PSAT381 Rising Preoperative TPO Titers Decrease the Risk for Differentiated Thyroid Cancer in a Linear Fashion: A Retrospective Analysis of 1620 Consecutive Thyroid Surgeries

Introduction

Chronic lymphocytic thyroiditis is an important risk factor for differentiated thyroid cancer (DTC) in surgical series, but the role of thyroid peroxidase antibodies (TPO) seems less clear in that regard. We designed the present study to evaluate that effect in our large patient population.

Methods

We recruited subjects operated with total thyroidectomy in 4 sites (USA: 1, Greece: 3) during a period of 14 consecutive years. We gathered data on TPO antibodies titers measured with commercially available radioimmunoassays, and reviewed data on surgical pathology. TPO≥34IU/ml was deemed high (TPO+). Odds ratios (OR) for DTC were calculated with Fischer's exact test. p<0.05 was deemed significant.

Results

We reviewed data on 8,425 thyroid surgeries, and TPO titers were available for 1,620 subjects: DTC n=702 (43.3%), benign pathology (BEN) n=918 (56.7%), TPO+ n=524 (32.3%) and TPO- (<34IU/ml) n=1096 (67.7%). DTC was found with a lower frequency in TPO+ (183/524, 34.9%) compared to TPO- (519/1096, 47.4%) subjects, OR 0.60 (0.48-0.74, p<0.0001). Subjects with the lowest TPO titers had the highest rate of DTC: TPO< 10IU/ml n=338/635 (49.3%), TPO 34-100IU/ml n=69/162 (42.6%), TPO 100-500IU/ml n=70/168 (41.7%), TPO 500-1000IU/ml n=16/50 (32.0%), TPO >1000IU/ml n=28/144 (19.4%), p<0.0001.

Conclusions

High TPO Antibodies appear protective against DTC in our large multicentre cohort of patients operated with a total thyroidectomy. Rising preoperative TPO titers confer linearly increasing protection against DTC in the surgical specimen. More research is needed to fully understand the role of thyroid autoimmunity in the genesis of DTC.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSUN231 Adoptive Cell Transfer for Type 1 Diabetes Reversal

 

We have discovered a way to cure type 1 diabetes in a mouse model that closely resembles the human disease. Specifically, we are able to genetically modify blood cells from affected individuals and re-infuse them back to rescue insulin-producing beta cells being destroyed by the immune system.When autoimmune diabetes affects the youth, it is known as Juvenile or type 1 diabetes (T1D). It is named Latent Autoimmune Diabetes of Adults (LADA) when it affects adults. T1D affects about 1 million people in the USA. LADA is estimated to affect at least 10% of the type 2 diabetes population (about 30 million patients in the USA). Combined, 4 million people live with the condition.Can you imagine reversing type 1 diabetes at once?Autoimmune diabetes as a whole is a disease without a cure that is chronically managed with insulin replacement. Even under best management, diabetes complications shorten life expectancy, including blindness, amputations, and kidney failure. These are the population that will benefit from our technology. Starting with new-onset diabetes, the technology can benefit almost any patient with autoimmune diabetes.Our group has developed two currently patented technologies that achieve the goal of reversing type 1 diabetes (our value proposition). One is a new spontaneous, humanized, transgenic mouse model of human T1D (1). The other one is an adoptive cell transfer (ACT) therapeutic approach for T1D (2). A 30-day pre-clinical study in which animals with diabetes were treated with this therapeutic approach provided the proof-of-concept that diabetes CAN BE CURED.Our technology involves a standard-of-care approach already Federal Drug Administration (FDA) approved for cancer treatment (ACT of Chimeric Antigen Receptor, CAR, T cells). We have the materials and know-how needed for the large-scale pre-clinical trial we are currently running. This will generate the necessary data for Investigational New Drug, IND, FDA filing so human clinical trials can be carried out.

