Ultrastructural changes of the internal limiting membrane removed during indocyanine green assisted peeling versus conventional surgery for idiopathic macular epiretinal membrane.

PURPOSE: To evaluate the histologic features of cellular retinal fragments on the internal limiting membrane (ILM) removed during idiopathic macular epiretinal membrane (MEM) peeling surgery with and without the aid of indocyanine green (ICG) diluted in 5% glucose. METHODS: ILM specimens removed from 88 eyes during idiopathic MEM surgery between 1995 and 2003 were reviewed retrospectively. Histologic analysis focused on the presence and characteristics of retinal fragments on the retinal surface of the ILM. Statistical analysis compared the results between group I (conventional surgery) and group II (ICG-assisted peeling). RESULTS: Seventy-one eyes underwent MEM surgery without the aid of ICG (group I) and seventeen underwent MEM ICG-assisted surgery (group II). The amount of Müller cell debris on the retinal surface of the ILM was more significant in the group I than in the group II (40.8 vs. 11.8; P = 0.024). Large fragments of Müller cells were more frequently observed in the group I (no ICG) than in the group II (ICG) (63.4 vs. 23.5%; P = 0.003). CONCLUSIONS: The use of ICG diluted with 5% glucose in ILM removal during MEM surgery was associated with less retinal debris attached to the retinal face of the ILM compared with surgery in which ICG was not used.

Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy.

BACKGROUND: Pancreatic fistula (PF), which is a major complication of pancreaticoduodenectomy (PD), can be treated conservatively or by reoperation. The aim of this study was to evaluate conservative management of PF, which was attempted whenever possible as a first-intention treatment in a large series of PD. STUDY DESIGN: From 1990 to 2000, 242 patients underwent PD with pancreaticogastrostomy. PF was observed in 31 (13%) and was defined by an amylase-rich surgical drainage fluid (above fivefold serum amylase) after postoperative day 5, or by presence on CT scan of a fluid collection located close to the anastomosis or containing amylase-rich fluid, or by operative findings in case of reoperation. Conservative management included total parenteral nutrition, nasogastric suction, imaging-guided percutaneous drainage of collection when necessary, and somatostatin or its analogues. RESULTS: PF was symptomatic in 20 patients (65%). Amylase level on surgical drainage fluid was elevated in 23 patients (74%). Four patients (13%), including two with hemorrhage and two with intraabdominal collection not accessible by percutaneous approach, were not considered for conservative management and underwent early reoperation. Conservative management was successful in the 27 patients (100%) in whom it was attempted, including the 10 who required percutaneous drainage. The only death (3%) occurred after massive hemorrhage complicating misdiagnosed PF. Mean hospital stay was 36 +/- 12 days (range 18 to 71) after successful conservative management. CONCLUSIONS: Conservative management of PF complicating PD is feasible and successful in above 85% of patients.

Management of transitional-cell carcinoma of the renal pelvis and ureter.

Transitional-cell carcinoma of the renal pelvis or ureter is a relatively rare disease. Several risk factors are smoking, occupational carcinogens, analgesic abuse or Balkan nephropathy. The grade and stage of the disease have the most significant impact on the outcome. The treatment of renal pelvis and ureter tumours is open or laparoscopic surgery varying from conservative to more extensive surgical procedures, i.e. radical nephroureterectomy including removal of the contents of Gerota's fascia with ipsilateral ureter and a cuff of bladder at its distal extent. Most available data are from retrospective studies and surgery is the mainstay of treatment. Chemotherapy and/or radiation therapy are possible adjuvant or primary treatment for selected patients; however, prospective studies are needed to confirm their use.

Nouvelles options dans le traitement de l'incontinence ano-rectale [New options in the treatment of ano-rectal incontinence]

Ano-rectal incontinence is known to affect about 2% of the population. Main risk factors are traumatic delivery and previous anal surgery. All patients should have a trial of conservative treatment. Patients with major external anal sphincter defect have a 70 to 80% improvement of their symptoms after an overlap sphincter repair Unfortunately, these results deteriorate over time. Sacral nerve modulation improves continence and quality of life in 75 to 100% of patients with various aetiologies. In case of idiopathic internal sphincter degeneration, sphincter augmentation with bulking agents seems to be the least expensive option.

