Abstract Background The role of splenectomy on prophylaxis against hepatitis B virus (HBV) recurrence after liver transplantation (LT) for HBV-related end-stage liver diseases with severe ...hypersplenism and splenomegaly remains unclear today. Methods A total of 510 consecutive patients with HBV-related end-stage liver diseases who underwent LT in Liver Transplantation Center, West China Hospital, Sichuan University (Chengdu, China) between June 1999 and October 2009 were studied retrospectively in this study. Patients were divided into three groups in this study: splenectomized group (group A, n = 137), including preoperatively splenectomized subgroup (group A1, n = 48) and intraoperatively splenectomized subgroup (group A2, n = 89); nonsplenectomized group with severe hypersplenism (group B, n = 95); and nonsplenectomized group without severe hypersplenism (group C, n = 278). The incidence of posttransplant rejection, posttransplant infection, posttransplant hepatic cell carcinoma recurrence rate, and HBV recurrence rate were recorded. The end of the follow-up period was October 2010. Results In this study, six patients with HBV recurrence were found in group A, 15 cases in group B, and 13 cases in group C during the follow-up period. (1) The incidence of posttransplant rejection in patients of group A was significantly lower than that in group B ( P = 0.0023) and also the HBV recurrence rates in group A markedly decreased ( P = 0.004). (2) The incidence of posttransplant rejection in group A was significantly lower than that in group C ( P = 0.0433); however, the incidence of posttransplant infection in group A largely increased compared with that in group C ( P = 0.0233). The HBV recurrence rates between group A and group C had no significant difference ( P = 0.804). (3) The HBV recurrence rates in group B were significantly higher than that in group C ( P = 0.001). Conclusions The results of this study showed that splenectomy could significantly reduce the incidence of posttransplant rejection and HBV recurrence rate for the patients undergoing LT for HBV-related end-stage liver diseases with severe hypersplenism and splenomegaly.
Objective Outcomes of patients with single ventricle physiology undergoing cavopulmonary palliations depend on pulmonary vascular resistance (PVR) and have been suggested to be adversely affected by ...living at elevated altitude. We compared the pulmonary hemodynamic data in correlation with postoperative outcomes at the 3 centers of Denver, Edmonton, and Toronto at altitudes of 1604, 668, and 103 meters, respectively. Methods Hemodynamic data at pre-bidirectional cavopulmonary anastomosis (BCPA) and pre-Fontan catheterization between 1995 and 2007 were collected. Death from cardiac failure or heart transplantation in the same period was used to define palliation failure. Results There was no significant correlation between altitude (ranged from 1 to 2572 meters) and PVR, pulmonary artery pressure (PAP) or transpulmonary gradient (TPG) at pre-BCPA and pre-Fontan catheterization. BCPA failure occurred in 11 (9.2%) patients in Denver, 3 (2.9%) in Edmonton, and 34 (11.9%) in Toronto. Fontan failure occurred in 3 (6.1%) patients in Denver, 5 (7.2%) in Edmonton, and 11 (7.0%) in Toronto. There was no significant difference in BCPA and Fontan failure among the 3 centers. BCPA failure positively correlated with PVR and the presence of a right ventricle as the systemic ventricle. Fontan failure positively correlated with PAP and TPG. Conclusions Moderate altitude is not associated with an increased PVR or adverse outcomes in patients with a functional single ventricle undergoing BCPA and the Fontan operation. The risk factors for palliation failure are higher PVR, PAP, and TPG and a systemic right ventricle, but not altitude. Our study reemphasizes the importance of cardiac catheterization assessments of pulmonary hemodynamics before BCPA and Fontan operations.
Abstract Background Patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) carry the risk of ventricular arrhythmias and sudden cardiac death (SCD). This study investigated ...the prognostic information of modified moving average T-wave alternans (MMA TWA) in patients with ARVD/C. Methods A total of 63 consecutive patients (mean age, 44.7 ± 14.8 years; 38 men) with ARVD/C were enrolled. Baseline characteristics and structural and electrocardiographic parameters were obtained. All patients underwent ambulatory electrocardiographic examination at the time of diagnosis, and MMA TWA data were exported for further analysis. Events were defined as documented SCD or ventricular tachyarrhythmias during clinical follow-up. Results During a mean follow-up of 28.1 ± 15.4 months, 19 of 63 (30.2%) patients experienced events, including SCD in 2 patients (10.5%) and ventricular tachyarrhythmias in 17 patients (89.5%). Patients with events had higher TWA within modified V5 and V1 channels than did those without events (54.7 ± 24.9 μV vs 35.0 ± 18.3 μV; P = 0.004; 58.8 ± 27.6 μV vs 38.4 ± 18.6 μV; P = 0.007, respectively). After multivariate Cox regression analysis, maximal TWA derived from either the modified CM5 or NASA channel predicted the occurrence of events ( P < 0.001; hazard ratio, 1.06; 95% confidence interval, 1.03-1.10). At the cutoff value of > 66 μV, maximal TWA yielded a sensitivity and a specificity of 89.5% and 90.5%, respectively, in predicting SCD or ventricular tachyarrhythmias. Conclusions The initial analysis of MMA TWA could provide prognostic implications in the prediction of SCD or ventricular tachyarrhythmias in patients with ARVD/C.
