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Odontogenic ghost cell carcinomaHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 4 2004
David Goldenberg MD
Abstract Background. Odontogenic ghost cell carcinoma (OGCC), a malignant counterpart of the calcifying odontogenic cyst (COC), is exceedingly rare. Previous descriptions of this tumor were based on identification of malignant histologic characteristics such as infiltration, cellular pleomorphism, numerous mitoses, and necrosis concurrent with classical benign COC or its solid benign variant, the odontogenic ghost cell tumor. Methods. We present a case of a young Asian man who underwent multiple local excisions of a recurring maxillary COC. After one such excision, a rapid onset of painful swelling ensued, and the patient was referred to our institution for definitive surgery. Results. The patient underwent a right subtotal maxillectomy. Intraoperatively, a 5-cm tumor was found to be extending into the right maxillary sinus and nasal cavity. The excised tumor was diagnosed as an OGCC. The tumor was excised with clear margins, and no adjunctive radiotherapy was given. The patient was free of residual or recurrent disease 18 months after surgery. Conclusions. On the basis of this case and prior cases found in the literature, OGCCs show a spectrum of growth from slow growing locally invasive tumors to highly aggressive, rapidly growing, infiltrative tumors. Wide local excision with histologically clean margins is the recommended mode of treatment. We recommend close long-term surveillance of recurrent or long-standing benign COCs and OGCC. © 2003 Wiley Periodicals, Inc. Head Neck26: 378,381, 2004 [source]
Mucous membrane pemphigoid, thymoma, and myasthenia gravisINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 9 2000
Haideh Yazdani Sabet
In November 1997, approximately 1 year before being evaluated at the Mayo Clinic, Rochester, a 63-year-old woman presented with erosive tongue lesions that were diagnosed by her physician as oral lichen planus. The lesions responded well to 3 months of treatment with systemic and topical corticosteroids and topical antiyeast medication. She stopped taking the medications and had a relapse. A few months after the oral lesions developed, her left eyelid became ptotic. Results of magnetic resonance imaging of her brain were normal, and the ptosis resolved spontaneously after 2 weeks. One year later, her right eyelid began to droop, and the results of edrophonium testing were positive. She was prescribed prednisone, 30 mg daily, and pyridostigmine, as needed. The ptosis improved, but never fully resolved. Radiography revealed a left ,,thyroid nodule,'' but computed tomography did not show a mediastinal mass. She was advised to have the ,,nodule'' removed surgically and came to the Mayo Clinic, Rochester, for a second opinion. Her medical history was significant for the following: tinnitus, glaucoma, early bilateral cataracts, and long-standing hypertension, for which she took losartan, 50 mg twice daily. Other medications included: prednisone, 30 mg daily; pyridostigmine as needed; famotidine, 40 mg daily; and eyedrops for glaucoma. She denied any history of hyperthyroidism or hypothyroidism, head and neck irradiation, family history of thyroid disease, or diplopia. Hepatitis serologic studies revealed hepatitis B exposure and recovery, hepatitis C immunity, and a previous hepatitis A viral infection. On examination at the Mayo Clinic, Rochester, an erosive hypertrophic plaque was noted on the posterior dorsal half of the tongue, and vesicles and erythematous erosions on the hard and soft palates ( Fig. 1a). A lace-like white pattern was seen on the buccal mucosa bilaterally, and a small erosive patch on the left buccal mucosa ( Fig. 1b). Ocular and nasal mucous membranes were normal in appearance, and there were no pertinent skin findings. Dermatopathologic examination of an excisional biopsy specimen from the left dorsum of the tongue demonstrated an ulcer with epitheliomatous hyperplasia and a granulomatous reaction, presumably due to yeast infection. Silver staining showed hyphae and yeast at the base of the tongue ulcer. The results of the direct immunofluorescence study were negative and revealed no lichenoid changes on hematoxylin and eosin staining. Indirect immunofluorescence testing of the serum revealed a 1 : 80 titer of basement membrane zone antibodies, reflecting pemphigoid. This test was positive on repeat study. Salt-split skin on monkey esophagus revealed an epidermal pattern of basement membrane zone antibodies. Treatment included fluocinonide gel applied to the involved areas four times daily and oral antiyeast therapy (fluconazole, 200 mg once daily by mouth) while the rest of the evaluation was being completed. Figure 1(a). Erosive hypertrophic tongue plaque. Figure (b) ,. Erosive patch on the buccal mucosa. As part of the evaluation of the ptosis, a myasthenia gravis antibody panel was performed. It revealed the following abnormalities: striated muscle antibody at 1 : 480 (reference range, <1 : 60), acetylcholine receptor binding antibody at 6.33 nmol/L (reference range, ,,0.02 nmol/L), acetylcholine receptor blocking antibody at 31% (reference range, 0,25%), and acetylcholine receptor modulating antibody at 100% (reference range, 0,20%), suggesting thymoma. Treatment included pyridostigmine, 30,45 mg 3,4 times daily, to control the myasthenia symptoms, while the ill-defined neck mass was being evaluated. A mildly enlarged thyroid was noted on physical examination. Hematology panel revealed thyroid-stimulating hormone (TSH) levels in the low normal range; the thyroid microsomal antibody was normal. Chest radiography showed minor tracheal deviation, and a previous computed tomogram showed what appeared to be a 3-cm enlarged mass in the thyroid. Ultrasonographically guided thyroid biopsy did not show malignancy, but a benign mesenchymal-type tumor was found and surgical excision was planned. Intraoperatively, a thymoma of the left cervical thymic tongue was found. At 6 months' follow-up, the ptosis and oral mucosal lesions had improved significantly, although she continued topical corticosteroid therapy intermittently for minor erosive oral disease. [source]
Preliminary experiences of the triple tibial osteotomy procedure: tibial morphology and complicationsJOURNAL OF SMALL ANIMAL PRACTICE, Issue 5 2009
A. I. C. Renwick
Objective: To document the effect of variable tibial morphology on the planning and execution of the triple tibial osteotomy (TTO) procedure in dogs and complications encountered while becoming familiar with the technique. Methods: The records of 21 consecutive cases that had a TTO performed were reviewed. Preoperative tibial morphology was assessed. Modifications in the described technique and complications were documented. Postoperative outcome was evaluated using a client-based questionnaire. Results: The size of the tibial wedge ostectomy was modified because of variable tibial morphology in four dogs (19 per cent) to avoid over or under correction of the tibial plateau angle (TPA). Intraoperatively, fracture through the caudal tibial cortex occurred in nine cases (41 per cent) and through the distal tibial crest cortex in four cases (18 per cent). Major complications occurred in five (23 per cent) of cases with four (18 per cent) requiring further surgery. The client questionnaire results demonstrated significant improvements in all parameters and no significant difference from the preinjury status. Clinical Significance: TPA measurement is recommended when planning a TTO to avoid over or under correction of the TPA. Despite frequent minor complications, it appears that the TTO is an effective procedure for management of cranial cruciate ligament rupture in the dog. [source]
Free flap failure in an anticardiolipin antibody-positive patient with neoplasm,A case reportMICROSURGERY, Issue 3 2010
Emiko Asai M.D.
