Is contrast enhanced ultrasonography a useful tool for the evaluation of muscular microcirculation in patients with critical limb ischaemia?

BACKGROUND: Evaluation of skin microcirculation in patients with critical limb ischemia (CLI) may be achieved by the measurement of transcutaneous oxygen pressure or skin perfusion pressure, but there is no practical method available for the evaluation of muscle microcirculation. Contrast enhanced ultrasonography (CEUS) has been used to assess muscle perfusion in patients with peripheral arterial disease. We conducted a monocentric pilot study evaluating the ability of CEUS to assess the impact of arterial revascularization on the perfusion of the calf muscle in patients with CLI. PATIENTS AND METHODS: Patients with CLI (TASC II criteria) and a possibility of proximal or medial revascularization were included. In addition to TcPO2 and toe systolic blood pressure measurements, CEUS of the calf muscle was performed just before and one month after the therapeutic procedure. Parameters derived from muscular perfusion curves were evaluated in a blinded fashion and compared with the clinical outcome. RESULTS: Thirty eight patients were included (74 % men, median age 71 years, 53 % diabetics). Thirty benefited from revascularization with a clinical success rate of 70 %. Twenty three patients could benefit from analysis before and after revascularization. No significant difference was shown in time to peak (22.3 s vs 24.0 s, P = 0.61) nor in peak intensity (2.30 dB vs 1.27 db, P = 0,26), contrasting with significant improvements of TcPO2 (43 mm Hg vs 20 mm Hg, P = 0.007) and toe systolic blood pressure (54 mm Hg vs 32 mm Hg, P = 0.002). CONCLUSIONS: The evaluation of muscular microvascular perfusion by CEUS as performed in this study is not enough sensitive to change to allow a clinically relevant evaluation of the improvement in muscle microvascular perfusion in patients with CLI benefiting from revascularization procedures.

Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons.

BACKGROUND: Despite advances in the medical management of secondary hyperparathyroidism due to chronic renal failure and dialysis (renal hyperparathyroidism), parathyroid surgery remains an important treatment option in the spectrum of the disease. Patients with severe and complicated renal hyperparathyroidism (HPT), refractory or intolerant to medical therapy and patients with specific requirements in prospect of or excluded from renal transplantation may require parathyroidectomy for renal hyperparathyroidism. METHODS: Present standard and actual controversial issues regarding surgical treatment of patients with hyperparathyroidism due to chronic renal failure were identified, and pertinent literature was searched and reviewed. Whenever applicable, evaluation of the level of evidence concerning diagnosis and management of renal hyperparathyroidism according to standard criteria and recommendation grading were employed. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled Hyperparathyroidism due to multiple gland disease: An evidence-based perspective. RESULTS: Presently, literature reveals scant data, especially, no prospective randomized studies to provide sufficient levels of evidence to substantiate recommendations for surgery in renal hyperparathyroidism. Appropriate surgical management of renal hyperparathyroidism involves standard bilateral exploration with bilateral cervical thymectomy and a spectrum of four standardized types of parathyroid resection that reveal comparable outcome results with regard to levels of evidence and recommendation. Specific patient requirements may favour one over the other procedure according to individualized demands. CONCLUSIONS: Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism. The overall success rate and long-term control of renal hyperparathyroidism and optimal handling of postoperative metabolic effects also depend on the timely indication, individually suitable type of parathyroid resection and specialized endocrine surgery.

What are the barriers to the completion of a home-based rehabilitation programme for patients awaiting surgery for lung cancer: a prospective observational study.

OBJECTIVES: Home-based rehabilitation programmes (H-RPs) could facilitate the implementation of pulmonary rehabilitation prior to resection for non-small cell lung cancer (NSCLC), but their feasibility has not been evaluated. The aim of this study was to identify determinants of non-completion of an H-RP and the factors associated with medical events occurring 30 days after hospital discharge. DESIGN: A prospective observational study. INTERVENTION: All patients with confirmed or suspected NSCLC were enrolled in a four-component H-RP prior to surgery: (i) smoking cessation, (ii) nutritional support, (iii) physiotherapy (at least one session/week) and (iv) home cycle-ergometry (at least three times/week). OUTCOMES: The H-RP was defined as 'completed' if the four components were performed before surgery. RESULTS: Out of 50 patients included, 42 underwent surgery (80% men; median age: 69 (IQR 25%-75%; 60-74) years; 64% Chronic Obstructive Pulmonary Disease (COPD); 29% type 2 diabetes). Twenty patients (48%) completed 100% of the programme. The median (IQR) duration of the H-RP was 32 (19; 46) days. Multivariate analysis showed polypharmacy (n=24) OR=12.2 (95% CI 2.0 to 74.2), living alone (n=8) (single vs couple) OR=21.5 (95% CI 1.4 to >100) and a long delay before starting the H-RP (n=18) OR=6.24 (95% CI 1.1 to 36.6) were independently associated with a risk of non-completion. In univariate analyses, factors associated with medical events at 30 days were H-RP non-completion, diabetes, polypharmacy, social precariousness and female sex. CONCLUSION: Facing multiple comorbidities, living alone and a long delay before starting the rehabilitation increase the risk of not completing preoperative H-RP. TRIAL REGISTRATION NUMBER: NCT03530059.

