Functional and surgical treatments in patients with spinal muscular atrophy (SMA).

Spinal muscular atrophies (SMA type 1, 2, 3) present with various severities according to the motor semeiology related to lesions of the peripheral nervous system (lesions of the anterior horn cells motoneuron or even brain stem). Early motor deficiency causes skeletal deformities responsible for the alteration or even absence of motor skills acquisition. The management of these patients involves several practitioners: pediatric neurologist, pediatric pneumologist, physical medicine and rehabilitation therapist, pediatric orthopedic surgeon, psychologist, physiotherapist, etc. Therefore, this multidisciplinary management must take place in a reference center. This has allowed for improvement of the natural history of SMA. Despite the severity of clinical presentation, especially in SMA type 1 or 2, the functional aspect is always to be taken into account in the first instance. Furthermore, the natural history of the disease is currently being modified by the emergence of innovative therapies that will change the evolution of the disease and its management. Indeed, current treatment objectives are the comfort of installation and the fight against neuro-orthopedic degradation. Although the rise in the number of innovative therapies has led to increased expectancies, such as motor function improvement, practitioners should be aware that these innovative treatments should be balanced against child development and the disease's natural history. Scoliosis surgery is almost systematic in SMA type 2 because of trunk muscular deficiency, especially intercostal muscle insufficiency, and spino-pelvic complex disorder. However, surgical techniques have evolved to become less invasive and more growth friendly in order to follow child development. The final goal of surgery in SMA patients is to obtain a 3-dimensional deformity correction along with a spino-pelvic realignment in order to allow for a comfortable seated position, which is the position of function in these patients, and to allow for better ventilation. Faced with this global approach and innovative therapies, global assessment is warranted not solely in an isolated manner, as is usually the case during hospital stays with traditional scales, but rather during daily activities. This is the case of daily monitoring, which allows for motor skill and activity assessments throughout the day. The principle is to characterize, according to SMA type and treatment, the activity type (standing, seated, walking), duration, intensity and frequency. The ultimate goal would be to identify the variety and occurrence of motor activities, and finally to clarify if the different treatments, including innovative therapies, lead to functional improvement in these patients. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

Operative management of supracondylar humeral fractures in children: Comparison of five fixation methods.

BACKGROUND: The best method for stabilising supracondylar humeral fractures (SHFs) in children remains unclear. The objective of this study was to compare the outcomes of five different fixation methods for SHFs in children. HYPOTHESIS: Differences in intra-operative and short-term post-operative parameters can be demonstrated across different fixation methods for SHFs in children. PATIENTS AND METHODS: We reviewed the medical files of paediatric patients managed at our centre between 2006 and 2016 for SHF with major displacement (type 3 or 4 in the Lagrange-Rigault classification). Clinical and radiological parameters collected post-operatively and at last follow-up included Baumann's angle, anteversion of the distal humeral epiphysis, and operative time. Over the 11-year study period, 251 patients were included; mean age was 6.4 years and mean follow-up 4.7 months. The five fixation methods used were elastic stable intra-medullary nailing (ESIN, n=16), two pins in an X configuration (n=33), two lateral pins and one medial pin (n=144), two lateral pins (n=33), and three lateral pins (n=25). A minimally invasive 2-cm approach was used to insert the medial pins. Immediate instability of the fixation was considered in patients with an at least 15° deficit in Baumann's angle or anteversion, or with rotational malalignment, on the radiographs taken on day 1. Outcomes were analysed in each of the five internal fixation groups. RESULTS: Immediate instability showed no significant differences across the five groups. Operative time was significantly shorter with two lateral pins (33min, P=0.046). Time to hardware removal was longer in the ESIN group (54 days, P=0.03). Use of a medial pin was associated with a lower risk of secondary displacement (2.0% vs. 8.6%, P=0.04) but did not affect the risk of nerve injury (4% vs. 3%, P=0.86). DISCUSSION: This is one of the largest retrospective cohort studies of outcomes according to the fixation technique used to treat SHFs in children. Adding a medial pin through a minimally invasive approach is associated with a longer operative time but limits the risk of secondary displacement without increasing the frequency of iatrogenic nerve injury and improves fracture site stability. Use of a medial pin therefore deserves to be considered in paediatric SHFs. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Free vascularised fibular flap harvesting in children: An analysis of donor-site morbidity.