We present herein a case of massive arterial thrombosis of a free rectus abdominal musculocutaneous flap used for reconstructive surgery of gingival carcinoma that could not be rescued. A 54-year-old woman underwent the operation. She had experienced two miscarriages in her 20s, but medical history was otherwise uneventful. Intraoperatively, the anastomosed artery often showed massive arterial thrombosis, and the flaps had become necrotic after bilateral flaps were used. Laboratory findings, 7 days postoperatively, showed high levels of immunoglobulin G anticardiolipin antibody. This value normalized by 2 months postoperatively after using chemotherapy. This case does not match the criteria for antiphospholipid syndrome, but some English-language reports have shown rising antiphospholipid antibody levels, particularly anticardiolipin antibodies, in patients with neoplasm. In those cases, levels have normalized after successful therapy. Antiphospholipid antibody levels should be examined before surgery to identify risks of hypercoagulability. © 2010 Wiley-Liss, Inc. Microsurgery, 2010. [source]
Case Report: Eculizumab, Bortezomib and Kidney Paired Donation Facilitate Transplantation of a Highly Sensitized Patient Without Vascular AccessAMERICAN JOURNAL OF TRANSPLANTATION, Issue 9 2010
B. E. Lonze
A 43-year-old patient with end-stage renal disease, a hypercoagulable condition and 100% panel reactive antibody was transferred to our institution with loss of hemodialysis access and thrombosis of the superior and inferior vena cava, bilateral iliac and femoral veins. A transhepatic catheter was placed but became infected. Access through a stented subclavian into a dilated azygos vein was established. Desensitization with two cycles of bortezomib was undertaken after anti-CD20 and IVIg were given. A flow-positive, cytotoxic-negative cross-match live-donor kidney at the end of an eight-way multi-institution domino chain became available, with a favorable genotype for this patient with impending total loss of a dialysis option. The patient received three pretransplant plasmapheresis treatments. Intraoperatively, the superior mesenteric vein was the only identifiable patent target for venous drainage. Eculizumab was administered postoperatively in the setting of antibody-mediated rejection and an inability to perform additional plasmapheresis. Creatinine remains normal at 6 months posttransplant and flow cross-match is negative. In this report, we describe the combined use of new agents (bortezomib and eculizumab) and modalities (nontraditional vascular access, splanchnic drainage of graft and domino paired donation) in a patient who would have died without transplantation. [source]
Comparative Assessment of Coagulation Changes Induced by Two Different Types of Heart,Lung MachineARTIFICIAL ORGANS, Issue 1 2010
Abstract The cardiopulmonary bypass (CPB) used in heart surgery has a deleterious effect on hemostasis. The aim of our study was to assess by means of standard laboratory and point-of-care methods changes induced by CPB in coagulation parameters, particularly in platelet function, and to determine whether these changes differ depending on the type of heart,lung machine (HLM) used: minimal extracorporeal circulation system (MECC) and standard HLM. The study enrolled 88 patients scheduled for coronary artery bypass surgery performed on pump. Forty-four interventions were performed with MECC and 44 with standard HLM. Blood was sampled preoperatively, after 30 min on CPB, after weaning from CPB, and 24 h postoperatively. Coagulation and platelet function were assessed using multiple electrode aggregometry (MEA), rotation thromboelastometry, as well as standard laboratory tests. Rotation thromboelastometry and standard laboratory reflected significantly impaired hemostasis after weaning from CPB but no significant differences between the two groups at different time points. Aggregation decreased significantly in both groups as early as 30 min after the institution of CPB (P < 0.05, Mann,Whitney U -test) and recovered within the first 24 h postoperatively, without reaching the preoperative level. Intraoperatively, aggregometry values reflected a significantly more severe reduction of platelet function in standard HLM group than in the MECC group (P < 0.01, ProcMixed test). Our findings suggest that MEA and thromboelastometry reflect impairment of coagulation in cardiac surgery performed on different types of HLM and that platelet function is less affected by MECC than by standard HLM. [source]
Indocyanine green-fluorescent imaging of hepatocellular carcinoma during laparoscopic hepatectomy: An initial experienceASIAN JOURNAL OF ENDOSCOPIC SURGERY, Issue 1 2010