References

1. Imam, S., Alfonso-Jaume, M., Jaume, J.C. (2019). Spontaneous Autoimmune Diabetes in Humanized Mice Carrying Human Type 1 Diabetes Susceptibility and Uses Therefor. United States Application No. 16530452, Publication Number. US20200037586. https://patentscope.wipo.int/search/en/detail.jsf?docId=US283198965&tab=NATIONALBIBLIO

2. Imam, S., Jaume, J.C. (2020). Immunosuppressive Antigen-Specific Chimeric Antigen Receptor Treg Cells for Prevention and/or Treatment of Autoimmune and Alloimmune Disorders. International Application No. PCT/US2019/060593, Publication Number WO/2020/097546. https://patentscope.wipo.int/search/en/detail.jsf?docId=WO2020097546&_cid=P10-KHXN2B-33433-1

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

RF11 | PSAT368 The role of thyroid peroxidase antibodies on the risk of thyroid cancer: a systematic review and meta-analysis of surgical cohort studies

Introduction

Hashimoto's thyroiditis raises the risk for differentiated thyroid cancer (DTC) in surgical series, but the role of thyroid peroxidase antibodies (TPO) remains controversial in that regard. We designed the present study to evaluate the effect of preoperative TPO titers in the risk of DTC.

Methods

A comprehensive search was conducted in PubMed, CENTRAL and Scopus databases in November 2021 for the terms "thyroid cancer" and "TPO" or "peroxidase antibodies". We characterized the differential risk found in patients with high titers of TPO (TPO+), as compared to those with low or undetectable titers (TPO-) with regard to DTC. Data are expressed as odds ratio (OR) with 95% confidence interval (CI).

Results

We retrieved and reviewed 408 records; 21 retrospective cohort studies (2006-2022) from 7 countries and n=30,5536 subjects, fulfilled the eligibility criteria: 15 studies in East Asia with n=25,125 subjects (82.2%) and 6 studies in the Western world with n=5,428 subjects (17.8%)]. These comprised n=17,684 subjects with benign disease (57.9%) and n=12,869 with DTC (42.1%). The reference used for TPO+ was 23.6±18.8 (Range 5.1-60.0 IU/ml); n=6,307 patients were TPO+ (20.6%) and n=24,246 were TPO- (79.4%). DTC was present in n=2,960 TPO+ patients (46.9%) and n=9,909 TPO- patients (40.9), OR 1.28, (95%CI 1.21-1.35), p&lt;0.001.

A high titer of TPO was associated with increased risk for DTC in both Asian cohorts, [OR 1.36 (1.28-1.45, p&lt;0.001)] and Western world alike, [OR 1.15 (1.02-1.31), p=0.025]. That risk was statistically significantly higher in the Asian world cohorts as compared to the Western World cohorts, p&lt;0.001.

Conclusions

Thyroid peroxidase antibodies are an integral part of Hashimoto's thyroiditis, which is a well characterized risk factor for thyroid cancer and seem to increase that risk as well. That effect seems significantly higher in East Asia as compared to the Western World region. Further studies are needed to characterize the effects of the immune response, with regard to thyroid cancer risk.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:24 p.m. - 1:29 p.m.

PSAT386 Thyroglossal Duct Carcinomas: Systematic Review and Meta-analysis of 550 Cases Reported in the Literature

Introduction

Thyroglossal duct (TGD) carcinoma is an uncommon entity, located in the TGD remnant, and is diagnosed in patients undergoing evaluation of the neck for midline swelling, or incidentally after removal of a TGD cyst. Despite the presence of multiple publications on the topic, no systematic characterization of these tumors has been performed to date. The present study aims to characterize the tumors found patients diagnosed with TGD remnant malignancies.

Methods

We performed a systematic search for the term "Thyroglossal duct" in Pubmed, Embase and Cochrane databases on December 1, 2021 and retrieved 1229 records. We included all manuscripts containing cohorts, case reports or case series, when the manuscript or its abstract was available in English, Italian, French or Spanish language. We reviewed the demographics, the histological report of the thyroglossal duct and the thyroidectomy specimen (when this was performed) and the features of tumor aggressiveness, when these were available.

Results

We incorporated data from 366 manuscripts, comprising 1202 patients operated for TGD disease. Out of these, n=550 cancers were identified, consisting of n=475 (86.4%) Papillary thyroid carcinomas (PTC), n=8 Follicular thyroid carcinomas (FTC) (1.5%), n=5 Hürthle cell carcinomas (HCC) (0.9%), n=27 Squamous cell carcinomas (SCC) (4.9%), n=2 poorly differentiated/anaplastic thyroid carcinomas (ATC) (0.4%), n=1 Adeno-SCC (0.18%), n=1 Adenocarcinoma (0.18%), n=12 synchronous PTC/FTC (2.2%), n=1 synchronous PTC/SCC (0.18%) and n=18 of unclear histological diagnosis (4.75%). N=173/446 (38.8%) patients were males and n=273/446 (61.2%) were females; gender was not available in n=104 cases. Mean cancer size was 1.4±1.4cm (range 0.01-7.0cm); n=88/173 (50.9%) were microcarcinomas (<1cm). Distant metastasis was present in n=7 patients (1.3%). Lymph node involvement was reported in n=76/286 cases (26.6%); extrathyroidal extension was present in n=75/234 cases (32.1%); capsular invasion was present in 72/142 cases (50.7%). Adjuvant therapy with I-131 was used in n=131/550 cases (23.8%).

