Stability measurements of 1-stage implants in the edentulous mandible by means of resonance frequency analysis

OBJECTIVE: Resonance frequency analysis (RFA) is a method of measuring implant stability. However, little is known about RFA of implants with long loading periods. The objective of the present study was to determine standard implant stability quotients (ISQs) for clinical successfully osseointegrated 1-stage implants in the edentulous mandible. MATERIALS AND METHODS: Stability measurements by means of RFA were performed in regularly followed patients who had received 1- stage implants for overdenture support. The time interval between implant placement and measurement ranged from 1 year up to 10 years. The short-term group comprised patients who were followed up to 5 years, while the long-term group included patients with an observation time of > 5 years up to 10 years. For further comparison RFA measurements were performed in a matching group with unloaded implants at the end of the surgical procedure. For statistical analysis various parameters that might influence the ISQs of loaded implants were included, and a mixed-effects model applied (regression analysis, P <.0125). RESULTS: Ninety-four patients were available with a total of 205 loaded implants, and 16 patients with 36 implants immediately after the surgical procedure. The mean ISQ of all measured implants was 64.5 +/- 7.9 (range, 58 to 72). Statistical analysis did not reveal significant differences in the mean ISQ related to the observation time. The parameters with overall statistical significance were the diameter of the implants and changes in the attachment level. In the short-term group, the gender and the clinically measured attachment level had a significant effect. Implant diameter had a significant effect in the long-term group. CONCLUSIONS: A mean ISQ of 64.5 +/- 7.9 was found to be representative for stable asymptomatic interforaminal implants measured by the RFA instrument at any given time point. No significant differences in ISQ values were found between implants with different postsurgical time intervals. Implant diameter appears to influence the ISQ of interforaminal implants.

Interventional management of hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor resection and bone stabilization

OBJECTIVE: The purpose of this study was to evaluate, in relation to intraoperative estimated blood loss (EBL), the effectiveness of preoperative transcatheter arterial embolization of hypervascular osseous metastatic lesions before orthopedic resection and stabilization. MATERIALS AND METHODS: Between June 1987 and November 2007, 22 patients underwent transcatheter arterial embolization of tumors of the long bone, hip, or vertebrae before resection and stabilization. Osseous metastatic lesions from renal cell carcinoma, malignant melanoma, leiomyosarcoma, and prostate cancer were embolized. All patients were treated with a coaxial catheter technique with polyvinyl alcohol (PVA) particles alone or a combination of PVA particles and coils. After embolization, each tumor was angiographically graded according to devascularization (grades 1-3) based on tumor blush after contrast injection into the main tumor-feeding arteries. RESULTS: In patients with complete devascularization (grade 1), mean EBL was calculated to be 1,119 mL, whereas in patients with partial embolization (grades 2 and 3) EBL was 1,788 mL and 2,500 mL. With respect to intraoperative EBL, no significant difference between devascularization grades was found (p > 0.05). Moderate correlation (r = 0.51, p = 0.019) was observed between intraoperative EBL and tumor size before embolization. Only low correlation (r = 0.44, p = 0.046) was found between intraoperative EBL and operating time. Major complications included transient palsy of the sciatic nerve and gluteal abscess in one patient. CONCLUSION: The results of this study support the concept that there is no statistically significant difference among amounts of intraoperative EBL with varying degrees of embolization.

A safe and simple solution for intravesical tension-free vaginal tape erosion: removal by standard transurethral resection

OBJECTIVE: To report our experience with the successful removal of visible tension-free vaginal tape (TVT) by standard transurethral electroresection, as intravesical tape erosion after TVT is a rare complication, and removal can be challenging, with few cases reported. PATIENTS AND METHODS: Five patients presenting with TVT erosion into the bladder were treated at our institutions from December 2004 to July 2007; all had standard transurethral electroresection. Their records were reviewed retrospectively to retrieve data on presenting symptoms, diagnostic tests, surgical procedures and outcomes. RESULTS: The median (range) interval between the TVT procedure and the onset of symptoms was 17 (1-32) months. The predominant symptoms were painful micturition, recurrent urinary tract infection (UTI), urgency and urge incontinence. There were no complications during surgery. The storage symptoms and UTI resolved completely after removing the eroded mesh in all but one patient. Cystoscopy at 1 month after surgery showed complete healing of the bladder mucosa. CONCLUSION: Although TVT erosion into the bladder is rare, persistent symptoms, particularly recurrent UTIs, must raise some suspicion for this condition. Standard transurethral electroresection seems to be a safe, simple, minimally invasive and successful treatment option for TVT removal.

