Prophylactic implantation of inferior vena cava filter during endovascular therapies for deep venous thrombosis of the lower extremity: is it necessary?

BACKGROUND: There is strong controversy as to whether to use filters temporarily in the inferior vena cava (IVC) during endovascular therapies for deep venous thrombosis (DVT) in the lower extremity. PURPOSE: To evaluate the necessity of implantation of a retrievable inferior vena cava filter during treatment of DVT in the lower extremity using various endovascular techniques. MATERIAL AND METHODS: Studied were all 37 consecutive sessions of endovascular treatments performed in 34 patients with symptomatic lower-limb DVT between April 2001 and October 2006. In all sessions, a Gunther tulip retrievable vena cava filter (GTF) was implanted during the procedures. The degree of trapped thrombus in the filter was evaluated by repeated venocavography. RESULTS: Implantation of a total of 66 GTFs was successfully performed in 37 sessions. Worsening of or new formation of pulmonary embolism was avoided in all patients. In 20 (54.1%) of the 37 sessions, a trapped thrombus in the filter was observed. In 14, the trapped thrombus was large, filling more than half the height of the filter. CONCLUSION: Temporary implantation of filters is effective in preventing pulmonary emboli during endovascular treatment of DVT in the lower extremities.

Antiemetic efficacy of combined aprepitant and dexamethasone in patients at high-risk of postoperative nausea and vomiting from epidural fentanyl analgesia.

BACKGROUND: Postoperative opioid analgesia increases the incidence of postoperative nausea and vomiting (PONV). We investigated whether a combination of the neurokinin-1 antagonist aprepitant and dexamethasone decreases PONV incidence compared with dexamethasone alone in high-risk patients receiving continuous epidural fentanyl. METHODS: Sixty nonsmoking female patients scheduled for elective knee osteoarthritis surgery were randomly allocated to receive oral aprepitant 80 mg (aprepitant+dexamethasone group, N.=30) 2 h before anesthesia induction or no oral aprepitant (dexamethasone group, N.=30). All patients received intravenous dexamethasone 8 mg immediately before anesthesia induction. Anesthesia was maintained with remifentanil and sevoflurane. Continuous infusion of epidural analgesia, including fentanyl, was provided during and after surgery. We assessed complete response (no PONV and no rescue antiemetic use), incidence of nausea and vomiting, nausea severity scale, vomiting frequency, rescue antiemetic use, and postoperative pain at 2 and 24 h after surgery. RESULTS: The cumulative incidence of vomiting at 24 h was 3% in the aprepitant+dexamethasone group and 27% in the dexamethasone group (P=0.011). The incidence and frequency of vomiting in the late postoperative period was also significantly lower in the aprepitant+dexamethasone group than in the dexamethasone group. However, there were no significant group differences in the proportion of patients who experienced a complete response, the incidence and severity of nausea, and rescue antiemetic use at 24 h. CONCLUSION: The combination of aprepitant and dexamethasone was more effective in preventing postoperative vomiting compared with dexamethasone alone in patients at high-risk of PONV from continuous epidural fentanyl analgesia.

Urinary tract infection in geriatric patients.

Elderly patients with urinary tract infection (UTI) are believed less likely to be cured by antimicrobial therapy than younger patients. The reasons for this poorer outcome have not yet been clarified. We have investigated the effect of antimicrobial therapy in elderly patients with complicated UTI. Four-hundred and eighty patients, 244 men and 236 women, who had complicated UTI (266 symptomatic and 236 asymptomatic) and were 20-79 years of age, were treated with one of three different drugs; one was a newer quinolone and two were oral cephems. Multivariate logistic regression analysis of treatment outcome revealed that the clinical response was significantly related to general underlying diseases and diseases of the urinary tract, but not to age, symptomatic or asymptomatic UTI, or infection site such as the kidney or bladder. We concluded that the clinical effectiveness of an antimicrobial agent was not directly related to age, and that urological examination for underlying diseases and control of them is quite important for effective treatment and control of complicated UTIs, especially in elderly patients.

Chordoma in the cervical spine managed with en bloc excision.

