Low Risk Of Surgical Complications Research Articles

Ex Vivo Expanded Human Regulatory T Cells Delay Islet Allograft Rejection via Inhibiting Islet-Derived Monocyte Chemoattractant Protein-1 Production in CD34+ Stem Cells-Reconstituted NOD-scid IL2rγnull Mice

Type 1 diabetes mellitus (T1DM) is an autoimmune disease caused by immune-mediated destruction of insulin-secreting β cells of the pancreas. Near complete dependence on exogenous insulin makes T1DM very difficult to control, with the result that patients are exposed to high blood glucose and risk of diabetic complications and/or intermittent low blood glucose that can cause unconsciousness, fits and even death. Allograft transplantation of pancreatic islets restores normoglycemia with a low risk of surgical complications. However, although successful immediately after transplantation, islets are progressively lost, with most of the patients requiring exogenous insulin within 2 years post-transplant. Therefore, there is an urgent requirement for the development of new strategies to prevent islet rejection. In this study, we explored the importance of human regulatory T cells in the control of islets allograft rejection. We developed a pre-clinical model of human islet transplantation by reconstituting NOD-scid IL2rγnull mice with cord blood-derived human CD34+ stem cells and demonstrated that although the engrafted human immune system mediated the rejection of human islets, their survival was significantly prolonged following adoptive transfer of ex vivo expanded human Tregs. Mechanistically, Tregs inhibited the infiltration of innate immune cells and CD4+ T cells into the graft by down-regulating the islet graft-derived monocyte chemoattractant protein-1. Our findings might contribute to the development of clinical strategies for Treg therapy to control human islet rejection. We also show for the first time that CD34+ cells-reconstituted NOD-scid IL2rγnull mouse model could be beneficial for investigating human innate immunity in vivo.

New options for combined cataract and glaucoma surgery

To review the current literature regarding the effectiveness and risks of new surgeries that can be combined with phacoemulsification in the management of cataract and glaucoma. Surgical options for concurrently managing cataract and glaucoma have expanded in recent years. Endoscopic cyclophotocoagulation, trabecular micro-bypass stent, ab interno trabeculectomy, and canaloplasty may be performed in conjunction with cataract extraction to provide additional intraocular pressure (IOP) reduction. Studies evaluating these new glaucoma procedures combined with phacoemulsification generally include retrospective case series without a comparison group. Because cataract surgery alone is associated with IOP reduction, the relative contribution of the glaucoma procedure in lowering IOP cannot be determined in these studies. Randomized clinical trials are needed to better evaluate the efficacy and safety of newer glaucoma procedures in combination with cataract surgery. The newer glaucoma procedures appear less effective than trabeculectomy, but they are associated with a lower risk of surgical complications.

Is Preoperative Chemotherapy Followed by Surgery the Appropriate Treatment for Signet Ring Cell Containing Adenocarcinomas of the Esophagogastric Junction and Stomach?

Recent data suggest primary resection as the preferable approach in patients with signet ring cell gastric cancer (SRC). The aim of our retrospective exploratory study was to evaluate the influence of SRC on prognosis and response in esophagogastric adenocarcinoma treated with neoadjuvant chemotherapy. A total of 723 locally advanced esophagogastric adenocarcinomas (cT3/4 N any) documented in a prospective database from two academic centers were classified according to the WHO definition for SRC (more than 50 % SRC) and analyzed for their association with response and prognosis after neoadjuvant treatment. A total of 235 tumors (32.5 %) contained SRC. Median survival of SRC was 26.3 compared with 46.6 months (p < 0.001) for non-SRC. SRC were significantly associated with female gender, gastric localization, advanced ypT and R1/2 categories, and lower risk of surgical complications and anastomotic leakage (each p < 0.001). Clinical (21.1 vs. 33.7 %, p = 0.001) and histopathological response (less than 10 % residual tumor: 16.3 vs. 28.9 %, p < 0.001) were significantly less frequent in SRC. Clinical response (p = 0.003) and complete histopathological response (pCR) (3.4 %) (p = 0.003) were associated with improved prognosis in SRC. Clinical response, surgical complications, ypTN categories, but not SRC were independent prognostic factors in forward Cox regression analysis in R0 resected patients. Risk of peritoneal carcinomatosis was increased (p < 0.001), while local (p = 0.015) and distant metastases (p = 0.02) were less frequent than in non-SRC. Prognosis of SRC is unfavorable. Although response to neoadjuvant chemotherapy is rare in SRC, it is associated with improved outcome. Thus, chemotherapy might not generally be abandoned in SRC. A stratification based on SRC should be included in clinical trials.