Aortic arch aneurysm occurs more commonly in the aging population. Rapid expansion and symptomatic patients should undergo aneurysm resection regardless of size. An 87-year-old man was brought to our ...emergency department because of choking on food during his dinner. The patient did not have hoarseness, dysarthria, dysphagia, as well as other neurologic symptoms. He was finally found to have an aortic arch aneurysm. Swallowing is complex neuromuscular activity consisting essentially of 3 phases: oral, pharyngeal, and esophageal. The pharyngeal phase was mainly mediated by the pharyngeal plexuses of both the glossopharyngeal and vagus nerves. Uncoordinated movement of the pharyngeal muscles because of a stretch of the left vagus nerve or its plexus by an enlarging aneurysm may be the possible mechanism of choking in this patient.
To evaluate the ability of diffusion-weighted magnetic resonance imaging (DWI) in differentiating malignant thyroid nodules from benign lesions with a meta-analysis.
Articles in English and Chinese ...language relating to the accuracy of DWI for this utility were retrieved. Pooled estimation and subgroup analysis data were obtained by statistical analysis.
A total of seven studies (17 subsets) with 358 patients, who fulfilled all of the inclusion criteria, were considered for the analysis. No publication bias was found (bias = 7.03, P > .05). Methodological quality was relatively high. DWI sensitivity was 0.91 (95% confidence interval CI, 0.87-0.94) and specificity was 0.93 (95% CI, 0.86-0.96). Overall, positive likelihood ratio was 12.24 (95% CI, 6.47-23.20) and negative likelihood ratio was 0.99 (95% CI, 0.06-0.15). Diagnostic odds ratio was 123.78 (95% CI, 56.85-269.48). The area under the curve of the summary receiver operating characteristic was 0.94 (95% CI, 0.92-0.96). In patients with high pretest probabilities, DWI enabled confirmation of malignant thyroid lesion; in patients with low pretest probabilities, DWI enabled exclusion of malignant thyroid lesion. Worst-case-scenario (pretest probability, 50%) posttest probabilities were 92% and 9% for positive and negative DWI results, respectively.
A limited number of small studies suggests that quantitative DWI is a reliable diagnostic method for differentiation between benign and malignant thyroid lesions.
Totally thoracoscopic cardiac surgery is an alternative to traditional cardiac surgery in adults, and in few cases, in small children. This study assesses totally thoracoscopic cardiac surgery and ...its advantages for application to small children with low body weight.
From March 2009 to October 2010, 28 patients, with a mean age of 5.8±2.1 years and mean weight of 15.0±4.65 kg (range, 13.5 to 22 kg), underwent totally thoracoscopic atrial septal defect closure. Three incisions 1.0 cm to 2.5 cm in length were made on the chest wall. Direct sutures were made in 20 patients, whereas Dacron patches were used in 8 patients. Mean follow-up was 6 months (range, 0 to 24 months).
Cardiopulmonary bypass time was 56 to 126 minutes, and the aortic cross-clamp time was 36 to 65 minutes. A total of 28 cases were classified as New York Heart Association functional class I. No patient required further operation.
Totally thoracoscopic surgical atrial septal defect closure in small children is feasible, minimally invasive, safe, and has good cosmesis.
Abstract Introduction To determine the effectiveness of noninvasive ventilation (NIV) in the management of postextubation respiratory failure. Methods Databases including PubMed, EMBASE, and the ...Cochrane Central Register of Controlled Trials were searched to find relevant trials. Randomized and quasi-randomized trials studying NIV in adult patients with postextubation respiratory failure were included. Effects on primary outcomes (i.e., reintubation rate, and ICU or/and hospital mortality) were accessed in this meta-analysis. Results Ten trials involving 1382 patients were included: two used NIV in patients with established postextubation respiratory failure, and eight used NIV immediately after extubation. The use of NIV following extubation for patients ( n = 302) with established respiratory failure did not decrease the reintubation rate (relative risk RR 1.02, 95% confidence interval CI 0.83-1.25) and ICU mortality (RR 1.14, 95% CI 0.43-3.00), compared to standard medical therapy (SMT). Early application of NIV after extubation ( n = 1080) also did not decrease the reintubation rate (RR 0.75, 95% CI 0.45-1.15) significantly. However, in the planned extubation subgroup ( n = 849), there were significant reductions in the reintubation rate (RR 0.65, 95% CI 0.46-0.93), ICU mortality rate (RR 0.41, 95% CI 0.21-0.82), and hospital mortality rate (RR 0.59, 95% CI 0.38-0.93) compared to SMT. Conclusion Current evidence suggests that the use of NIV in patients with established postextubation respiratory failure should be monitored cautiously. Early use of NIV can benefit patients with planned extubation by decreasing the reintubation rate and the ICU and hospital mortality rates.
