Effect of Functionalization of Texturized Polypropylene Surface by Silanization and HBII-RGD Attachment on Response of Primary Abdominal and Vaginal Fibroblasts.

Soft tissue defects, such as incisional hernia or pelvic organ prolapse, are prevalent pathologies characterized by a tissue microenvironment rich in fragile and dysfunctional fibroblasts. Precision medicine could improve their surgical repair, currently based on polymeric materials. Nonetheless, biomaterial-triggered interventions need first a better understanding of the cell-material interfaces that truly consider the patients' biology. Few tools are available to study the interactions between polymers and dysfunctional soft tissue cells in vitro. Here, we propose polypropylene (PP) as a matrix to create microscale surfaces w/wo functionalization with an HBII-RGD molecule, a fibronectin fragment modified to include an RGD sequence for promoting cell attachment and differentiation. Metal mold surfaces were roughened by shot blasting with aluminum oxide, and polypropylene plates were obtained by injection molding. HBII-RGD was covalently attached by silanization. As a proof of concept, primary abdominal and vaginal wall fasciae fibroblasts from control patients were grown on the new surfaces. Tissue-specific significant differences in cell morphology, early adhesion and cytoskeletal structure were observed. Roughness and biofunctionalization parameters exerted unique and combinatorial effects that need further investigation. We conclude that the proposed model is effective and provides a new framework to inform the design of smart materials for the treatment of clinically compromised tissues.

The Effects of Nebulized Lidocaine on the Laryngeal Adductor Reflex.

The laryngeal adductor reflex (LAR) is a brainstem reflex that closes the vocal fold and constitutes a new method for continuously monitoring the vagus and laryngeal nerves during different surgeries. Previous reports concluded that topical lidocaine in spray inhibited LAR responses. However, topical anesthesia in the upper airway may be necessary in awake intubation. We present six patients who underwent neck endocrine surgery due to an intrathoracic goiter that compromised the airway. Before awake intubation, a nebulization of lidocaine 5% was applied for at least 10 min. The intubation procedure was well tolerated, and bilateral LAR with suitable amplitudes for monitoring was obtained in all cases. In our series, the nebulization of lidocaine 5% did not affect the laryngeal adductor reflex. Laryngoscope, 2024.

The colon does not reach! A technical note with tricks to avoid colorectal anastomoses under tension.

AIM: We describe two options for colorectal anastomosis suitable in cases when the colon would reach the pelvis under tension. METHOD: Deloyers procedure and the retro-ileal colorectal anastomosis are presented, focusing on practical tips and tricks to perform them. Insights on patients who underwent the procedures are provided to demonstrate the advantages and feasibility of the techniques. RESULTS: Each step of both techniques is detailed. Ten patients underwent Deloyers procedure and nine underwent retro-ileal anastomosis at our unit. A minimally invasive approach was attempted in 13 patients, of whom five required conversion to open surgery due to the technical complexity of the abdominal procedure. Colorectal anastomosis was successfully performed in all patients. There were no major intra-operative complications, although five patients had postoperative complications requiring further treatment. CONCLUSIONS: Both techniques are effective in patients at risk of receiving a colorectal anastomosis under tension, and a minimally invasive approach can be used. However, owing to the complexity of surgery in this group of patients, the perioperative morbidity is not negligible. Careful postoperative management is advisable, and patients should be informed of the risks. In expert hands, the outcomes are acceptable, avoiding an ileorectal anastomosis and its constraints.

Analysis of the Variability in Different Criteria to Define the Success of Bariatric Surgery: Retrospective Study 5-Year Follow-Up after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass.