Double rhomboidal flap for reconstruction of large surgical defect of the labial commissure

Closure of perioral surgical defects involving the oral commissures is highly challenging. We describe a 69-year-old male patient with a large basal cell carcinoma of the right perioral region, extending to the right oral commissure. This lesion was radically excised, and the resulting surgical defect was closed using a homolateral double opposing rhomboidal flap. The final result was esthetically very satisfactory, with total preservation of lip function. Double opposing rhomboidal flaps are viable surgical options for the reconstruction of surgical defects involving the perioral area and oral commissures. In this relatively simple procedure, donor skin is obtained from the nearby cheek and mandibular areas, under low risk of surgical complications, preserving lip function without distortion of the labial anatomy.

Donor-Dependent Risk Factors for Early Surgical Complications After Simultaneous Pancreas–Kidney Transplantation

Introduction The success of simultaneous pancreas–kidney transplantation (SPK) depends in a large degree on avoidance of surgical complications in the early postoperative period. The aim of the study was to analyze the Pre-procurement Pancreas Allocation Suitability Score (P-PASS) and the deceased donor parameters included within it as risk factors for early surgical complications after SPK. Material and Methods Forty-six consecutive donors whose kidney and pancreas were simultaneously transplanted were included in the study. Results Donor age was older among recipients who lost their pancreatic grafts: 30.4 ± 6.9 versus 24.1 ± 6.9 years. Donor age was also older among recipients who lost their pancreatic grafts or died compared with those discharged with a functioning graft: 29.3 ± 5.7 versus 24.0 ± 6.9 years. Donor body mass index (BMI) was higher among patients who died compared with those who were discharged: 25.3 ± 1.1 versus 23.2 ± 2.5 kg/m 2. P-PASS was higher in patients who lost their pancreatic grafts (17.6 ± 2.1 vs 15.2 ± 1.8) or died (15.3 ± 1.9 vs 17.2 ± 1.9), or lost pancreatic graft or died (15.2 ± 1.8 vs 17.0 ± 2.2) or with intra-abdominal infections (IAI; 17.1 ± 1.7 vs 15.0 ± 1.8). The incidence of donors ≥30 years old was higher among recipients with IAI (45.4% vs 14.3%; P = .04). An higher rate of donors with P-PASS >16 was revealed among patients who lost their pancreatic grafts (26.7% vs 3.2%), died (26.7% vs 3.2%), lost the pancreatic graft or died (33.3% vs 6.4%), or experienced IAI (46.7% vs 9.7%). Multivariate logistic regression analysis revealed P-PASS (odds ratio 2.57; P = .014) and serum sodium (odds ration, 0.91; P = .048) to be important predictors of IAI development. Conclusion Older age and higher BMI among deceased donors increased the risk of IAI, pancreatic graft loss, or recipient death after SPK. Transplantation of a pancreas from a donor with a low P-PASS score was associated with a lower risk of surgical complications after SPK.

RETALHO ROMBOIDAL DUPLO PARA ENCERRAMENTO DE DEFEITO CIRÚRGICO DA COMISSURA LABIAL

Os lábios, enquanto estruturas anatómicas móveis da face, apresentam crucial importância em termos funcionais e cosméticos. A abordagem de defeitos cirúrgicos da região perioral é um desafio importante na prática cirúrgica dermatológica, atendendo ao risco de distorção da anatomia local. Apresentamos o caso de um doente do sexo masculino, de 69 anos, com extenso carcinoma basocelular ulcerado da região perioral direita, com envolvi- mento da comissura labial. Foi realizada excisão radical da lesão e encerramento do defeito cirúrgico com retalho romboidal duplo das regiões geniana e mandibular homolaterais. Não houve complicações pós-operatórias e o re- sultado cosmético final foi bastante satisfatório, com preservação da funcionalidade das estruturas labiais. O retalho romboidal duplo é uma alternativa viável para o encerramento de defeitos cirúrgicos da comissura labial, utilizando pele das regiões geniana e mandibular adjacentes. É uma técnica de execução relativamente simples, com baixo risco de complicações, que oferece óptimos resultados funcionais e cosméticos.PALAVRAS-CHAVE – Procedimentos Cirúrgicos Reconstrutivos; Retalhos Cirúrgicos; Comissura Labial; Carcinoma Basocelular; Neoplasias do Lábio.

