First-intention Treatment Research Articles

Decompression: a first-intention treatment for “large” non-syndromic odontogenic keratocysts

Though odontogenic keratocysts (OKCs) are benign lesions, they have a high recurrence rate. Because of their aggressive behavior, they have been classified as tumors by the WHO until 2017. Main differential diagnoses are amelobastoma and dentigerous cyst. Anatomopathological examination can reach a final diagnosis. Several treatments have been proposed: curettage, resection, enucleation (alone or together with peripheral ostectomy) and decompression. Decompression aims to decrease the volume of the lesion of “large” OKCs, in order to prevent surgery-related fractures and to preserve the surrounding important anatomical structures such as the inferior alveolar nerve. It could lead to a complete regression. If not, secondary enucleation can be performed in better conditions: a reduced volume to remove, a thicker epithelium to detach, a lower risk to damage neighboring anatomic structures and a lower recurrence rate. Long-term follow-up however remains necessary. Nowadays, minimally invasive surgery prevails. And since OKC was returned into the odontogenic cysts group in the WHO classification, decompression should be considered as the first intention treatment. The purpose of this paper is to provide an update about OKC features and biological mechanisms, to review the different treatment options and to provide a step-by-step protocol for decompression.

Outcomes of carotid artery stenting at a high-volume Brazilian interventional neuroradiology center

OBJECTIVES:Carotid artery stenting is an emerging revascularization alternative to carotid endarterectomy. However, guidelines have recommended carotid artery stenting only if the rate of periprocedural stroke or death is < 6% among symptomatic patients and < 3% among asymptomatic patients. The aim of this study is to evaluate and compare clinical outcomes of symptomatic and asymptomatic patients who had undergone carotid artery stenting as a first-intention treatment.METHOD:A retrospective analysis of patients who underwent carotid artery stenting by our interventional neuroradiology team was conducted. Patients were divided into two groups: symptomatic and asymptomatic patients. The primary endpoints were ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage and major adverse cardiac and cerebrovascular events at 30 days. The secondary endpoints included ipsilateral ischemic stroke, ipsilateral parenchymal hemorrhage, ipsilateral transient ischemic attack and major adverse cardiac and cerebrovascular events between the 1- and 12-month follow-ups.RESULTS:A total of 200 consecutive patients were evaluated. The primary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral stroke (2.4% vs. 2.7%, p = 1.00), ipsilateral parenchymal hemorrhage (0.8% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (4.7% vs. 2.7%, p = 0.71). The secondary endpoints obtained in the symptomatic vs. asymptomatic groups were ipsilateral ischemic stroke (0.0% vs. 0.0%), ipsilateral parenchymal hemorrhage (0.0% vs. 0.0%), ipsilateral TIA (0.0% vs. 0.0%, p = 1.00) and major adverse cardiac and cerebrovascular events (11.2% vs. 4.1%, p = 0.11).CONCLUSIONS:In this retrospective study, carotid artery stenting was similarly safe and effective when performed as a first-intention treatment in both symptomatic and asymptomatic patients. The study results comply with the safety requirements from current recommendations to perform carotid artery stenting as an alternative treatment to carotid endarterectomy.

Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database

Postpancreatectomy hemorrhage (PPH) is a dreaded complication in pancreatic surgery. Today, there is a definition and grading of PPH without therapeutic consensus. We reviewed our prospective database to identify predictors and assess therapeutic strategy. We included all patients who underwent pancreatectomy between 2005 and 2010. Data were collected prospectively. We used the International Study Group Of Pancreatic Surgery (ISGPS) definition for PPH to include patients in the PPH group. Forty-six of 285 patients showed a PPH (16.1 %). The ISGPS classification was graded A = 3, B = 26, and C = 17. The average time to the onset of PPH was 7 days. CT-scan identified the origin of PPH in 43.5 % of the cases. PPH was responsible for a longer duration of hospital stay (p = 0.004), a higher hospital mortality (21.7 vs 2.5 %, p < 0.0001) and a lower survival (40 vs 70 % (p = 0.05) at 36 months). The first-intention treatment of PPH was conservative in 32 % and interventional in 68 %: endoscopy (6.4 %), transcatheter arterial embolization (TAE, 30.4 %), and surgical (30.4 %). In multivariate analysis, predictors of PPH were: pancreatic fistula (24 vs 8 % p = 0.028), pancreatoduodenectomy (70 vs 43 % p = 0.029), age (61.6 vs 58.8 %, p = 0.03), and nutritional risk index (NRI) (p = 0.048). In our series, risk factors for PPH were age, pancreatic fistula, pancreatoduodenectomy, and NRI. Its occurrence is associated with significantly higher hospital mortality and a lower survival rate. Our first-line treatment was radiological TAE. Surgical treatment is offered in case of failure of interventional radiology or in case of uncontrolled hemodynamic.