Isolated limb perfusion with tumor necrosis factor and melphalan for non-resectable soft tissue sarcomas: long-term results on efficacy and limb salvage in a selected group of patients

Background And Objectives: Isolated limb perfusion with TNF-alpha and melphalan (TM-ILP) is a limb salvage therapy for non-resectable soft tissue sarcomas (STS) of the extremities. It is indicated for patients for whom amputation or debilitating surgery is the only alternative. It can be used either as an exclusive therapy (in palliation) or as a neo-adjuvant treatment, followed by marginal resection of tumor remnants with minimal functional impairment. Methods: Between February 1992 and March 2006, 57 TM-ILPs were performed on 51 patients with 88% high grade and 84% advanced stage tumors. Results: Mean follow-up is 38.9 months (4-159, median 22 months). Twenty-one percent patients had significant early complications, with 3 major re-operations, and 23% suffered long-lasting complications. Complete response was observed in 25%, partial response in 42%, stable disease in 14% and progressive disease in 14%. Resection of the tumor remnants was possible in 65%. A complementary treatment was necessary in 31%, mostly radiation therapy. A local recurrence was observed in 35%, after a mean of 20.3 months (2-78), and distant relapse was seen in 45%, after a mean of 13.4 months (5-196). Mean Disease-free survival was 14.9 months, and overall 5-year-survival 43.5%. Amputation rate at 5 years was 24%. Conclusions: TM-ILP is a conservative treatment with a high complications rate, but it can be successful even for the most severe STS of extremities. As a consequence the limb can be spared from amputation or debilitating surgery on the long term in about 75% of patients

Three short perioperative infusions of n-3 PUFAs reduce systemic inflammation induced by cardiopulmonary bypass surgery: a randomized controlled trial.

BACKGROUND: Fish oil (FO) has antiinflammatory effects, which might reduce systemic inflammation induced by a cardiopulmonary bypass (CPB). OBJECTIVE: We tested whether perioperative infusions of FO modify the cell membrane composition, inflammatory responses, and clinical course of patients undergoing elective coronary artery bypass surgery. DESIGN: A prospective randomized controlled trial was conducted in cardiac surgery patients who received 3 infusions of 0.2 g/kg FO emulsion or saline (control) 12 and 2 h before and immediately after surgery. Blood samples (7 time points) and an atrial biopsy (during surgery) were obtained to assess the membrane incorporation of PUFAs. Hemodynamic data, catecholamine requirements, and core temperatures were recorded at 10-min intervals; blood triglycerides, nonesterified fatty acids, glucose, lactate, inflammatory cytokines, and carboxyhemoglobin concentrations were measured at selected time points. RESULTS: Twenty-eight patients, with a mean ± SD age of 65.5 ± 9.9 y, were enrolled with no baseline differences between groups. Significant increases in platelet EPA (+0.86%; P = 0.0001) and DHA (+0.87%; P = 0.019) were observed after FO consumption compared with at baseline. Atrial tissue EPA concentrations were higher after FO than after control treatments (+0.5%; P < 0.0001). FO did not significantly alter core temperature but decreased the postoperative rise in IL-6 (P = 0.018). Plasma triglycerides increased transiently after each FO infusion. Plasma concentrations of glucose, lactate, and blood carboxyhemoglobin were lower in the FO than in the control group on the day after surgery. Arrhythmia incidence was low with no significant difference between groups. No adverse effect of FO was detected. CONCLUSIONS: Perioperative FO infusions significantly increased PUFA concentrations in platelet and atrial tissue membranes within 12 h of the first FO administration and decreased biological and clinical signs of inflammation. These results suggest that perioperative FO may be beneficial in elective cardiac surgery with CPB. This trial was registered at clinicaltrials.gov as NCT00516178.

Are patients at nutritional risk more prone to complications after major urological surgery?