(1) Background: The current criteria for defining good or bad responders to bariatric surgery based on the percentage of weight loss do not properly reflect the therapeutic impact of the main bariatric techniques. At present there is an urgent need to fill this gap and provide scientific evidence that better define the success or failure of bariatric surgery in the long term. (2) Methods: This is a retrospective database study of a prospective cohort with 5-year follow-up. We established the success or failure of bariatric surgery in terms of weight loss according to a selected criterion: (1) Halverson and Koehler; (2) Reinhold modified by Christou; (3) Biron; (4) TWL > 20%; (5) percentage of changeable weight (AWL > 35%). We analyzed sensitivity and specificity for successful weight loss. (3) Results: 223 (38.7%) patients underwent sleeve gastrectomy (LSG) and 353 (61.2%) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). The success rates at 5 years are: EWL > 50% 464 (80%), Reinhold 436 (75.6%), Biron 530 (92%), TWL > 20% 493 (85.5%), AWL < 35% 419 (72.7); ≥50% EWL and alterable weight loss AWL > 35 were the most adequate criteria as their specificities and sensibility were far above >80%. (4) Conclusions: The present study shows how the different definitions of success or failure are inconsistent in relation to the outcomes of BS. However, there are some criteria that associate statistically significant differences for the resolution of comorbidities and show the highest sensitivity and specificity rates.

Massive necrotizing fasciitis: a life threatening entity.

Necrotizing fasciitis (NF) is a complicated soft tissue infection frequently associated with severe sepsis if an early medical and surgical treatment is not performed. We report two postoperative cases of severe NF after oophorectomy and colorectal resection. Because of the similarity with more benign skin infections at the early steps, clinical suspicion is crucial. Surgical exploration and resection will provide both the diagnosis confirming necrotizing infection of the fascia with vessels and treatment. Also, empirical broad-spectrum antibiotics must be initiated as soon as possible. Regardless of the presence of risk factors, NF is a condition with a high mortality rate and only an expeditious and undelayed treatment may improve the patient's outcome. Surgical focus control requires wide and repeated resections, and planned reconstructive plastic surgery might be necessary.

Lung Transplantation in Cystic Fibrosis and the Impact of Extracorporeal Circulation. / El trasplante pulmonar en la fibrosis quística y la influencia de la circulación extracorpórea.

INTRODUCTION: Lung disease is the major cause of death among cystic fibrosis (CF) patients, affecting 80% of the population. The impact of extracorporeal circulation (ECC) during transplantation has not been fully clarified. This study aimed to evaluate the outcomes of lung transplantation for CF in a single center, and to assess the impact of ECC on survival. METHODS: We performed a retrospective observational study of all trasplanted CF patients in a single center between 1992 and 2011. During this period, 64 lung transplantations for CF were performed. RESULTS: Five- and 10-year survival of trasplanted patients was 56.7% and 41.3%, respectively. Pre-transplantation supplemental oxygen requirements and non-invasive mechanical ventilation (NIMV) do not seem to affect survival (P=.44 and P=.63, respectively). Five- and 10-year survival among patients who did not undergo ECC during transplantation was 75.69% and 49.06%, respectively, while in those did undergo ECC during the procedure, 5- and 10-year survival was 34.14% and 29.87%, respectively (P=.001). PaCO2 is an independent risk factor for the need for ECC. CONCLUSIONS: The survival rates of CF patients undergoing lung transplantation in our hospital are similar to those described in international registries. Survival is lower among patients receiving ECC during the procedure. PaCO2 is a risk factor for the need for ECC during lung transplantation.

Evolution of differentiated thyroid cancer: a decade of thyroidectomies in a single institution.

BACKGROUND: Numerous studies have shown an increase in the incidence of thyroid cancer (TC) in recent years. OBJECTIVES: In this paper, we reviewed the incidence of TC in a series of patients undergoing thyroid surgery at a single institution over a 10-year period. PATIENTS AND METHODS: The cohorts were divided into two periods (2001-2005 and 2006-2010) with the purpose of comparing various clinicopathologic variables. RESULTS: A total of 1,263 patients were included. A significant increase in the number of malignancies was shown in the second period, namely 90 cases in 2001-2005 (15.2% of all interventions) compared to 163 cases in 2006-2010 (24.3%) (p < 0.001). These differences were attributed to an increase in papillary thyroid carcinoma (PTC), as there were 66 PTC cases in the first period (11.13% of thyroidectomies performed) compared to 129 cases in the second period (19.25%). There were no clinicohistological differences among PTC cases in these two periods. CONCLUSIONS: Over the last decade, there has been an increase in the incidence of TC in patients undergoing thyroid surgery. This increase is exclusively due to increases in PTC. Our study verifies the existence of this trend in our geographical area, similar to that noted in other parts of the world.