Low-grade endometrial stromal sarcoma with inferior vena cava tumor thrombus and intracardiac extension: radical resection may improve recurrence free survival

BACKGROUND: Endometrial stromal sarcoma (ESS) represents 0.2% of all uterine malignancies. Based on the mitotic activity, a distinction is made between low and high-grade ESS. Although the overall five-year survival rate for low-grade ESS exceeds 80%, about 50% of the patients show tumor recurrence, mostly after a long latency period. Tumor invasion of the great vessels is extremely rare. We describe a patient with advanced low-grade ESS with tumor invasion of the infrarenal aorta and the inferior vena cava. The patient presented with a large tumor thrombus extending from the inferior vena cava into the right atrium. METHODS: Review of literature and identification of 19 patients, including our own case report, with advanced low-grade ESS with invasion of the great vessels and formation of an inferior vena cava tumor thrombus. RESULTS: All 19 patients presented with an abdominal tumor mass and a tumor thrombus protruding into the inferior vena cava. The tumor thrombus extended into the right heart cavities in nine patients reaching the right atrium in four, the right ventricle in three and the pulmonary artery in two patients. There were 5 patients with an advanced primary tumor and 14 patients with an advanced recurrent tumor. Seven patients presented with synchronous metastatic disease and six patients with a pelvic tumor infiltrating the bladder, the rectosigmoid colon or the infrarenal aorta. Mean age at surgery was 45.9+/-12.3 years (median 47, range 25-65 years). Tumor thrombectomy was accomplished by cavatomy or by right atriotomy after installation of a cardiopulmonary bypass. There was no peri-operative mortality and a very low morbidity. Radical tumor resections were achieved in 10 patients. The follow-up for these 10 patients was 2+/-1.3 years (median 2, range 0.3-4.5 years). Nine patients remained recurrence free whereas one patient suffered an asymptomatic local recurrence. CONCLUSIONS: Low-grade ESS is a rare angioinvasive tumor with a high recurrence rate. Resection of an inferior vena cava tumor thrombus, even with extension into the right heart cavities, can be performed safely. Extensive radical surgery is therefore justified in the treatment of advanced tumor manifestations of a low-grade ESS potentially improving recurrence free survival.

[Tumor surveillance after resection of colorectal cancer]

Because recurrent adenocarcinoma of the colon and rectum (CRC) can still be treated with acceptable 5-year survival rates, tumor surveillance plays an important role. Early detection of recurrent disease from CRC allows for effective treatment with intention for cure. This is why, in 2007, an interdisciplinary group modified the popular "FAGAS" criteria, a proposition for surveillance after curative resection of colorectal cancer. Proposed are the 3-monthly follow-up of the tumor marker CEA (carcino embryonic antigen), which, in case of lower sigmoid or rectal cancer, would be completed by rectosigmoidoscopy and endosonography every 6 months. As a major change liver sonography is now proposed to be replaced by annual thoraco-abdominal CT scan. Colonoscopy within the first year after resection has its place in the surveillance due to a high rate of metachronous secondary tumors missed in the initial endoscopy. Once completed it needs not to be repeated for at least 3 years. Only in cases where early stage CRC was been completely resected no schematic surveillance must take place.