PURPOSE: The nutritional risk score is a recommended screening tool for malnutrition. While a nutritional risk score of 3 or greater predicts adverse outcomes after digestive surgery, to our knowledge its predictive value for morbidity after urological interventions is unknown. We determined whether urological patients at nutritional risk are at higher risk for complications after major surgery than patients not at nutritional risk. MATERIALS AND METHODS: We performed a prospective observational study in consecutive patients undergoing major surgery. A priori sample calculation resulted in a study cohort of 220 patients. Interim analysis was planned after 110 patients. The nutritional risk score was assessed preoperatively by a specialized study nurse. Nutritional care was standardized in all patients. Postoperative complications were defined previously using the standardized Dindo-Clavien classification. The primary end point was 30-day morbidity. Univariate and multivariate analysis was performed to identify predictors of complications. RESULTS: The study was discontinued due to significant results after interim analysis. A total of 125 patients were included in analysis from June 2011 to June 2012 and 15 were excluded because of incomplete data. Of 51 patients at nutritional risk 38 (74%) presented with at least 1 complication compared to 28 of 59 controls (47%). Patients at nutritional risk were at threefold risk for complications on univariate and multivariate analysis (OR 3.3, 95% CI 1.3-8.0). Cystectomy was the only other predictor of morbidity (OR 10, 95% CI 2-48). CONCLUSIONS: Patients at nutritional risk are more prone to complications after major urological procedures. Whether this increased morbidity can be reversed by perioperative nutritional support should be studied.

Non-functioning pituitary macro-incidentalomas benefit from early surgery before becoming symptomatic.

OBJECTIVE: Pituitary incidentalomas (PIs) constitute an increasingly clinical problem. While the therapeutic management is well defined for symptomatic non-functioning PIs (NFPIs), a controversy still exists for asymptomatic macro-NFPIs between surgery and a "wait and see" approach. The aim of this study is to compare surgical results between symptomatic and asymptomatic macro-NFPIs. METHODS: We conducted a retrospective study on 76 patients with newly diagnosed symptomatic and asymptomatic macro-NFPIs operated on between 2001 and 2010. We compared age, tumor size and surgical results between these two patient groups. RESULTS: After the initial evaluation, 48 patients were found to be symptomatic. Gross total removal (GTR) rate was significantly higher in asymptomatic (82%) than in symptomatic patients (58%; p=0.03). Gross total removal was strongly associated with Knosp's classification (p=0.01). Postoperative endocrinological impairment was significantly associated with the existence of preoperative symptoms (p=0.03). It was 10 times less frequent in the asymptomatic group. In symptomatic patients, postoperative visual and endocrinological impairment were present in 49% and 78% versus 0% and 14% in asymptomatic patients respectively. CONCLUSIONS: The endocrinological and visual outcome was better in those patients who underwent surgery for asymptomatic tumors. The extent of tumor resection was also significantly greater in smaller tumors. It would therefore be appropriate to offer surgery to patients with asymptomatic macro-NFPIs.

The unresolved case of sacral chordoma: from misdiagnosis to challenging surgery and medical therapy resistance.

PURPOSE: A sacral chordoma is a rare, slow-growing, primary bone tumor, arising from embryonic notochordal remnants. Radical surgery is the only hope for cure. The aim of our present study is to analyse our experience with the challenging treatment of this rare tumor, to review current treatment modalities and to assess the outcome based on R status. METHODS: Eight patients were treated in our institution between 2001 and 2011. All patients were discussed by a multidisciplinary tumor board, and an en bloc surgical resection by posterior perineal access only or by combined anterior/posterior accesses was planned based on tumor extension. RESULTS: Seven patients underwent radical surgery, and one was treated by using local cryotherapy alone due to low performance status. Three misdiagnosed patients had primary surgery at another hospital with R1 margins. Reresection margins in our institution were R1 in two and R0 in one, and all three recurred. Four patients were primarily operated on at our institution and had en bloc surgery with R0 resection margins. One had local recurrence after 18 months. The overall morbidity rate was 86% (6/7 patients) and was mostly related to the perineal wound. Overall, 3 out of 7 resected patients were disease-free at a median follow-up of 2.9 years (range, 1.6-8.0 years). CONCLUSION: Our experience confirms the importance of early correct diagnosis and of an R0 resection for a sacral chordoma invading pelvic structures. It is a rare disease that requires a challenging multidisciplinary treatment, which should ideally be performed in a tertiary referral center.