Treatment of Appendicitis in Neutropenic Children

Appendicitis in the neutropenic patient places the clinician in a precarious position; balancing the timing and risks of surgery and the risk of an uncontrolled infectious source in the abdomen. Multi-center retrospective review from 2000 to 2010 of appendicitis occurring in patients with neutropenia secondary to chemotherapy. Patient demographics and surgical outcomes were tracked. There were 11 patients, mean age of 11 y (3-17 y); six were male. Mean weight was 46.9 kg (18.1-72.6 kg). Mean body mass index was 20.9 kg/m(2) (16.8-27.3 kg/m(2)). There were five acute lymphocytic leukemias, four acute myeloblastic leukemias, one T-Cell lymphoma, and one Ewing's sarcoma. Mean presenting white blood cell count was 1900 (0.2-4.4). Average absolute neutrophil count was 900 (0.00-2.6). Computed tomography scan was used in all patients. Appendectomy was performed within 24 h of presentation in all patients, three were perforated. Mean time to first feeding was 1 d (range, 0-5 d), goal feeds at 3 d (range, 1-6 d ). Mean length of stay from appendicitis was 4 d. Early appendectomy for appendicitis in neutropenic patients appears to be tolerated well with a low risk of surgical complications.

Clinical Evaluation of 24 Cases of Primary Thyroid Malignant Lymphoma

We analyzed open biopsy in diagnosing primary thyroid lymphoma (PTL) and tumor management with compression symptoms and therapy. We retrospectively studied 24 subjects diagnosed with PTL from December 1997 to June 2010. Open biopsy was done in 23 of 24 subjects. Incisional biopsy was done in 14, 13 of whom yielded sufficient materials in the first biopsy. Excisional biopsy was done in the remaining 9, 2 of whom developed permanent recurrent laryngeal nerve palsy after biopsy. The five with airway obstruction underwent incisional biopsy followed by immediate steroid administration of dexamethasone or methylprednisolone. All had histopathologically confirmed diagnosis and airway symptoms were resolved within a few days. Multidisciplinary therapy including chemotherapy, radiotherapy, and surgery was applied in 20 of 24 subjects. Single therapy was done in 4-chemotherapy in 2 and radiotherapy and surgery in 1 each. Overall results were satisfactory, with a 92% 10-year disease-free survival rate and an 86% 10-year overall survival rate based on the Kaplan-Meier method with 46-month median follow up. When diagnosing PTL, especially large tumors spreading into extrathyroid tissue, incisional biopsy is more advantageous in histopathological diagnosis than excisional biopsy due to the lower risk of surgical complications. In a case involving a small intrathyroidal nodule, excisional biopsy is safer and more diagnostically accurate. In an airway obstruction emergency, once a definitive diagnosis is made, steroid administration plus endotracheal intubation, if necessary, for airway management is optimal management. Subjects with stage IE mucosa-associated lymphoid tissue (MALT) lymphomas can be treated with radiotherapy or surgery alone. Those with diffuse large B-cell lymphoma (DLBCL) or greater than stage IE MALT lymphoma, however, should be treated with multidisciplinary therapy because they have a potentially poor outcome.

Laparoscopic Splenectomy for Immune Thrombocytopenic Purpura (ITP): A Single Center Experience