Abstract Introduction: Laparoscopic hepatectomy has disadvantages in intraoperative diagnosis, because it offers limited visualization and palpability of the liver surface. Recently, we developed a novel fluorescent imaging technique using indocyanine green (ICG), which would enable identification of liver cancers during open hepatectomy. However, this technique has not yet been applied to laparoscopic hepatectomy. Materials and Surgical Technique: A patient with a hepatocellular carcinoma (HCC) located in Couinaud's segment II was administered ICG (0.5 mg per kg body weight) intravenous injection 5 d before surgery, as a routine liver function test. The prototype fluorescent imaging system was composed of a xenon light source and a laparoscope with a charge-coupled device camera that could filter out light with wavelengths below 810 nm. Intraoperatively, fluorescent imaging of the HCC was performed by changing color images to fluorescent images with a foot switch. Then, the fluorescing tumor was clearly identified on the visceral surface of segment II during mobilization of the left liver for resection of segments II and III. On the cut surface of the specimen, the tumor showed uniform fluorescence and was microscopically diagnosed as a well-differentiated HCC. Discussion: Laparoscopic fluorescent imaging using preoperative injection of ICG enabled real-time identification of HCC. This technique may be an easy and reliable tool to enhance the accuracy of intraoperative diagnosis during laparoscopic hepatectomy. [source]
Congenital Atresia of the Ostium of Left Main Coronary Artery: A Rare Coronary Anomaly, Diagnostic Difficulty and Successful Surgical RevascularizationCONGENITAL HEART DISEASE, Issue 5 2007
Philip Varghese MRCS
ABSTRACT We report the case of an 8-month-old infant who was referred for mechanical circulatory support (extracorporeal membrane oxygenation). Aortogram was compatible with the diagnosis of anomalous origin of left coronary artery to pulmonary trunk. A definitive diagnosis of atresia of the left coronary ostium was only established intraoperatively. Patient underwent successful surgical angioplasty with an autologous pericardial patch. [source]
Hydrophilic Polymers with Potassium Salt and Microporous Polysaccharides for Use as Hemostatic AgentsDERMATOLOGIC SURGERY, Issue 12 2007
JULIA HO MD
BACKGROUND Postoperative bleeding can lead to complications such as hematoma, infection, dehiscence, and an unscheduled office visit. Topical hemostatic agents can be used to aid in hemostasis. OBJECTIVE The objective is to familiarize physicians with topical hemostatic agents,hydrophilic polymers with potassium salts (Urgent QR powder) and microporous polysaccharide hemispheres (Bleed-X). METHODS Two hemostatic agents, microporous polysaccharide hemospheres and hydrophilic polymers with potassium salt, are discussed. The literature is reviewed. RESULTS Numerous types of hemostatic agents exist. Topical hemostatic agents are safe, cost-effective, and efficient. CONCLUSION Microporous polysaccharide hemospheres and hydrophilic polymers with potassium salts can be an adjunct to hemostasis after cautery and ligation. Patients can apply hemostatic agents if they experience any bleeding leading to decreased office visits. Hemostatic agents used intraoperatively shorten bleeding time and enable the physician to use less cautery. Using hemostatic agents can lead to fewer hematomas, infections, and office visits. [source]
Intraoperative cytology,Role in bone lesionsDIAGNOSTIC CYTOPATHOLOGY, Issue 9 2010
Khaliqur Rahman M.D.
Abstract In spite of becoming an integral part of surgical pathology, very few reports are available regarding the utility of intraoperative cytology (IOC) exclusively for bone lesions. This study was undertaken in a view to fill this lacuna. Sixty bone lesions were evaluated intraoperatively with the help of cytology smears prepared by touch, scrape, or crush technique. The diagnosis made on cytological preparation was compared with histopathological diagnosis taking the latter as gold standard. Different parameters like reasons for Intraoperative consultation, best technique for preparation of smear, average time taken to render a diagnosis, and finally the accuracy of IOC was evaluated. Common reasons for the intraoperative consultation were to make or confirm a diagnosis for proper surgical intervention and to evaluate the surgical resection margin. Scrape was found to be the best method for cytological smear preparation. Average time taken to render a diagnosis was 20 minutes. Sensitivity, specificity, and overall diagnostic accuracy was 96.7, 96.6, and 96.6%, respectively. Cytology can play a valuable role in the intraoperative diagnosis of bone lesions. The method is simple, cheap, quick, and has no complication. It should be undertaken routinely, as a rapid intraoperative diagnosis will expedite timely and proper management of the patients, along with early post operative treatment and thus avoid the aggravating delays. Diagn. Cytopathol. 2010;38:639,644. © 2009 Wiley-Liss, Inc. [source]
Intraoperative evaluation of sentinel lymph nodes in breast carcinoma by imprint cytology, frozen section and rapid immunohistochemistryDIAGNOSTIC CYTOPATHOLOGY, Issue 12 2009
Sharma Upender M.D.