Persistent symptoms after elective sigmoid resection for diverticulitis

PURPOSE: Despite technically successful surgery for diverticular disease, a significant group of patients who experience persistent or recurrent symptoms remains. This study was designed to determine the incidence and pattern of persistent symptoms and their association with peroperative parameters. METHODS: Follow-up (33 (range, 4-72) months) through structured interviews with patients who had surgery for diverticulitis in our department from December 1999 to November 2004 was conducted. Of 162 patients, 124 (76.5 percent) were available for follow-up. Nonparametric tests were used for comparison of patients who had undergone elective (n = 68) or emergency (n = 56) procedures. RESULTS: Of patients who had elective surgery, 25 percent suffered persistent symptoms, including painful constipation, painful abdominal distension, abdominal cramps, and frequent painful diarrhea. Neither the stage of disease (complicated or uncomplicated) nor the surgical technique (laparotomy or laparoscopy) were significantly related to the occurrence of symptoms. Recurrent diverticulitis was not observed. Similar results were obtained from comparisons with emergency patients. CONCLUSIONS: The prevalence of persistent symptoms after successful surgery for diverticular disease may be an additional reason to carefully discuss the indication for prophylactic surgery. In any case, preoperative counseling and informed consent regarding the possibility of persistent symptoms after prophylactic elective surgery is essential.

The mean anatomical shape of the tibial plateau at the knee arthroplasty resection level: an investigation using MRI

Clinical assessments after Total Knee Arthroplasty (TKA) show persisting pain after implantation in over 20% of patients. Impingement of soft tissue around the knee, due to imprecise geometry of the tibial implant, can be one reason for persisting ailment. Two hundred and thirty seven MRI scans were evaluated using an active contour detection algorithm (snake) to obtain a high-resolution mean anatomical shape of the tibial plateau. Differences between female and male, older and younger (40) and left and right averaged shapes were determined. The shapes obtained were asymmetric throughout. Absolute differences between the subgroups fell short of inter-individual variations represented by calculated one-sigma confidence intervals. Our results indicate that a differentiation in TKA tibial plateau design by gender, age, or side is of minor relevance.

Bronchial and bronchovascular sleeve resection for treatment of central lung tumors

BACKGROUND: To improve postoperative pulmonary reserve, we have employed parenchyma-sparing resections for central lung tumors irrespective of pulmonary function. The results of lobectomy, pneumonectomy, and sleeve resection were analyzed retrospectively. METHODS: From October 1995 to June 1999, 422 typical lung resections were performed for lung cancer. Of these, 301 were lobectomies (group I), 81 were sleeve resections (group II), and 40 were pneumonectomies (group III). RESULTS: Operative mortality was 2% in group I, 1.2% in group II, and 7.5% in group III (group I and II vs. group III, p<0.03). Mean time of intubation was 1.0+/-4.1 days in group I, 0.9+/-1.3 days in group II, and 3.6+/-11.2 days in group III (groups I and II vs. group III, p<0.01). The incidence of bronchial complications was 1.3% in group I, none in group II, and 7.5% in group III (group I and II vs group III, p<0.001). After 2 years, survival was 64% in group I, 61.9% in group II, and 56.1% in group III (p = NS). Freedom from local disease recurrence was 92.1% in group I, 95.7% in group II, and 90.9% in group III after 2 years (p = NS). CONCLUSIONS: Sleeve resection is a useful surgical option for the treatment of central lung tumors, thus avoiding pneumonectomy with its associated risks. Morbidity, early mortality, long-term survival, and recurrence of disease after sleeve resection are similar to those seen after lobectomy.

Long-term follow-up after complete resection of well-differentiated cancer confined to the thyroid gland

BACKGROUND: Papillary or follicular thyroid carcinomas exhibit a relatively benign course. Hence, long-term follow-up studies with well-defined disease stages and treatment details are needed to evaluate treatment strategies. METHODS: Patients who underwent complete resection of well-differentiated thyroid carcinoma (WDTC) confined to the thyroid gland between 1972 and 1990 identified from a prospective database were assessed. Follow-up was performed by interview, review of patient charts, and analysis of the Death Registry. Primary endpoints were overall survival (OS) and disease-specific survival (DSS). Review of histology was performed and extent of thyroid resection, postoperative therapy, and recognized prognostic factors but not lymphadenectomy were evaluated. RESULTS: Of 2,867 patients, 213 had complete resection of WDTC confined to the thyroid gland. Follow-up was completed in 166 patients with median age 54.2 (range, 20-85) years, and median follow-up of 27.2 (range, 15.6-34.5) years. The 10- and 20-year OS was 71 and 55%, respectively. DSS at 10 and 20 years was 81 and 69%, respectively, and correlated with age, histology, tumor size, radio-iodide ablation (RIA), and external beam irradiation (EBR) treatment. No patient died of WDTC more than 18 years after resection. Total or near-total thyroidectomy without lymphadenectomy was not superior to partial thyroidectomy. In multivariate analysis for DSS, age was the dominant factor, which correlated with histology. CONCLUSION: After a median follow-up of 27 years, about one-third of patients died of WDTC. Age, histology and postoperative therapy but not extent of thyroid resection determined DSS.

