Laparoscopic ultrasound: a surgical "must" for second line intra-operative evaluation of pancreatic cancer resectability.

BACKGROUND: Advanced laparoscopy for pancreatic cancer surgery should include laparoscopic ultrasound (LUS), in order to accurately evaluate resectability and rule out the presence of undetected metastases and/or vascular infiltration. LUS should be done as a preliminary step whenever pre-operative imaging casts doubts on resectability. PATIENTS AND METHODS: We hereby report our experience of 18 consecutive patients, aged 43-76, coming to our attention during a six months period (Jan-Jun 2013), with a diagnosis of pancreas head or body cancer. RESULTS: LUS allowed to rule out undetected metastases or mesenteric vessels infiltration in 11 patients (61.1%), who were submitted, as previously scheduled, to radical duodeno-pancreatectomy (9 cases) and spleno-caudal pancreatectomy (2 cases). Among the remaining patients, three had been correctly evaluated as non resectable radically at pre-operative work out, and confirmed at LUS, while LUS detected non resectable disease in further 4 patients (22.2%), who underwent palliative procedures. In 2 patients of this group liver micro-metastases were found, while 2 were excluded because of mesenteric vessels infiltration. CONCLUSIONS: LUS provided a higher level of diagnostic accuracy, allowing in our experience to exclude 4 patients from radical surgery (22.2%). The evaluation of surgical resectability is an issue of crucial importance to decide surgical strategy in pancreas tumor surgery. In our opinion LUS should be considered a mandatory step in laparoscopic approach to pancreatic tumors, to better define disease staging and evaluate resectability.

Operative time and postoperative pain following minimally invasive video-assisted parathyroidectomy.

BACKGROUND: Mininvasive surgical techniques have been proposed to treat the patients affected by parathyroid adenoma starting by endoscopically-assisted parathyroidectomy up to video-assisted and radio-guided approaches. PATIENTS AND METHODS: Our technique, minimally invasive video-assisted parathyroidectomy (MIVAP), in accord with Miccoli's technique, has been introduced in our center since 2006 after extensive experience with MIVAT (minimally invasive videoassisted thyroidectomy). From September 2006 to October 2008 we performed 32 MIVAP on 32 patients, 21 female and 11 males with a mean age of 53.4 years (range 25-77) affected by parathyroid adenoma. Patients have been divided in two groups in chronological order: Group A included the first 15 patients, Group B the second ones. RESULTS: Mean operative time from incision to skin closure has been 47.4+/-14.2 minutes for group A and 34+/-10.3 minutes for group B (p<0.01). Postoperative pain, scored from 0 to 10 evaluated at time 0 and after 24 hours from the procedure, has been of 2.6+/-0.5 and 1.4+/-0.5 in group A (p<0.001) while in group B of 2.58+/-0.51 and 1.16+/-0.38 (p<0.001) respectively. The difference in postoperative pain was not significant between the two groups and the pain was controlled by the administration of paracetamol 1 g. On the other side, the comparison between postoperative pain in patients operated via traditional bilateral cervical exploration and MIVAP (2.61+/-0.5 vs 3.55+/-0.51 and 1.38+/-0.5 vs 2.16+/-0.61 at 0 and 24 hours respectively), was statistically significant (p<0.001) and in favour of MIVAP. CONCLUSIONS: We showed a shorter operative time between the A group and B group. 15 cases are sufficient as good learning curve if the surgeon is experienced in videoassisted neck procedure. The postoperative pain is lower in videoassisted procedure than cervical bilateral approach.

Can we use ionized calcium in the evaluation of post-thyroidectomy hypocalcemia?

