Lung biopsy in children: when is it useful?

AIM: To provide a further insight into the usefulness of lung biopsy in children. METHODS: Lung biopsies in children from January 2007 to December 2017 were reviewed (n=39). The histology results were categorised as: definitive diagnosis, normal lung parenchyma, inconclusive. RESULTS: Lung biopsy provided a definitive diagnosis in 25 (64%) cases. A suspected diagnosis was confirmed in 16 (41%) and a new diagnosis was found in 9 (23%) children. Histology was inconclusive in 11 (28%) cases and normal in 3 (8%). Fifteen (38%) children had treatment altered due to the biopsy result. CONCLUSION: Lung biopsy mostly confirmed the suspected diagnosis and was associated with a low procedure related morbidity (n=1) and mortality (n=0). Importantly, the biopsy result identified a pathology which altered treatment in over one third of patients. However, in a number of cases the histology was inconclusive, therefore careful patient selection is recommended to maximise diagnostic yield.

Prognostic impact of the Bismuth-Corlette classification: Higher rates of local unresectability in stage IIIb hilar cholangiocarcinoma.

BACKGROUND: The Bismuth-Corlette (BC) classification is used to categorize hilar cholangiocarcinoma by proximal extension along the biliary tree. As the right hepatic artery crosses just behind the left bile duct, we hypothesized that BC IIIb tumors would have a higher likelihood of local unresectability due to involvement of the contralateral artery. METHODS: A retrospective review of a prospectively maintained database identified patients with hilar cholangiocarcinoma taken to the operating room for intended curative resection between April 2008 and September 2016. Cases were assigned BC stages based on preoperative imaging. RESULTS: Sixty-eight patients were included in the study. All underwent staging laparoscopy after which 16 cases were aborted for metastatic disease. Of the remaining 52 cases, 14 cases were explored and aborted for locally advanced disease. Thirty-eight underwent attempt at curative resection. After excluding cases aborted for metastatic disease, the chance of proceeding with resection was 55.6% for BC IIIb staged lesions compared to 80.0% of BC IIIa lesions and to 82.4% for BC I-IIIa staged lesions (P < 0.05). About 44.4% of BC IIIb lesions were aborted for locally advanced disease versus 17.6% of remaining BC stages. CONCLUSIONS: When hilar cholangiocarcinoma is preoperatively staged as BC IIIb, surgeons should anticipate higher rates of locally unresectable disease, likely involving the right hepatic artery.

A prospective observational study of the utility of early diagnostic laparoscopy for right lower abdominal pain: a safe and effective diagnostic and therapeutic tool.

BACKGROUND AND AIMS: Diagnostic laparoscopy is commonly performed for diagnosis of right lower abdominal pain and its use is increasing in the emergency setting. Some studies have reported that diagnostic laparoscopy and laparoscopic appendicectomy have advantages over conventional surgery. Many emergency surgeons now perform diagnostic laparoscopy for both clinically diagnosed appendicitis and when the diagnosis is in doubt. The aim of the present study was to assess whether the use of diagnostic laparoscopy is justified and safe for those admitted with right lower abdominal pain. METHODS AND RESULTS: Data were collected prospectively on consecutive patients attending the acute surgical receiving unit with right iliac fossa pain or a suspected diagnosis of acute appendicitis. A total of 284 patients underwent diagnostic laparoscopy. Of them 233 (82%) had a positive finding at laparoscopy, 207 (88%) underwent appendicectomy, the majority of which were carried out laparoscopically. Surgical trainees performed the majority of operations and this did not have a negative impact on operative findings (p 0.856), operation performed (0.642), or operative duration (0.831). No intra-operative complications were sustained. Ultrasound examination was carried out in 49 patients, while CT was carried out in 24. CONCLUSION: The results of the present study highlight the utility of early diagnostic laparoscopy as both a diagnostic and therapeutic tool in the acute setting.

Effects of dermal wounding on distal primary tumor immunobiology in mice.