As medical therapy for ITP is expanding to include monoclonal antibodies and thrombopoietin mimetic agents, the role and safety profile of surgical therapy needs to be reassessed, taking into consideration the improvements made over the years both in surgical technique and infection prophylaxis and surveillance. For this purpose pts who underwent laparoscopic splenectomy for ITP between July 2000 – when the procedure became standard practice at our Institution - and July 2008 were retrospectively analyzed to evaluate short-term outcome and perioperative complications. Pts were candidate to splenectomy when refractory (platelet counts ≤30 × 109/L) to one or more lines of therapy and/or steroid-dependant. All pts received steroids as first-line treatment. All pts were vaccinated (pneumococcal, haemophilus, meningococcal vaccine) before the procedure. A total of 26 pts (8 females, 18 males) underwent the procedure: 22 had a diagnosis of ITP according to ASH criteria; the remaining 4 had immune thrombocytopenia associated with isolated LAC positivity (1), HCV infection (2), and HCV+HIV co-infection (1). Median age at splenectomy was 46 yrs (range 18–79). At the time when splenectomy was planned, median platelet (plt) count was 19 × 109/L (range 3–197) with 11/26 pts having plt counts ≥ 30 × 109/L either off therapy (3/11) or on chronic steroids (8/11).The remaining 15 pts required pre-operative therapy to improve plt levels: pre-op plt transfusion (1 pt), IVIg (5 pts), HD steroids (dexametasone 40 mg i.v. or metilprednisolone 125 mg i.v.) either alone (3 pts) or combined with IVIg (4 pts); IVIg and plt concentrates (1 pt), HD steroids + IVIg + platelet concentrates (1 pt); 11/15 responded to therapy, while in 4/15 plt counts remained ≤15 × 109/L and received plt concentrates during surgery. At splenectomy median plt count was 62 × 109/L, range 3– 212 × 109/L. Median surgical time was 150′(range 50–240′); in no case the surgical procedure had to be converted to open laparotomy. No significant correlation (Spearman's rank correlation ρ = − 0.1569; p = 0.4441) was found between plt counts at splenectomy and duration of the surgical procedure. Median post-splenectomy hospital stay was 6 days (range 4–18). All pts received low-molecular weight heparin prophylaxis; no thrombotic complications were recorded. Two pts developed haematoma; pt 1: plts at surgery 4 × 109/L, hospital stay 18 days, no red cell transfusion required; pt 2: platelet at surgery 109 × 109/L, reintervention needed with 4 units of red cells transfused, hospital stay 11 days. Four pts experienced transient post-operative low-grade fever with no concomitant signs of systemic infection. Median platelet counts at discharge from the hospital was 353 × 109/L, range 47–1,056 × 109/L. In our experience no relevant complications followed laparoscopic splenectomy. Open splenectomy in itself is known to be associated with a very low risk of surgical complications, but the laparoscopic technique is nevertheless advantageous to the pts in terms of shorter duration of hospital stay, convalescence and time to return to work. Rituximab (R) and thrombopoietin mimetic agents are being suggested as alternatives to splenectomy in patients failing first line therapy with steroids. However, splenectomy does not compromise the efficacy of R, while administration of R prior to splenectomy may compromise immune response to subsequent pre-surgical vaccination for a long time. This may increase the risk of overwhelming infections in those pts with persistently very low plt counts requiring splenectomy as an emergency procedure. Moreover, potential harmful long-term effects of B-cell depletion in non-oncologic patients need to be considered. Although promising, little information is as yet available on thrombopoietin mimetic agents, but they are a life-long therapy. Therefore it is our belief that the very good safety and long-term efficacy profile of splenectomy still makes this procedure standard second line therapy for ITP.

Surgical Treatment for the Vulvar Vestibulitis Syndrome

This study is an evaluation of surgical treatment for vulvar vestibulitis, a major cause of superficial dyspareunia in premenopausal women. Its estimated prevalence in a general gynecologic population is 15%. Those affected have severe vestibular pain on touch or vaginal entry as well as tenderness to pressure within the vulvar vestibule. It is not uncommon for symptoms to last longer than 6 months with no apparent cause. The investigators reviewed the records of 155 women 40 years of age or younger who were operated on for this condition in the years 1998 through 2001. Just over 80% of these women (n = 126) were interviewed by telephone 1 to 4 years postoperatively. A single gynecologist performed all operations in a uniform manner under general anesthesia on an outpatient or short-admission setting. Vestibulectomy and advancement plasty are carried out. The procedure entails total removal of the hymen and the full thickness of skin on the adjacent vestibulum (Hart's line and the fourchette are boundaries). The remaining defect is covered by vaginal wall after it has been undermined and advanced. Vaginal dilation exercises with a mold begin 6 weeks postoperatively if wound healing is satisfactory; at the same time, women are encouraged to begin or resume intercourse. The phone interview, carried out a median of 37 months after surgery, revealed that 93% of women were able to have intercourse and that 62% had no pain in doing do. Just over 60% of women had no postoperative complications. The most common problem, affecting approximately one fourth of patients, was decreased lubrication during sexual arousal. Eight patients (6%) developed a Bartholin's cyst. The odds ratio (OR) for being able to have intercourse only after surgery was 3.43 (95% confidence interval [CI], 1.48-7.96). For women 30 years of age or younger, the OR was 8.20 (95% CI, 1.54-43.73). Younger women were especially disposed to suggest the procedure to other patients. The results were basically the same after adjusting ORs for the follow-up interval. The outcome of surgery could not be related to parity, the ability to have intercourse before surgery, or previous nonsurgical treatment. Surgery has a role in the management of vulvar vestibulitis syndrome; and, because there is a low risk of surgical complications, it can be presented as a potentially helpful option when medical measures have proved not to be effective.

Closure of bronchial defects using a pedicled pericardial flap

A technique for closure of lateral or terminal defects in the bronchial wall after tissue-saving procedures, which obviates the need for sleeve resection in few selected situations, is described. Its main advantages are a low risk of surgical complications at the suture line and easy performance.