AIM: The postoperative hypocalcaemia has the higher incidence as complications related to thyroidectomy. METHODS: From 1 June 2006 to 30 June 2008, we examined 492 patients operated on consecutively in our unit with a total thyroidectomy for thyroid disease. We evaluated the values of ionized calcium in all the cases, matching these with the preoperative and postoperative values of serum calcium. The pre- and postoperative (24 hours after treatment) data for ionized calcium and serum calcium were examined statistically with the Student's t-test; results with a P-value <0.05 were considered to be statistically significant. RESULTS: Two-hundred-and-twenty-three of the 492 patients (45.2%) treated with total thyroidectomy had preoperative values of ionized calcium lower than 1.13 mmol/L (normal values 1.13-1.32 mmol/L), while the ionized calcium values were lower than 1.10 mmol/L in 154 of the 223 patients. The mean value of ionized calcium in all 223 cases was 1.04+/-0.07 mmol/L. The mean serum calcium value in these patients was 9.13+/-0.291 mg/dL (normal values 8.3-10.5 mg/dL). In the other 259 cases, the values of ionized calcium and serum calcium were 1.21+/-0.03 mmol/L and 9.1+/-0.29 mg/dL, respectively. In 75 cases on 223 with symptomatic hypocalcemia, the mean value of ionized calcium was 0.88+/-0.05 mmol/L, while, in the remaining 148 cases, the mean value was equal to 0.97+/-0.08 mmol/L (P<0.001). We compared this, in both groups, with the values of postoperative serum calcium; in the 75 cases with clinical hypocalcemia, the value of serum calcium was 7.32+/-0.35 mg/dL, while the value was equal to 8.4+/-0.34 mg/dL in the other cases (P<0.001). CONCLUSIONS: The values of ionized calcium must not be used as marker of hypocalcemia but must be seen as a diagnostic aid linked to others laboratory values, such as serum calcium.

Utility of Computed Tomography versus Abdominal Ultrasound Examination to Identify Iliosacral Lymphadenomegaly in Dogs with Apocrine Gland Adenocarcinoma of the Anal Sac.

BACKGROUND: Apocrine gland adenocarcinoma of the anal sac (AGAAS) is associated with high rates of iliosacral lymph node metastasis, which may influence treatment and prognosis. Magnetic resonance imaging (MRI) recently has been shown to be more sensitive than abdominal ultrasound examination (AUS) in affected patients. OBJECTIVE: To compare the rate of detection of iliosacral lymphadenomegaly between AUS and computed tomography (CT) in dogs with AGAAS. ANIMALS: Cohort A: A total of 30 presumed normal dogs. Cohort B: A total of 20 dogs with AGAAS that underwent AUS and CT. METHODS: Using cohort A, mean normalized lymph node : aorta (LN : AO) ratios were established for medial iliac, internal iliac, and sacral lymph nodes. The CT images in cohort B then were reviewed retrospectively and considered enlarged if their LN : AO ratio measured 2 standard deviations above the mean normalized ratio for that particular node in cohort A. Classification and visibility of lymph nodes identified on AUS were compared to corresponding measurements obtained on CT. RESULTS: Computed tomography identified lymphadenomegaly in 13 of 20 AGAAS dogs. Of these 13 dogs, AUS correctly identified and detected all enlarged nodes in only 30.8%, and either misidentified or failed to detect additional enlarged nodes in the remaining dogs. Despite limitations in identifying enlargement in all affected lymph nodes, AUS identified at least 1 enlarged node in 100% of affected dogs. CONCLUSION AND CLINICAL IMPORTANCE: Abdominal ultrasound examination is an effective screening test for lymphadenomegaly in dogs with AGAAS, but CT should be considered in any patient in which an additional metastatic site would impact therapeutic planning.

Use of real-time PCR and the LightCycler system for the rapid detection of Pneumocystis carinii in respiratory specimens.

Pneumocystis carinii pneumonia (PCP) remains a major cause of morbidity and mortality in immunocompromised patients, including those infected with human immunodeficiency virus (HIV). The advent of real-time PCR technology offers the potential for rapid PCR results for the detection of P. carinii. In this report we describe the modification and evaluation of an existing PCR-based method for the detection of P. carinii DNA, into a real-time PCR assay suitable for use with the LightCycler system. Twenty eight induced sputum and bronchial washing specimens from 28 patients were tested by both a conventional PCR assay and a real-time PCR assay. Twelve specimens (42.9%) were positive in both the conventional and real-time PCR assays and sixteen (57.1%) were negative in both assays. The melting points of the amplified P. carinii DNA product obtained by melting curve analysis by the LightCycler of all P. carinii positive specimens ranged from 81.5 degrees C to 83.9 degrees C. There were no discordant results between the two assays for any of the specimens tested and results were available within 2 h for the real-time PCR assay compared to up to 11 h for the conventional PCR assay.

Evaluation of a commercial polymerase chain reaction assay for the detection of Chlamydia trachomatis.