BACKGROUND: The free vascularised fibular flap (FVFF) is widely used to treat bone defects, although it must be harvested from a healthy site. The objective of this study was to assess clinical morbidity and radiological changes at the FVFF donor site in children. HYPOTHESIS: Distal fibular stabilisation using a tibial strut decreases the prevalence of valgus ankle deformity. MATERIAL AND METHOD: Thirty-one children managed at two centres between 1994 and 2014 were included. Mean age was 8.9 years (range, 2-14 years) and mean follow-up was 6.6 years (range, 2-21 years). Early and delayed complications were evaluated. RESULTS: Of the 17 early complications, 82.4% resolved fully within 7 months. Valgus ankle deformity developed in 6 (19.4%) patients. Age-residual fibula index under 16 was not significantly associated with valgus ankle deformity, although the P-value was borderline (P<0.058). Residual distal fibula length did not predict valgus ankle deformity. Three techniques were used for fibular reconstruction: syndesmotic screw, tibial strut, and both. None of these techniques prevented the occurrence of valgus ankle deformity. DISCUSSION: Clinical donor-site morbidity after FVFF harvesting, although noticeable, usually resolved promptly. Taken alone, an age-residual fibula index under 16 did not predict valgus ankle deformity. We recommend a distal tibio-fibular quadricortical syndesmotic screw or combined syndesmotic screw-tibial strut fixation to prevent valgus ankle deformity, which is common when a tibial strut is used alone. LEVEL OF EVIDENCE: IV.

Posterior elements disruption with hybrid constructs in AIS patients: is there an impact on proximal junctional kyphosis?

PURPOSE: Proximal junctional kyphosis (PJK) is a frequent proximal adjacent segment disease following spinal fusion in adolescent idiopathic scoliosis (AIS) and its rate has been estimated to 28% in the literature. The etiology is multifactorial, and risk factors associated with PJK are controversial. The aim of this study was to demonstrate that the disruption of muscular and bony tissue above the upper instrumented vertebra (UIV) during surgery does not increase the rate of PJK in patients undergoing posterior fusion for adolescent idiopathic scoliosis. MATERIAL AND METHOD: 50 patients with AIS operated between June 2014 and January 2016 were included. Every patient underwent a long posterior spine arthrodesis with a hybrid construct (proximal lamino-laminar claw, thoracic sublaminar bands and lumbar screws). The dissection of posterior elements above the UIV was necessary for the placement of proximal anchors. Radiographic analysis including proximal junctional angle, spino-pelvic parameters (cervical lordosis, thoracic kyphosis TK, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope) and sagittal vertical axis were collected preoperatively and postoperatively at the last control. The numbers of fused levels, locations of upper instrumented vertebra, locations of lower instrumented vertebra, length of fusion segments were also recorded. Multiple odd ratios and other statistical analysis were performed to evaluate the relation between PJK and the potential risk factors. RESULTS: There were 43 females and 7 males with a mean age of 14.8 years at surgery. PJK occurred in 5 out of 50 cases with an incidence of 10%. The mean follow-up was 18 months. There was no significant difference in gender (OR 1.36, p = 0.8), decrease of TK (OR 1.63, p = 0 0.69), location of UIV (OR 2.25, p = 0.4), LIV (OR 2, p = 0.55), and SVA change (OR 1.63, p = 0.46). CONCLUSIONS: The disruption of ligamentous and bony tissue proximal to the UIV during the surgery does not increase the rate of PJK. Level of evidence IV.

Intraoperative spinal cord monitoring: Lesional level diagnosis.

BACKGROUND: In spinal deformity surgery, iatrogenic spinal cord injury is the most feared complication. Intraoperative monitoring (IOM) of the spinal cord assesses its functional integrity and allows significant reduction of the rate of spinal cord injury. HYPOTHESIS: In case of severe IOM alert, lesional level diagnosis constitutes supplementary and useful information. MATERIAL AND METHODS: This study was retrospective and monocentric. In our institution, 1062 pediatric spinal deformity surgeries have been monitored since 2004. We review the records of the six patients who presented a severe and prolonged IOM alert with lesional level determination. Somatosensory evoked potentials (SSEP), neurogenic mixed evoked potentials (NMEP) and D-waves were performed. In cases of IOM alert, sequentially moving an epidural electrode along the spinal cord allows lesional level determination, using this electrode either for stimulation or recording. RESULTS: Six patients, aged 12 to 17 years, characterized by severe IOM alerts during spinal deformity surgery are reported. Postoperative neurological examination was normal for five out of six cases. For patient 2, lesional level diagnosis allowed to determine a bi-laminar claw between T2 and T3 as the etiology of IOM alert. This IOM alert was delayed in time, being detectable only 30minutes after the placement of this claw. Postoperative neurological examination was normal. For patient 6, a Stagnara wake-up test demonstrated paraplegia. Lesional level was established. Following corrective surgical maneuvers, postoperative neurologic deficit was limited to a pyramidal syndrome in one lower limb. Postoperative MRI demonstrated a spinal cord lesion at the determined lesional level. CONCLUSION: During an IOM alert, lesional level determination allows localization of spinal cord dysfunction. This data, obtainable whatever the IOM device, constitutes supplementary information in order to rapidly identify the etiology of IOM alert and thus to react in the most appropriate way. LEVEL OF EVIDENCE: IV, retrospective study.