Endovascular Coiling as the First Treatment Strategy for Ruptured Pericallosal Artery Aneurysms: Results, Complications, and Follow Up

We apply endovascular coiling as the first treatment option for ruptured pericallosal artery aneurysms. We conducted a retrospective analysis of the clinical and radiological outcomes of this treatment strategy and morphological factors associated with the success of endovascular coiling, to assess the safety and feasibility of our management strategy. From January 2003 to January 2012, we attempted endovascular coiling as the first-intention treatment for 30 consecutive patients with ruptured pericallosal artery aneurysms including those with intracerebral hematoma. Twenty-seven cases of ruptured pericallosal artery aneurysms were successfully embolized with coiling whereas three failures required surgery. Four patients experienced periprocedural complications including thromboembolic event in two and hematoma enlargement after coiling in two. A maximum aneurysm diameter of <3 mm was most strongly associated with failure of endovascular coiling. Of the 27 coil-treated aneurysms, immediate angiographic results showed complete aneurysm occlusion in 19 cases, neck remnant in 6, and residual aneurysm in 2. One patient had a major aneurysm recurrence that was uneventfully reembolized. Sixteen of our 30 patients had good outcomes (modified Rankin scale [mRS] 0-2), 7 had moderate disability (mRS 3), and 4 had severe disability (mRS 4-5) at 3 months after treatment. The management strategy for coiling as the first-intention treatment for ruptured pericallosal artery aneurysms has the potential to become an acceptable alternative to surgical clipping for selected cases, although a larger study population and longer follow-up periods are needed before definitive conclusions can be drawn.

Results of Embolization Used as the First Treatment Choice in a Consecutive Nonselected Population of Ruptured Aneurysms: Clinical Results of the Clarity GDC Study

The International Subarachnoid Aneurysm Trial (ISAT) showed that for ruptured aneurysms suitable for both techniques, coiling should be the first-choice treatment. Only a small proportion of patients (22%) with ruptured aneurysms were included in that trial. Operators were selected on their experience. One could then criticize the impact of the ISAT on clinical practice as a result of recruitment biases and operators' selection. To evaluate the morbidity and mortality of coiling when used as first-choice treatment in a consecutive population of patients with ruptured aneurysms treated by nonselected operators. Thirty-four operators from 19 French centers treated 405 patients with GDC coils from November 2006 to July 2007. The method of treatment was not prespecified. World Federation of Neurological Societies grade at admission was I/II in 65.7% and IV/V in 30.6% of patients. At the 3- to 6-month follow-up, 23.3% of patients were dependent or dead. Thromboembolic events and intraoperative rupture resulted in permanent deficit in 13 (3.2%) and 2 (0.5%), respectively, and death in 4 (1.0%) and 0. Early rebleeding occurred in 2 patients (0.5%) with 2 subsequent deaths. Permanent treatment morbidity and mortality were 3.7 % and 1.5 %, respectively. Clinical results of the multicenter prospective Clarity registry show that when coiling is performed as first-intention treatment in a consecutive series of nonselected ruptured aneurysms by nonselected operators, clinical results are similar to those of the ISAT.

