No difference in postoperative complications,pain, and functional outcomes up to 2 years after incidental durotomy in lumbar spinal fusion: a prospective,multi-institutional,propensity-matched analysis of 1,741 patients

BackgroundIncidental durotomies occur in up to 17% of spinal operations. Controversy exists regarding the short- and long-term consequences of durotomies.PurposeThe primary aim of this study was to assess the effect of incidental durotomies on the immediate postoperative complications and patient-reported outcome measures.Study designProspective study.Patient sampleA total of 1,741 patients undergoing index lumbar spine fusion were selected from a multi-institutional prospective data registry.Outcome measuresPatient-reported outcome measures used in this study included back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), and Oswestry Disability Index.MethodsA total of 1,741 patients were selected from a multi-institutional prospective data registry, who underwent primary lumbar fusion for low back pain and/or radiculopathy between January 2003 and December 2010. We collected and analyzed data on patient demographics, postoperative complications, back pain, leg pain, and functional disability over 2 years, with risk-adjusted propensity score modeling.ResultsIncidental durotomies occurred in 70 patients (4%). Compared with the control group (n=1,671), there was no significant difference in postoperative infection (p=.32), need for reoperation (p=.85), or symptomatic neurologic damage (p=.66). At 1- and 2-year follow-up, there was no difference in patient-reported outcomes of back pain (BP-Visual Analog Scale), leg pain (LP-Visual Analog Scale), or functional disability (Oswestry Disability Index) (p>.3), with results remaining consistent in the propensity-matched cohort analysis (p>.4).ConclusionWithin the context of an on-going debate on the consequences of incidental durotomy, we found no difference in neurologic symptoms, infection, reoperation, back pain, leg pain, or functional disability over a 2-year follow-up period.     

胆管癌组织中信号转导及转录激活因子3信号通路相关基因的表达与意义

目的 探讨胆管癌组织中信号转导及转录激活因子3（STAT3）信号通路相关基因Survivin及环氧化酶2（COX-2）的表达及其与胆管癌患者临床病理特征和预后的关系.方法 收集2007年9月至2012年7月安徽医科大学附属省立医院收治的43例胆管癌患者的癌组织标本,收集同期行胆肠内引流术和胆管修复的12例肝内外胆管结石和胆管损伤患者的正常胆管组织标本作为对照.应用免疫组织化学染色检测胆管癌及正常胆管组织中STAT3、磷酸化STAT3（p-STAT3）、Survivin及COX-2蛋白的表达,并分析其与胆管癌患者临床病理特征和预后的关系.采用门诊或电话方式对胆管癌患者进行随访,随访时间截至2014年3月.计数资料采用x2检验,相关性分析采用Spearman检验.采用Kaplan-Meier法绘制生存曲线,生存分析采用Log-rank检验.结果 STAT3、p-STAT3、Survivin、COX-2蛋白在胆管癌组织中阳性表达率分别为69.8％ （30/43）、65.1％（28/43）、72.1％ （31/43）、79.1％（34/43）,在正常胆管组织中阳性表达率分别为41.7％（5/12）、8.3％（1/12）、16.7％（2/12）、41.7％（5/12）.p-STAT3、Survivin、COX-2蛋白在胆管癌组织中的阳性表达率显著高于正常胆管组织,两组比较,差异有统计学意义（x2=12.136,9.811,4.679,P＜0.05）.p-STAT3、Survivin、COX-2蛋白在胆管癌组织中的高表达与肿瘤局部浸润转移有关（x2=14.700,5.959,4.075,P＜0.05）;p-STAT3蛋白阳性表达与肿瘤神经侵犯有关（x2=10.384,P＜0.05）;Survivin、COX-2蛋白表达与胆管癌患者肿瘤神经侵犯无关（x2=2.718,3.024,P＞0.05）;p-STAT3、Survivin、COX-2蛋白表达与胆管癌患者性别、年龄、肿瘤位置、分化程度、肿瘤直径无关（x2=0.148,0.720,1.835,1.040,0.236;0.001,0.009,0.029,1.863,0.197;0.433,0.686,0.002,2.974,0.029,P＞0.05）.Survivin及COX-2蛋白的表达与p-STAT3呈正相关（r=0.524,0.583,P＜0.05）.43例胆管癌患者获得随访,随访时间为6个     

Assessment of the value of carcinoembryonic antigen reduction ratio as a prognosis factor in rectal cancer

Background

Carcinoembryonic antigen (CEA) is the most widely used tumor marker for colorectal cancer. This study aimed to investigate the role of CEA reduction ratio after preoperative chemoradiotherapy (CRT).

