Visual Loss Following Dacryocystectomy

Dacryocystectomy is the surgery of choice for elderly patients with chronic dacryocystitis with a fibrotic sac. Although a simple procedure, it can cause serious complications (however rare) such as visual impairment. A 65-year-old woman who underwent bilateral dacryocystectomy is described. On the first postoperative day, she complained of pain in her left eye. Her visual acuity was light perception in the left eye. Computed tomography scan of the orbit revealed a retrobulbar hematoma on the left eye. The hematoma was drained, but the patient did not regain vision. A rare complication of visual loss following dacryocystectomy is described.

Experimental rabbit hemilaminotomy model in the evaluation of peridural fibrosis: a minimally invasive peridural fibrosis model

The neuronal adhesions of newly synthesized scar tissue to dura mater after spinal peridural operations represent an unsolved problem in neurosurgical practice. This experimental study was planned to compare the success of a rabbit hemilaminotomy procedure with the total laminectomy model in the evaluation of peridural fibrosis in terms of proposing a lesser invasive peridural adhesion model. Fourteen New Zealand white rabbits were used in this experiment. Laminectomy was performed in one level, and hemilaminotomy was done in another level. Four weeks after operation the rabbits were sacrificed by perfusion with 10 % neutral buffered formalin solution. The lumbar spines were removed and immersed in 10 % neutral buffered formalin for approximately 24 hours. Then each specimen was decalcified in 5 % formic acid for approximately 3 weeks. Specimens were cut coronally for gross inspection. Two blocks of tissue were taken from each laminectomy site to be processed and embedded in paraffin. In seven (50 %) of the laminectomy sites of the rabbits, fibrous tissue penetrated the spinal canal through the laminectomy defect and produced neural compression (Grade III). Eight (57 %) hemilaminotomy sites were in Grade III fibrosis. There was no difference between laminectomy and hemilaminotomy in regard to the dural adhesions. In this experimental study, we modified the rabbit total laminectomy model by using a hemilaminotomy procedure in the study of peridural scar formation. The authors conclude that this procedure is more simple, reliable, and lesser invasive than the total laminectomy model.

A review of prosthodontic management of fibrous ridges

'Fibrous' or 'flabby' alveolar ridges pose significant problems for the provision of stable and retentive dental prostheses for affected patients. In particular, problems arise during the act of impression taking, when forces cause the mobile denture bearing tissues to become distorted. The purpose of this paper is to review the impression techniques that can be used to optimise the treatment of edentulous patients with 'flabby' alveolar ridges.

La plastie d'expansion en Oméga « Ω ». Une nouvelle technique d'expansion des poulies annulaires du tunnel digital fléchisseur