Évaluation de l’efficacité des dermocorticoïdes pour le traitement du phimosis de l’enfant à travers une analyse de la littérature

Questions concerning nonretractile foreskin are frequently asked by parents in infant consultations. Topical steroid treatment could be a less expensive and less traumatizing alternative to surgery. To assess the effectiveness of topical steroid therapy in boys with phimosis. Literature review. All randomized controlled trials were selected, using the following research sources: Medline, Cochrane Library, Pascal, Embase, Blackwell Science, Google, Google scholar, SUDOC, international register of trials, and congress abstracts. Unpublished trials were also searched. The trials were analyzed using the ANAES guide from a therapeutic article. Seven randomized controlled trials (n=714 patients) were in accordance with the inclusion criteria. The patients were between 1 and 12 years old. The treatment lasted for 4-8 weeks. The success rate at the end of the study was higher with the steroid (53.8-95%) than with the placebo (6.25-52%), P<0.05 for 6 randomized control trials. According to the ANAES criteria, the level of scientific evidence is low (gradeC) because of the lack of power in clinical trials and numerous methodological shortcomings and biases, even when examining both randomized control trials and nonrandomized trials. Only a few local side effects were noted. The use of topical steroids can be recommended in first-intention treatment before surgery for the management of phimosis.

Renal Transplantation After Endovascular Aortic Aneurysm Repair: Case Report and Literature Review

An increased number of aortic aneurysms are expected to be diagnosed in chronic renal failure patients awaiting kidney transplantation because of its strong association with atherosclerosis. The development of endovascular aortic aneurysm repair in the 1990s, which is characterized by low morbidity as well as shorter operative time and length of hospital stay, is particularly suited to these patients who are at high risk for conventional surgery. Herein we describe a case of a 58-year-old, man who was diagnosed with a 5.5-cm aortic aneurysm in 2001 and treated with a Gore Excluder (WL Gore and Assoc, Flagstaff, Ariz) aorto-iliac stent-graft. In 2004, he underwent uneventful deceased donor kidney transplantation in the right iliac fossa. With a follow-up of 6 and 9 years, respectively, there is no evidence of an endoleak. The renal function remains normal. This promising new surgical technique has been the subject of only a few published cases. At our center, endovascular aortic aneurysm repair is the first-intention treatment for these patients, as long as it is possible to preserve the iliac arteries for the renal anastomoses and the anatomic conditions are suitable for stent-graft deployment.

Hydrocortisone administration increases pulmonary artery pressure in asphyxiated newborn piglets reoxygenated with 100% oxygen

In severely asphyxiated neonates developing vasopressor-resistant shock, hydrocortisone is commonly used to improve perfusion. However, its acute haemodynamic effects in asphyxiated neonates are largely unknown. In a swine model of neonatal asphyxia, effects of hydrocortisone on systemic and pulmonary circulations were examined. Piglets (1–3 d, 1.5–2.4 kg) were acutely instrumented to measure heart rate, systemic and pulmonary artery pressures, and pulmonary artery flow. After 2 h of normocapnic hypoxia, animals were resuscitated with 100% oxygen for 1 h followed by 21% oxygen for 3 h. Intravenous hydrocortisone (1 mg/kg) or saline was given in a blinded, randomized fashion 2 h after reoxygenation (n = 6/group). Haemodynamic parameters, blood gases, plasma cortisol, as well as levels of endothelin-1, nitrite/nitrate, nitrotyrosine, matrix metalloproteinases-2 and -9 in the lung were analysed. Severe hypoxia caused metabolic acidosis (mean pH: 6.91–6.97, mean plasma lactate: 17.2–18.3 mM), tachycardia and shock. Hydrocortisone did not affect systemic haemodynamics which recovered with reoxygenation, but it increased pulmonary artery pressure at 90–120 min after administration (36 ± 3 vs. 27 ± 2 and 26 ± 1 mm Hg for hypoxia–reoxygenation control and sham-operated piglets, respectively, P < 0.05). In the lung tissue, hydrocortisone significantly increased endothelin-1 and nitrite/nitrate levels, but had no effect on nitrotyrosine. Further, it decreased lung matrix metalloproteinase-9, but not matrix metalloproteinase-2, activity, which were both elevated with hypoxia–reoxygenation. It is most likely that the increase in pulmonary artery pressure observed after hydrocortisone treatment was associated with increased endothelin-1 level in the lung. Our findings caution the use of hydrocortisone as a first-intention treatment of shock in asphyxiated neonates.