BACKGROUND: Before primary oral tumors are treated, various prophylactic procedures that require tissue repair are often necessary (e.g. biopsies, tooth extractions, radiation, and tracheotomies). Wound healing and tumor growth harness similar immune/inflammatory mechanisms. Our previous work indicates that tumors impair wound healing, although the extent to which tissue repair conversely influences tumor growth is poorly understood. Here, we test the hypothesis that dermal wound healing exacerbates primary tumor growth and influences tumor immunobiology. MATERIALS AND METHODS: Female, immunocompetent mice were inoculated subcutaneously with murine oral cancer cells (AT-84) to induce flank tumors. Half of the mice received dermal excisional wounds (4 × 3.5 mm diameter) on their dorsum 16 days later, whereas the skin of controls remained intact. Tumor and blood tissues were harvested 1 and 5 days post wounding, and tumor myeloid cell populations and inflammatory gene expression were measured. Circulating myeloid cells, cytokines, and corticosterone were also quantified. RESULTS: Wounding increased tumor mass, early tumor infiltration of macrophages, and tumor inflammatory gene expression. While wounding attenuated tumor growth-induced increases in circulating myeloid cells, no effects of wounding on circulating cytokine/endocrine measures were observed. CONCLUSIONS: These results indicate that modest skin immune/inflammatory processes can enhance distal tumor growth and alter innate tumor immunity. The implication for this work is that, in the presence of a tumor, the benefits of tissue-damaging procedures that occur clinically must be weighed against the potential consequences for tumor biology.

Algunos aspectos de interés sobre la cirugía bariátrica en la infancia y la adolescencia / Some aspects of interest about bariatric surgery applied in childhood and adolescence

Antecedentes: un porcentaje significativo de los niños y adolescentes afectados por la obesidad desarrollarán obesidad mórbida en algún momento de su vida adulta. Actualmente, el empleo de la cirugía bariátrica en estos pacientes es un tema polémico, por lo que resulta de interés conocer sus aspectos más relevantes, así como sus resultados en esta etapa de la vida. Objetivo: describir algunos aspectos de interés sobre la cirugía bariátrica en la infancia y la adolescencia. Desarrollo: se exponen y comentan los principales riesgos asociados a la obesidad en la niñez y adolescencia, los objetivos del tratamiento y los criterios de inclusión en un programa de cirugía bariátrica. Se enfatiza en el tiempo de tratamiento previo para valorar la necesidad de la intervención, la edad, el índice de masa corporal, la madurez sexual, ósea y psicológica del paciente, entre otros criterios, para autorizarla. También, se describen las contraindicaciones y medidas preoperatorias, ya que su conocimiento y cumplimiento posibilitarían la obtención de los resultados esperados. Se hace mención de las vías y técnicas quirúrgicas empleadas, así como algunos de sus resultados y complicaciones. Consideraciones finales: se exponen algunos aspectos de interés sobre cirugía bariátrica en la infancia y la adolescencia, con hincapié en los elementos más controversiales, lo que permite seleccionar a los pacientes que mejor evolución puedan tener con este tipo de intervención(AU)

Background: a significant percentage of obese children and adolescents develop morbid obesity at some time of their adulthood. The use of bariatric surgery in these patients is a controversial issue at present, so it is interesting to find out its most relevant aspects and results in this stage of life. Objective: to describe some aspects of interest on bariatric surgery applied in childhood and adolescence. Development: this review sets forth and comments on the main risks associated to obesity in childhood and adolescence, the objectives of the treatment and the inclusion criteria to be met in a bariatric surgery program. Emphasis was made on length of previous treatment to assess the need for intervention, age, body mass index, sexual, bone and psychological maturity of the patient, among other criteria, for giving authorization. Counterindications and preoperative measures were also described since knowing and complying with them would facilitate the expected results. Mention was made to the surgical paths and techniques as well as some results and complications of the bariatric surgery. Final thoughts: some aspects of interest on bariatric surgery in childhood and adolescence were explained, with emphasis on the most controversial elements, which will allow selecting the patients that could present better evolution with this type of intervention(AU)

Oral glucose and breast milk as a strategy for pain reduction during the heel lance procedure in newborns.

