The role of 99Tcm-sestamibi scintigraphy in the staging and prediction of the therapeutic response of stage IV neuroblastoma: comparison with 131I-MIBG and 99Tcm-MDP scintigraphy

In this study, we investigated prospectively the diagnostic role of 99Tcm-MIBI for staging and for predicting the therapeutic response of stage IV neuroblastoma compared with 131I-MIBG imaging and 99Tcm-MDP bone scintigraphy. Nine patients (4 girls and 5 boys aged 1-7 years) with suspected or proven stage IV neuroblastoma were studied with 99Tcm-MIBI at initial diagnosis and after 12-18 months of multidrug therapy. After the injection of 80 MBq.kg-1 99Tcm-MIBI, early (10 min) and delayed (1 h) images were obtained. The data were correlated with 131I-MIBG scans, bone scintigraphy, ultrasound, computed tomography and/or magnetic resonance imaging, and bone marrow biopsy. Eight of nine primary tumours and 41 metastatic lesions were detected by 131I-MIBG scintigraphy. None of the primary lesions demonstrated significant 99Tcm-MIBI accumulation. Sestamibi was positive in 16 of 41 MIBG-avid metastatic lesions. After six courses of multidrug chemotherapy, 30 131I-MIBI-avid neuroblastoma metastases that were 99Tcm-MIBI-negative at the time of diagnosis still did not show significant sestamibi accumulation. Follow-up demonstrated that all lesions that were 99Tcm-MIBI-avid at the time of diagnosis remained negative. Of these 16 lesions, seven were positive for 131I-MIBG accumulation with no reduction in size, and nine showed resolution after therapy. New metastatic foci detected by MIBG scintigraphy did not accumulate 99Tcm-MIBI. Clinical evaluation of patients with no 99Tcm-MIBI uptake in primary and secondary sites of neuroblastoma confirmed that they were resistant to multidrug chemotherapy. All 99Tcm-MIBI-positive lesions, irrespective of clinical outcome, demonstrated significant clearance of tracer on the delayed images. We conclude that 99Tcm-MIBI has no role in the staging of neuroblastoma. Sestamibi is a well-documented transport substrate for P-glycoprotein-related multidrug resistance and serial imaging may provide prognostic information on the therapeutic value of chemotherapy.     

False-negative scintigraphy with Tc-99m sestamibi in stage IV neuroblastoma.

Tc-99m sestamibi, originally developed for myocardial studies, has been used as a tumor-seeking agent. Recently, the agent also was reported to be a functional tracer to predict multidrug resistance-related p-glycoprotein expression in tumor tissue. The current report presents the authors' experience with sestamibi tumor scintigraphy in a neuroblastoma. Although I-131 MIBG tumor imaging and Tc-99m MDP bone scanning accurately demonstrated the extent of the disease, Tc-99m sestamibi showed no accumulation in primary and metastatic foci. Lack of sestamibi uptake was initially thought to be suggestive of failure to respond to chemotherapy because of p-glycoprotein expression. However, the patient responded well to chemotherapy and complete remission was achieved. The failure of Tc-99m sestamibi to detect a neuroblastoma and the lack of sestamibi accumulation in the tumor may not always be related to chemotherapy resistance.     