Abstract Sentinel lymph nodes (SLN) isolated in 40 patients of breast carcinoma (stage T1/T2) were evaluated intraoperatively by imprint cytology and frozen section. Rapid immunohistochemistry (IHC) was done in cases where both imprint smears and frozen sections were negative for any metastatic tumor deposits. The results of these different techniques were compared with postoperative paraffin sections taken as "Gold Standard." Nottingham modification of Bloom Richardson scoring system was used for grading the tumors. Further, the correlation of the SLN status with tumor size, grade, and lymphovascular invasion was studied. The sensitivity, specificity, and overall accuracy of imprint cytology were 91.7, 100, and 95% respectively, and those of the frozen section were 95.8, 100, and 97.5% respectively. Examination of multiple serial sections improved the sensitivity and overall accuracy of frozen section. Results of intraoperative rapid IHC were equivalent to final paraffin sections. Histological grade and lymphovascular invasion were in direct correlation with SLN metastasis (P < 0.05). The risk of lymphovascular invasion increased from 22.2% in grade I tumors to 85.7% in grade III tumors. SLN biopsy is a reliable method to evaluate the status of the axillary lymph nodes. Imprint cytology can be used reliably where the facility of frozen section is not available. Diagn. Cytopathol. 2009. © 2009 Wiley-Liss, Inc. [source]
Cytologic features of meningiomas on crush preparations: A reviewDIAGNOSTIC CYTOPATHOLOGY, Issue 4 2008
F.I.A.C., Momin T. Siddiqui M.D.
Abstract Meningiomas are rarely subjected to aspiration, however, since they may occur outside the central nervous system, it is important to recognize their cytologic features. The goal of this study was to examine the cytologic features of meningiomas in crush preparations and cytologic imprints prepared at the time of frozen section. A total of 97 cases of meningiomas evaluated intraoperatively by frozen section with concomitant crush preparation and cytologic imprint were reviewed to assess their cytologic features. The cytologic features of meningiomas identified in our study are cohesive syncitial clusters of cells with ill-defined boundaries. The nuclei are oval and may be eccentrically placed, along with small central nucleoli. The cytologic features may not reflect the histologic subtype. The psammomatous variant can however be easily recognized in touch preps/imprints. The presence of nuclear anaplasia, macronucleoli, mitotic activity, and sheet-like growth may suggest an atypical meningioma. In conclusion, the cytologic features identified would be helpful in diagnosis of meningiomas, especially in unusual locations. Diagn. Cytopathol. 2008;36:202,206. © 2008 Wiley-Liss, Inc. [source]
Recurrence of intramucosal esophageal adenocarcinoma arising in a former esophagostomy site: a unique case reportDISEASES OF THE ESOPHAGUS, Issue 6 2009
J. M. Leers
SUMMARY., A 75-year-old male with a long history of gastroesophageal reflux symptoms developed adenocarcinoma proximally within a long segment of Barrett's esophagus. He was taken for esophagectomy and gastric pull-up, but intraoperatively, he was found to have a marginal blood supply in the gastric tube. A temporary left-sided esophagostomy was created with the gastric tube sutured to the left sternocleidomastoid muscle in the neck. Pathology showed an intramucosal adenocarcinoma, limited to the muscularis mucosa with surrounding high-grade dysplasia and intestinal metaplasia. The proximal esophageal margin showed no tumor cells, but there was low-grade dysplasia within Barrett's esophagus. He was reconstructed after several months, and 2 years after reconstruction, the patient noticed a nodule at the former esophagostomy site. Biopsy revealed an implant metastasis of esophageal adenocarcinoma. Here, we review the literature and discuss the possible etiology. [source]
Perimembranous Ventricular Septal Defect and Gerbode DefectECHOCARDIOGRAPHY, Issue 2 2010
Adolfo A. Blanco M.D.
A 27-year-old male presented with a known history of congenital ventricular septal defect (VSD). A Gerbode-type defect was discovered intraoperatively that was originally misinterpreted as pulmonary hypertension. The case report will review the Gerbode defect and the transesophageal echocardiography findings. It is important, in patients with history of perimembranous VSD, to consider Gerbode-type defect when the tricuspid regurgitation jet velocity is high (Echocardiography 2010;27:215-217) [source]
The Rupture of Periaortic Infective Aneurysm into the Left Atrium and the Left Ventricular Outflow Tract: Preoperative Diagnosis by Transthoracic EchocardiographyECHOCARDIOGRAPHY, Issue 3 2002
Ewa Lastowiecka M.D.