SPECT/CT sentinel lymph node identification in papillary thyroid cancer: lymphatic staging and surgical management improvement.

PURPOSE: Lymphadenectomy in papillary thyroid carcinoma (PTC) continues to be controversial. A better staging method is needed to provide adequate individual surgical treatment. SPECT/CT lymphoscintigraphy and sentinel lymph node (SLN) biopsy may improve lymphatic staging and surgical treatment. Our main objectives were to describe the lymphatic drainage of PTC using lymphoscintigraphy, to evaluate the lymphatic spread (comparing SLN and lymphadenectomy results) and to analyse the impact of SLN identification in surgery. METHODS: We prospectively studied 24 consecutive patients with PTC (19 women; mean age 52.7 years, range 22-81 years). The day before surgery, lymphoscintigraphy with ultrasound-guided intratumoral injection ((99m)Tc-nanocolloid, 148 MBq) was performed, obtaining planar and SPECT/CT images. All patients underwent total thyroidectomy, SLN biopsy (hand-held gamma probe) with perioperative analysis, central compartment node dissection, or laterocervical lymphadenectomy if perioperative stage N1b or positive SLNs in this lymphatic basin. RESULTS: Lymphoscintigraphy revealed at least one SLN in 19 of 24 patients (79 %) on planar and SPECT/CT images, and in 23 of 24 patients (96 %) during surgery using a hand-held gamma probe. Lymph node metastases were detected with classical perioperative techniques (ultrasound guidance and surgical inspection) in 3 of 24 patients, by perioperative SLN analysis in 10 of 23, and by definitive histology in 13 of 24. The false-negative (FN) ratio for SLN was 7.7 % (one patient with bulky lymph nodes). The FN ratio for perioperative frozen sections was 15.4 % (two patients, one with micrometastases, the other with bilateral SLN). Lymphatic drainage was only to the central compartment in 6 of 24 patients (3 of the 6 with positive SLNs for metastases), only to the laterocervical basin in 5 of 24 patients (all unilateral, 2 of 5 positive SLNs) and to the central and laterocervical compartments in 12 of 24 patients (6 of 12 and 3 of 12 positive SLNs, respectively). CONCLUSION: Lymphoscintigraphy reveals the lymph node drainage in a high proportion of patients. It detects laterocervical drainage in a significant percentage of patients, allowing the detection of occult lymph node metastases and improving the surgical management in PTC.

Laparoscopic repair of a postadrenalectomy left-sided diaphragmatic hernia complicated by chronic colon obstruction.

Iatrogenic diaphragmatic hernias are a rarely reported complication of abdominal surgery. We present a case of an iatrogenic diaphragmatic hernia diagnosed 2 years after an adrenalectomy. Corrective laparoscopic surgery was performed, and the postoperative course was uneventful. The patient remained asymptomatic 6 months after the repair. To our knowledge, this is the first such case to be reported.

Single-port transumbilical laparoscopic appendectomy: a preliminary multicentric comparative study in 87 patients with acute appendicitis.

Introduction. Laparoscopic appendectomy (LA) has been performed in many approaches such as open, laparoscopic and recently Single Port Access (SPAA). In order to elucidate its potential advantages, we compared the two laparoscopic approaches. Methods. 87 patients were included in a multicentric study for suspected appendicitis in order to perform (SPAA) appendectomy or laparoscopic appendectomy (LA). All outcomes, including blood loss, operative time, complications, and length of stay and pain were recorded prospectively. Results. There were 46 patients in the SPAA group and 41 in the LAG with a mean operative time of 40,4 minutes in the SPAA group and 35,0 minutes in the LA group. Only one patient was converted to an open approach. We described only 2 complications. Pain was graded 2,8 in the SPAA group and 2,9 in the LA group, according to the AVS after 24 hours. Patients in the SPAA Group were more satisfied (7,5 versus 6,9) (P < 0.05). Same results were found for the cosmetic result (8,6 versus 7,4) (P < 0.05). Conclusion. Using the single port approach feasible and safe. The true benefit of the technique should be assessed by new randomised controlled trials.