Local resection of metanephric adenoma with kidney preservation

Metanephric adenoma (MA) is a rare renal neoplasm present at any age. Usually, a total nephrectomy is performed. Some successful partial nephrectomies or selective tumor resections are described in adults but not in children. We present here the case of a 15-month-old boy, the youngest patient yet to be reported with an MA. We performed a local resection of the tumor. Today, 2 1/2 years after surgery, we can document a favorable clinical course and normal ultrasound findings in the follow-up of the operated kidney. This case gives further evidence that organ-sparing resection of MA is feasible in selected cases. A close clinical and ultrasound follow-up is mandatory for this approach.

Early loading of nonsubmerged titanium implants with a chemically modified sand-blasted and acid-etched surface: 6-month results of a prospective case series study in the posterior mandible focusing on peri-implant crestal bone changes and implant stability quotient (ISQ) values

PURPOSE: The aim of this prospective case series study was to evaluate the short-term success rates of titanium screw-type implants with a chemically modified sand-blasted and acid-etched (mod SLA) surface after 3 weeks of healing. MATERIAL AND METHODS: A total of 56 implants were inserted in the posterior mandible of 40 partially edentulous patients exhibiting bone densities of class I to III. After a healing period of 3 weeks, all implants were functionally loaded with a screw-retained crown or fixed dental prosthesis. The patients were recalled at weeks 4, 7, 12, and 26 for monitoring and assessment of clinical and radiological parameters, including implant stability quotient (ISQ) measurements. RESULTS: None of the implants failed to integrate. However, two implants were considered "spinners" at day 21 and left unloaded for an extended period. Therefore, 96.4% of the inserted implants were loaded according to the protocol tested. All 56 implants including the "spinners" showed favorable clinical and radiographic findings at the 6-month follow-up examination. The ISQ values increased steadily throughout the follow-up period. At the time of implant placement, the range of ISQ values exhibited a mean of 74.33, and by week 26, a mean value of 83.82 was recorded. Based on strict criteria, all 56 implants were considered successfully integrated, resulting in a 6-month survival and success rate of 100.0%. CONCLUSION: This prospective study using an early-loading protocol after 3 weeks of healing demonstrated that titanium implants with the modified SLA surface can achieve and maintain successful tissue integration over a period of at least 6 months. The ISQ method seems feasible to monitor implant stability during the initial wound-healing period.

Bone response to loaded implants with non-matching implant-abutment diameters in the canine mandible

BACKGROUND: One way to evaluate various implant restorations is to measure the amount of bone change that occurs at the crestal bone. The objective of this study was to histologically evaluate the alveolar bone change around a bone-level, non-matching implant-abutment diameter configuration that incorporated a horizontal offset and a Morse taper internal connection. METHODS: The study design included extraction of all mandibular premolars and first molars in five canines. After 3 months, 12 dental implants were placed at three levels in each dog: even with the alveolar crest, 1 mm above the alveolar crest, and 1 mm below the alveolar crest. The implants were submerged on one side of the mandible. On the other side, healing abutments were exposed to the oral cavity (non-submerged). Gold crowns were attached 2 months after implant placement. The dogs were sacrificed 6 months postloading, and specimens were processed for histologic and histometric analyses. RESULTS: Evaluation of the specimens indicated that the marginal bone remained near the top of the implants under submerged and non-submerged conditions. The amount of bone change for submerged implants placed even with, 1 mm below, and 1 mm above the alveolar crest was -0.34, -1.29, and 0.04 mm, respectively (negative values indicate bone loss). For non-submerged implants, the respective values were -0.38, -1.13, and 0.19 mm. For submerged and non-submerged implants, there were significant differences in the amount of bone change among the three groups (P <0.05). The percentage of bone-to-implant contact for submerged implants was 73.3%, 71.8%, and 71.5%. For non-submerged implants, the respective numbers were 73.2%, 74.5%, and 76%. No significant differences occurred with regard to the percentage of bone contact. CONCLUSIONS: Minimal histologic bone loss occurred when dental implants with non-matching implant-abutment diameters were placed at the bone crest and were loaded for 6 months in the canine. The bone loss was significantly less (five- to six-fold) than that reported for bone-level implants with matching implant-abutment diameters (butt-joint connections).