Conclusions

TGD remnant cancers include various tumors, with histology and features of aggressive behavior similar to what we see in thyroid cancer cases. More research is needed to enhance our understanding of the mechanisms involved in the pathogenesis and malignant behavior of these infrequently identified tumors.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

MON-547 Post-Surgically Discovered Differentiated Thyroid Microcarcinomas Are More Commonly Found in Patients eith Chronic Lymphocytic Thyroiditis Compared to Those with Multinodular Goiter or Graves' Disease

Introduction: Incidental finding of differentiated thyroid microcarcinomas (DTMc) in patients with thyroid nodules, undergoing thyroid surgery for benign indications, have become increasingly common. Even though carcinogenesis might relate to the background disease of the gland, the incidence of DTMc in the setting of various thyroid disorders remains unclear. We designed the present study to address this question. Methods/ Subjects: We reviewed the data from two prospectively collected databases of patients undergoing thyroid surgery in two high-volume tertiary care referral centers, one in the USA (A) and the other one in Greece (B) over 14 consecutive years. We collected data on the preoperative surgical indication, FNA cytology and surgical pathology. We excluded subjects operated for thyroid cancer or indications at high risk for malignancy (FNA suspicious for thyroid cancer, follicular neoplasm, suspicious for follicular neoplasm, FLUS/AUS, cellular specimen or sonographic features of malignancy), and those with post-surgical pathology consistent with PTC >9mm in largest diameter. We split our subjects based on pathology data in those with chronic lymphocytic thyroiditis (CLT), Graves disease (GR) or multinodular goiter (MNG). Incidence of DTMc or features of tumor aggressiveness were compared among groups, using Fischer’ s exact test and odds ratios (OR) were calculated. Categorical values were compared with Kruskal Wallis test. P values <0.05 were deemed significant. Results: We reviewed 6096 cases of thyroid surgery (A:2711, B:3385). We included 3909 subjects. Overall 609 (15.6%) DTMc were identified [A:256/2003 (12.8%), B:353/1906(18.5%) OR 0.79, p<0.0001]. CLT was present in 626 subjects; where DTMc was present in 155 (24.8%) [A:83/410 (20.2%), B: 72/216 (33.3%), OR 0.51 p<0.001]. GR was present in 377 subjects; where DTMc was present in 39 (10.3%) subjects [A:14/209 (6.7%) B: 25/168 (14.9%) OR 0.41, p=0.01]. MNG was present in 1964 subjects; where DTMc was present in 314 (15.9%) subjects [A: 58/686 (8.5%), B:256/1278 (20.0%)]. The incidence of DTMc was significantly higher in CLT compared to MNG (OR 1.73) or GR (OR 2.85) (p<0.001 for both) and in MNG compared to GR (OR 1.64, p=0.0064). Maximal tumor diameter was not significantly different among groups (CLT 0.46cm, MNG 0.44cm, GR 0.44cm, p=0.56). Conclusions: Incidentally discovered differentiated thyroid microcarcinomas are more commonly identified in surgical specimens from subjects with chronic lymphocytic thyroiditis as compared to patients with multinodular goiter, while patients with Graves' disease present with a much smaller incidence compared to both groups. This data supports previously published findings that euthyroid Hashimoto thyroiditis could allow for carcinogenesis, while Graves disease could have a protective role.