The authors report a new technique of pulley plasty of the flexor digital system. It is not an operative procedure to reconstruct a damaged pulley but an original way to expand the volume of an intact pulley in order to adapt its volume to the diameter of the repaired flexor tendon. The flexor tendons ruptures in Verdan zone II and particularly in Tang zones IIA and IIB are often accompanied by an osteofibrous tunnel injury. Initially, the tendon sheath closure was advised after tendons repair. This sheath recovery had to have an effect on tendons nutrition by establishing the synovial cavity continuity and particularly to protect the tendons from adhesions formation. The closure of the digital tube was rapidly shown to be unnecessary creating an obstacle to the tendons movements without any effect on tendons healing. In primary tendon management, the tendon repair is associated with an increase of the tendon diameter. An incongruence appears with the surrounding digital tube with gliding resistance complicating the tendon injury recovery. In secondary tendon injury management, the flexor digital tube is subject to healing and inflammatory process. This situation with the absence of the flexor tendon generates a retraction with a collapse of the digital tunnel over the injured area. This incongruence between the repaired flexor tendons and the narrowed digital tube required a release of the retracted zone to restore an adequate volume. The only way reported is the "Venting" of a part or the total length of the pulley. This procedure even if it resolves the tendon gliding resistance, is still unacceptable. Indeed it destroys an important anatomical structure of the flexor tendon dynamic system. The flexor pulley Omega plasty "Omega" consists in releasing the lateral palmar attachment of the pulley enhancing its internal volume and increasing the flexor tendon gliding area. The digital tube is composed by the succession of five annular and three cruciform pulleys. The cruciform pulleys are thin and flexible. They retract during the digital flexion assuring the continuity of the digital tube, while the annular pulleys are thicker and fill a biomechanical function. There are two types of annular pulleys: the joint pulleys as A1, A3 and A5; they are attached to the palmar plates of the MP, PIP and DIP joints respectively. During the digital movement, they retract approximately 50% of their length. The osseous pulleys as A2 and A4 are fixed over the lateral and palmar borders of the first and the second phalanx respectively. It is on these pulleys that the Omega plasty is practised. The operative procedure is simple. It consists on a periosteal dissection over the one lateral border of the phalanx. The liberation is undergone palmarly releasing the lateral attachment of the pulley. It respects the anatomical continuity of the pulley and its mechanical properties. Indeed, the continuity of the pulley is fully respected with the periosteal flap of the digital tube floor maintaining sufficient attachment to the pulley to resist to the flexor tendon forces. The level of the flexor tendon injury and the digit position during the initial trauma will determine the level of tendon resistance and where the pulley plasty must be made. If the flexor zone II injury occurred with the digit in an extension position, the tendon conflict appears with the A2 pulley, while it arises with the A4 pulley if the digit was in flexed position. The Omega plasty creates the ideal conditions for an optimal flexor tendon movement recovery. It is a simple and a reproducible procedure. It doesn't distort the mechanical properties of the pulley and the digital tube. We used this pulley Omega plasty fifteen times in twelve patients. In 60% of the cases, the injury concerned the dominant hand, and in 67% of the cases, it was a work accident. In eight of our cases, the omega plasty was done in emergency at the same time of flexor tendon repair, while in the other seven cases, the pulley Omega plasty accompanied the late flexor tendon repair forgotten during the initial trauma management. In ten cases, the plasty concerned the A4 annular pulleys, while in the other five cases, it concerns the A2 annular pulleys. Four cases necessitate a secondary tenolysis three months after the tendon repair. Two patients moved out and cannot be included in our results. On the thirteen-remainder cases, nine retrieved a full digital flexion particularly those who underwent digital tenolysis, while the other four cases retrieved a satisfying digital function in spite of the partial DIP flexion. In our hand, the pulley Omega plasty "Omega" becomes almost a systematic procedure in conjunction with the flexor tendon repair. It offers the ideal conditions for a tendon healing and a physiological flexor tendons motion recovery.

Patellar clunk syndrome in patellofemoral arthroplasty--a case report

Patellar clunk syndrome is characterised by the formation of a fibrous nodule at the articular side of junction of superior pole of patella and the quadriceps tendon. Until now, it is only described in posterior cruciate substituting total knee replacements. We report the patellar clunk syndrome in a lady with patellofemoral joint replacement.

Feature selection in Bayesian classifiers for the prognosis of survival of cirrhotic patients treated with TIPS

The transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for cirrhotic patients with portal hypertension. A subgroup of patients dies in the first 6 months and another subgroup lives a long period of time. Nowadays, no risk factors have been identified in order to determine how long a patient will survive. An empirical study for predicting the survival rate within the first 6 months after TIPS placement is conducted using a clinical database with 107 cases and 77 variables. Applications of Bayesian classification models, based on Bayesian networks, to medical problems have become popular in the last years. Feature subset selection is useful due to the heterogeneity of the medical databases where not all the variables are required to perform the classification. In this paper, filter and wrapper approaches based on the feature subset selection are adapted to induce Bayesian classifiers (naive Bayes, selective naive Bayes, semi naive Bayes, tree augmented naive Bayes, and k-dependence Bayesian classifier) and are applied to distinguish between the two subgroups of cirrhotic patients. The estimated accuracies obtained tally with the results of previous studies. Moreover, the medical significance of the subset of variables selected by the classifiers along with the comprehensibility of Bayesian models is greatly appreciated by physicians.

Mitral stenosis after mitral valve repair using the duran flexible annuloplasty ring for degenerative mitral regurgitation

The case is presented of a 47-year-old woman who had undergone mitral valve repair using the Duran annuloplasty ring four years earlier, and who was diagnosed with mitral stenosis owing to fibrous tissue overgrowth. In this patient, dense whitish fibrous tissue covered the annuloplasty ring and extended onto both leaflets of the mitral valve, narrowing its orifice and rendering the leaflets stiff and immobile. The pannus covering the mitral valve could not be stripped off without damaging the leaflets, making mitral valve replacement necessary. Mitral valve replacement with a St. Jude Medical mechanical heart valve prosthesis was successfully performed, and no major perioperative complications were encountered.