Abstract Background In the first posttransplant month, the most frequent complications are due to technical problems related to complex vascular and bile duct reconstructions during the operation. ...Moreover, despite great improvements in suturing technique and materials, severe organ ischemia-reperfusion caused by time-consuming hand suturing is still an important factor in graft survival. During the operation, severe hypotension, hypoxic acidosis, hyperkalemia, and renal dysfunction may occur during the anhepatic phase due to the prolonged venous clamping time required for hand suturing. Therefore, hand suturing is a handicap in the development of further advancements in liver transplantation. In this study, we aimed to test a new “mechanical installation method” for rapid vascular reconstruction. Methods The magnetic pinning-ring device was developed consisting of paired magnetic rings coated with titanium oxide and embedded in a polypropylene shell. The rings were equipped with alternately spaced holes and titanium pins. Forty adult mongrel dogs were randomly divided into groups: A ( n = 16), all vascular and bile duct reconstruction by magnetic ring without venous bypass; B ( n = 16), all vascular and bile duct reconstruction by hand suturing with venous bypass; C ( n = 8), sham transplantation group, transection of all vessels and common bile duct followed by anastomosis with the magnetic rings without liver transplantation. From groups A and B, dogs were randomly selected as donors ( n = 8) or recipients ( n = 8) of liver transplantations. We recorded operation time, vascular and bile duct anastomosis time, anhepatic time, administration of supplemental fluids during operation, and survival; blood samples were collected for the detection of liver damage (alanine aminotransferase ALT and aspartate aminotransferase AST) and tumor necrosis factor α level. Patency was confirmed using ultrasound scans at various time points as late as 24 wk after surgery. Angiography was used to evaluate the anastomoses formed with magnetic rings. In group C, gross observation, histologic staining, and scanning electron microscopy were used to evaluate the vessels and bile ducts 12 wk postoperatively. Results In group A, the total operation time, inferior vena cava, and portal vein anastomosis times were significantly shortened, and the anhepatic phase was reduced to about one-fifth that of group B, which was a significant difference between the two groups ( P < 0.01). The mean total operative time was 2.54 ± 0.45 h. In order to maintain adequate blood pressure, the mean fluid volume infused was 800.56 ± 60.56 mL in the recipients of group A, which was lower than that in group B (2241.67 ± 390.78 mL, P < 0.01). Use of a pressor agent in group A was unnecessary. After operation, five of eight animals in group A survived more than 7 d after operation. The main cause of death was acute rejection. Only three of eight animals in group B survived more than 1 wk after operation due to chronic anastomotic bleeding, kidney failure, heart failure, and gastrointestinal bleeding. There was a statistically significant difference ( P < 0.01) between the short-term survival rate in the two groups (75.0% versus 37.5%). The ALT (1544.46 ± 286.27) U/L and AST (1710.74 ± 252.27) U/L levels after operation in the animals with hand suturing were significantly higher than those in the sutureless group (ALT = 1116.41 ± 210.55 U/L; AST = 1176.95 ± 248.25) U/L after reperfusion ( P < 0.01). The serum tumor necrosis factor α levels (45.56 ± 10.78) ng/L in group B were significantly higher than those of group A (26.64 ± 10.84) ng/L after reperfusion ( P < 0.01). Re-endothelialization was confirmed in all vessels in group C, with neither formation of aneurysms nor thickening of the vascular wall noted after 12 wk. The bile duct anastomoses also healed well. Conclusions The magnetic pinning-ring device offers a simple, fast, reliable, and efficacious technique for nonsuturing vascular and bile duct anastomoses. Use of this device shortens operation time, maintains a high patency rate, and improves the healing of tissue. Application of the magnetic ring anastomosis technique can effectively reduce the complications caused by hand suturing, and can reduce the extent of ischemia-reperfusion injury, leading to smoother operations and improved prognosis.
Purpose To systematically review the literature to determine if utilities (a quantitative way to express patient preferences for health outcomes) have been measured in hand surgery studies. Methods A ...literature search was conducted using Cochrane, EMBASE, HealthSTAR, MEDLINE, and CINAHL electronic databases (1966–2013). This search was supplemented by cited and manual reference searches and expert consultation to retrieve all relevant studies. Studies were selected by 2 independent reviewers if they pertained to hand or wrist surgery, were published in English, and measured utilities as an outcome. Descriptive data were extracted, including the hand surgery procedure investigated, study design, value of utilities, and methodology of utilities measurement. Results Eleven studies were included after reviewing 989 studies. Most hand conditions were associated with utilities less than 0.8. Utilities in the reviewed studies were measured using different methods and from different subjects. Three studies paradoxically mapped greater utilities for poorer heath states. Conclusions Hand conditions cause impairment, as evidenced by their utilities. Measurement of utilities remains uncommon in hand surgery literature. Future studies should not only measure utilities but also do so with consistent and appropriate methodology to ensure that mapped values are valid and comparable. Type of study/level of evidence Economic/decision analysis III.
PDF