Pediatric orthopedic surgery in humanitarian aid.

Pediatric orthopedic surgery in humanitarian aid is conducted mainly in cooperation with emerging countries. Each mission is different, and depends on numerous parameters such as the country, the frequency of such missions, the pathologies encountered, the local structure and team, and the non-governmental organization (NGO) involved. Pathologies vary in etiology (tuberculosis, poliomyelitis) and severity. Each mission requires the presence of an experienced surgeon. Working conditions are often rudimentary. Surgical indications should be restricted to procedures that are going to be effective, with minimal postoperative complications, without any surgical "acrobatics". Teaching should be in association with the local university, and adapted to local needs. Mission objectives need to be realistic. Surgical indications should be adapted to local conditions, and the surgeon needs to be able to say "no" to procedures involving undue risk. The surgeon on mission should cooperate with local teams and be able to adapt to unusual situations. Assessment of results is essential to improving efficacy and evaluating the success of the mission.

Transplantar intramedullary locking nailing in childhood congenital pseudarthrosis of the tibia: A report of 3 cases.

The treatment objectives in congenital pseudarthrosis of the tibia are bone consolidation and a restored lower-limb axis. They are difficult to achieve, and various surgical techniques have been described, with varying results in terms of bone consolidation and complications. The present study reports clinical and radiographic results in 3 patients managed by the same original technique of transplantar intramedullary nailing using a custom-made proximal locking nail, without surgical approach or resection of the pseudarthrosis site. Good assembly stability allowed immediate weight-bearing. The technique is relatively noninvasive, offering a first-line alternative in under-3 year-olds.

Randomized phase III trial in elderly patients comparing LV5FU2 with or without irinotecan for first-line treatment of metastatic colorectal cancer (FFCD 2001-02).

BACKGROUND: Metastatic colorectal cancer (mCRC) frequently occurs in elderly patients. However, data from a geriatric tailored randomized trial about tolerance to and the efficacy of doublet chemotherapy (CT) with irinotecan in the elderly are lacking. The benefit of first-line CT intensification remains an issue in elderly patients. PATIENTS AND METHODS: Elderly patients (75+) with previously untreated mCRC were randomly assigned in a 2 × 2 factorial design (four arms) to receive 5-FU (5-fluorouracil)-based CT, either alone (FU: LV5FU2 or simplified LV5FU2) or in combination with irinotecan [IRI: LV5FU2-irinotecan or simplified LV5FU2-irinotecan (FOLFIRI)]. The CLASSIC arm was defined as LV5FU2 or LV5FU2-irinotecan and the SIMPLIFIED arm as simplified LV5FU2 or FOLFIRI. The primary end point was progression-free survival (PFS). Secondary end points were overall survival (OS), safety and objective response rate (ORR). RESULTS: From June 2003 to May 2010, 71 patients were randomly assigned to LV5FU2, 71 to simplified LV5FU2, 70 to LV5FU2-irinotecan and 70 to FOLFIRI. The median age was 80 years (range 75-92 years). No significant difference was observed for the median PFS: FU 5.2 months versus IRI 7.3 months, hazard ratio (HR) = 0.84 (0.66-1.07), P = 0.15 and CLASSIC 6.5 months versus SIMPLIFIED 6.0 months, HR = 0.85 (0.67-1.09), P = 0.19. The ORR was superior in IRI (P = 0.0003): FU 21.1% versus IRI 41.7% and in CLASSIC (P = 0.04): CLASSIC 37.1% versus SIMPLIFIED 25.6%. Median OS was 14.2 months in FU versus 13.3 months in IRI, HR = 0.96 (0.75-1.24) and 15.2 months in CLASSIC versus 11.4 months in SIMPLIFIED, HR = 0.71 (0.55-0.92). More patients presented grade 3-4 toxicities in IRI (52.2% versus 76.3%). CONCLUSION: In this elderly population, adding irinotecan to an infusional 5-FU-based CT did not significantly increase either PFS or OS. Classic LV5FU2 was associated with an improved OS compared with simplified LV5FU2. CLINICALTRIALSGOV: NCT00303771.