[Chronic duodenal stenosis and periduodenal fibrosis secondary to a intramesenteric cyst arising from an old traumatic hematoma: a case report]

A case of mesenteric fibrosis secondary to post-traumatic mesenteric hematoma, resulting in duodenal stenosis eight years after the traumatic event is presented. A 50 year-old man was hospitalized with nausea and vomiting. An intraabdominal cystic mass was seen in abdominal ultrasonography and CT. Duodenum was found to be obstructed due to extrinsic compression in upper endoscopy. At laparotomy there was an intramesenteric traumatic cyst and fibrosis around the duodenum resulting in duodenal obstruction. After the cyst was unroofed a Roux-en-Y duodenojejunostomy was performed. Both early and late (after 4 months) follow-up results were excellent.

Reactive nodular fibrous pseudotumors of the gastrointestinal tract: report of 8 cases

Eight cases of reactive nodular fibrous pseudotumor of the gastrointestinal tract are presented. The patients included 6 males and 2 females between the ages of 1 and 68 years (mean age 41.5 years). Three tumors involved the small intestine, and 5 of the investigated lesions were located in the large bowel. Of these, 2 originated in the sigmoid colon, 1 in the cecum, 1 in the appendix, and 1 in the large bowel not otherwise specified. The tumors' size varied from 3 to 10 cm in the greatest diameter (mean 6.2 cm). Histologically they were composed of stellate or spindle shaped cells resembling fibroblasts arranged haphazardly or in intersecting fascicles, embedded in a collagen-rich stroma, with sparse intralesional mononuclear cells frequently arranged in lymphoid aggregates. Immunohistochemically, the lesions were positive for vimentin (7/7), smooth muscle actin (8/8), muscle-specific actin (5/7), cytokeratins AE1/AE3 (6/7), and CAM 5.2 (1/7), and antigen CD68 (1/7). No case (0/8) reacted positively with antibody to CD117 (c-kit). Genetically no substitutions, deletions, or insertions occurred in exon 11 in all analyzed samples. Likewise, no deletions or insertions in part of exon 9 were observed. Ultrastructurally the tumor cells revealed features typical of myofibroblasts. According to the morphologic, immunohistochemical, and ultrastructural features mentioned above, especially to the positivity of low-molecular-weight cytokeratins, we propose this lesion to be related to a proliferation of multipotential subserosal cells rather than ordinary myofibroblasts or fibroblasts.

Use of hepatectomy and splenectomy to treat hepatocellular carcinoma with cirrhotic hypersplenism

Background

The aim of this study was to compare the outcome after simultaneous hepatectomy and splenectomy with that after hepatectomy alone for hepatocellular carcinoma with associated hypersplenism.

Methods

Two hundred and four patients with hepatocellular carcinoma and cirrhotic hypersplenism were divided non-randomly into two groups. Ninety-four underwent simultaneous hepatectomy and splenectomy and 110 underwent hepatectomy alone. White blood cell (WBC) and platelet counts, total serum bilirubin levels, immune function, incidence of complications and 5-year survival rates in the two groups were compared.

Results

WBC and platelet counts, distribution of T cell subsets, and levels of bilirubin, interferon γ and interleukin 2 were different between the two groups after operation. All patients who underwent hepatectomy and splenectomy but only 15·5 per cent of those who had hepatectomy alone completed adjuvant chemotherapy. The 5-year tumour-free survival rate was significantly higher after hepatectomy and splenectomy than after hepatectomy alone (37 versus 27·3 per cent; P = 0·003), although overall survival rates were similar.

Conclusion

Simultaneous hepatectomy and splenectomy was associated with improved 5-year tumour-free survival in patients with hepatocellular carcinoma and hypersplenism.

[Current status of liver transplantation]

The authors present current status of liver transplantation (LTx) in Poland. Till 2004, 845 LTx were performed: 604 in adults and 241 in children; 71 of them were the living donor LTx. Post-inflammatory cirrhosis in adults and biliary atresia in children were the most common indications for LTx. The results of LTx in Poland are good and comparable with the results published by other centers. The number of available cadaveric grafts is growing and in 2004 achieved an index of harvesting as high as 14,7 per million people.

Fatal hepatic failure associated with graft rejection following reduced-intensity stem-cell transplantation for chronic idiopathic myelofibrosis (CIMF)

A 54-year-old man with chronic idiopathic myelofibrosis (CIMF) underwent RIST. His clinical course had been uneventful until day 60, when splenomegaly reappeared. Hepatic dysfunction developed on day 75. Recipient-type hematopoiesis increased to 51% on day 90. After rapid tapering of cyclosporin, serum levels of AST and ALP normalized in parallel with recovery of complete chimerism on day 134. Yet, jaundice progressed. He died of liver failure on day 176. Postmortem examination revealed neither GVHD nor VOD. Graft rejection following RIST for CIMF may lead to fatal hepatic damage through extramedullary hematopoiesis in the liver or cytokine-mediated immune dysregulations.