We present a rare complication of infective endocarditis, perforated periaortic abscess with fistulous communication between the aortic root, the left atrium, and the left ventricular outflow tract. Preoperative transthoracic echocardiographic diagnosis was confirmed intraoperatively. The patient was treated successfully by aortic homograft implantation. [source]
Intraoperative Ultrasound to Define Focal Cortical Dysplasia in Epilepsy SurgeryEPILEPSIA, Issue 1 2008
Summary Focal cortical dyplasia (FCD) is a frequent cause of medication-resistant focal epilepsy. Patients with FCD may benefit from epilepsy surgery. However, it is difficult to intraoperatively define lesion boundaries. In this case report we present a novel tool to identify FCD intraoperatively. A patient with frontal lobe epilepsy underwent resection of a left frontomesial FCD. Image guidance was achieved by intraoperative ultrasound, which depicted the lesion with a higher resolution than preoperative MRI. Postoperatively the patient remained seizure free. Intraoperative ultrasound may be helpful in identifying and targeting subtle epileptogenic lesions, which are difficult to visualize. [source]
Effect of preoperative prophylaxis with filgrastim in cancer neck dissectionEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 5 2000
Background Cancer surgery is known to lead to a deterioration in host defence mechanisms and an increase in susceptibility to infection after operation. Filgrastim enhances important antimicrobial functions of neutrophils including chemotaxis, phagocytosis and oxidative killing mechanisms. Methods The effects of additional (all patients received perioperative 3 , 25 mg kg,1 cefotiam and 1 , 20 mg kg,1 metronidazole) preoperative prophylaxis with filgrastim (5 ,g kg,1 12 h prior to surgery plus 5 ,g kg,1 0 h prior to surgery) on neutrophil phagocytosis and reactive oxygen radical production and postoperative infections in 24 patients undergoing cancer neck dissection were studied. Phagocytic capacity was assessed by measuring the uptake of fluorescein isothiocyanate-labelled Escherichia coli and Staphylococcus aureus by flow cytometry. Reactive oxygen generation after phagocytosis was estimated by determining the amount of dihydrorhodamine 123 converted to rhodamine 123, intracellularly. Results In the filgrastim-treated patients a higher neutrophil phagocytic capacity was seen intraoperatively, and 1,5 days postoperative, but not prior to surgery. Reactive oxygen radical production was significantly higher in filgrastim-treated patients prior to surgery, intraoperative and postoperative (1,5 days). 2/12 (17%) patients had postoperative infections in the filgrastim group and 9/12 (75%) patients had infections in the placebo group (P < 0.001). In particular, wound infections were recorded more often in the placebo group (1/12 vs. 6/12; P = 0.004). Conclusion We conclude that filgrastim enhances perioperative neutrophil function and could be useful in the prophylaxis of postoperative wound infections in patients undergoing cancer neck dissection. [source]
Prior pallidotomy reduces and modifies neuronal activity in the subthalamic nucleus of Parkinson's disease patientsEUROPEAN JOURNAL OF NEUROSCIENCE, Issue 2 2008
Abstract Parkinson's disease (PD) patients with prior radio-frequency lesions in the internal segment of the globus pallidus (GPi, pallidotomy), whose symptoms have deteriorated, may be candidates for further invasive treatment such as subthalamic deep brain stimulation (STN DBS). Six patients with prior pallidotomy (five unilaterally; one bilaterally) underwent bilateral STN DBS. The microelectrode recordings (MERs, used intraoperatively for STN verification), ipsilateral and contralateral to pallidotomy, and MERs from 11 matched PD patients who underwent bilateral STN DBS without prior pallidotomy were compared. For each trajectory, average, variance and mean successive difference (MSD, a measure of irregularity) of the root mean square (RMS) of the STN MER were calculated. The RMS in trajectories ipsilateral to pallidotomy showed significant reduction of the mean average and MSD of STN activity when compared with trajectories from patients without prior pallidotomy. The RMS parameters contralateral to pallidotomy tend to lie between those ipsilateral to pallidotomy and those without prior pallidotomy. The average STN power spectral density of oscillatory activity was notably lower ipsilateral to pallidotomy than contralateral, or without prior pallidotomy. The finding that pallidotomy reduces STN activity and changes firing characteristics, in conjunction with the effectiveness of STN DBS despite prior pallidotomy, calls for reappraisal and modification of the current model of the basal ganglia (BG) cortical network. It highlights the critical role of direct projections from the BG to brain-stem structures and suggests a possible GPi,STN reciprocal positive-feedback mechanism. [source]
Accuracy of technetium-99m SPECT-CT hybrid images in predicting the precise intraoperative anatomical location of parathyroid adenomasHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 4 2008
Luke Harris MD
Abstract Background. This study evaluated the accuracy of single photon emission computed tomography (SPECT)-CT imaging for the preoperative localization of parathyroid adenomas. Methods. This study included both a quantitative and qualitative accuracy measure. The quantitative measure was the distance between the location of the adenoma on the SPECT-CT scan and the location of the adenoma intraoperatively. Qualitatively, surgeons were asked whether or not the adenoma was in the exact location predicted by the SPECT-CT scan. The time from initial incision to identification of the parathyroid was recorded. Patients referred to London Health Sciences Centre for a suspected parathyroid adenoma were eligible for this study. Results. Twenty-three patients participated in this study. Eighteen (78.3%) had a single adenoma, 2 (8.7%) had double adenomas, and 3 (13.0%) had multiglandular hyperplasia. SPECT-CT correctly detected and localized 16 of 18 (88.9%) cases of single parathyroid adenomas. The mean distance between the location of the adenoma on the SPECT-CT scan and the location of the adenoma intraoperatively was 16.3 mm (95% , 19.0 mm). For single adenomas, the median time from skin incision to identification was 14 minutes (range, 8,40 minutes). The preoperative detection and localization of a single focus of sestamibi uptake yielded a parathyroid adenoma in the specified location in 80.0% of cases (95% CI, 97.4,66.5%). Conclusions. SPECT-CT predicted the intraoperative location of a single parathyroid adenoma within 19.0 mm with 95% confidence. The correct detection and localization of multiglandular disease remains difficult. © 2007 Wiley Periodicals, Inc. Head Neck, 2008 [source]
A novel approach to the intraoperative assessment of the uncinate margin of the pancreaticoduodenectomy specimenHPB, Issue 2 2007
MAHMOUD A. KHALIFA
