was observed on serial testing, but 70% of CAS sites demonstrated velocity spectra consistent with <50% diameter reduction. The surveillance algorithm used, including reintervention for asymptomatic high-grade CAS stenosis, was associated with stent patency and the absence of disabling stroke.     

Progressive exercise for anabolism in kidney disease (PEAK): a randomized, controlled trial of resistance training during hemodialysis

Skeletal muscle wasting is common and insidious in patients who receive maintenance hemodialysis treatment for the management of ESRD. The objective of this study was to determine whether 12 wk of high-intensity, progressive resistance training (PRT) administered during routine hemodialysis treatment could improve skeletal muscle quantity and quality versus usual care. Forty-nine patients (62.6 +/- 14.2 yr; 0.3 to 16.7 yr on dialysis) were recruited from the outpatient hemodialysis unit of the St. George Public Hospital (Sydney, Australia). Patients were randomized to PRT + usual care (n = 24) or usual care control only (n = 25). The PRT group performed two sets of 10 exercises at a high intensity (15 to 17/20 on the Borg Scale) using free weights, three times per week for 12 wk during routine hemodialysis treatment. Primary outcomes included thigh muscle quantity (cross-sectional area [CSA]) and quality (intramuscular lipid content via attenuation) evaluated by computed tomography scan. Secondary outcomes included muscle strength, exercise capacity, body circumference measures, proinflammatory cytokine C-reactive protein, and quality of life. There was no statistically significant difference in muscle CSA change between groups. However, there were statistically significant improvements in muscle attenuation, muscle strength, mid-thigh and mid-arm circumference, body weight, and C-reactive protein in the PRT group relative to the nonexercising control group. These findings suggest that patients with ESRD can improve skeletal muscle quality and derive other health-related adaptations solely by engaging in a 12-wk high-intensity PRT regimen during routine hemodialysis treatment sessions. Longer training durations or more sensitive analysis techniques may be required to document alterations in muscle CSA.