INTRODUCTION: This paper presents the results of a study on pain reduction in newborns that undergo painful medical procedures. This research analyzed the reactions of babies before and after the heel lance procedure, a diagnostic test performed to detect phenylketonuria. This test involved the extraction of a capillary blood sample with a heel lance, a medical procedure that is painful for neonates. OBJECTIVE: The main objective of this research was to evaluate the effectiveness of a 24% oral glucose solution and breastfeeding during heal lance. METHOD: An experimental study was thus conducted on a sample of 93 newborns in the San Cecilio University Hospital in Granada in 2010. The babies in the sample were divided into three groups, depending on what they ingested during the heal lance. RESULTS: The results obtained showed that there was an association between the difference in HR and the time before the newborn's HR returned to normal after the heel lance (r = 0.562; p = 0.000). Moreover, a positive relation was found between the absolute difference in HR and the difference in oxygen saturation (OS) (r = 0.538; p = 0.000). CONCLUSION: The OS was found to be greater in the group of newborns that received breast milk.

Introducción: Para la detección de la fenilcetonuria, se realiza la prueba diagnóstica que consiste en la extracción de una muestra de sangre capilar, mediante la punción del talón al recién nacido. Este proceder es muy doloroso para el neonato. Objetivo: Valorar la efectividad de la administración de glucosa oral al 24 % y lactancia materna durante la punción del talón en el recién nacido. Método: Se realizó un estudio experimental en una muestra de 93 recién nacidos del Hospital Clínico "San Cecilio" de Granada durante el año 2010. La muestra se distribuyó en tres grupos en función del tipo de ingesta administrada en la realización de la prueba del talón. Resultados: El estudio pone de manifiesto que existe asociación en la diferencia de la FC con el tiempo transcurrido hasta alcanzar la normalidad después de la punción (r = 0,562; p = 0,000). También se halló una relación positiva entre la diferencia absoluta en la FC y la diferencia en la Saturación de Oxígeno (SO) (r = 0,538; p = 0,000). Conclusión: La SO es mayor en el grupo de lactancia materna que en el resto; así como en el de glucosa oral 24% que en el de control.

Complication rate of right ventricular endomyocardial biopsy via the femoral approach: a retrospective and prospective study analyzing 3048 diagnostic procedures over an 11-year period.

BACKGROUND: An unequivocal diagnosis of myocarditis and cardiac virus persistence is based on histological, immunohistological, and molecular biological analyses of endomyocardial biopsies (EMBs). Biopsy-based diagnosis of myocarditis has become increasingly important because recent studies have demonstrated the beneficial effects of biopsy-based causal treatment strategies (immunosuppressive or antiviral). Because the risks of major complications caused by EMB procedures have not yet been well defined, we evaluated the incidence of major and minor complications of right ventricular EMB procedures in this retrospective and prospective single-center study. METHODS AND RESULTS: With the use of a modified Cordis bioptome, 1919 patients underwent 2505 EMB procedures retrospectively over a 9-year period (January 1995 to December 2003), and 496 patients underwent 543 EMB procedures prospectively between January 2004 and December 2005. A total of 2415 patients had 3048 EMB procedures via the right femoral vein approach under biplane fluoroscopic control to evaluate unexplained left ventricular dysfunction (retrospective left ventricular ejection fraction, 49.8+/-18.8%; prospective, 48.8+/-19.7%) after exclusion of secondary causes. During each EMB procedure, an average of 8.2+/-0.8 EMBs were obtained retrospectively and 10.1+/-0.6 specimens prospectively for a total of 26 025 specimens. No patient died or required emergency cardiac surgery. Other major complications like cardiac tamponade requiring pericardiocentesis or complete atrioventricular block requiring permanent pacing were very rare: 0.12% in the retrospective study and 0% in the prospective study. Minor complications such as pericardial effusion, conduction abnormalities, or arrhythmias occurred in 0.20% of the EMB procedures in the retrospective study and 5.5% in the prospective study. CONCLUSIONS: The EMB procedure via the femoral vein approach under fluoroscopic guidance has a very low complication rate when performed by experienced operators.