SUN-512 Denosumab Improves Trabecular but Not Cortical Bone Osteoporosis in a Patient with Refractory Primary Hyperparathyroidism

Background: Primary hyperparathyroidism is a disorder of parathyroid glands in which one or more of these glands is/are overactive. As a result, the overactive gland releases too much parathyroid hormone (PTH) which increases serum calcium levels from thinning of the bones. Osteoporosis occurs in patients with hyperparathyroidism, but it is usually reversible post parathyroidectomy. In the United States, about 100,000 people develop primary hyperparathyroidism each year. The disorder is diagnosed most often in people between age 50 and 60, and women are affected about three times as often as men. Case: This is the case of a 71-year-old lady with history of primary hyperparathyroidism treated with left parathyroidectomy for severe hypercalcemia and osteoporosis. However, although quiescent for few months, the hyperparathyroidism recurred and the osteoporosis worsened. She was referred to our Osteoporosis clinic for evaluation and management. Patient had multiple Sestamibi scans for re-localization of the abnormal parathyroid which were all unsuccessful. Also, she went through a second neck exploration which failed to find the abnormal parathyroid gland. She even underwent fine needle aspiration of intrathyroidal cysts with PTH washouts for identification of possible parathyroid adenoma with negative results. Patient was then treated with bisphosphonates for 5 years and her DEXA scan T score of (-) 2.9 at the radius never improved. Bisphosphonates were discontinued, and patient was treated with Denosumab infusions every 6 months for the last two years in an attempt to help with both osteoporosis and hypercalcemia. Repeated DEXA scan revealed significant improvement of bone mineral density at the level of the lumbar spine, with worsening of osteoporosis at the femurs and radius. Hypercalcemia normalized while PTH remained inappropriately high normal. Discussion: Osteoporosis from hyperparathyroidism affects predominantly long bones. Aside from parathyroidectomy of parathyroid adenomas, no other therapy has been shown to improve cortical bone osteoporosis due to hyperparathyroidism. Denosumab is a human monoclonal antibody which is used for the treatment of osteoporosis in postmenopausal women who have high risk of bone fracture. It has been used lately also for treatment of hypercalcemia of malignancy. Although our patient’s hypercalcemia and trabecular bone osteoporosis improved with Denosumab, cortical bone osteoporosis worsened. This case illustrates the power of continuous PTH secretion on cortical bone resorption which is able to counteract the beneficial effect of Rank ligand blockade at the trabecular bone level. It also demonstrates the need for more research on potential therapies to address this PTH specific action.

MON-LB033 Unleashing the Anti-Inflammatory Potential of Treg Cells Against Type I Diabetes Using Advanced Chimeric Antigen Receptor Technology

Regulatory T (Treg) cells play a critical role in maintenance of tolerance and are ideal for development of therapies designed to suppress inflammation and autoimmunity. Emerging data indicate that, compared to polyclonal Tregs, adoptive transfer of disease-relevant antigen-specific Tregs is advantageous in terms of reduced risk of nonspecific immune suppression and need for fewer cells. The successful use of chimeric antigen receptor (CARs) technology for the generation of antigen-specific effector T cells suggests that a similar approach can be used to generate antigen-specific Tregs. Here, we aimed at developing pancreatic Beta cell-specific CAR Tregs and explore their therapeutic application against Type 1 diabetes (T1D). Methods: Two GAD65 B cell epitopes known to interact with two immunodominant regions in the N-terminal (CAR-N), and Middle (CAR-M) regions were selected for assembly onto T cell receptors (1). These GAD65 CAR Tregs were used to prevent/treat diabetes in our humanized mouse model that closely resembles human T1D (2). Autologous, amplified Tregs were transduced with CAR-M and CAR-N Treg constructs. Treg expression of CAR-M/N was confirmed by PCR and western blot. First, a group of humanized mice was infused with 5 million GAD65 specific CAR-M/N Tregs co-expressing GFP, 24 hr before sacrifice. CAR Treg cells were then processed into single cell suspensions and tracked in peripheral blood, pancreas (PN), peri-pancreatic lymph nodes (PLN), and spleen using flow cytometry. Also, 3D iDISCO image was collected from the same sites for visualization of CAR Treg cells 24 post-infusion. Second, three groups of humanized mice were treated with 5 million either GAD65 specific CAR-M/N Tregs, or untreated (normal control) Tregs or EPCAM (CAR Treg control). These mice were euthanized 30 days after treatment. Again, Tregs were tracked in PN, PLN, and spleens using flow cytometry. Also, glucose tolerance tests (GTT) were carried out before cell infusion and at 30 days. Results: GAD65 specific CAR-M/N Tregs homed to pancreatic islets 24 hours after infusion. The Treg population was also significantly increased in PN and spleen of CAR-M/N Treg treated groups as compared to untreated Treg and EPCAM treated groups at 30 days. GTT showed that humanized mice had significantly lower blood glucose at 60 min after being treated with CAR-M Tregs as compared to controls. CAR-N Treg treated mice had lower blood glucose at 90 and 120 min time points as compared to controls. Untreated Tregs group showed no significant differences as compared to EPCAM. Conclusion: The results demonstrated the potential use of CAR technology to generate potent, functional, and stable Beta cell-specific CAR Tregs as therapeutic against T1D in humans. This project sets a stage for making antigen-specific CAR Treg to treat other autoimmune diseases. 1) U.S. Provisional Patent #62/757,313 2) U.S. Provisional Patent #62/713,827 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

