Endoscopic ultrasonography and small‐bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small‐bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device‐assisted enteroscopy have quickly become the reference standard for the diagnosis of small‐bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up‐to‐date overview of the latest advances in endoscopic ultrasonography and small‐bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.     

Idiopathic Headache as a Possible Risk Factor for Phantom Tooth Pain

Following tooth pulp extirpation, some subjects suffer from persistent pain which affects edentate sites in absence of any local pathology. As regards this peculiar pain, called phantom tooth pain (PTP), what is puzzling is the fact there is a low prevalence of PTP in a very large population showing identical conditions of tooth pulp extirpation. The present investigation indicates that PTP mainly affects migraine (M) and cluster headache (CH) sufferers, whereas it does not affect subjects who have a negative personal and family history for idiopathic headache (IH). These results circumscribe the presence of PTP to a specific section of the population. The present results, besides indicating that PTP may be the result of a peculiar neuronal predisposition relating to IH pathogenesis, suggests some practical therapeutic hints. In fact, successful anti- M and anti-CH prophylactic treatment greatly improve PTP syndrome.     

Continuous mixed venous oximetry in critically ill surgical patients. 'High-tech' cost-effectiveness

Mixed venous oxygen saturation (Svo2) provides a measure of cardiorespiratory ability to meet the body's needs for oxygen. The Svo2 was measured continuously in 20 critically ill surgical patients using a pulmonary-artery oximetry system. The accuracy of the technique was validated by comparing initial continuous Svo2 to the laboratory determination of Svo2. Oximetry was used to guide therapeutic decisions regarding fluid, inotropic agents, vasodilators and ventilator setting and was useful in ten cases. Sepsis developed in nine patients; this severely limited the usefulness of the technique. With clinical decision making based on oximetry, there was a savings per catheter of 2.65 cardiac output determinations and 5.9 venous blood gas determinations, resulting in a net savings per catheter of +75.     

The risk of pneumonectomy over the age of 70. A case-control study.

OBJECTIVE: A higher mortality has been reported after pneumonectomy over the age of 70. The aim of the study was to quantify the additional risk due to age after standard pneumonectomy for lung cancer by a case-control study. METHODS: Our clinical database was reviewed to search for patients aged 70 years or more who underwent standard pneumonectomy for lung cancer between 1998 and 2005. A control group of patients younger than 70 (one case/two controls) was matched for sex, cardiovascular disease, American Association of Anaesthetists score, respiratory function, side of pneumonectomy, induction chemotherapy and stage. Overall mortality and morbidity were compared. Long-term survival data were also analysed. RESULTS: During the considered period, 35 patients aged 70 years or more underwent pneumonectomy (30 males, median age 73 years, 15 right-sided procedures). The control group was composed of 70 patients. The two groups were homogeneous in the variables used for matching. Overall mortality and morbidity were 11.4 and 54.2% in the elderly group as compared to 4.3 and 41.6% in controls (p-value not significant). Elderly patients experienced a higher rate of respiratory complications (25.7%) as compared to controls (8.3%, p=0.01). At univariate analysis, the only risk factor for death was the occurrence of respiratory complications (OR 6.5, CI 1.8-18.2). At multivariate analysis, age >or=70 years (OR 5.36, CI 1.48-19.3) and preoperative chemotherapy (OR 7.65, CI 2.04-28.6) were confirmed as predictors of respiratory complications. Five-year survival was 17.5% in the elderly group and 53.6% in the control group (p=0.003). Elderly patients with a better respiratory function (FEV1>70%) had a 5-year survival of 45.4%. CONCLUSIONS: In the elderly patients, the risk of respiratory complications after pneumonectomy is increased as compared to younger patients with equivalent respiratory function. Age and preoperative chemotherapy are independent risk factors for respiratory complications. A lower mortality and a better long-term survival are obtained in elderly patients with a better respiratory function (FEV1>or=70%).     

Segmental portal hypertension caused by splenic vein thrombosis

Seventeen cases of segmental portal hypertension due to splenic vein thrombosis are reported. This syndrome may be asymptomatic for a long time and then present suddenly in the form of a serious picture of high digestive haemorrhage due to rupture of gastric fundus varices as a result of hypertrophied submucous collateral drainage circulation. Useful for diagnosis are oesophagogastroduodenoscopy, which points to stomach varices, and splenoportography or splenic artery angiography with venous phase, which highlight pathognomonic dilatation and tortuosity of the gastroepiploic veins. Surgical exploration typically shows: presence of large epiploic vessels, splenomegaly, absence of changes in the liver and in the portal and mesenteric circulation. Curative treatment of choice is splenectomy.