non-AL Group Research Articles

Cauda Equina Atrophy in Amyotrophic Lateral Sclerosis on Routine Lumbar Magnetic Resonance Imaging.

The aim of the study was to evaluate the cross-sectional area of the cauda equina in amyotrophic lateral sclerosis (ALS) on routine lumbar magnetic resonance imaging and investigate the diagnostic accuracy in comparison with age- and sex-matched non-ALS controls. This retrospective study included 15 ALS patients and 15 age- and sex-matched non-ALS controls. Two independent neuroradiologists measured and compared the total cross-sectional area of the cauda equina of ALS patients and the non-ALS controls at the level of the L3 and L4 using axial T2-weighted images. The cutoff value, sensitivity, specificity, and area under the curve were measured. The interobserver reproducibility of the 2 independently obtained measurements was evaluated. The total cross-sectional area of the cauda equina in the ALS group was significantly smaller than that in the non-ALS group (L3: median, 66.73 vs 90.19 mm 2 , P < 0.001; L4: median, 52.9 vs 67.63 mm 2 , P < 0.001). The cutoff values at L3 and L4 were 76.95 and 61.04 mm 2 with a sensitivity and specificity of 1 and 0.87 and 0.8 and 0.87, respectively. The area under the curve at L3 and L4 were high at 0.96 and 0.94, respectively. The interobserver reproducibility was 0.88 at L3 and 0.89 at L4. The ALS patients showed significant atrophy of the cauda equina compared with non-ALS patients.

Alcohol abuse has a potential association with unfavourable clinical course and brain atrophy in patients with status epilepticus

To evaluate chronological changes on serial magnetic resonance imaging (MRI) examinations and clinical prognosis in patients with status epilepticus (SE), as well as the effect of alcohol abuse and heavy alcohol use on clinicoradiological findings. This retrospective, single-centre study was approved by the institutional review board. Among 345 patients with seizures between January 2010 and October 2021, 27 patients with SE who had undergone both initial MRI (within a week after onset) and follow-up MRI (within 1 month after the initial MRI) were included. Five and three patients with concurrent or previous alcohol abuse and heavy alcohol-use history were included, respectively, and they were classified into the AL (Alcohol use) group. The remaining 19 patients were classified into the non-AL group. Two neuroradiologists independently evaluated both initial and follow-up MRI examinations of each patient; MRI findings were compared between the AL and non-AL groups using Fisher's exact test. In 15 patients, including four patients from the AL group, clinical information 6 months after the onset of SE was available; this information was compared between the two groups. Brain atrophy (5/8 versus 2/19, p=0.011; odds ratio, 12.29 [95% confidence interval, 1.32-189.2]) and unfavourable clinical course with uncontrollable seizures (3/4 versus 1/11, p=0.033; odds ratio, 30[1.43-638.19]) were significantly more frequent in the AL group than in the non-AL group. Among patients with SE, alcohol abuse and heavy alcohol-use history were associated with unfavourable seizure control and brain atrophy.

Air leak syndromes (Pneumomediastinum, pneumothorax, and subcutaneous emphysema) in critically ill COVID-19 patients – Prevalence, risk factors, and outcome

Background: A high incidence of air leak syndromes (ALSs) has been reported in critically ill coronavirus disease 2019 (COVID-19) patients, which affects disease outcome. Objective: To evaluate the incidence, outcome, and risk factors associated with ALSs in critically ill COVID-19 patients receiving invasive or non-invasive positive pressure ventilation. Result: Out of 79 patients, 16 (20.2%) patients had ALS. The mean age of the ALS group was 48.6 ± 13.1 years as compared to 52.8 ± 13.1 (p = 0.260) years in the non-ALS group. The study group had a lower median body mass index (25.9 kg/m2 vs 27.6 kg/m2, P = 0.096), a higher D-dimer value (1179.5 vs 762.0, P = 0.024), lower saturation (74% vs 88%, P = 0.006), and a lower PF ratio (134 vs 189, P = 0.028) at presentation as compared to the non-ALS group. Patients with ALS had received a higher median positive end-expiratory pressure (PEEP) (10 cm vs 8 cm of water, P = 0.005). The pressure support, highest driving pressure, and peak airway pressure were not significantly different in the two groups. The ALS group had a significantly longer duration of hospital stay (17.5 vs 9 days, P = 0.003). Multiple logistic regression analyses indicated that patients who received inj. dexamethasone were less likely to develop ALS (OR: 12.6 (95% CI 1.6-95.4), P = 0.015). Conclusion: A high incidence of ALS is present in critically ill COVID-19 patients. High inflammatory parameters, severe hypoxia at presentation, and use of high PEEP are significant risk factors associated with ALS. The risk of developing ALS was lower in patients who received inj. dexamethasone.