Benign prostatic obstruction and parkinson's disease--should transurethral resection of the prostate be avoided?

PURPOSE: According to the literature transurethral resection of the prostate in patients with Parkinson's disease has an increased risk of postoperative urinary incontinence. However, this conclusion might have been reached because some patients with multiple system atrophy incorrectly diagnosed as Parkinson's disease were included in these reports. Therefore, we investigated the outcome of transurethral prostate resection in patients with a secure neurological diagnosis of Parkinson's disease. MATERIALS AND METHODS: A total of 23 patients with Parkinson's disease who underwent transurethral prostate resection for benign prostatic obstruction were evaluated retrospectively. Subsequent neurological developments in patients were followed, ensuring that those with multiple system atrophy had not been included in analysis. RESULTS: At transurethral prostate resection median patient age was 73 years, median duration of Parkinson's disease before the resection was 3 years, and median Hoehn and Yahr scale was 2. Of the 14 patients with a preoperative indwelling urinary catheter transurethral prostate resection restored voiding in 9 (64%) and only 5 (36%) required catheterization postoperatively. Of the 10 patients with preoperative urge urinary incontinence, continence was restored in 5 and improved in 3 following transurethral prostate resection. There were no cases of de novo urinary incontinence after transurethral prostate resection. At a median postoperative followup of 3 years transurethral prostate resection was successful in 16 of the 23 patients (70%). CONCLUSIONS: Transurethral prostate resection for benign prostatic obstruction in patients with Parkinson's disease may be successful in up to 70% and the risk of de novo urinary incontinence seems minimal. Thus, Parkinson's disease should no longer be considered a contraindication for transurethral prostate resection provided that preoperative investigations including urodynamic assessment indicate prostatic bladder outlet obstruction.

Reliability of intraoperative high-resolution 2D ultrasound as an alternative to high-field strength MR imaging for tumor resection control: a prospective comparative study

OBJECT: Ultrasound may be a reliable but simpler alternative to intraoperative MR imaging (iMR imaging) for tumor resection control. However, its reliability in the detection of tumor remnants has not been definitely proven. The aim of the study was to compare high-field iMR imaging (1.5 T) and high-resolution 2D ultrasound in terms of tumor resection control. METHODS: A prospective comparative study of 26 consecutive patients was performed. The following parameters were compared: the existence of tumor remnants after presumed radical removal and the quality of the images. Tumor remnants were categorized as: detectable with both imaging modalities or visible only with 1 modality. RESULTS: Tumor remnants were detected in 21 cases (80.8%) with iMR imaging. All large remnants were demonstrated with both modalities, and their image quality was good. Two-dimensional ultrasound was not as effective in detecting remnants<1 cm. Two remnants detected with iMR imaging were missed by ultrasound. In 2 cases suspicious signals visible only on ultrasound images were misinterpreted as remnants but turned out to be a blood clot and peritumoral parenchyma. The average time for acquisition of an ultrasound image was 2 minutes, whereas that for an iMR image was approximately 10 minutes. Neither modality resulted in any procedure-related complications or morbidity. CONCLUSIONS: Intraoperative MR imaging is more precise in detecting small tumor remnants than 2D ultrasound. Nevertheless, the latter may be used as a less expensive and less time-consuming alternative that provides almost real-time feedback information. Its accuracy is highest in case of more confined, deeply located remnants. In cases of more superficially located remnants, its role is more limited.