Interest of T1 parameters for sagittal alignment evaluation of adolescent idiopathic scoliosis patients.

PURPOSE: In the last few years several reports stressed the importance of sagittal alignment in adolescent idiopathic scoliosis (AIS) patients. It was recently reported that T1 slope, defined as the angle between the superior endplate of T1 and the horizontal, correlates strongly with overall sagittal parameters. The aim of this study was to assess the impact of T1 parameters (T1-slope and T1-tilt) on sagittal alignment of AIS hypokyphotic patients preoperatively and postoperatively. METHODS: Twenty-nine AIS patients with <20° preoperative hypokyphosis were included in a retrospective study. Surgery systematically comprised hybrid construct with screws below T11, sublaminar bands at thoracic level and a lamino-laminar claw on the upper instrumented vertebra. Preoperative, postoperative and 2-year follow-up radiological assessment included Cobb angle, T1 slope, T1 sagittal tilt, regional sagittal parameters and pelvic parameters. RESULTS: In the series as a whole, coronal Cobb angle was significantly reduced postoperatively (58° vs. 17°; p < 0.001), thoracic kyphosis significantly improved (12.4° vs. 25.6°; p < 0.001) and cervical lordosis significantly restored (6.2° kyphosis vs. 4.1° lordosis; p < 0.001). There was a significant modification in T1-slope (10.2° vs. 18.2°; p < 0.001). Preoperatively, T1 slope was significantly correlated with T1 tilt (r = 0.427; p = 0.029). Postoperatively, T1 slope was significantly correlated with T1 tilt (r = 0.549; p = 0.002), thoracic kyphosis (r = 0.535, p = 0.005) and cervical lordosis (r = -0.444, p = 0.03). Restoration of cervical lordosis was significantly correlated to changes of T1-slope (r = -0.393, p = 0.032), which was significantly correlated to postoperative thoracic kyphosis. CONCLUSION: According to these results, T1 seems to be of major interest in postoperative modifications of sagittal alignment. T1 slope and sagittal tilt are good indicators of postoperative changes for regional (cervical lordosis and thoracic kyphosis) and global parameters. We therefore consider these parameters as essential in the assessment of AIS patients. Further studies and correlation with clinical scores will, however, be necessary in order to confirm the present findings.

Evolution of adolescent idiopathic scoliosis: results of a multicenter study at 20 years' follow-up.

INTRODUCTION: To date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth. OBJECTIVE: The objective of this study was to assess outcome in patients with moderate AIS. MATERIAL AND METHODS: A multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30-60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up. RESULTS: A total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P < 0.001. In lumbar scoliosis, the risk of progression to ≥ 20° was significantly higher for initial Cobb angle > 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores. DISCUSSION: Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation. LEVEL OF EVIDENCE: IV, retrospective study.

Proximal ulnar osteotomy in the treatment of neglected childhood Monteggia lesion.

INTRODUCTION: The aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children. MATERIAL AND METHODS: This retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling. RESULTS: Twenty-eight patients were reviewed, at a mean 6 years' follow-up (range, 2-34y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation. DISCUSSION: Proximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful. LEVEL OF EVIDENCE: IV (retrospective).

Minimally invasive repair of pectus excavatum using the Nuss technique in children and adolescents: indications, outcomes, and limitations.