Abstract Background. Currently, there is no consensus regarding the pancreaticoduodenectomy (PD) margins examined intraoperatively or the technical protocol for frozen section examination. The aim of this work was to summarize our experience regarding the intraoperative examination of the uncinate margin and to compare it with the published literature. Materials and methods. Our local protocol for the intraoperative assessment of the uncinate margin of the PD specimen is described in this article. A PubMed® search limited to English language publications using terms along the theme of pancreaticoduodenectomy and margin was performed. Retrieved articles were categorized according to whether they discussed frozen section margin examination. Results. Ten articles published between 1981 and 2005 were retrieved which discussed the intraoperative examination of PD specimens. Of the 10 articles, 5 discussed the intraoperative consultation for diagnostic purposes only, 2 discussed the consultation for both diagnostic purposes and assessment of margins, and 3 discussed intraoperative assessment of margins only. Of the total of five articles that discussed the intraoperative assessment of margins, none detailed the technical protocol for examining the uncinate margin. Discussion. Our proposed protocol for the intraoperative assessment of the uncinate margin of PD specimens allows for its accurate evaluation and has not been described previously in the English literature. [source]
The effect of desmopressin on blood loss in patients with rheumatoid arthritis undergoing hip arthroplastyACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2010
K. A. LEINO
Background: Blood loss is an important issue for patients with rheumatoid arthritis undergoing hip surgery. We hypothesised that intraoperative desmopressin treatment would result in a reduction in blood loss in rheumatoid patients undergoing total hip arthroplasty. Methods: Seventy-five patients scheduled for elective total hip arthroplasty were randomised to three groups to receive 0.4 ,g/kg desmopressin (D 0.4), 0.2 ,g/kg desmopressin (D 0.2) or placebo intraoperatively in a double-blind fashion. Blood transfusions were based on calculated safe allowable blood loss and haemoglobin measurements (trigger 90 g/l, 5.59 mmol/l). The primary endpoint was the total blood loss measured till the end of the fourth post-operative day. Secondary endpoints included red cell transfusion requirements and haemoglobin. Results: Total blood loss during the study period was not significantly different between the groups (D 0.4 1829 ± 1068; D 0.2 2240 ± 843 and placebo 2254 ± 1040 ml; P= 0.50). The total amount of red cell transfusions was fewer in group D 0.4 (3.6 ± 1.6 U) when compared with D 0.2 (4.4 ± 1.7 U; P=0.009) and placebo (4.5 ± 2.0 U; P= 0.011) groups. Haemoglobin concentration was lower in the placebo group in the first (5.42 ± 1.16 vs. 5.98 ± 0.47 mmol/l; P=0.033) and the second (6.28 ± 0.66 vs. 6.69 ± 0.47 mmol/l; P=0.033) post-operative mornings compared with group D 0.4. Conclusion: Despite a lack of difference in the primary outcome, total blood loss, intraoperative administration of 0.4 ,g/kg desmopressin resulted in fewer total red cell transfusion requirements in rheumatoid patients undergoing total hip arthroplasty when compared with 0.2 ,g/kg treatment and placebo. [source]
The new adhesion prophylaxis membrane A-part®,From in vitro testing to first in vivo resultsJOURNAL OF BIOMEDICAL MATERIALS RESEARCH, Issue 2 2009
Bernd Martin Jaenigen
Abstract Introduction: Formation of postoperative intra-abdominal adhesions is a severe problem in surgery. Apart from standard surgical procedures, a variety of different substances is available to prevent adhesions, but no universal method has been developed so far. A membrane consisting of polyvinyl alcohol (PVA) and carboxymethylcellulose (CMC) has been demonstrated to be antiadhesive. Here, the in vitro testing and first in vivo results in a rabbit sidewall model are reported. Materials and Methods: A-part® membrane contains a PVA/CMC mixture in a thickness of 40 ,m. The composition, dissolution, tensile strength, and elasticity were examined to characterize the membrane in vitro. Experiments in vivo were carried out using a ,rabbit sidewall model' in which a standardized peritoneal trauma was covered with a 5 × 6 cm A-part® membrane. Adhesion formation in A-part®-treated animals was compared with that in Adept® (15 mL/kg body weight) and untreated controls. Results: An 80/20 PVA/CMC mixture forms a stable, elastic, transparent membrane, which can easily be placed intraoperatively. The dissolution shows a half-life of about 2 weeks [day 15: (45.1 ± 4.9)% SD], which affords good adhesion protection during the initial critical phase of adhesion formation. In wet conditions, the membrane follows abdominal movements without tearing (tensile strength 5.0 ± 4.2 N/cm SD; elasticity 29.5%). In a rabbit sidewall model, A-part® membrane significantly reduced adhesion development by (83.1 ± 31.5)% SD compared with the control and the Adept group (p < 0.001). Conclusion: The properties of the A-part® membrane suggest that it may be useful as an antiadhesive in surgery. A-part® is effective in invivo testing as determined in a rabbit sidewall model. © 2008 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2009 [source]
Real-time Visualization and Quantification of Retrograde Cardioplegia Delivery using Near Infrared Fluorescent ImagingJOURNAL OF CARDIAC SURGERY, Issue 6 2008
Aravind T. Rangaraj M.D.
Presently, there exist no established methods to quantitatively assess cardioplegia distribution intraoperatively and determine when retrograde cardioplegia is required. In this study, we evaluate the feasibility of near infrared (NIR) imaging for real-time visualization of cardioplegia distribution in a porcine model. Methods: A portable, intraoperative, real-time NIR imaging system was utilized. NIR fluorescent cardioplegia solution was developed by incorporating indocyanine green (ICG) into crystalloid cardioplegia solution. Real-time NIR imaging was performed while the fluorescent cardioplegia solution was infused via the retrograde route in five ex vivo normal porcine hearts and in five ex vivo porcine hearts status post left anterior descending (LAD) coronary artery ligation. Horizontal cross-sections of the hearts were obtained at proximal, middle, and distal LAD levels. Videodensitometry was performed to quantify distribution of fluorophore content. Results: The progressive distribution of cardioplegia was clearly visualized with NIR imaging. Complete visualization of retrograde distribution occurred within 4 minutes of infusion. Videodensitometry revealed retrograde cardioplegia, primarily distributed to the left ventricle (LV) and anterior septum. In hearts with LAD ligation, antegrade cardioplegia did not distribute to the anterior LV. This deficiency was compensated for with retrograde cardioplegia supplementation. Conclusions: Incorporation of ICG into cardioplegia allows real-time visualization of cardioplegia delivery via NIR imaging. This technology may prove useful in guiding intraoperative decisions pertaining to when retrograde cardioplegia is mandated. [source]
Predictors and Outcomes Associated with Intraoperative Aortic Dissection in Cardiac SurgeryJOURNAL OF CARDIAC SURGERY, Issue 5 2008
Amber Hurt M.D.