Methods

We enrolled 284 patients who underwent preoperative CRT followed by radical surgical resection. Patients were divided into 3 groups: serum CEA levels before CRT (pre-CRT CEA) less than 5 ng/mL (group 1); pre-CRT CEA of 5 ng/mL or more with CEA reduction ratio of 50% or more (group 2); and pre-CRT CEA of 5 ng/mL or more with CEA reduction ratio less than 50% (group 3).

Results

The 5-year disease-free survival (DFS) rate was not different between groups 1 (71.8%) and 2 (69.4%) but was signi?cantly lower in group 3 (49.5%). CEA group, lymph node status after CRT (ypN) stage, and histologic type were independent prognostic factors for DFS on multivariate analysis.

Conclusions

CEA reduction ratio might be an independent prognostic factor for DFS in rectal cancer patients treated with preoperative CRT and radical surgery.     

Early detection of peroneal neuropathy by ultrasound

A 12 year old boy presented with ankle sprain. The physical examination revealed mild weakness of ankle dorsiflexion. An ultrasound was done for the soft tissues of the ankle. In addition to relative atrophy of the peroneus longus muscle, a compressive common peroneal nerve (CPN) lesion with a synovial cyst at the level of the proximal tibiofibular joint (PTFJ) was accidently found. Since there were features of CPN compression by the synovial cyst, total excision of the cyst was performed. After the operation, muscle strength improved and the neurological deficit subsided. Therefore, the early diagnosis of PTFJ synovial cyst with nerve injury was crucial in order to achieve a better result. The obscure nature of clinical presentations can delay the diagnosis, which may potentially lead to a poor prognosis after treatment in such cases. This report highlights the fact that ankle sprain do need a thorough clinical work up in some cases.     

Effects of terlipressin on microcirculation of small bowel mesentery in rats with endotoxic shock

Background

Septic shock is still related to unacceptably high morbidity and mortality. Microcirculatory alteration has been demonstrated to be one important reason associated with this evolution. Vasoactive drugs are often used to restore adequate arterial pressure and tissue perfusion in septic shock. To define the roles of different drugs, the effects of terlipressin (TP) on the microcirculation of small bowel mesentery in rats with endotoxic shock were evaluated and compared with those of norepinephrine (NE).

Methods

Twenty-five adult male Wistar rats were randomized to the control (n = 5), TP (n = 10), and NE (n = 10) groups. After endotoxic shock was induced by intravenous lipopolysaccharide administration for 30 min, rats in the NE and TP groups were infused with saline 5 mL/kg/h and simultaneously given NE 4 μg/kg/min or TP 8 μg/kg/h. The mean arterial pressure, heart rate, blood gas analysis, and microvascular blood flow images of small bowel mesentery were recorded.

Results

After fluid resuscitation and vasopressor infusion, the mean arterial pressure was restored to the baseline values in the NE and TP groups. In the TP group, the heart rate was significantly lower compared with the NE group (P = 0.013). The proportion of perfused vessels and the microvascular flow index (MFI) were significantly increased; furthermore, the heterogeneity index of small vessels was markedly decreased in both the interventional groups with respect to the control group. Compared with the NE group, the MFI was significantly higher (P < 0.05) and the heterogeneity index was significantly lower (P < 0.05) in the TP group.

Conclusions

Both TP and NE improved hemodynamic and microcirculatory alterations in rats with endotoxic shock. Compared with NE, TP was more effective in promoting MFI and improving the heterogeneity of small bowel mesentery in rats.     

Repeated Introperative Cholangiography is Helpful for Donor Safety in the Procurement of Right Liver Graft with Supraportal Right Bile Duct Variants in Living-Donor Liver Transplantation

Background

Despite recent advances in preoperative diagnostic imaging and operative techniques, biliary variation of the donor still remains a challenge in the procurement of graft. The supraportal right bile duct (BD) variant including presentation as trifurcation is a potential trap for injuring the remnant bile duct of donor.

Methods

Before living/related-donor liver transplantation (LRLT), cholangiogram with magnetic resonance images of each donor was performed as a routine. After exploration of the donor before hilar dissection, intraoperative chloangiography (IOC) was routinely performed. Among the supraportal right bile duct variants, if the preoperative cholangiography showed a suspected trifurcation of the bile duct, we then performed 3 sessions of IOC during liver graft procurement, including prior to hilar dissection, before the division of bile ducts and after the division. We reviewed the cholangiogram and the postoperative laboratory data of a consecutive series of 25 donors of LRLT.

Results

There was no division injury of the remnant bile duct of all of the donors.

Conclusions

Repeated IOC is suggested as a routine for variants of supraportal right bile ducts especially trifurcation pattern in graft procurement to avoid the injury of donor remnant bile ducts.