Usefulness of near-infrared angiography for identifying the intersegmental plane and vascular supply during video-assisted thoracoscopic segmentectomy.

OBJECTIVES: Segmentectomy by video-assisted thoracoscopic surgery (VATS) permits anatomical resection for diagnosis and treatment of small lung nodules but requires that intersegmental planes and segmental vessels be identified accurately. Near-infrared angiography with systemic injection of indocyanine green (ICG) can precisely identify the intersegmental plane. The purpose of this study was to confirm the usefulness of ICG angiography during VATS segmentectomy. METHODS: We retrospectively reviewed the records of 22 consecutive patients who underwent VATS segmentectomy performed with near-infrared angiography between November 2014 and October 2015. Segments were localized and anatomical vascular supply was identified on preoperative computed tomography scans. VATS segmentectomy was performed using an anterior approach with 2 ports and 1 non-spreading minithoracotomy, with ICG injected systemically after arterial ligation. RESULTS: VATS was feasible for all 22 segmentectomies, and in all patients, the intersegmental plane was identified accurately by ICG angiography. This angiography method was also useful in patients whose anatomical vascular segmentation was difficult to identify and, in a few patients, to assess the distribution of an artery before sectioning, to determine the vascular supply of the remaining lung and to distinguish between segmental and intersegmental veins. The postoperative course was uneventful for 18 patients and complicated for 2 patients who had prolonged air leak (10 and 15 days) with pneumonia, 1 patient with gastroparesis and 1 with colonic ileus. The drain was removed before the 3rd postoperative day in all but 2 patients, and the mean hospital stay was 5.4 ± 4.5 days. Anatomopathological examination indicated that 4 benign lesions and 18 primary lung cancers were completely removed, including 14 that were Stage IA, 2 Stage IIA and 2 Stage IIIA. CONCLUSIONS: Indocyanine green angiography provides technical support for identifying the intersegmental plane and the vasculature during VATS segmentectomy. It contributes to the quality of diagnostic and therapeutic excisions of small nodules that are often not visible and not palpable during VATS.

Ischemic Gastric Conditioning by Preoperative Arterial Embolization Before Oncologic Esophagectomy: A Single-Center Experience.

PURPOSE: Surgical esophagectomy is the gold standard treatment of early-stage esophageal cancer. The procedure is complicated with significant morbidity; the most severe complication being the anastomotic leakage. Anastomotic fistulas are reported in 5-25% of cases and are mainly due to gastric transplant ischemia. Here, we report our experience of ischemic pre-conditioning using preoperative arterial embolization (PreopAE) before esophagectomy. MATERIALS AND METHODS: The medical records of all patients who underwent oncologic esophagectomy from 2008 to 2015 were retrospectively reviewed. Patients were divided into two groups: patients who received PreopAE, and a control group of patients who did not benefit from ischemic pre-conditioning. The target arteries selected for PreopAE were the splenic artery, left gastric artery, and right gastric artery. Evaluation of the results was based on anastomotic leakage, postoperative mortality, technical success of PreopAE, and complications related to the embolization procedure. RESULTS: Forty-six patients underwent oncologic esophagectomy with PreopAE and 13 patients did not receive ischemic conditioning before surgery. Thirty-eight PreopAE were successfully performed (83%), but right gastric artery embolization failed for 8 patients. Anastomotic leakage occurred in 6 PreopAE patients (13%) and in 6 patients (46%) in the control group (p = 0.02). The mortality rate was 2% in the PreopAE group and 23% in the control group (p = 0.03). Eighteen patients suffered from partial splenic infarction after PreopAE, all treated conservatively. CONCLUSION: Preoperative ischemic conditioning by arterial embolization before oncologic esophagectomy seems to be effective in preventing anastomotic leakage.

Subtotal Parathyroidectomy Under Indocyanine Green Angiography.