A giant euthyroid endemic multinodular goiter with no obstructive or compressive symptoms.

Diffusely enlarged thyroid glands (goitres) are becoming increasingly infrequent. However, in some geographical areas they are still relatively common and can cause compressive symptoms involving the trachea, oesophagus, and recurrent laryngeal nerve. Surgical treatment of diffusely enlarged thyroid glands requires a high level of expertise and may lead to severe complications. Here we present a case report of surgical treatment of an extremely enlarged thyroid gland, found in a 61-year-old female patient. The patient underwent surgery, and a thyroidectomy was performed. The resulting specimen weighed 4.7 kg (10.4 lbs). Histopathological examination revealed a multinodular goitre with multiple cysts and areas of haemorrhage and necrosis. Surgical excision can immediately resolve local symptoms and is often recommended when substernal extension is evident. To the best of our knowledge, this is the largest thyroid gland ever reported in the literature. Only experienced surgeons should treat large thyroid goitres. Ideally, large thyroid goitres should be treated before they reach a substernal component, otherwise any sudden growth in gland size could seriously compromise respiration.

Isolated langerhans cell histiocytosis of the thyroid in an adult female: one-year followup.

Thyroid gland involvement as the unique presentation of Langerhans cell histiocytosis is a rare phenomenon that can result in misdiagnosis. We report a case of Langerhans cell histiocytosis (LCH) presenting as a thyroid mass. It is a 52-year-old woman who presented an enlarged, diffusely firm, nontender, nonmobile, and not particularly nodular thyroid gland with mild compressive symptoms. Ultrasound and fine-needle aspiration showed a unique right node with benign signs. Patient was referred to our Ambulatory Surgery Department, where a hemithyroidectomy was performed. Histologic evaluation of the right thyroid gland revealed an involvement by LCH, confirmed by immunohistochemical analysis showing Langerhans cells that were positive for CD1a. LCH was a completely incidental occult finding apparent only after surgical resection and examination of the gland. Patient was evaluated, and no evidence of systemic affectation was found. LCH can rarely involve the thyroid gland in adults. Few cases have been reported in the literature. Most patients had evidence of LCH involving other anatomic sites.

Single port access sleeve gastrectomy: Is it reasonable?

This short letter is in response to the article published in your publication about single-incision laparoscopic bariatric surgery, by Chih-Kun Huang. We want to focus on the technical aspects.

Management of patients with hernia or incisional hernia undergoing surgery for morbid obesity.

Morbidly obese patients (MOPs) are predisposed to developing abdominal wall hernias with the potential complication of small bowel obstruction and other morbidity. We report our experience in treating morbidly obese patients. Hernia prophylaxis has been attempted as a means of decreasing the incisional hernia risk associated with weight loss surgery. The controversy regarding the optimal time and method of repair of abdominal wall hernias in patients undergoing open or laparoscopic gastric bypass is discussed with emphasis placed on either a simultaneous repair or splits of the omentum, and of leaving a plug in the hernia defect, to allow time to perform a delayed repair.

Cavernous hemangioma: unusual benign tumor of the transverse colon.