STUDY DESIGN: En bloc resection of a chordoma in the midcervical vertebral spine was performed. OBJECTIVES: To document the surgical technique used for en bloc excision of a chordoma arising in the midcervical spine. SUMMARY OF BACKGROUND DATA: Malignant tumors arising in long bones are excised en bloc. The authors recently designed a technique for en bloc resection of malignant tumors in the thoracolumbar spine using the T-saw. However, this technique is difficult in tumors of the cervical spine, and there are no previous reports of successful en bloc resection of such tumors. METHODS: Using an anterior approach, the ipsilateral vertebral artery was ligated. This was followed by sharply cutting the pedicle of the cervical vertebra with a specially designed T-saw. RESULTS: En bloc excision of chordomas in the cervical spine was achieved using the T-saw. CONCLUSION: Although the surgical margin was intralesional in a small area, the technique used in this case study indicates that en bloc excision of such tumors can be used with a safety margin even in the cervical spine.

Ideal laparotomy closure: comparison of retention sutures with new retention bridging devices.

Three techniques of retention suture application are compared for inflammatory complications. The conventional technique is compared with two new devices. Using the derivation for pressure generation, reasons are provided for the varying degree of inflammation found. Advantages of the nonspan bridging device, which allows for more precise control of applied force, are emphasized.

Cytokine patterns and the effects of a preoperative steroid treatment in the patients with abdominal aortic aneurysms.

BACKGROUND: The aim of this study was to investigate the cytokine patterns of patients with abdominal aortic aneurysms and the effects of preoperative steroid administration on surgical stress. METHODS: From January 1996 to August 1996, 20 consecutive patients underwent an elective reconstruction of infrarenal abdominal aortic aneurysms. The patients were randomly divided into two groups consisting of a control group (n=10) and a steroid group (n=10), in whom 1 g of methylprednisolone was intravenously administered two hours before the operation. MEASURES: Interleukin-6 was serially measured and the perioperative parameters including C-reactive protein were compared between both the control and the steroid groups. RESULTS: The interleukin-6 values in the steroid group immediately after declamping, as well as at one and three postoperative days were significantly lower than those in the control group. C-reactive protein values at one postoperative day in the steroid group were also significantly lower than those in the control group. In one patient with a ruptured abdominal aortic aneurysm, the interleukin-6 values were higher than those in the patients undergoing elective surgery throughout the study. CONCLUSIONS: These results thus suggest that preoperative steroid administration using methylprednisolone in patients with abdominal aortic aneurysms appears to reduce surgical stress by decreasing cytokine release.

Dandy-Walker syndrome successfully treated with cystoperitoneal shunting--case report.

A neonate presented with Dandy-Walker syndrome manifesting as a large posterior cranial fossa cyst, aplasia of the lower cerebellar vermis, and elevation of the confluence of the sinuses but without hydrocephalus. A cystoperitoneal shunt was placed at one month after birth. The cyst diminished in size, and marked development of the cerebellar hemispheres and descent of the confluence of sinuses were observed, but not vermis development. The primary pathology of Dandy-Walker syndrome is posterior cranial fossa cyst formation due to passage obstruction in the fourth ventricle exit area and aplasia of the lower cerebellar vermis. The first choice of treatment in patients with Dandy-Walker syndrome in whom the cerebral aqueduct is open is cystoperitoneal shunt surgery, regardless of the presence or absence of hydrocephalus.

[Mitral valve replacement 41 years after right pneumonectomy].

Mitral valve replacement was performed successfully on a 68-year-old patient who had undergone right pneumonectomy and thoracoplasty 41 years earlier. Preoperative pulmonary function tests revealed poor results; the forced vital capacity was 950 ml (28.0% of the predicted value) and the forced expiratory volume in 1 second was 750 ml (28.9% of the predicted value). Despite such poor pulmonary function, the patient tolerated the operation well and led uneventful course. Careful perioperative management to prevent pulmonary edema and aggressive postoperative pulmonary toilet to facilitate recovery of the pulmonary function seem important.