Biomechanical evaluation of paracoccygeal transsacral fixation

STUDY DESIGN: This is a biomechanical study using human cadaveric lumbar spine. OBJECTIVE: To evaluate the biomechanics of paracoccygeal transsacral rod fixation. SUMMARY OF BACKGROUND DATA: Various types of transsacral fixation either by posterior and paracoccygeal approaches have been described in the literature. The biomechanical advantage of transsacral rod fixation is the preservation of supporting structures at L5-S1 level. No biomechanical data on human cadavers have been reported in the literature. The aim of this study is to evaluate the biomechanics of the transsacral rod fixation. METHODS: Six fresh human cadaveric L5-S1 motion segments (mean age 67.5 y; range 46 to 82 y ) were used in the study. Unconstrained and nondestructive pure moments in axial torsion (AT), lateral bending (LB), and flexion-extension (FE) were applied to each specimen after applying transsacral rod and after additional augmentation methods, including bilateral screws, facet screws, and pedicle screw and rod system. Range of motion (ROM) was calculated for each surgical treatment. The disc space was measured with lateral plain radiographs of intact specimens and after transsacral rod insertion to evaluate the amount of distraction. RESULTS: The mean ROM of the intact specimens was 3.5, 6.4, and 11.0 degrees in AT, LB, and FE, respectively. Standalone transsacral rod reduced ROM more than 40% compared with the intact condition (P=0.002). Bilateral screws further reduced the ROM in AT (64%) and LB (70%), but not in FE (53%). Both facet screws and pedicle screw and rod system achieved high construct stability under all loading conditions. The transsacral rod augmented with facet screws reduced ROM by 70%, 80%, and 90% compared with the intact condition. When augmented with pedicle screw and rod system, the transsacral rod reduced ROM by 73%, 87%, and 88% in AT, LB, and FE, respectively. There was no statistical difference between these 2 facet screws and pedicle screw and rod system (P>0.8). CONCLUSIONS: Transsacral rod fixation provides strong ligamentotaxis due to intact annulus. Standalone transsacral rod is able to reduce ROM significantly and achieve indirect decompression by distracting L5-S1 disc space. However, additional posterior fixation, such as facet screws or pedicle screws, is required to achieve better construct stability for successful fusion.     

Impact of percutaneous nephrolithotomy on estimated glomerular filtration rate in patients with chronic kidney disease

BACKGROUND AND PURPOSE: We investigated the impact of percutaneous renal procedures on estimated glomerular filtration rate (GFR) of patients with chronic kidney disease (CKD). PATIENTS AND METHODS: The GFRs of adult patients were calculated using the Modification of Diet in Renal Disease formula, and the patients were staged according to the Kidney Disease Outcome Quality Initiative CKD classification system. The study included 185 patients with preoperative GFR values less than 60 mL/min/1.73 m(2). The impact of percutaneous nephrolithotomy (PCNL) on GFR was analyzed by comparing the preoperative GFR with the GFR before discharge and at postoperative month 3. RESULTS: Patients with CKD had a significant increase in the GFR after the procedure. In postoperative month 3, the mean GFR was more than 60 mL/min/1.73 m(2) in 25% of the patients with CKD and less than 60 mL/min/1.73 m(2) in 75%. While all patients with stage 5 CKD improved to better stages, some other patients' conditions declined to stage 5 from better stages at the end of postoperative month 3. No patient needed dialysis. The presence of urinary tract infections tended to affect GFR negatively. CONCLUSION: Estimated GFR, as a better indicator of renal function, is significantly affected by the PCNL procedure. While significant improvement was observed in late-stage patients with CKD, unexpected deterioration could occur in patients at earlier stages.     

Fluorodeoxyglucose positron emission tomography as an adjunct to carcinoembryonic antigen in the management of patients with presumed recurrent colorectal cancer and nondiagnostic radiologic workup

BACKGROUND: The purpose of this study was to determine the role of fluorodeoxyglucose positron emission tomography (PET) in localizing disease in patients with colorectal cancer with radiologically occult symptomatology or increases in carcinoembryonic antigen (CEA) level. METHODS: Two hundred seventy-seven patients with colorectal cancer underwent PET scanning between November 1998 and September 2000 prompted by (1) increasing CEA level and nondiagnostic imaging or (2) symptoms with normal CEA level and nondiagnostic imaging. PET results were correlated with operative findings/histology, clinical follow-up data, and CEA level to determine PET's accuracy in determining the source of symptoms or CEA. RESULTS: Fifteen patients had increasing CEA levels, and 14 had abnormal PET. Two of these 14 were denied exploration because PET suggested widely metastatic disease. Nine patients underwent exploration with curative intent. In 1 patient, recurrence was not pathologically confirmed (false-positive rate, 8%). Two had disease beyond that predicted by PET, and 6 underwent complete resection and normalized their CEA levels. Four symptomatic patients with normal CEA levels and negative x-rays had abnormal PET; at exploration, 3 had no evidence of recurrence. CONCLUSIONS: PET imaging can often accurately localize the source of radiologically occult increases in CEA level and select that subset of patients eligible for therapeutic laparotomy. Symptomatic, PET-positive patients with normal CEA levels frequently undergo nontherapeutic laparotomy, and PET findings should be interpreted with caution in these patients.     