Curso de Atualização em Cardiologia: aula 4: Avaliação pré-operatória do paciente cardiopata / Updating in Cardiology Course: class 4: Preoperative evaluation of cardiopath patient

Mundialmente, cerca de 500 mil a 900 mil pacientes operados sofrem um evento cardiovascular relacionado ao ato cirúrgico, tal como morte cardiovascular, infarto do miocárdio (IM) ou parada cardiorrespiratória não-fatais. Os pacientes acometidos por IM relacionado a cirurgia não-cardíaca apresentam mortalidade intra-hospitalar de 15 por cento a 25 por cento, sendo tal evendo um fator de risco independente para morte cardiovascular e IM em até seis meses após a cirurgia. A fisiopatologia do IM no contexto peroperatório é menos conhecida. A correta identificação de pacientes de alto risco cardiovascular é fundamental para determinar quais medidas devem ser tomadas visando diminuir o risco de eventos peroperatórios. Há vários índices publicados (de Lee, Goldman, Lersen e Gilbert) usados para estimar o risco cirúrgico de um paciente, os quais levam em conta o número de preditores de risco (p. ec.: história de angina, diabetes ou cirurgia de emergência que o paciente possui. Todos são limitados, uma vez que a maioria se baseia em resultados de estudos que ocorreram em um único centro, em geral um hospital universitário, além do que a maioria não avaliou desfechos compostos com semelhantes graus de relevância. Para escolher qual teste não-invasivo solicitar, deve-se considerar os resultados das meta-análises relevantes e de suas limitações. Intervenções atualmente utilizadas para a prevenção de eventos cardíacos peroperatórios carecem de evidências científicas mais robustas que as justifiquem.

Prevención de malposiciones palpebrales posblefaroplastia inferior / Prevention the palpebral malpositions in the inferior blepharoplasty

La blefaroplastia inferior es un procedimiento habitual que tiene ciertas limitaciones en lo que respecta a la corrección del excedente cutáneo y arrugas dinámicas, las cuales deben ser discutidas con el paciente previo a la cirugía. Las malposiciones palpebrales son las secuelas más frecuentes de la blefaroplastia inferior yse producen generalmente por insuficiente evaluación prequirúrgica, más que por un error de técnica quirúrgica. Evaluando correctamente los factores de riesgo, se podrán tomar conductas que minimicen la aparición de estas complicaciones

The dangers of diagnostic laparoscopy in the head injured patient.

Pneumoperitoneum during laparoscopy has been known to result in a rise in intracranial pressure (ICP) in experimental studies. There are no reports of the effect of pneumoperitoneum during diagnostic laparoscopy in patients suffering closed head injuries. We present the case of a 39 year old male with a closed head injury. Diagnostic laparoscopy was performed while intracranial pressure was monitored. ICP increased from 9 mmHg to over 60 mmHg within 10 min of pneumoperitoneum. Laparoscopy was terminated and the ICP returned to normal levels within 35 min. The authors recommend that pneumoperitoneum laparoscopy should not be used in the trauma setting where head injury is suspected.

Diagnostic mini-video assisted thoracic surgery. Effectiveness and accuracy of new generation 2.0 mm instruments.

OBJECTIVE: Recently 2.0 mm mini-VATS has aroused much interest among surgeons involved with endoscopic surgery. We report our initial experience with the first first 54 patients who underwent this procedure. The aim of this study is to evaluate the effectiveness and accuracy of mini-VATS. METHODS: 54 patients were undertaken to mini-VATS for diagnostic purposes. Patients were randomly selected and the indication for operation was set by the classic VATS criteria. 35 (65%) patients were treated under general anesthesia, while 19 (35%) patients were treated under local anesthesia. RESULTS: The average length of hospital stay was 1.8 +/- 0.9 days. The days of requirement for narcotic analgesia were 1.9 +/- 1.0. Diagnostic accuracy was 100%; morbidity and mortality rates were 0%. CONCLUSIONS: The high diagnostic accuracy and low operative danger, combined with less postoperative pain, due to minor surgical trauma and faster patient recovery, has established mini-VATS as a dynamic competitor to the classic VATS procedure. Since high technology is a strong partner in endoscopic surgery, a strong potentiality for evolution exists.