Introduction: Subtotal parathyroid resection is indicated when secondary or tertiary hyperparathyroidism (HPT) develops and may be indicated also in patients with primary HPT and multiglandular disease. Three different surgical procedures are used to treat diffuse parathyroid hyperplasia: total parathyroidectomy with or without autotransplantation, and subtotal parathyroidectomy. One of the main complications is transient or persistent hypoparathyroidism. In this video, we show our technique of subtotal parathyroidectomy using a fluorescent dye (indocyanine green [ICG]) to check for the vascularization of the parathyroid remnant, to avoid definitive postoperative hypoparathyroidism. Methods: We present a 64-year-old man with end-stage chronic kidney disease dialyzed since 2008. His parathyroid hormone (PTH) level was 106 pmol/L, corrected calcium level was 2.29 mmol/L and phosphate 1.63 mmol/L under maximal medical treatment, and he had significant bone disease. A subtotal parathyroidectomy was scheduled. After reclining pre-thyroid muscles, we medialized the right thyroid lobe to expose the right parathyroid glands. The superior one was a good candidate to be preserved partially because it looked hyperplastic, but without a macroscopic nodule and was the smallest of the four parathyroid glands. The inferior one was located deep in the mediastinum, in the thymus, and was therefore not suitable for subtotal resection. The procedure was the same for the left side. The inferior parathyroid gland harbored nodular hyperplasia and, therefore, was not very suitable for partial resection, but the superior one looked as a good candidate for subtotal resection too. We started reducing the volume of the parathyroid glands with clips, preserving carefully each parathyroid's vascular pedicle. Then, we intravenously injected 3.5 mL of indocyanine green solution to check the perfusion of the parathyroid remnant, using a fluorescent imaging camera (PINPOINT camera; Novadaq, Mississauga, ON, Canada). The perfusion can be seen as green or white, depending on the selected image mode. We finally chose the right superior parathyroid gland and resected the gland outside of the clips. The other glands have finally been entirely removed. Results: The postoperative course was uneventful except for hypocalcemia needing intravenous calcium for 48 hours. On the first postoperative day, corrected calcium level was 1.93 mmol/L and PTH level was 8 pmol/L. The two inferior parathyroid glands showed nodular hyperplasia at pathologic examination and the two superior glands showed diffuse hyperplasia without nodules. Conclusion: With this new procedure, subtotal parathyroidectomy under ICG angiography, we can check for the good vascularization of the parathyroid remnant before resecting the other parathyroid glands. Therefore, we can intraoperatively guarantee the absence of definitive hypoparathyroidism. This technique is safe, reproducible, and its easy use makes it the procedure of choice in these situations, when the device is available. No competing financial interests exist. Runtime of video: 6 mins 33 secs.

A Giant Purely Polypoid Esophageal Leiomyoma.

We present a case of a giant (13-cm length) purely polypoid esophageal leiomyoma without any intramural development. This form of leiomyoma is rare and develops due to proliferation originating from the muscularis mucosae, although the intramural type originates in the muscularis propria. This should not be confused with giant fibrovascular polyps, which are postulated to arise at the pharyngoesophageal junction when a flap of mobile, redundant submucosa prolapses distally and may cause asphyxia when protruding into the mouth. Our case was successfully removed by a right thoracotomy.

Surgery of the thyroid: recent developments and perspective.

In the past century, thyroid surgery has benefited from physiological and technical revolutions. In the early 1900s, the most important aspect of thyroidectomy was the volume resected, without knowledge of exactly what was removed and if there were important structures around the thyroid gland. The main indications were respiratory problems for tracheal compression and the death rate was greater than 36% due to bleeding, infections, unrecognised bilateral recurrent laryngeal nerve lesions and unrecognised severe hypocalcaemia leading to tetany. At some point this surgery was, therefore, banned in some countries such as France and the United States. Today, thyroid surgery is a common surgery: about 45,000 thyroidectomies are performed per year in France, 60,000 in Germany and 4,000 in Switzerland. Thyroid surgery has become very safe with a mortality of almost 0% and a very low complication rate. In our centre, the number of thyroidectomies has more than tripled in the last decade. There are many indications leading to thyroid surgery, but the three main indications covering 90% of the interventions are cancer (or suspected cancer), hyperthyroidism and size / volume / intrathoracic goitres. In this paper, we highlight some historical points, describe important knowledge and technical improvements made during the last century and give our opinion on expected evolution in this field for the near future.

Femoral nerve palsy following mini-open extraperitoneal lumbar approach: report of three cases and cadaveric mechanical study.

Anterior extraperitoneal exposures to the lumbar spine are being increasingly used owing to the expanding use of novel technologies to treat degenerative disc disease. Lumbar plexus injuries are potential, albeit uncommon, complications of such exposures and can lead to significant perioperative morbidity. In this report, we present three patients with thoracolumbar fractures who sustained isolated femoral nerve palsies after a mini-open extraperitoneal approach to the midlumbar spine was undertaken to perform a partial corpectomy. To further understand the pathophysiology of this nerve injury, we conducted a cadaveric experiment to evaluate the effect of performing this approach and the effect of hip positioning on linear displacement of the femoral nerve. The displacement of the femoral nerve during the anterolateral extraperitoneal exposure through a 4- to 6-cm incision was equal to 6.6% of the full femoral nerve length. Relaxation of the femoral nerve was equal to 25% of the full nerve length when the hip was flexed to 90 degrees in neutral abduction-adduction. We conclude that the anterolateral extraperitoneal exposure of the midlumbar spine can potentially stretch the femoral nerve beyond its physiologic limits, particularly in trauma cases where exposure of the lateral vertebral body necessitates substantial retraction of the psoas muscle. The avoidance of self-retaining retractors for prolonged periods of time and the positioning of the hip in flexion may help to avoid such nerve injuries.