Cavernous hemangioma of the colon is an uncommon disease and a rare cause of bleeding. Few cases have been reported in the literature. The rectosigmoid is the most common site of this disease in the gastrointestinal tract, while colonic localization is very uncommon. We report the case of a 66-year-old female with recurrent episodes of rectal bleeding. She underwent a colonoscopy and was diagnosed with diffuse cavernous hemangioma of the transverse colon. A laparoscopic extended right hemicolectomy was performed. Colonic hemangiomas are very rare vascular malformations and their clinical presentation is usually acute, recurrent or chronic rectal bleeding. This tumor can be diagnosed as solitary, multiple, or part of a more complex syndrome with cutaneous manifestations. They can also invade adjacent structures. Colonoscopy is a useful diagnostic test. The extension of the lesion, its morphology and its localization can be established, but imaging such as magnetic resonance or computerized tomography scan has to be performed. Sometimes, however, recognition of these tumors is difficult and can be a cause of failed surgical treatment and severe complications. Surgical treatment is recommended, after a full diagnostic evaluation for other causes of gastrointestinal bleeding.

A comparison of long-term post-thymectomy outcome of anti-AChR-positive, anti-AChR-negative and anti-MuSK-positive patients with non-thymomatous myasthenia gravis.

OBJECTIVE: A single-centre, non-randomized, non-controlled study was designed to compare the long-term post-thymectomy clinical outcome in anti-AChR-positive, anti-AChR-negative and anti-MuSK-positive patients with non-thymomatous myasthenia gravis (MG). METHODS: A total of 331 consecutive patients with seropositive MG, 55 with seronegative MG and 10 with anti-MuSK-positive MG underwent extended transsternal thymectomy (T-3b according to Myasthenia Gravis Foundation of America). The primary endpoint was to assess differences in the rate of complete stable remission (CSR) in patients with and without anti-AChR and anti-MuSK antibodies. RESULTS: The mean follow-up was 218.3 (SD 128.1) months in the seropositive MG group, 149.8 (SD 131.1) in the seronegative group and 169.9 (SD 116) in the anti-MuSK-positive group. In the seropositive MG group, the probability of obtaining CSR at 5 years post-thymectomy was 51.1% for the seropositive group compared with 40 for the seronegative group (p = 0.05) and 20 for the anti-MuSK-positive group (p = 0.03). Differences between the seronegative and anti-MuSK-positive groups were not observed. The estimated median follow-up to obtain a CSR was 17.8 months (95% confidence interval [CI] 15.7 - 19.8 months) in seropositive MG patients, 22.1 (95% CI 16.7 - 27.4 months) in seronegative MG patients and 20.6 (95% CI 13.3 - 27.9 months) in anti-MuSK-positive MG patients (long-rank test, p = 0.07). CONCLUSIONS: Long-term post- thymectomy clinical outcome was better in patients with conventional anti-AChR antibodies than in those with seronegative disease. In seronegative anti-MuSK-positive MG, thymectomy seems to be less effective than in anti-MuSK-negative MG but this study cannot answer the question of whether thymectomy should be undertaken in anti-MuSK-positive patients.

Influence of ectopic thymic tissue on clinical outcome following extended thymectomy in generalized seropositive nonthymomatous myasthenia gravis.

OBJECTIVE: We determined the effect of detecting ectopic thymic tissue in thymectomy specimens on the long-term outcome of patients with myasthenia gravis. METHODS: A total of 83 consecutive patients with generalized seropositive nonthymomatous myasthenia gravis underwent transsternal extended thymectomy (T-3b according to Myasthenia Gravis Foundation of America). Ectopic thymic tissue was only accepted when Hassal's corpuscles in the excised cervicomediastinal fat were documented. The primary endpoint was to assess differences in time to obtain complete stable remission (CSR) according to the presence or absence of ectopic thymus. RESULTS: Thirty-five patients (42.2%) had ectopic thymic tissue. The mean follow-up was 88.4+/-36.3 months (range 20-144). By the Kaplan-Meier analysis method, the estimated median follow-up to obtain a CSR in the group without ectopic thymic tissue was 32.9 months (95% confidence interval [CI] 21.1-44.8 months) and 117.8 months (95% CI 98.0-137.6 months) for the group with ectopic thymic tissue (log-rank test, p=0.0002). The probability over time of obtaining CSR for the groups without and with ectopic thymic tissue was 65% vs 26% at 5 years. After stratification by hyperplasia or involution of the thymus as well as by post-thymectomy immunomodulating regimen (prednisone and prednisone-tacrolimus), the probability over time of obtaining CSR at 5 years was also significantly higher for patients without ectopic thymic tissue than for those with ectopic thymic tissue. CONCLUSIONS: The clinical outcome of patients with nonthymomatous seropositive myasthenia gravis is significantly affected by the presence of ectopic thymic tissue in the mediastinal fat.