The objective of this study was to assess risk factors of aortic dissection and assess outcomes in patients with aortic dissection experience. Methods: A study from a 10-year hospitalization cohort (N = 12,907) with prospective data collection was conducted. Patients without aortic dissection were matched to 33 aortic dissection patients 3:1 on the type of procedure. The study examined 24 potential confounding risk factors and 12 outcome variables. Results: Univariate analysis on potential confounding risk factors revealed two significant risk factors. There was a significant difference between aortic dissection and nonaortic dissection patients with New York Heart Association (NYHA) functional class (p = 0.03). Patients with aortic dissection were more likely to be in Class I or II. Patients with aortic dissection had significantly longer perfusion time (p = 0.008). There was a significant difference between patients with and without aortic dissection on four outcome variables. Patients with an aortic dissection were more likely to need prolonged ventilation (p = 0.046), have renal failure (p = 0.005), require intraaortic balloon pump (IABP) (0.043), and have a higher mortality rate (p < 0.001). Conclusion: Aortic dissection occurs infrequently during coronary artery bypass grafting, but is a devastating complication and greatly increases morbidity. Although few patients dissect intraoperatively, this study attempted to identify predictors that may label a patient as high risk for possible aortic dissection. Although two factors in this study were statistically significant, they are not reliable preoperative predictors of high-risk patients that can be used to screen patients and help prevent aortic dissection and its sequela. [source]
Surgical Ablation of Atrial Fibrillation: The Columbia Presbyterian ExperienceJOURNAL OF CARDIAC SURGERY, Issue 5 2006
Veli K. Topkara M.D.
However, it is not widely applied due to its complexity, increased operative times, and the risk of bleeding. Various energy sources have been introduced to simplify the traditional "cut and sew" approach. Methods: This study involves patients undergoing surgical atrial fibrillation ablation (SAFA) at a single institution from 1999 to 2005. Type of concomitant procedures, preoperative clinical characteristics, and chronicity of AF were evaluated in overall patient population. Parameters including surgical approach, lesion pattern, and energy source used were collected intraoperatively. Clinical outcomes examined were postoperative rhythm success, stroke, early mortality, and long-term survival. Results: Three hundred thirty-nine patients were identified. Three hundred twenty-eight (96.8%) patients had associated cardiac disease and underwent concomitant procedures; 75.8% of patients had persistent AF. Energy sources used were microwave (49.8%), radiofrequency (42.2%), and laser (8.0%). In 41.9% of cases a pulmonary vein encircling lesion was the only lesion created. Combination lesion sets were performed in the remaining cases. Rhythm success rates at 3, 6, 12, and 24 months were 74.1%, 68.2%, 74.5%, and 71.1%, respectively. Patients who underwent surgical removal of left atrial appendage by means of stapling or simple excision had no early postoperative stroke. Early mortality was 4.9%. Postoperative survival rates at 1, 3, and 5 years were 89.6%, 83.1%, and 78.0%. Conclusions: Surgical ablation of atrial fibrillation is a safe and effective procedure in restoring sinus rhythm with excellent postoperative survival rates. Further advancements in the field will eventually result in minimally invasive procedures with higher success rates. [source]
PEEP Therapy for Patients With Pleurotomy During Coronary Artery Bypass GraftingJOURNAL OF CARDIAC SURGERY, Issue 3 2000
Susumu Ishikawa M.D.
We studied the efficacy of intraoperative positive end-expiratory airway pressure (PEEP) therapy for the prevention of postoperative pulmonary oxygenation impairment. A total of 66 patients with solitary CABG procedure were included in this study. The pleural cavity was intraoperatively opened in 44 patients and not opened in 22. PEEP therapy was not used in any patient before May 1996 (referred to herein as the former period) and was used more recently in eight patients with pleurotomy (referred to herein as the latter period). PEEP was initiated immediately after pleurotomy during the harvest of the internal mammary artery graft. Without PEEP therapy, values of PaO2, A-aDO2, and respiratory index (RI) were worse in patients with pleurotomy than in those without pleurotomy. Meanwhile, there were no major differences in these values between patients with or without pleurotomy after the induction of PEEP therapy. Respiratory insufficiency (A-aDO2 > 400 mmHg and RI > 1.5) was detected in six patients with pleurotomy in the former period. Three of these six patients required over 1 week of long-term mechanical respiratory support. No respiratory insufficiency occurred in patients of the latter period. In conclusion, PEEP therapy, which is initiated just after pleurotomy, may prevent oxygen impairment and pulmonary atelectasis after extracorporeal circulation (ECC) and is recommended for patients with pleurotomy, especially for patients with preoperative low respiratory function. [source]
Identification and Characterization of Atrioventricular Parasympathetic Innervation in HumansJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 8 2002
KARA J. QUAN M.D.