Cell culture has traditionally been considered the most sensitive method for detecting Chlamydia trachomatis from clinical specimens, but depends upon the organisms being viable at the time of cell inoculation. Furthermore, cell culture is slow and labor intensive. Even when a special transport medium is used, there is a progressive loss of viability of C. trachomatis during transport. The detection of C. trachomatis by cell culture is more rapid when immunofluorescence is used to detect early antigen, but requires considerable experience to interpret. The Amplicor C. trachomatis system is a commercial polymerase chain reaction (PCR)-based assay combined with nucleic acid hybridization for the direct detection of C. trachomatis in urine and swabs of appropriate sites, with results available within 6 h. All specimens for C. trachomatis received by the Royal Perth Hospital Department of Microbiology during the period 1 July 1994 to 30 June 1995 that were suitable for culture and Amplicor PCR were tested by both methods (2029 specimens). Discordant results were obtained in nine cases and resolved by additional testing. Seventy-one specimens were confirmed as true positives, of these Amplicor PCR correctly detected 67 (sensitivity 94.4%) and culture correctly detected 62 (sensitivity 87.3%). The Amplicor PCR assay was found to be more sensitive and as specific as culture. It had the added advantages of ease of use, rapid availability of results, standardization and was more suited than culture to processing large number of specimens.

Diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae. Genitourinary infections in males by the Amplicor PCR assay of urine.

The Amplicor CT/NG polymerase chain reaction (PCR) test on urine specimens from males was prospectively evaluated against established specimens and laboratory methods for diagnosing Chlamydia trachomatis and Neisseria gonorrhoeae genitourinary infections, in patients from a remote region of Western Australia. Seventy-three males who were tested for both C. trachomatis and N. gonorrhoeae by both conventional methodology and Amplicor PCR on urine were enrolled in the study. Established testing comprised enzyme immunoassay/immunofluorescence antigen testing (EIA/IF) for C. trachomatis and microscopy and/or culture for N. gonorrhoeae on urethral swabs. Positive test results were confirmed using a set of criteria that included supplemental PCR testing and clinical history. Overall, 13.7% of patients were resolved as positive for C. trachomatis and 52.1% as positive for N. gonorrhoeae. The sensitivity and specificity of the Amplicor CT/NG PCR on male urine specimens for C. trachomatis were 80.0% (8/10) and 95.2% (60/63), compared with 60.0% (6/10) and 100.0% (63/63) for EIA/IF on urethral swabs. For N. gonorrhoeae, the sensitivity and specificity of the Amplicor CT/NG PCR on male urine specimens were both 100% (38/38 and 35/35, respectively) compared with 86.8% (33/38) and 100% (35/35) for microscopy and/or culture on urethral swabs. The results of this study indicate that the Amplicor CT/NG multiplex PCR test for C. trachomatis and N. gonorrhoeae performed on urine in males provides a highly sensitive, specific, and robust method for the diagnosis of both C. trachomatis and N. gonorrhoeae, for the early detection of both symptomatic and asymptomatic infected individuals.

Catheter-related septicemia caused by a vancomycin-resistant Coryneform CDC group A-5.

A case of catheter-related septicemia, due to Coryneform CDC group A-5, in an 11 yr old boy with acute myelomonocytic leukemia is discussed. The child failed to respond to initial antibiotic therapy, even following the addition of vancomycin. Laboratory studies later showed the organism to be vancomycin resistant but cefotaxime susceptible.

Preliminary results on Digenea found in fishes in the coastal waters of Terra Nova Bay, Antarctica.

A list of fish parasites (Digenea) from the coastal waters of Terra Nova Bay (Ross Sea, Antarctica) concerns 10 identified species, namely Macvicaria pennelli, Neolebouria terranovaensis, Helicometra pisanoae, Lepidapedon balgueriasi, L. garradi, Genolinea bowersi, Derogenes johnstoni, Gonocerca phycidis, Elytrophalloides oatesi, Lecithaster macrocotyle, 1 genus Aporocotyle sp. and one specimen undetermined. The total number of species known from the Ross Sea increased from 9 to 12. This number is smaller than those of other Antarctic areas, such as Western Antarctic and Weddell Sea where more extensive investigations were carried out to date.

Fixation of the Austin procedure with the Herbert screw. A modified technique.

Although the Austin osteotomy is intrinsically stable, some surgeons use fixation to enhance stability. One form of fixation that may be used for this procedure is the Herbert screw. The author presents a modification of a previously reported technique, and describes it as a five-step process. The advantages and potential disadvantages of the use of the Herbert screw with the presented technique are discussed.