Tacrolimus for myasthenia gravis: a clinical study of 212 patients.

Tacrolimus is a macrolide T cell immunomodulator that is used in myasthenia gravis (MG) patients to affect muscle contraction (ryanodine receptor by modulating intracellular calcium-release channels and increasing muscular strength), glucocorticoid receptors (increasing intracellular concentration of steroids and blocking the steroid export mechanism), and an increase in T cell apoptosis. In this study, we report the results of low-dose tacrolimus (0.1 mg/kg/day) treatment in 212 MG patients. There were 110 thymectomized, cyclosporine- and prednisone-dependent patients; 68 thymectomized patients who started tacrolimus early postoperatively (24 h after operation); and 34 patients over 60 years old with nonthymomatous generalized MG or in whom thymectomy was contraindicated. The mean follow-up time was 49.3 +/- 18.1 months. Muscular strength showed an increase of 23% after 1 month of treatment and 29% at the end of the study. The acetylcholine receptor antibodies decreased significantly from a mean of 33.5 nmol/L at base line to 7.8 nmol/L at the final visit. In the thymectomy group with combined prednisone and tacrolimus stratified by histology of the thymus, the mean probability to attain complete stable remission at 5 years was 80.8% in patients with hyperplasia, 48.1% in thymic involution, and 9.3% in patients with thymoma. In 4.9% of patients, tacrolimus was withdrawn because of major adverse effects. Our results suggest that a low dose of tacrolimus is effective for MG and could be included to the armamentarium for this autoimmune disease. The present results should be interpreted considering the limitations of a retrospective clinical study. Confirmation of these results in randomized studies is desirable.

Post-thymectomy combined treatment of prednisone and tacrolimus versus prednisone alone for consolidation of complete stable remission in patients with myasthenia gravis: a non-randomized, non-controlled study.

BACKGROUND: Thymectomy is a standard treatment of myasthenia gravis (MG). Immunomodulating agents are frequently given during the post-thymectomy latency period until complete remission is fully consolidated. OBJECTIVE: A single-centre, non-randomized, non-controlled study was conducted to compare rates of complete stable remission (CSR) to post-thymectomy early treatment with prednisone alone or prednisone combined with tacrolimus, in 80 patients with MG. METHODS: Thirty-nine consecutive patients underwent elective transsternal extended thymectomy in 1997-1999 and received prednisone alone (1.5 mg/kg/day) postoperatively, whereas 41 patients operated on in 2000-2002 received prednisone combined with tacrolimus (0.1 mg/kg per day b.i.d. starting 24 hours after thymectomy). RESULTS: The mean follow-up was 59 months (SD 32.9) in the prednisone group and 35.9 months (SD 17.1) in the tacrolimus group (p = 0.003). CSR was achieved in 47.5% of patients in the tacrolimus group and in 41.0% in the prednisone group (p = 0.60). The estimated median follow-up to obtain a CSR in non-thymomatous MG was 38.2 months (95% confidence interval [CI] 30.1-46.4 months) for the tacrolimus group and 64.6 months (95% CI 50.9-78.2 months) for the prednisone group, and in patients with hyperplasia, 32.2 months (95% CI 23-41.5 months) and 62.9 months (95% CI 45.7-80.1 months), respectively (log-rank test, p = 0.03). The behavior of the two study groups stratified by thymic histology were significantly different (log-rank test, p = 0.006). CONCLUSIONS: Post-thymectomy administration of tacrolimus combined with prednisone was more effective than prednisone alone for the consolidation of CSR in a substantially shorter period of time in patients with MG.