Bacteriological concentration of peritoneal drainage fluid could make an early diagnosis of anastomotic leakage following rectal resection

To investigate that the bacteriological concentration and pH value in peritoneal drainage fluid might serve as indicators of early diagnosis of anastomotic leakage following rectal resection. We prospectively analyzed consecutive patients who were treated for rectal diseases with anastomosis at the department of general surgery, the affiliated hospital of Nanjing University Medical School between August 2018 and December 2020. The bacteriological concentration and the pH value in peritoneal drainage fluid were tested on the first, fourth, seventh days postoperatively. A total of 300 consecutive patients underwent rectal resection were tested. 21 patients present with AL and the overall AL rate was 7%. The bacteriological concentration in peritoneal drainage fluid of AL group was significantly higher than that in non-AL group. The AUC value was 0.98 (95% confidence intervals 0.969–1.000) according to the ROC curve. The best cut-off value was 1143/uL. The sensitivity and specificity were 100% and 93.19% respectively. There was no difference of pH value between the AL and non-AL groups. According the results of present study, a high bacteriological concentration in peritoneal drainage fluid is a good marker for predicting and diagnosing AL following rectal resection. However, owing to the limitation of the sample, there was no validation attempt in the study. A large sample study is needed to validate the conclusion.

Peritoneal cytokines as a predictor of colorectal anastomotic leaks on postoperative day 1: a systematic review and meta-analysis

Anastomotic leakage (AL) is a major complication of colorectal surgery resulting in morbidity, mortality and poorer quality of life. The early diagnosis of AL is challenging due to the poor positive predictive value of tests available and reliance on clinical presentation which may be delayed. The aim of this systematic review was to assess the applicability of peritoneal cytokine levels as an early predictive test of AL in postoperative colorectal cancer patients. A comprehensive literature search was performed from inception to January 2021, in MEDLINE and EMBASE databases using MeSH and non-MeSH terms in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies evaluating peritoneal cytokines in the context of AL were included in this review. Two hundred ninety-two abstracts were screened, 30 full manuscripts evaluated, and 12 prospective studies were included. There were 8 peritoneal cytokines evaluated (interleukin [IL]-1β, IL-6, IL-8, IL-10, vascular endothelial growth factor [VEGF], tumour necrosis factor alpha [TNF alpha] and matrix metalloproteinase [MMP]2 and MMP9) between AL and non-AL groups on postoperative day 1. Those that included IL-6 (7 studies), IL-10 (4 studies), TNF alpha (6 studies) and MMP9 (2 studies) were included in the meta-analysis. IL-10 was the only cytokine in the meta-analysis that was significantly (p < 0.05) raised in drain fluid on postoperative day 1 in AL patients. Peritoneal IL-10 was significantly raised on postoperative day 1 in patients who subsequently developed AL. This may be a useful early predictor of AL and aid in an earlier diagnosis for postoperative colorectal patients. The range of cytokines investigated within the literature is limited and from heterogeneous studies which suggests more research is needed.

Risk stratification of anastomotic leakage using eGFR and FIB-4 index in patients undergoing esophageal cancer surgery

Renal insufficiency and liver cirrhosis are identified as independent risk factors for anastomotic leakage (AL) after esophagectomy. However, research evaluating the incidence of AL using quantitative data to measure renal function and liver fibrosis remain to be limited. Therefore, this study was conducted to evaluate postoperative AL after esophagectomy using estimated glomerular filtration rate (eGFR) and fibrosis-4 (FIB-4) index. In total, 184 patients who underwent esophagectomy were included in this study; then, they were divided into the non-AL group (n = 161) and AL group (n = 23), after which their background data and intraoperative and postoperative outcomes were compared. In addition, risk factors for AL were evaluated using a logistic regression model. Preoperative body mass index of ≥21.5kg/m2, hemoglobin A1c level of ≥7.3%, FIB-4 index of ≥1.44, and eGFR of <59ml/min/1.73m2 were found to be significantly frequent in the AL group compared with the non-AL group. Multivariate analysis revealed FIB-4 index of ≥1.44 (p = 0.013; OR, 3.780; 95% CI, 1.320-10.800) and eGFR of <59ml/min/1.73m2 (p = 0.018; OR, 3.110; 95% CI, 1.220-8.020) as the independent risk factors for AL. In addition, we stratified the patients into three groups based on the incidence of AL as follows: low risk (5.5%, low FIB-4 index), intermediate risk (13.0%, high FIB-4 index and eGFR), and high risk (37.5%, high FIB-4 index and low eGFR). Preoperative eGFR and FIB-4 index were found to be useful markers to predict AL after esophagectomy.