Abdominal cocoon. An unusual cause of intestinal obstruction

We report a case of abdominal cocoon in a young male patient, presenting with acute intestinal obstruction and abdominal mass. This is a rare acquired condition of the peritoneum in which the small bowel is encased either partially or totally by a dense fibrous membrane. Operative findings, perioperative imaging and treatment guidelines are discussed. A better awareness of this condition may facilitate preoperative diagnosis; prevent inadvertent bowel damage at laparoscopy and unnecessary bowel resection at laparotomy.

Arthroscopic treatment of the arthrofibrotic knee

The management of motion loss of the knee is challenging. A clear understanding of the pathoanatomic causes of motion loss is necessary to establish a careful and rational approach to treatment. Early recognition and physical therapy are effective for the majority of patients, but when these conservative measures fail, operative intervention is indicated. The purpose of this article is to outline a comprehensive approach to the arthroscopic evaluation and treatment of the arthrofibrotic knee. This technique is designed to allow the surgeon to systematically address the numerous causes of motion loss of the knee.

Long-term expression of fibrogenic cytokines in radiation-induced damage to the internal anal sphincter

BACKGROUND

There is accumulating evidence, both quantitative and qualitative, that pelvic irradiation affects anorectal function. However, the molecular mechanisms responsible for radiation-induced damage to the anal sphincter remain unclear.

AIM

To determine the expression of transforming growth factor-beta 1 (TGF-beta 1) and its downstream effector connective tissue growth factor (CTGF) in the anal sphincter of a patient irradiated for prostate cancer.

PATIENT

A 82 year-old patient developed a rectal adenocarcinoma and underwent an abdomino-perineal resection (APR), four years after receiving pelvic irradiation for prostate carcinoma.

METHODS

Tissue sections of the anal sphincter were processed for histology. Immunostaining for TGF-beta 1 and CTGF were performed.

RESULTS

CTGF and TGF-beta 1 immunoreactivity was detected in the irradiated anal sphincter, and was absent in controls. Immunoreactivity for both cytokines predominated in the internal sphincter. CTGF and TGF-beta 1 were preferentially detected in endothelial cells, myofibroblasts and fibroblasts; in addition, there was strong immunoreactivity for TGF-beta 1, but not for CTGF in smooth muscle cells of the anal canal.

CONCLUSION

Four years after pelvic irradiation, radiation-induced damage appeared to affect predominantly the smooth muscle layer of the anal canal. The molecular mechanisms responsible for radiation-induced fibrosis to these tissues involve prolonged activation of TGF-beta 1 and its downstream effector CTGF.

Vasoprotective VEGF as a candidate for prevention of recurrence of fibrotic diseases such as Dupuytren's contracture

Dupuytren's contracture is a disease caused by the proliferation of contractile, fibroblastic cells adjacent to the palmar fascia of the hand. Cellular proliferation is apparently related to similar 'fibroblast' proliferation in wound healing, but continues in the absence of wounding. I propose that this is a similar processes to that which happens in the vascular wall during vascular surgery, that the myofibroblasts are at least partially similar to smooth muscle cells in phenotype, and consequently that treatment with VEGF, either as protein or via gene therapy, which has proven successful in controlling aberrant, wounding-related cell proliferation in arterial grafting, may be valuable in preventing recurrence of Dupuytren's disease after surgery.

Ergebnisse der chirurgischen Therapie der Arthrofibrose am Kniegelenk

This retrospective study reports the evaluation of the surgical treatment of arthrofibrosis of the knee joint. Patients (n = 53) developed arthrofibrosis due to different index operations and various causes. Based on severe preoperative disability, patients of our series can be considered as difficult to treat. Our management concept suggests a step by step, pathology-oriented treatment: if necessary, arthroscopic arthrolysis and gentle manipulation is supported by posterior capsulotomy. To evaluate the results, we assessed the range of motion of the knee joint, the relative gain in range of motion, extension- and flexion-deficit, as well as the Tegner, Lysholm and Flandry score. As a result of arthrolytic surgery, all 53 patients showed statistically significant (P < 0.01) improvement of the above parameters. The mean gain in the range of motion was 73%. To emphasize the importance of the correct timing of arthrolysis, patients were divided into early and late arthrolysis groups. patients with an early arthrolysis obtained a significantly (P < 0.01) greater improvement in the absolute range of motion than those with a later treatment. By the additional procedure of a posterior capsulotomy, the average extension deficit (absolute) was significantly (P < 0.01) more reduced than for patients without this treatment. Our data support an early therapeutic intervention for patients with a large restriction in the range of motion. Patients with an extension deficit after arthroscopic arthrolysis and gentle manipulation will improve with the additional procedure of posterior capsulotomy.