AV Parasympathetic Innervation.Introduction: We hypothesized that in humans there is an epicardial fat pad from which parasympathetic ganglia supply the AV node. We also hypothesized that the parasympathetic nerves innervating the AV node also innervate the right atrium, and the greatest density of innervation is near the AV nodal fat pad. Methods and Results: An epicardial fat pad near the junction of the left atrium and right inferior pulmonary vein was identified during cardiac surgery in seven patients. A ring electrode was used to stimulate this fat pad intraoperatively during sinus rhythm to produce transient complete heart block. Subsequently, temporary epicardial wire electrodes were sutured in pairs on this epicardial fat pad, the high right atrium, and the right ventricle by direct visualization during coronary artery bypass surgery in seven patients. Experiments were performed in the electrophysiology laboratory 1 to 5 days after surgery. Programmed atrial stimulation was performed via an endocardial electrode catheter advanced to the right atrium. The catheter tip electrode was moved in 1-cm concentric zones around the epicardial wires by fluoroscopic guidance. Atrial refractoriness at each catheter site was determined in the presence and absence of parasympathetic nerve stimulation (via the epicardial wires). In all seven patients, an AV nodal fat pad was identified. Fat pad stimulation during and after surgery caused complete heart block but no change in sinus rate. Fat pad stimulation decreased the right atrial effective refractory period at 1 cm (280 ± 42 msec to 242 ± 39 msec) and 2 cm (235 ± 21 msec to 201 ± 11 msec) from the fat pad (P = 0.04, compared with baseline). No significant change in atrial refractoriness occurred at distances > 2 cm. The response to stimulation decreased as the distance from the fat pad increased. Conclusion: For the first time in humans, an epicardial fat pad was identified from which parasympathetic nerve fibers selectively innervate the AV node but not the sinoatrial node. Nerves in this fat pad also innervate the surrounding right atrium. [source]
A systematic review of the effectiveness of cutaneous warming systems to prevent hypothermiaJOURNAL OF CLINICAL NURSING, Issue 5 2009
Cristina M Galvăo
Aims., To retrieve and critique recent randomised trials of cutaneous warming systems used to prevent hypothermia in surgical patients during the intraoperative period and to identify gaps in current evidence and make recommendations for future trials. Background., Hypothermia affects up to 70% of anaesthetised surgical patients and is associated with several significant negative health outcomes. Design., Systematic review using integrative methods. Methods., We searched CINAHL, EMBASE, Cochrane Register of Controlled Trials and Medline databases (January 2000,April 2007) for recent reports on randomised controlled trials of cutaneous warming systems used with elective patients during the intraoperative period. Inclusion criteria., We included randomised control trials examining the effects of cutaneous warming systems used intraoperatively on patients aged 18 years or older undergoing non-emergency surgery. Studies published in English, Spanish or Portuguese with a comparison group that consisted of either usual care or active cutaneous warming systems without prewarming were reviewed. Results., Of 193 papers initially identified, 14 studies met the inclusion criteria. There was moderate evidence to indicate that carbon-fibre blankets and forced-air warming systems are equally effective and that circulating-water garments are most effective for maintaining normothermia during the intraoperative period. Few trials reported costs. Conclusions., Carbon-fibre blankets and forced-air warming systems are effective and circulating-water garments may be preferable. Future research should measure the direct and indirect costs associated with competing systems. Relevance to clinical practice., Nurses can use this review to inform their selection of warming interventions in perioperative nursing practice. They can also assess other factors such as nursing workload, staff training and equipment maintenance, which should be incorporated into future research. [source]
MRI-guided procedures in various regions of the body using a robotic assistance system in a closed-bore scanner: Preliminary clinical experience and limitations,JOURNAL OF MAGNETIC RESONANCE IMAGING, Issue 4 2010
Michael Moche MD
Abstract Purpose: To present the clinical setup and workflow of a robotic assistance system for image-guided interventions in a conventional magnetic resonance imaging (MRI) environment and to report our preliminary clinical experience with percutaneous biopsies in various body regions. Materials and Methods: The MR-compatible, servo-pneumatically driven, robotic device (Innomotion) fits into the 60-cm bore of a standard MR scanner. The needle placement (n = 25) accuracy was estimated by measuring the 3D deviation between needle tip and prescribed target point in a phantom. Percutaneous biopsies in six patients and different body regions were planned by graphically selecting entry and target points on intraoperatively acquired roadmap MR data. Results: For insertion depths between 29 and 95 mm, the average 3D needle deviation was 2.2 ± 0.7 mm (range 0.9,3.8 mm). Patients with a body mass index of up to ,30 kg/m2 fitted into the bore with the device. Clinical work steps and limitations are reported for the various applications. All biopsies were diagnostic and could be completed without any major complications. Median planning and intervention times were 25 (range 20,36) and 44 (36,68) minutes, respectively. Conclusion: Preliminary clinical results in a standard MRI environment suggest that the presented robotic device provides accurate guidance for percutaneous procedures in various body regions. Shorter procedure times may be achievable by optimizing technical and workflow aspects. J. Magn. Reson. Imaging 2010;31:964,974. ©2010 Wiley-Liss, Inc. [source]
Accurate localization of supernumerary mediastinal parathyroid adenomas by a combination of structural and functional imagingJOURNAL OF MEDICAL IMAGING AND RADIATION ONCOLOGY, Issue 3 2004
Summary Reoperation for refractory or recurrent hyperparathyroidism following parathyroidectomy carries the potential for increased morbidity and the possibility of failure to localize and remove the lesion intraoperatively. Reported herein are three cases demonstrating the combined use of sestamibi scintigraphy, CT and MR for accurate localization of mediastinal parathyroid adenomas. [source]