Incisional Hernia in Recipients of Adult to Adult Living Donor Liver Transplantation

Background

After receiving a living donor liver transplant (LDLT), an incisional hernia is a potentially serious complication that can affect the patient’s quality of life. In the present study we evaluated surgical hernia repair after LDLT.

Materials and methods

Medical records of patients who underwent surgery to repair an incisional hernia after LDLT in Turgut Ozal Medical Center between October 2006 and January 2010 were evaluated in this retrospective study. A reverse-T incision was made for liver transplantation. The hernias were repaired with onlay polypropylene mesh. Age, gender, post-transplant relaparatomy, the type, the result of surgery for the incisional hernia, and risk factors for developing incisional hernia were evaluated.

Results

An incisional hernia developed in 44 of 173 (25.4 %) patients after LDLT. Incisional hernia repair was performed in 14 of 173 patients (8.1 %) who underwent LDLT from October 2006 to January 2010. Relaparatomy was associated with incisional hernia (p = 0.0002). The mean age at the time of the incisional hernia repair was 51 years, and 79 % of the patients were men. The median follow-up period was 19.2 (13–36) months after the hernia repair. Three patients with intestinal incarceration underwent emergency surgery to repair the hernia. Partial small bowel resection was required in one patient. Postoperative complications included seroma formation in one patient and wound infection in another. There was no recurrence of hernia during the follow-up period.

Conclusions

The incidence of incisional hernia after LDLT was 25.4 % in this study. Relaparatomy increases the probability of developing incisional hernia in recipients of LDLT. According to the results of the study, repair of an incisional hernia with onlay mesh is a suitable option.     

Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

Pyloric atresia associated with epidermolysis bullosa: report of two cases and review of the literature

The coexistence of pyloric atresia (PA) and epidermolysis bullosa (EB) is a rare but well-known surgical emergency in neonates. PA/EB is described by the association of atresia of the pylorus and bullous lesions on the skin. Ninety one cases have been reported in the literature to date. We present two new cases and evaluate the association of PA/ EB, its etiopathogenesis and the clinical properties. Case 1: A three-day-old female presented with nonbilious vomiting and bullous lesions 2-3 cm in diameter on the extremities. Abdominal X-ray showed a single air-fluid level in the left upper quadrant. At laparotomy, we found PA and performed a pyloro-pylorostomy. The patient died due to sepsis complication of EB two months after surgery. Case 2: A two-day-old male presented with severe dermal bullous lesions on the trunk, neck and extremities. His stomach was dilated and there was no gas distally. We found PA and performed gastroduodenostomy. Initially, he tolerated the feeding well, but he died due to severe sepsis on the postoperative 23rd day. Almost all neonates born with the PA/EB result in a fatal outcome in the first few years. The complications related to EB are usually the cause of death. Even after successful repair of PA, skin lesions lead to death due to infection.     

Minimally disruptive decompression and transforaminal lumbar interbody fusion.

BACKGROUND: Posterior spinal procedures through tubular exposures have been described. However, tubes restrain visibility and require co-axial instrument manipulation, increasing difficulty and potentially compromising surgical results. An independent-blade retractor system overcomes the obstacles of working through a tube and has been used to perform minimally-disruptive decompression and instrumented tranforaminal lumbar interbody fusion (TLIF). PURPOSE: To evaluate the advantages to patient recovery and surgical efficacy of this technique. METHODS/RESULTS: Retrospective review of technique employing a minimally-disruptive approach to decompression and transforaminal lumber interbody fusion (TLIF). CONCLUSIONS: Minimally-disruptive decompression and instrumented TLIF can be performed in a safe and effective manner using an independent-blade retractor system. Relative to traditional-open techniques, surgical goals can be accomplished, but with the benefits of minimally-disruptive surgery.     

A rare complication of lumbar disk surgery: Ureteral avulsion

A 49-year-old woman was admitted to our clinic with high fever, left lumbar pain and a mass at the flank following spinal surgery for disk disease. Complete left ureteral avulsion with urinoma formation was detected and she was treated with ureteroureterostomy. As in this case shows that the possibility of ureteral injury to the ureter during surgery for a disk hernia should be familiar to all neurosurgeons, orthopedic surgeons and urologists. When the diagnosis is made during early postoperative period, good results with preservation of the kidney can be achieved.