Biopsia por punción con aguja fina sin aspiración en el diagnóstico prequirúrgico del nódulo del tiroides / Fine needle biopsy without aspiration in the presurgical diagnosis of thyroid nodule

Se estudió un grupo de 100 pacientes operados de nódulo único del tiroides en el Servicio de Cirugía General del Hospital "Cmdte. Manuel Fajardo", para validar el método de la biopsia por punción con aguja fina sin aspiración (citopunción) en el diagnóstico prequirúrgico de esa afección. A cada paciente se le realizó una citopunción con aguja No. 25 antes de la intervención quirúrgica; los resultados se clasificaron en negativos (benignos) y positivos (malignos y sospechosos) y la histología posoperatoria, en benigna y maligna, según los intereses de nuestro trabajo y de criterios preestablecidos en el Departamento de Anatomía Patológica del hospital. El 100 (por ciento) de las muestras fue útil para diagnóstico con una correspondencia entre citopunción e histología del 83 (por ciento). Los valores de los indicadores de validación fueron: sensibilidad: 76 (por ciento), especificidad: 85 (por ciento), valor predictivo positivo: 57 (por ciento), valor predictivo negativo: 93 (por ciento) y eficacia general del método: 85 (por ciento). Concluimos que la citopunción es un método diagnóstico útil en el nódulo único del tiroides y que logra iguales resultados que la BAF, pero la primera es más recomendable por ser de más fácil aplicación, menos traumático y más económico

An unusual complication of tapping a ventriculoperitoneal shunt.

A case is reported describing a complication of an unsuccessful attempt to aspirate the reservoir of a ventriculoperitoneal shunt system with a suspected shunt infection. This arose due to a misunderstanding of the anatomy of the shunt and resulted in an intracerebral haematoma. The complications of cerebrospinal fluid shunting and the difficulty in the diagnosis thereof are outlined. We discuss the role and method of shunt tapping in diagnosing shunt problems before reviewing the literature describing the rationale. The variation in shunt design is emphasized. Guidelines are then proposed not to dissuade physicians from tapping shunts but to ensure that the procedure is performed safely and in collaboration with neurosurgical units.

[Invasive diagnosis of coronary heart disease in patients over 75 years old]. / Invasive Abklärung der koronaren Herzkrankheit bei über 75-jährigen Patienten.

Between January 1, 1993, and August 31, 1995, 268 patients over 75 years underwent coronary angiography at the University Hospital of Bern. Their clinical reports were analyzed in order to determine whether invasive diagnosis of coronary artery disease (CAD) is justifiable also in the elderly considering risks and complications. The main indication for coronary angiography were symptoms of ischemic heart disease. Twenty-nine underwent the procedure for planned cardiac surgery, mostly valve replacement. In 79% of patients, coronary angiography revealed CAD. In the remaining 21% there were no significant coronary stenoses, but 82% of them had valvular heart disease. Only 4% had neither coronary nor valvular heart disease. Following coronary angiography 63% of patients had a therapeutical intervention: 24% coronary angioplasty (PTCA), 13% bypass-grafting, 17% valve replacement, 8% combined surgery (revascularization and valve-replacement), and 1% another intervention. Four percent had no cardiac disease, 1% died before a planned surgery. The remaining 32% were continued on medical therapy. As indicators of appropriateness and success of the invasive procedure the rates of complications and the duration of hospitalization were analyzed. The incidence of deaths, myocardial infarctions, cerebral complications, and arrhythmias was five to ten times higher for cardiac surgery than for PTCA or conservative treatment. Invasive diagnosis and therapy of CAD in patients over 75 years can nevertheless be reasonable and successful if the decision is taken carefully considering risk factors and concomitant disease.