A prospective study on split-hand index as a biomarker for the diagnosis of amyotrophic lateral sclerosis

Objective To determine the practical diagnostic utility of split-hand index (SI) values calculated from F-wave persistence (SIFP) and the F/M amplitude ratio (SIF/M) for differentiating patients with amyotrophic lateral sclerosis (ALS) from other conditions. Methods: This prospective study recruited consecutive patients from Peking Union Medical College Hospital, China, between June 2019 and December 2019. Patients 18-80 years old who had clinical neuromuscular symptoms affecting the upper limbs and required electrophysiological examinations to aid diagnosis were eligible. Compound muscle action potentials (CMAPs) and F-waves recorded from the abductor pollicis brevis (APB), first dorsal interosseous muscle (FDI), and abductor digiti minimi (ADM) were examined. SIFP and SIF/M were calculated as: SI = (APB × FDI)/ADM. The sensitivity and specificity of SIFP and SIF/M in differentiating ALS from non-ALS conditions were derived using receiver operating characteristic (ROC) curves. Results: A total of 309 participants, comprising 91 (29.4%) with ALS and 218 (70.6%) with other neuromuscular disorders, were enrolled after 54 were excluded. SIFP was significantly reduced and SIF/M increased in the ALS group compared with the non-ALS group (p < 0.001). By ROC curve analysis, an SIFP cutoff of 73.3 showed 85.7% sensitivity and 80.7% specificity for differentiating ALS from non-ALS. SIF/M and SICMAP showed lower sensitivity (67% and 75.8%, respectively, p < 0.001) than SIFP for ALS diagnosis. SIFP and SIF/M combined did not outperform SIFP alone. Conclusion: SIFP could be a sensitive, noninvasive neurophysiological diagnostic marker for ALS patients with affected upper limbs. In particular, an SIFP value of 73.3 might be the optimal cutoff for diagnosing ALS.

Electrical impedance myography (EIM) in a natural history study of C9ORF72 mutation carriers

Objective: Electrical Impedance Myography (EIM) was used to evaluate disease progression in subjects with C9ORF72 expansion mutations and to assess correlations with Medical Research Council (MRC) Scale and revised ALS Functional Rating Scale (ALSFRS-R) measurements. Four types of clinical presentations were assessed; Amyotrophic Lateral Sclerosis (ALS), Frontotemporal dementia (FTD) or other dementia, ALS-FTD, and asymptomatic (ASYMP). Methods: Subjects were divided into an ALS Group (ALS/ALS-FTD) and non-ALS Group (FTD/ASYMP) based on initial visit and evaluated at 0, 6, 18, and 30 months with EIM of 4 arm and 4 leg muscles, ALSFRS-R, and MRC scales. The change in EIM from baseline and correlation with the functional scale and strength testing were analyzed. Results: EIM 50kHz phase values significantly declined over time in the ALS group (n = 31) compared to the non-ALS group (FTD/ASYMP) (n = 19). In the ALS group, the decline in EIM was correlated with decline in the ALSFRS-R and MRC scores using within-subject correlations. Conclusion: In clinical trials with small populations of genetically associated ALS such as C9ORF-related ALS, EIM may be a useful quantitative biomarker. We did not detect decline in asymptomatic subjects, but longer term studies may detect early changes in this group.

Quantitative Indocyanine Green Fluorescence Imaging Used to Predict Anastomotic Leakage Focused on Rectal Stump During Laparoscopic Anterior Resection.