Therapeutic management of intracranial dural arteriovenous shunts with leptomeningeal venous drainage: report of 53 consecutive patients with emphasis on transarterial embolization with acrylic glue

There is a strong correlation between the venous drainage pattern of intracranial dural arteriovenous shunts (ICDAVSs) and the affected patients' clinical presentation. The ICDAVSs that have cortical venous reflux (CVR) (retrograde leptomeningeal drainage: Borden Type 2 and 3 lesions) are very aggressive and have a poor natural history. Although the necessity of treatment remains debatable in ICDAVSs that drain exclusively into a sinus (Borden Type 1), lesions with CVR must be treated because of the negative effects of the retrograde venous drainage. Surgery, radiosurgery, and embolization have been proposed for management of these lesions, but endovascular therapy is considered the most appropriate therapeutic strategy in ICDAVSs. New embolic materials, such as Onyx, have been recently developed and are considered to represent a kind of "gold standard" for embolization of these lesions. The purpose of this study is to emphasize the importance of transarterial embolization using acrylic glue in the therapeutic management of ICDAVSs with CVR, and to compare the results the authors obtained using this treatment with those reported in the literature for Onyx treatment of the same type of dural shunts. The clinical and radiological records of 53 consecutive patients suffering from ICDAVSs with CVR (Borden Types 2 or 3) were reviewed. All cases were managed with the same angiographic and therapeutic protocol. Localization of the lesions, their clinical symptoms, their angioarchitecture, their therapeutic management, and the results were analyzed. Fourteen ICDAVSs were located at the superior sagittal sinus and/or convexity veins, 13 at the transverse and sigmoid sinuses, 10 at the tentorium, 5 in the anterior cranial fossa, 4 at the foramen magnum, 3 at the torcula, 2 at the straight sinus, and 1 at the vein of Galen. One patient presented with an infantile form of ICDAVS with multiple shunts. Hemorrhage had occurred in 36% of cases. Forty-three patients underwent transarterial embolization (42 with acrylic glue). Complete closure of the fistula was obtained in 34 patients. Suppression of the CVR with partial occlusion of the main shunt was achieved in all other cases. No mortality or permanent morbidity was observed in this series. Intracranial dural arteriovenous shunts can be safely managed by transarterial embolization, which can be considered in most instances as an effective first-intention treatment. Acrylic glue still allows a cheap, fast, and effective treatment with high rates of cures that compare favorably to those obtained with new embolic materials.

MANAGEMENT OF CYSTIC CRANIOPHARYNGIOMAS WITH STEREOTACTIC ENDOCAVITARY IRRADIATION USING COLLOIDAL 186

Abstract OBJECTIVE We retrospectively reviewed the results of stereotactic endocavitary irradiation with colloidal 186Re in the treatment of cystic craniopharyngiomas. METHODS Among 54 consecutive patients included in a 186Re stereotactic endocavitary irradiation procedure, 42 patients (29 male and 13 female; average age, 38.7 years) received therapeutic injection via intracystic catheter introduced under stereotactic conditions. The mean follow-up period was 43 months (range, 8–148 months). Endocavitary irradiation was the primary treatment for 15 patients and an adjuvant treatment for 27 patients. The mean volume before irradiation was 8.07 mm3, and the mean radiation dose was 381 MBq. RESULTS Cystic mean volume after irradiation was 2.6 cm3 (P &amp;lt; 0.001 with initial volume). The retraction of the cyst was complete for 17 patients (44%) and partial for 17 (44%). In partial retraction, cystic volume decreased more than 50% for 12 (3%) patients and less than 25% (13%) for 5. Cystic volume remained the same or increased for 5 (13%) patients. Concerning visual functions, 12 (44.5%) patients improved and 2 worsened, despite tumor control. No endocrinological deterioration occurred. Among 17 patients with preoperative cognitive dysfunction, 10 improved and 6 had no change. One patient showed memory alteration 4 months after stereotactic endocavitary irradiation despite cyst volume reduction. No mortality occurred. CONCLUSION 186Re stereotactic endocavitary irradiation for the treatment of cystic craniopharyngiomas is a safe and effective procedure with a tumor control rate greater than 70%. This treatment can be used for first-intention treatment of pure cystic craniopharyngiomas or for second-intention treatment of cystic recurrences.