BACKGROUND: Pectus excavatum (PE) is a common congenital deformity. The Nuss technique for minimally invasive repair of PE involves thoracoscopy-assisted insertion of a bar or plate behind the deformity to displace the sternum anteriorly. Our objective here was to clarify the indications and limitations of the Nuss technique based on a review of 70 patients. MATERIALS AND METHODS: A retrospective review of children managed at two centres identified 70 patients who had completed their growth and had their plate removed. Mean age was 13.8 years (range, 6-19 years). The reason for surgery was cosmetic disfigurement in 66 (95%) patients. The original Nuss technique was used in 63 patients, whereas 7 patients required an additional sub-xiphoid approach. Time to implant removal ranged from 8 months to 3 years. RESULTS: The cosmetic outcome was considered satisfactory by the patients in 64 (91%) cases and by the surgeon in 60 (85.7%) cases. Major complications requiring further surgery occurred in 6 (8.5%) patients and consisted of haemothorax (n=2), chest wall sepsis (n=2, including 1 after implant removal), allergy (n=1), and implant displacement (n=1). Early or delayed minor complications occurred in 46 (65%) patients and resolved either spontaneously or after non-surgical therapy. DISCUSSION: The minimal scarring and reliably good outcomes support the widespread use of the Nuss technique in children and adolescents. Our complication rates (minor, 65%; and major, 8.5%) are consistent with previous publications. In our opinion, contra-indications to thoracoscopic PE correction consist of a history of cardio-thoracic surgery and the finding by computed tomography of a sternum-to-spine distance of less than 5 cm or of sternum rotation greater than 35°. In these situations, we recommend a sub- and retro-xiphoid approach to guide implant insertion or a classic sterno-chondroplasty procedure. LEVEL OF EVIDENCE: Level IV, retrospective descriptive cohort study.

Role of thoracoscopy for the sagittal correction of hypokyphotic adolescent idiopathic scoliosis patients.

PURPOSE: Thoracic adolescent idiopathic scoliosis (AIS) curves (Lenke 1-4) are often characterized by hypokyphosis. Sagittal alignment remains challenging to correct, even with recent posterior segmental instrumentation. Some authors recommend anterior endoscopic release (AER) to reduce anterior column height, and facilitate thoracic kyphosis correction. The aim of this study was to assess the contribution of AER to sagittal correction in hypokyphotic AIS. METHODS: Fifty-six hypokyphotic (T4T12<20°) AIS patients were included. In group 1 (28 patients), patients first underwent AER, followed by posterior instrumentation and correction 5-7 days later. In group 2 (28 patients), patients underwent the same posterior procedure without AER. Posterior correction was performed in all cases using posteromedial translation and hybrid constructs consisting of lumbar pedicle screws and thoracic sublaminar bands. From radiological measurements performed using low-dose EOS radiographs, the correction of thoracic kyphosis was compared between the two groups. RESULTS: Groups 1 and 2 were comparable regarding demographic data and preoperative thoracic kyphosis (group 1: 11.7° ± 6.9° vs group 2: 12.1° ± 6.3°, p = 0.89). Postoperative thoracic kyphosis increase averaged 18.3° ± 13.6° in group 1 and 15.2° ± 9.0° in group 2. The benefit of anterior release was not statistically significant (p = 0.35). CONCLUSION: Although previous studies have suggested that thoracoscopic release improved correction compared to posterior surgery alone, the current study did not confirm this finding. Moreover, results of the current series showed that no significant benefit can be expected from AER in terms of sagittal plane improvement when the posteromedial translation technique is used, even in challenging hypokyphotic patients.

Proximal migration of fibular malleolus during tibial lengthening despite syndesmotic screw fixation: a series of 22 cases.

INTRODUCTION: During tibial lengthening procedures, it is recommended to prevent fibular malleolus proximal migration using a distal tibiofibular syndesmotic screw, which is removed at 6 months. We have observed proximal migrations of the fibular malleolus despite placement of this syndesmotic screw. OBJECTIVE: The objective of this study was to demonstrate this migration and to study the influence of two factors that may favor its occurrence: positioning of the syndesmotic screw and union of the fibula at the time of removal. HYPOTHESIS: An unhealed fibula at the time the distal tibiofibular syndesmotic screw is removed and its tricortical position promote the proximal migration of the fibular malleolus. MATERIAL AND METHODS: This was a retrospective, single-center, analytical study that included 22 lengthening procedures in 18 patients from 5 to 17 years of age who had undergone tibial lengthening and presented a preoperative continuous fibula. The position of the fibular malleolus, union of the fibula, and the tri- or quadricortical position of the screw were assessed based on four successive x-rays. RESULTS: Tricortical positioning of the syndesmotic screw was significantly associated with proximal migration of the fibular malleolus during lengthening (P=0.0248<0.05). However, there was no significant relation between an unhealed fibula and proximal migration of the fibular malleolus when the screw was removed (P=0.164>0.05). DISCUSSION: Proximal migration of the fibular malleolus during lengthening is promoted by placing a non-quadricortical syndesmotic screw. Quadricortical positioning of the screw should be recommended. Migration of the fibular malleolus after ablation of the syndesmotic screw seems to be related to absence of fibular union but this series was too small to demonstrate this clearly. LEVEL OF EVIDENCE: Level IV: Retrospective study.