Background: Anastomotic leakage (AL) is arguably the most troublesome complication of anterior resection (AR). In recent years, however, indocyanine green (ICG) fluorescence imaging has been recently used to evaluate blood flow in the anastomosis site, and it has been suggested that AL may be predicted. We reported the effectiveness of predicting AL in colorectal cancer surgery by observing a quantitative laparoscopic ICG fluorescence imaging for the first time. The purpose of this study was to predict the risk of postoperative AL by quantitative laparoscopic ICG fluorescence imaging focused on the rectal stamp, which is one of the major causes of AL in AR, and to construct diverting stoma (DS) only in appropriate cases. Methods: We studied the 25 patients who underwent elective laparoscopic AR for rectal cancer at our hospital between July 2016 and June 2017. Before enforcing double-stapling technique anastomosis, we injected ICG intravenously, and laparoscopically evaluated blood flow on the rectal stump. We analyzed quantitatively the relationship between various parameters and AL. Results: Median T0, from when the ICG was injected intravenously and the ICG disappeared from the injection route to the rise of the histogram of intensity, in AL group was significantly longer than that in non-AL group (P = .03). There were no other significant differences between AL and non-AL groups. Conclusions: T0 was longer in patients with AL than in those without. If prolonged T0 can be recognized intraoperatively, it will be possible to construct DS for appropriate patients only.

Low pelvic incidence is associated with Andersson lesions in ankylosing spondylitis patients with kyphosis.

This study was to investigate the role of pelvic incidence (PI) in the development of Andersson lesions (ALs) in ankylosing spondylitis (AS) patients with kyphosis and to evaluate the difference in sagittal spinopelvic parameters between inflammatory ALs and mechanical ALs. A total of 135 AS patients with kyphosis were reviewed. The patients were classified into AL group and non-AL group based on the presence or absence of ALs. Additionally, AS patients with ALs were also classified as either inflammatory or mechanical lesions depending on the radiological features of the lesions. The sagittal spinopelvic parameters of all these AS patients were measured and compared. Logistic regression analysis was performed to determine the powerful variables for predicting ALs in AS patients. ALs were detected in 34 patients (25.2%) of the total 135 AS patients. The mean PI of the AL group was 40.0°, which was significantly lower than that (48.3°) of the non-AL group (P < 0.001). No statistically significant difference was observed in PI (P = 0.350) between the inflammatory lesion group and the mechanical lesion group. Logistic regression analysis showed that only PI was a statistically significant risk factor for ALs (P < 0.001) and was negatively correlated with ALs (odds ratio = 0.76). These data suggest that low PI is closely associated with ALs in AS patients with kyphosis and that it might be a possible risk factor for the development of ALs. Moreover, both inflammatory and mechanical ALs patients had similarly low PI.Key Points• Low PI was closely associated with ALs in AS patients with kyphosis and might be a possible risk factor for development of ALs.• Either inflammatory or mechanical ALs patients had similar low PI.

Clinical Influence of Anastomotic Leakage on Esophageal Cancer Survival and Recurrence.

We investigated the clinical influence of anastomotic leak (AL) on esophageal cancer survival and recurrence after curative surgery. This study included 122 patients who underwent curative surgery for esophageal cancer between 2008 and 2018. The patients were classified into those with AL and those without. The risk factors for overall (OS) and recurrence-free (RFS) survival were identified. AL was found in 44 out of the 122 patients (36.1%). The respective OS rates at 3 and 5 years after surgery were 43.9% and 40.2% in the AL group and 63.9% and 53.2% in the non-AL group, which were significantly different (p=0.0049). In contrast, the respective RFS rates at 3 and 5 years after surgery were 44.8% and 29.8%, and 44.9% and 42.4%, which were not significantly different (p=0.2306). A multivariate analysis showed that AL was a significant independent risk factor for both poorer OS and RFS in patients who underwent curative surgery for esophageal cancer. To improve survival of patients with esophageal cancer, the surgical procedure, perioperative care and surgical strategy must be carefully planned in order to prevent AL.