An analysis of bone regeneration at a segmental bone defect by controlled release of bone morphogenetic protein 2 from a biodegradable sponge composed of gelatin and ß-tricalcium phosphate.

To treat large bone defects is a clinically challenging problem and utilizing tissue engineering technology is an attractive approach for overcoming such a problem. Previously, a biodegradable sponge incorporating bone morphogenic protein-2 (BMP-2), which can control the release of BMP-2 for a prolonged time in an in vivo environment, was reported. In addition, a biodegradable sponge composed of gelatin and ß-tricalcium phosphate (ßTCP), gelatin-ßTCP sponge to develop a more ideal scaffold for enhancing bone regeneration was also created and previously reported. The purpose of this study was to investigate the effectiveness of the gelatin-ßTCP sponge for the promotion of bone regeneration in a critical-sized bone defect site in vivo. Apparent bone regeneration was induced by the gelatin sponge incorporating BMP-2 and the gelatin-ßTCP sponge with BMP-2 incorporation. In contrast, no apparent bone formation was induced by either the gelatin sponge only or the gelatin-ßTCP sponge without BMP-2. To investigate the quality of the regenerated bone, we conducted a biomechanical evaluation with a three-point bending test. We found no significant difference between the gelatin sponge incorporating BMP-2 and the gelatin-ßTCP sponge incorporating BMP-2 groups. Incorporation of ßTCP into the gelatin sponge was expected to enhance biomechanical strength during the initial bone regeneration. However, our observations showed that the gelatin-ßTCP sponge did not significantly improve the quality of regenerated bone from the viewpoint of biomechanical assessment, even though it did not impair the effectiveness of the promotion of bone regeneration by BMP-2 in the bone defect.

Novel technique for total laparoscopic myomectomy: the "bottom-up suture".

INTRODUCTION: As more women with symptomatic uterine myomas undergo laparoscopic management without hysterectomy, we increasingly encounter many difficult situations, such as of the need to extract large intramural myomas. Even for a skilled surgeon, laparoscopic myomectomy in such a situation is difficult. We have established a new technique for laparoscopic myomectomy to solve these issues called the "bottom-up suture" method. MATERIALS AND SURGICAL TECHNIQUE: Before complete removal of the myoma, countertraction is applied by an assistant with a claw forceps, elevating the bed of the myoma to make suturing easy. The deep myometrium can be sutured while the myoma is still attached to the uterus. DISCUSSION: This technique, the "bottom-up suture," may improve the suturing of laparoscopic myomectomies. The advantages of this technique are that it is easy to control unexpected bleeding, and dead space formation can be prevented even when the myomas have grown deep into the uterine myometrium. This technique will become a reliable standard for laparoscopic myomectomy.

Prophylactic implantation of inferior vena cava filter during interventional radiological treatment for deep venous thrombosis of the lower extremity.

The purpose of this study was to evaluate the filtering effect of the Gunther tulip retrievable vena cava filter (GTF) during treatment of deep venous thrombosis (DVT) in the lower extremity using various interventional radiological procedures. Subjects of the study were all 17 consecutive patients (8 women, 9 men; age range 18-87 years; mean age 55.9 years) with symptomatic lower limb DVT referred for interventional radiological treatment between February 2001 and September 2004. In all of these patients, the GTF was implanted during interventional radiological treatment. Trapped thrombus in the filter was evaluated with venocavography performed repeatedly during the treatment for DVT. Implantation of a total of 29 GTFs was successfully performed in the 17 patients. In 10 (58.8%), more than 2 filters were subsequently implanted to prolong implantation time. Also in 10 patients, the DVT resolved after therapy and retrieval of the final GTF was successful with one exception. Worsening of or new formation of pulmonary embolism was avoided in all patients. In 8 (47.1%) of the 17 patients, a trapped thrombus in the GTF was observed during treatment for DVT. In six patients the trapped thrombus was large, filling more than half the height of the filter. In conclusion, we found that the GTF is effective in filtering the relieved thrombus from DVT in the lower extremity and in protecting against movement of the thrombus to the pulmonary artery during therapies with interventional radiological procedures.