Premier métacarpien flottant avec luxation trapézo-métacarpienne récidivante chez un sujet hyperlaxe

A case of trapezometacarpal dislocation associated with metacarpophalangeal dislocation (floating first metacarpal) is described. The trapezometacarpal dislocation re-occurred twice despite well conducted orthopedic treatment. Ligamentoplasty of the carpal radial flexor tendon using the Eaton and Littler method then provided an excellent result. Failure of orthopedic treatment was probably related to the congenital hyperlaxity presented by this patient. Considering this hypothesis, the presence of hyperlaxity would affect management practices used for trapezometacarpal dislocation. In the presence of hyperlaxity, it would be preferable to propose first-intention surgery with suture and pinning or ligamentoplasty. Conversely, for patients without hyperlaxity, orthopedic treatment remains the first-intention treatment of choice.

Endovascular treatment of intracranial aneurysms as the first thérapeutic option

Background and purpose To prospectively evaluate the results of endovascular treatment (EVT) of intracranial aneurysms when it is considered as first-intention treatment. Methods From April 2004–October 2006, 167 consecutive patients with 202 aneurysms were treated in our institution. Five patients with a ruptured aneurysm with an associated haematoma were excluded. In 162 patients with 197 aneurysms, EVT was considered as first-intention treatment. Results Surgical clipping was performed in 25 aneurysms (25/197 = 12.7%) including 22 aneurysms excluded from EVT and three EVT failures. EVT was thus attempted in 144 patients with 175 aneurysms and successfully performed in 141 patients with 172 aneurysms (172/197 = 87.3%). EVT failure rate was 1.7%. Clinical outcome according to the modified Glasgow Outcome Scale was: Excellent, 81.5%; Good, 7%; Poor or Fair, 3.5%; Death, 8%. Procedural complications occurred in 17 cases (10%). Balloon- or stent-assisted techniques were used in 60 cases (34.9%) and were not associated with higher complication rate. Overall procedural morbidity and mortality rates were 4.2 and 2.1%. Initially, complete occlusion was obtained in 68%, neck remnant in 23%, and incomplete occlusion in 9% of aneurysms. Follow-up (mean 11 months) was obtained in 119 aneurysms and showed major recanalisation — that required re-treatment — in 13 cases (11%) and minor recanalisation in 17 cases (14.3%). Conclusion Our findings suggest that new endovascular techniques allow proposing EVT as first-intention treatment in 87.3% of patients with intracranial aneurysms. This therapeutic strategy is associated with good clinical results. However, anatomical results are not improved and remain the EVT limiting factor.

Initial primary endovascular treatment in the management of ruptured intracranial aneurysms: a prospective consecutive series

From January 1998 to December 2002, endovascular treatment (EVT) was used as first intention in all patients with ruptured aneurysms. The objective of this study was to analyze the results of this therapeutic strategy. Among 401 patients admitted with a subarachnoid hemorrhage (SAH), 73 (18%) had a nonaneurysmal perimesencephalic SAH, 28 were not explored by angiography due to very poor clinical status, and 28 with aneurysmal SAH were not treated due to poor clinical status. Thus, of the 300 patients with a proven aneurysmal SAH, 272 (83%) were treated. EVT was attempted in 230 patients and was successful in 222 (82%), and clipping was performed in 50 (18%). Finally, EVT was successful in 234 aneurysms (96.7%) in 222 patients out of 242 aneurysms in 230 patients (some of the patients were treated for more than one aneurysm in the same procedure). EVT-related morbidity occurred in ten patients (4.5%) and mortality in eight (3.6%). Rate of dependency or death (modified Rankin scale 3-5) was 24.5% at 26 months. Initially, complete aneurysm occlusion was obtained in 81%, a dog ear in 3.4%, a neck remnant in 8% and incomplete occlusion in 8.1% of the patients. At follow-up (mean 26 months), the occlusion rate remained stable at 75%. This consecutive prospective series shows that EVT can be performed routinely as first-intention treatment in most aneurysmal SAH. Using this therapeutic strategy, EVT was performed in 82% of patients with long-term clinical results similar to those of the ISAT study.