Articulation contact pressures scaled to the physiologic range of the tongue in amyotrophic lateral sclerosis: A pilot study

ObjectiveThe aim of this study was to compare the percentage of the maximum isometric lingual strength range at which lingual-alveolar consonants are produced (%Pmax) by people with amyotrophic lateral sclerosis (PALS) compared to people without the disease measured at study entry, and then 3 and 6 months later. DesignProspective cohort comparison study over time. MethodsTen people with ALS and nine without produced the consonants /t, d, s, z, l, n/ in real words within sentences as the articulatory contact pressure (ACP) between the tongue tip and palate was sensed by a miniature transducer. Maximum isometric tongue pressing values also were obtained to allow calculation of %Pmax. Data were analyzed to compare PALS with bulbar symptoms, PALS with spinal-only symptoms, and people without ALS. Results%Pmax did not differ between any of the three participant groups at any of the three measurement times. Maximum isometric pressure did decrease significantly in both ALS groups when comparing baseline to 3- and 6-months later. Maximum pressures remained stable for the non-ALS group at the three measurement times. ConclusionThe results suggest that speech motor activity of the tongue in people with ALS may be scaled relative to their overall tongue strength, such that the %Pmax does not change as the tongue gets progressively weaker.

Anastomotic leakage following retrosternal pull-up.

Narrow thoracic inlet might be associated with increased incidence of cervical anastomotic leakage (AL) after esophagectomy with retrosternal reconstruction. We retrospectively evaluated the relationship of the length from the suprasternal notch to the trachea (LST) and AL using computed tomography. In this retrospective study including 121 patients with esophageal cancer who underwent subtotal esophagectomy with retrosternal reconstruction between 2008 and 2016, clinicopathological characteristics, including the LST, surgical procedures, and perioperative outcomes, were compared between the AL and non-AL groups. AL occurred in 19 of the 121 patients (15.7%). There were no associations between AL development and age, sex, body mass index, tumor location, TNM stage, histological type, surgical approach, or type of the anastomotic procedure. Surgery duration was longer in the AL group than in the non-AL group (p = 0.004). Other surgical factors such as intra-operative blood loss and anastomotic technique were not associated with AL. LST was significantly shorter in the AL group than in the non-AL group (p < 0.001). Multivariate analysis revealed that LST was a significant predictor of AL (p < 0.001). LST is a simple and useful predictor of AL after esophagectomy with retrosternal reconstruction.

Ultralow anterior resection with implantation of gentamicin-collagen sponge and no defunctioning stoma: anastomotic leakage and local cancer relapse.

BackgroundAnterior resection with total mesorectal excision (TME) of ultralow rectal cancer may result in the increased risk of the anastomotic leakage (AL). The aim of this study was to evaluate the usefulness of the gentamicin-collagen sponge (GCS) for the protection against symptomatic AL and investigate association between AL and local relapse (LR).Patients and methodsA series of 158 patients with ultralow rectal cancer was studied. All the patients underwent R0 sphincter-saving TME with anastomosis wrapping using GCS. In none of the cases a temporary protective stoma was constructed.ResultsAL rate was 3.2% (5/158) while median time to AL diagnosis was 5 days following surgery (range 3-15). There was no postoperative and leakage-related mortality. Patient age > 75 years and smoking were independent risk factors related to significantly increased AL rate: 12.5% vs. 0.8% (P = 0.0004) and 5.7% vs. 0% P = 0.043), respectively. LR was observed in 12% of cases. It was highly significantly more common and developed earlier in patients who have had AL when compared with non-AL group: 80% vs. 9% (P = 0.00001) and 8.5 vs. 17 months (P = 0.014), respectively.ConclusionsAnastomosis wrapping with GCS after anterior resection with TME is a safe procedure resulting in the low incidence of anastomotic leakage which may be also associated with decreased risk of local relapse.

Cytogenetic intraclonal heterogeneity of plasma cell dyscrasia in AL amyloidosis as compared with multiple myeloma

AbstractAnalysis of intraclonal heterogeneity has yielded insights into the clonal evolution of hematologic malignancies. We compared the clonal and subclonal compositions of the underlying plasma cell dyscrasia in 544 systemic light chain amyloidosis (PC-AL) patients with 519 patients with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), or symptomatic MM; ie, PC–non-AL patients). Using interphase fluorescence in situ hybridization, subclones were stringently defined as clone size below two thirds of the largest clone and an absolute difference of ≥30%. Subclones were found less frequently in the PC-AL group, at 199 (36.6%) of 544 as compared with 267 (51.4%) of 519 in the PC–non-AL group (P < .001), and were not associated with the stage of plasma cell dyscrasia in either entity. In both groups, translocation t(11;14), other immunoglobulin heavy chain translocations, and hyperdiploidy were typically found as main clones, whereas gain of 1q21 and deletions of 8p21, 13q14, and 17p13 were frequently found as subclones. There were no shifts in the subclone/main clone ratio depending on the MGUS, SMM, or MM stage of plasma cell dyscrasia. In multivariate analysis, t(11;14) was associated with lower rates of subclone formation and hyperdiploidy with higher rates. PC-AL itself lost statistical significance, demonstrating that the lower subclone frequency in AL is a reflection of its exceptionally high t(11;14) frequency. In summary, the subclone patterns in PC-AL and PC–non-AL are closely related, implying that subclone formation depends on the main cytogenetic categories and is independent of disease entity and stage.