[Bone dysplasia in mucopolysacchoridoses]. / Atteintes osseuses des mucopolysaccharidoses.

Mucopolysaccharidoses (MPS) are a group of disorders characterized by the accumulation of glycosaminoglycans. Skeletal abnormalities are early and prominent features of MPS. Cervical spine and atlantoaxial instability, thoracolumbar kyphosis, hip dysplasia and osteonecrosis, genu valgum, and carpal tunnel syndrome are frequently observed. MPS disease-awareness is important for pediatric healthcare providers who should be able to recognize the clinical presentation, musculoskeletal abnormalities, and radiographic findings associated with this group of disorders.

Perioperative medullary complications in spinal and extra-spinal surgery in mucopolysaccharidosis: a case series of three patients.

The mucopolysaccharidoses (MPS) are genetic lysosomal storage diseases. Peripheral bone dysplasia and spinal involvement are the predominant orthopedic damage. The risk of spinal cord compression due to stenosis of the craniocervical junction is well known in these patients, whereas the thoracolumbar kyphosis is often well tolerated over a long period of time. Thus, signs of spinal cord compression at this level occur later and more insidiously. The authors describe three cases of patients with thoracolumbar kyphosis who suffered from postoperative spinal cord compression in the absence of direct surgical trauma. Analysis of these cases and review of the literature helped identify causal factors resulting in spinal cord ischemia. The risk of perioperative spinal cord complications related to a thoracolumbar kyphosis must be discussed with patients with MPS and their families prior to any surgery, including extra-spinal procedures.

Idarubicin-loaded beads for chemoembolisation of hepatocellular carcinoma: results of the IDASPHERE phase I trial.

BACKGROUND: A phase I dose-escalation trial of transarterial chemoembolisation (TACE) with idarubicin-loaded beads was performed in cirrhotic patients with hepatocellular carcinoma (HCC). AIM: To estimate the maximum-tolerated dose (MTD) and to assess safety, efficacy, pharmacokinetics and quality of life. METHODS: Patients received a single TACE session with injection of 2 mL drug-eluting beads (DEBs; DC Bead 300-500 µm) loaded with idarubicin. The idarubicin dose was escalated according to a modified continuous reassessment method. MTD was defined as the dose level closest to that causing dose-limiting toxicity (DLT) in 20% of patients. RESULTS: Twenty-one patients were enrolled, including nine patients at 5 mg, six patients at 10 mg, and six patients at 15 mg. One patient at each dose level experienced DLT (acute myocardial infarction, hyperbilirubinaemia and elevated aspartate aminotransferase (AST) at 5-, 10- and 15-mg, respectively). The calculated MTD of idarubicin was 10 mg. The most frequent grade ≥3 adverse events were pain, elevated AST, elevated γ-glutamyltranspeptidase and thrombocytopenia. At 2 months, the objective response rate was 52% (complete response, 28%, and partial response, 24%) by modified Response Evaluation Criteria in Solid Tumours. The median time to progression was 12.1 months (95% CI 7.4 months--not reached); the median overall survival was 24.5 months (95% CI 14.7 months--not reached). Pharmacokinetic analysis demonstrated the ability of DEBs to release idarubicin slowly. CONCLUSIONS: Using drug-eluting beads, the maximum-tolerated dose of idarubicin was 10 mg per TACE session. Encouraging responses and median time to progression were observed. Further clinical investigations are warranted (NCT01040559).

Minimally invasive endogastric removal of migrated gastric band after endoscopic failure: how I do it.

Intragastric band migration is a rare and late complication of laparoscopic -adjustable gastric banding and should be recognized by all digestive surgeons. Endoscopic removal is most commonly performed, but surgery is an alternative in cases of endoscopic failure. Many different procedures have been reported. We show here (see Video) a fully laparoscopic endogastric procedure through two 5-mm antral gastrotomies. This technique can also be used to remove benign endogastric tumors. The procedure is safe and provides a large endogastric operative area, with no particular morbidity. Endogastric removal through a fully laparoscopic approach should be considered as the first alternative to endoscopic approach.