Résultats à moyen terme de la prothése totale du genou Wallaby I ® conservant le ligament croisé postérieur : À propos des 425 premiers cas suivis prospectivement

Purpose of the study Posterior Wallaby I ® is a fixed polyethylene tibial plateau prosthesis enabling preservation of the posterior cruciate ligament (PCL). Its asymmetrical and divergent femoral condyles articulate with also asymmetrical tibial plateaus. The purpose of this prospective study was to analyze outcome of the first 425 Wallaby I ® prosthesis of the Guepar group implanted for first-intention treatment. Materials and methods These 425 prostheses were implanted from December 1992 to February 1995 by senior and junior surgeons. Mean patient age at implantation was 70.5 years. 91% had primary or secondary osteoarthritis and only 8.9% had inflammatory rheumatoid disease. The mean preoperative IKS score was 25.34 points and the IKS function score was 29.04. 10.35% of knees were aligned normally (mechanical axis between 2° varus and 3° valgus) according to the IKS criteria (Ewald), 24% presented valgus ≥ 4° and 65.6% varus ≥ 3°. All tibial and patellar components (except one) were cemented, 5.8% of the femoral pieces were inserted without cement. All but 11 patellae were resurfaced. Clinical outcome was assessed with the IKS score and radiological outcome with the IKS criteria. The patella was considered to be tilted when the alpha angle was > 5° and dislocated when the AA’ distance was > 5 mm. The chi-square test was used for comparison of quantitative variables (significance set at 0.05). Results Early postoperative complications were rare: two infections cured with debridement-lavage and antibiotics without removal of the prosthesis, one peronal nerve palsy which regressed partially, ten late unions without clinical consequence (particularly in the inflammatory rheumatoid patients). Twenty-six prostheses were followed less than one year (eight patients died and eighteen were lost to follow-up) and 84 less than five years (27 patients died and 57 lost to follow-up before five years). 315 prostheses were followed for more than five years (5-9 years) with a mean follow-up of 6.3 years. Among the 399 prostheses followed for one year or more, we noted: four infections including three requiring change of the prosthesis (one cured by arthroscopic lavage), two aseptic loosenings which were revised (one global one tibial), one tibial loosening and three patellar loosenings which were not revised, and two femoral ossifications limiting joint motion but improved by arthrolysis and resection of the ossifications. Three patients experienced anterior pain requiring secondary patellar resurfacing in two and section of the lateral patellar wing in one. Ninteen patellar fractures (4.7%) were noted, including 17 with no significant functional impact which were not revised. The mean IKS knee score among prostheses followed for five years was 90.5 points, with mean motion 110.5°. Mean IKS function score was 61.63 points. 72.9% of the knees were aligned, 22.2% in varus and 4.9% in valgus. The mechanical axis of 94.3% of the knees was between 5° varus and 5° valgus. Prosthesis survival at eight years (Kaplan-Meier method) was 97.7% considering all reasons for prosthesis removal and 98.5% for removal for aseptic loosening. Conclusion This prospective multicentric study demonstrated that the results obtained with the Wallaby I ® prosthesis are as good as those obtained with other prostheses sparing the PCL and published in the literature. Preservation of the PCL enables better knee stability, correct motion (110.5° in our series) with almost no radiological wear of the tibial polyethylene at eight years. The only worrisome complication is patellar fracture.

Management of bleeding peptic ulcer in France: a national inquiry

To evaluate and compare management practices in France for bleeding peptic ulcers using a national inquiry of university and non-university hospitals. Responses to questionnaires sent to 812 gastroenterologists, 496 practicing in non-university hospitals and 316 in university hospitals, were compared. An analysis was possible in 279 (34% response rate) of the questionnaires. Forrest classification was used more frequently in university hospitals (83% vs 60%, P<0.01). Endoscopic hemostatic therapy was used more frequently in university hospitals for Forrest Ib (92% vs 81%, P=0.02), IIa (93% vs 73%, P<0.001), and IIb (58% vs 29%, P<0.001) ulcers. Injection therapy, mainly epinephrine, was the first-intention treatment for 99% of the responding gastroenterologists. Proportions of clinicians employing hemoclips (27%) or argon plasma coagulation (21%) were similar in both types of practice. Anti-secretory treatment included mainly omeprazole (82%), given intravenously (76%), sometimes as bolus i.v. doses followed by i.v. high-dose continuous infusion (15%) with some variations according to the type of hospital. In the event of recurrent or persistent bleeding, surgery was more frequent in non-university hospitals. When rebleeding occurred, a second endoscopic treatment was performed in about one quarter of patients. In France, management practices for bleeding peptic ulcer vary between university and non-university hospitals.