F48. A novel muscle ultrasound score in the diagnosis of amyotrophic lateral sclerosis

Introduction Muscle ultrasound is a non-invasive and powerful tool in detecting fasciculations. The accuracy of diagnosis of ALS is enhanced by the use of a combination of muscle ultrasound and needle electromyography (n-EMG) compared to n-EMG alone (Misawa et al., 2011; Grimm et al., 2015). However, a standardised method to evaluate fasciculations in amyotrophic lateral sclerosis (ALS) using muscle ultrasound remains to be elucidated. The aims of this study are to develop a “fasciculation ultrasound score”, a novel fasciculation score using muscle ultrasound, for differentiation between patients with ALS and those with other conditions mimicking ALS. Methods In this prospective study, we enrolled 38 consecutive patients who were suspected of having ALS because of clinical fasciculations or upper and lower motor neuron signs. All patients were registered in the Department of Neurology at Kyoto Prefectural University of Medicine from April 2012 until February 2015. Ultrasound of preselected 21 limb and truncal muscles was performed to detect fasciculations in each patient. The difference in the distribution and frequency of fasciculations was analyzed. And we developed a “fasciculation ultrasound score” to diagnose ALS using the statistical method as follows: one or more muscles in each anatomical region based on El Escorial criteria were selected for the score using relative operating characteristic and multivariate logistic regression analysis. “Fasciculation ultrasound score” was defined as the sum of the number of muscles with fasciculation among statistically selected muscles. Results A total of 525 muscles in 25 ALS patients and 231 in 11 non-ALS patients were analyzed. Two patients were excluded from the analysis because of uncertain diagnoses. The number of muscles with fasciculations per person was 9.9 ± 5.4 (mean ± SD) in the ALS group and 0.9 ± 1.0 in the non-ALS group (p Conclusion “Fasciculation ultrasound score” is a simple and easy scoring method using muscle ultrasound, with a high sensitivity and specificity. This score can be useful in the clinical setting for the diagnosis of ALS.

4. Median/ulnar nerve ultrasound cross-sectional area ratio in ALS

Background It has been shown that hand muscle wasting in amyotrophic lateral sclerosis (ALS) preferentially affects the thenar muscles, with relative sparing of the hypothenar muscles. This so-called “split-hand” is clinical sign that can be used to differentiate ALS from mimic disorders, and is thought to be caused by a difference in nerve excitability between median and ulnar nerve. The split-hand phenomenon has been largely discussed in regard to neurophysiological finding, but no studies performed comparing median and ulnar nerve size using ultrasound. We therefore sought to compare nerve size between the median and ulnar nerves in ALS using ultrasound in order to determine whether this may give further insight into the split-hand phenomenon. Objective To identify whether nerve ultrasound results might reflect the clinical split-hand sign in ALS patients and whether these findings can be used to differentiate ALS from other neuromuscular disorders. Methods Ultrasound was used to image both the median and ulnar nerves of 98 patients with ALS and 82 patients with other neuromuscular disorders (non-ALS). The nerve cross-sectional area (CSA) was measured at the wrist, the forearm, and the upper arm bilaterally. Nerve CSA values and median/ulnar nerve CSA ratios were compared at different locations between the two groups. Result Both the median and ulnar nerve CSA values were smaller in the ALS group than in the non-ALS group, except for the median nerve at the wrist. The median/ulnar nerve CSA ratio was comparatively decreased in the upper arm segment. There was a significant difference between the two groups at the wrist on the left side and at upper arm on the right side (Left wrist (IQR) ALS: 2.00 (1.67, 2.33) vs non-ALS: 1.63 (1.35, 2.18) p = 0.003, Right upper arm (IQR) ALS: 1.29 (1.12, 1.50) vs non-ALS: 1.37 (1.16, 1.69) p = 0.003). Conclusion We observed that the median/ulnar nerve CSA ratio was decreased in ALS patient at the upper arm segment. Overall, these findings suggest that there is preferential involvement of the median nerve compared to the ulnar nerve in ALS, which is consistent with the clinical findings of the split hand in these patients. This adds further support to the involvement of peripheral mechanisms underlying this phenomenon. Therefore, ultrasound may be a useful non-invasive tool to objectively detecting changes. Further studies assessing cortical contribution to the clinical and ultrasound findings are warranted to elucidate this pathology further.