Metatarsus adductus and selected radiographic measurements of the first ray in normal feet.

Radiographic evaluation of hallux abducto valgus frequently involves the measurement of the metatarsus adductus angle, first-second intermetatarsal angle, hallux abductus angle, and proximal articular set angle. While the concept that there is a relationship between untreated metatarsus adductus and hallux abducto valgus deformity is not new, a quantifiable relationship between the metatarsus adductus angle and intermetatarsal angle, hallux abductus angle, and the proximal articular set angle in normal feet is relatively undocumented. The purpose of this study is to document relationships between the metatarsus adductus angle and the other three measurements, and to establish normal values for the intermetatarsal angle, hallux abductus angle, and proximal articular set angle within metatarsus adductus angle subgroups.

Electrical stimulation of cutaneous ulcerations. A literature review.

The effect of electrical currents on living cellular systems has been studied by many researchers and is becoming useful in clinical medicine. Alteration of cellular activity with externally applied currents can positively or negatively influence the status of a healing tissue, thereby directing the healing process to a desired outcome. A review of the literature pertaining to the effect of electrical currents on tissue healing is presented and the relevance of this modality to ulcer healing is discussed.

Cubonavicular coalition.

The cubonavicular coalition is a rare form of tarsal coalition that probably accounts for less than 1% of all coalitions. The authors present a new case of cubonavicular coalition as well as the findings of the 17 previously published accounts. Etiology, clinical presentation, diagnosis, and treatment of the condition are discussed.

Distraction systems for ankle arthroscopy.

It is clear that for most of the routine pathology addressed with ankle arthroscopy, including most talar dome transchondral fractures, manual distraction (or none at all) is all that is necessary to successfully complete the procedure. There is little need to add the expense and potential complications associated with some distraction systems. However, some cases involve pathology or surgical techniques that either would be better addressed with distraction or absolutely demand distraction. It is recommended that invasive ankle distraction be reserved for (1) cases in which noninvasive distraction has not yielded adequate field visualization or instrument maneuvering room, (2) cases of preoperatively documented pathology involving the posterior talar dome (including some medial talar dome fractures) or inferior tibial surface, or (3) arthroscopic ankle fusion. Consideration should be given to providing 6 to 12 weeks of protected function of the extremity to avoid delayed fracture presentation. In general, the invasive distraction system should be reserved for those cases that would not ordinarily be managed with aggressive rehabilitation and early return to activities. For those cases where the benefits of distraction are desired (some dome fractures, meniscoid lesions, gutter pathology, and adhesive capsulitis) and aggressive rehabilitation with early return to activities may be planned, noninvasive distraction systems are now available that offer a sustainable joint separation of good magnitude. With the growing availability and effectiveness of the commercial noninvasive ankle distractors, I do not disagree with Stone and Guhl98 when they advocate the use of noninvasive distraction for routine arthroscopic procedures, with conversion to invasive distraction should there be insufficient joint separation. In summary, providing optimal field visualization and maneuvering room for instrumentation is essential for the successful performance of arthroscopic ankle surgery. This article has discussed options available to the arthroscopist that can assist in achieving these objectives. The exact method of distraction selected for a given case may be determined by the arthroscopist by weighing the issues discussed in this article.

Surgical approaches of the rearfoot and ankle.

The number of alternative approaches for the variety of rearfoot and ankle procedures commonly performed is clearly as great as the imagination of the surgeon. To ensure that the incisional approach is to contribute to the overall success of the procedure, the right approach must be selected and properly performed. To facilitate this process, general principles of incision placement and performance in the rearfoot and ankle have been presented. Building on those principles, one can learn the various techniques, as well as their respective advantages and disadvantages. Finally, the discerning surgeon should be able to apply the information presented here to select and perform the right incisional approach. Furthermore, the same process may lead the surgeon to improvise and create a successful alternative.

Pressure-removing strategies in neuropathic ulcer therapy. An alternative to total contact casting.

Technical considerations, advantages, and disadvantages of felt and foam contact pads have been presented. Anecdotally, it appears the technique provides a more dynamic, safe, and practical method of ulcer decompression compared with total contact casting. In light of the apparent advantages of felt and foam contact padding, a randomized prospective study would be worthwhile to determine the effectiveness of this modality as compared with total contact casting.