Arthrofibrosis of the knee following ligament surgery

Arthrofibrosis of the knee is one of the most serious complications that can result from ligament surgery. Reported incidence of arthrofibrosis following anterior cruciate ligament reconstruction ranges from 4% to 35%. The loss of motion caused by arthrofibrosis can be even more disabling than the instability for which the reconstruction was performed, often requiring extensive physical therapy and/or surgical lysis of adhesions. With aggressive rehabilitation and modifications in the bracing of knees undergoing ligament reconstruction, the incidence of this complication has decreased significantly. Additionally, delaying anterior cruciate ligament reconstruction until the acute inflammatory period has resolved has also been shown to be a significant factor in the reduction of postoperative knee stiffness.

Massive exophytic abscesses and fibrotic masses of the chin: a variant of the follicular occlusion triad

We present a patient with an extensive cluster of exophytic nodules that developed on his chin. These nodules consisted of abscesses and fibrotic areas. Lesion morphology, histology, and microbiology support a follicular occlusion triad entity. However, the distribution is striking and does not fit the entities described in the triad. We present the case to show that follicular occlusion was the inciting factor in our patient's eruption and to broaden our concept of clinical manifestations that can arise from this pathologic process.

Proposal of fibrosis index using image analyzer as a quantitative histological evaluation of liver fibrosis in biliary atresia

This study was designed to elucidate whether the fibrosis index (FI), which was measured as a ratio of histological fibrotic tissue area to the whole area using an image analyzer, could reflect liver function and long-term prognosis in biliary atresia (BA). Liver biopsies were performed in 46 BA patients at hepatic portoenterostomy (HPE) and stoma closure. The chronological difference rate of FI (FIDR) was the monthly FI difference between HPE and stoma closure. FI at HPE and stoma closure was significantly higher than in the control. FI at HPE and at stoma closure significantly correlated with gammaGTP or T.Bil, D.Bil, cholinesterase and total bile acid, respectively. FIDR in jaundice-free group was significantly lower than in jaundiced group at 5 years after HPE. FIDR in V-2 (varices with red-color sign) was significantly higher than in V-0 (no varices) or V-1 (varices without red-color sign). ICG-K value significantly correlated with FIDR. FI at stoma closure or FIDR was significantly lower in living patients than in patients who eventually died or underwent liver transplantation. In conclusion, FI can reflect the degree of cholestasis in BA. FIDR would be useful for predicting long-term outcome in BA.

Mitral stenosis due to fibrous tissue overgrowth after mitral valve repair

We report an extremely rare case of fibrous tissue overgrowth 3 years after mitral valve repair using a mitral annuloplasty ring in a 53-year-old woman who underwent mitral valve replacement for mitral stenosis. Whitish fibrous tissue had overgrown from the ring on the atrial side of the annulus, and had severely reduced the valvular area. However, the motion of the mitral leaflets was not restricted. Considering the presence of concomitant aortitis syndrome, it is strongly suggested that the overgrowth of fibrous tissue was promoted as a reaction to chronic inflammation.

Epidural lysis of adhesions and myeloscopy

Chronic low back pain is one of the most common ailments in modern medicine, with as many as 79% of patients with acute pain continuing to suffer with chronic or recurrent low back pain 1 year after its onset. Lumbar epidural fibrosis and post-lumbar laminectomy syndrome are increasingly recognized as being responsible for persistent low back pain. Estimations show that approximately 5% to 40% of lumbar surgeries result in failed back surgery syndrome. Epidural adhesiolysis with myeloscopy is an interventional technique based on the premise that the three-dimensional visualization of the contents of the epidural space provides the physician with the ability to directly visualize the structures, perform appropriate adhesiolysis, and administer drugs specifically to the target. This review describes pathophysiologic aspects, purposes and goals, rationale and indications, complications, and effectiveness of epidural lysis of adhesions with myeloscopy.