The influence of antibiotic-loaded cement spacers on the risk of reinfection after septic two-stage hip revision surgery

PurposeThe aim of this study was the evaluation of possible outcome differences of patients undergoing two-stage hip exchange with antibiotic-loaded spacers, compared to patients without an interim spacer implantation.MethodsWe evaluated 46 patients undergoing two-stage hip revision surgery. Twenty-five patients received an interim ALS. Additional to a Kaplan–Meier survival analysis, a competing risk analysis was performed to estimate the cumulative incidence function for re-revisions due to infection accounting for death as a competing event.ResultsNine patients (seven non-ALS vs. two ALS) had to undergo re-revision surgery due to reinfection of the hip joint. The non-ALS group showed a risk of re-revision of 19% (95% CI 5–38%) at 12 and 24 months and 30% (95% CI 12–51%) at 36 months. The group with ALS implantation displayed a 0% risk of re-revision surgery in the first 36 months. The Gray test revealed a significant difference in the cumulative incidence between both observed groups (p = 0.026).ConclusionOur findings suggest that ALS implantation significantly reduces the risk of reinfection after two-stage hip revision surgery.

ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery.

Fluorescence technology with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. However, a subjective evaluation of fluorescence intensity based on the surgeon's visual judgement is a major limitation. This study evaluated the quantitative assessment of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery. This is a retrospective analysis of a prospectively maintained database of 112 patients who underwent laparoscopic surgery for left-sided colorectal cancers. After distal transection of the bowel, the specimen was extracted extracorporeally and then the proximal colon was divided within the well-perfused area based on the ICG fluorescence imaging. We evaluated whether quantitative assessment of intestinal perfusion by measuring ICG intensity could predict postoperative outcomes: F max, T max, T 1/2, and Slope were calculated. Anastomotic leakage (AL) occurred in 5 cases (4.5%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 18 cases (16.1%). Among the 18 patients, AL occurred in 4 patients (4/18: 22.2%), whereas it occurred in only 1 case (1/94: 1.0%) in the good perfusion patients who did not need proximal change of the transection line. The F max of the AL group was less than 52.0 in all 5 cases (5/5), whereas that of the non-AL group was in only 8 cases (8/107): with an F max cutoff value of 52.0, the sensitivity and specificity for the prediction of AL were 100 and 92.5%, respectively. Regarding postoperative bowel movement recovery, the T max of the early flatus group or early defecation group was significantly lower than that of the late flatus group or late defecation group, respectively. ICG fluorescence imaging is useful for assessing anastomotic perfusion in colorectal surgery, which can result in more precise operative decisions tailored for an individual patient.

Fecal Volume after Laparoscopic Low Anterior Resection Predicts Anastomotic Leakage

Background/Aim: Anastomotic leakage (AL) is a major complication after laparoscopic low anterior resection (Lap-LAR). Many surgeons encounter AL following severe postoperative diarrhea. However, little is known about the relationship between postoperative fecal volume and AL. This study determined whether postoperative fecal volume can predict AL. Methods: A retrospective assessment was performed with data from 176 patients with rectal cancers who underwent Lap-LAR between April 2011 and August 2015. A transanal tube was routinely placed in all cases. The fecal volume from the transanal tube was measured daily. The total fecal volume for 3 days after surgery was compared between the AL and non-AL groups. Results: AL occurred in 11 patients. There were 3 patients with a fecal volume ≥1,000 mL for 3 days after surgery. AL occurred in these 3 patients. In patients with a fecal volume <1,000 mL, the total fecal volume was significantly greater in the AL group than that in the non-AL group (p = 0.0003). The cut-off value of the total fecal volume in AL was 118 mL. Conclusions: The volume of fecal discharge for 3 days after surgery is associated with the incidence of AL, and a fecal volume ≥118 mL may be a reliable predictor for AL.