Sclérectomie profonde non perforante au Brésil: Étude rétrospective sur trois ans

Nonpenetrating deep sclerectomy with external trabeculectomy has been proved to be an effective alternative to classic trabeculectomy for surgical treatment of primary open-angle glaucoma. However, this procedure is not well known nor well accepted among Brazilian ophthalmic surgeons. The aim of this study was to assess the results and success rate of this new filtering surgical procedure in a Brazilian population, with a 3-year follow-up.One-hundred eleven primary open-angle glaucoma patients underwent deep sclerectomy with external trabeculectomy between 1999 and 2002 (the surgery was performed by two different surgeons using the same procedure). The antimetabolite mitomycin C (0.2 mg/ml) was applied intraoperatively in 80 patients with high surgical risk of failure (80 patients under 45 years of age, black, and having had previous ocular surgery). The postoperative follow-up included assessment of visual acuity, measure of intraocular pressure (IOP), evaluation of the filtration site and optic nerve head using biomicroscopy, and analysis of visual field deficits. Complete success was defined as IOP less than 18 mmHg without medical treatment, while relative success was defined as IOP less than 18 mmHg with medical treatment.The mean age was 63.7 +/- 13.1 years and 42.3% of patients were black. Mean follow-up was 19.4 months (+/- 11.7). The mean preoperative intraocular pressure was 22.57 +/- 4.92 mmHg, while mean IOP at the last follow-up visit was 14.22 +/- 2.89 mmHg, so that at the end of the follow-up, complete success was 82.7% and relative success was 93.3%. The cumulative probability of complete success was 76% at 3 years. The complication rate was low: intraoperative microperforations (14.4%), conjunctival seidel (12.5%), hyphema (3.8%), flat anterior chamber (2.9%), choroidal detachment (1%), and filtering bleb fibrosis (17.3%).These results demonstrate that deep nonpenetrating sclerectomy with external trabeculectomy is a safe and efficient filtering procedure that provides satisfactory IOP control with a minimal rate of complications, even in patients with high surgical risk of failure such as the highly mixed Brazilian population. The results suggest that this revolutionary procedure could be used as first-intention treatment in Brazilian glaucomatous patients that do not have access to expensive medical treatment.

Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy.

Pancreatic fistula (PF), which is a major complication of pancreaticoduodenectomy (PD), can be treated conservatively or by reoperation. The aim of this study was to evaluate conservative management of PF, which was attempted whenever possible as a first-intention treatment in a large series of PD. From 1990 to 2000, 242 patients underwent PD with pancreaticogastrostomy. PF was observed in 31 (13%) and was defined by an amylase-rich surgical drainage fluid (above fivefold serum amylase) after postoperative day 5, or by presence on CT scan of a fluid collection located close to the anastomosis or containing amylase-rich fluid, or by operative findings in case of reoperation. Conservative management included total parenteral nutrition, nasogastric suction, imaging-guided percutaneous drainage of collection when necessary, and somatostatin or its analogues. PF was symptomatic in 20 patients (65%). Amylase level on surgical drainage fluid was elevated in 23 patients (74%). Four patients (13%), including two with hemorrhage and two with intraabdominal collection not accessible by percutaneous approach, were not considered for conservative management and underwent early reoperation. Conservative management was successful in the 27 patients (100%) in whom it was attempted, including the 10 who required percutaneous drainage. The only death (3%) occurred after massive hemorrhage complicating misdiagnosed PF. Mean hospital stay was 36 +/- 12 days (range 18 to 71) after successful conservative management. Conservative management of PF complicating PD is feasible and successful in above 85% of patients.