SAT-LB036 Late Weaning Leads to Enrichment of Treg Cells Which Consequently Regulates Effector T Cell Responses in Peri-Pancreatic Lymph Nodes and Pancreas of Humanized Model T1D

The hallmark of type 1 diabetes (T1D) is immune-mediated destruction of insulin secreting β-cells in pancreatic islets. Children who progress to clinical T1D have detectable levels of islet-specific autoantibodies before age three. Early development of gut microbiota also has limited resilience and is vulnerable to perturbation. We recently developed humanized mice that spontaneously develop T1D. This mouse model mimics clinical human T1D, allowing us to carry out controlled studies where we investigated diabetes development and gut microbiota after normal weaning (NW) and late weaning (LW) stages. Our data revealed that the gut microbiota changes as weaning is delayed and that disease progression correlates with these changes. We hypothesized that a delay in T1D onset in our model might have been due to an enrichment of regulatory T (Treg) cells secondary to increased diversity of gut microbiome. We tested this hypothesis by setting up experiments where the breeder’s cages with larger litter sizes (8 pups) were separated into two groups. We allowed the breeder mice for a second-time pregnancy, and after birth, the second litters were sacrificed, and first litter (late weaning group) were allowed to stay with their mothers until day 45 as normal weaning group was separated at day 21. Late weaning was then separated from mothers and allowed to settle into new cages. At day 60 and 150, mice from both groups (n=10-12) were sacrificed. Organs (Peyer’s patches, peri-pancreatic lymph nodes (PLN), pancreas (PN) and spleen) were harvested and lymphocytes isolated. Flow cytometry of Peyer’s patches, a site of first immune cell interaction/activation with gut antigens, revealed that Tregs were significantly increased in late weaning group. In PLN, a site for islet antigen-specific T cell activation and recruitment in case of pancreas autoimmunity, flow cytometry data revealed that late weaning leads to enrichment of Tregs and consequently regulation of cytotoxic CD8 T lymphocytes (CTLs). Most interestingly, late weaning enriched the Treg population at the spleen level too. The enrichment of Tregs may have been due to a more diverse microbiome, which is known to increase immune tolerance, which might have regulated the diabetogenic Th1, Th17, and CTLs at PLN, PN, and spleen. Our data is the first to provide a scientific explanation for observed prolong nursing as affecting T1D outcomes in humans. We also investigated the possibility that induction of immune tolerance would protect pancreatic islet architecture. Newborn mice littermates were divided into late weaning and normal weaning groups. Pancreatic sections were stained with hematoxylin/eosin (H&E) for histological identification and localization of islets and lymphocytic infiltrates. Late weaning group, preserved the pancreatic islet architecture with fewer lymphocytic infiltrates and a significantly higher number of islet per H&E section. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

OR28-4 Spontaneous Autoimmune Diabetes in Humanized Mice Carrying Human Type 1 Diabetes Susceptibility

An animal model of type 1 diabetes (T1D), in which human beta cell autoantigen(s) are presented to effector cells in the context of human Major Histocompatibility Complex (MHC) diabetes-susceptibility genes, would be highly desirable for studies of molecular mechanisms of disease and development of antigen-specific immune-therapies applicable to man. It would be especially advantageous to develop an animal model of human T1D that also exhibits the chronic complications of diabetes. Our new spontaneous mouse model of T1D wherein mouse MHC-II was replaced by human DQ8 in all antigen-presenting cells (APCs), and pancreatic Beta-cells were made to express human GAD65 autoantigen resembles most human characteristics of the disease. Our humanized transgenics have a genetic background providing for compromised Beta-cell neogenesis and/or regeneration. Immune cells attack Beta-cells, which in turn leads to a chronically progressive disease characterized by the development of anti-GAD65 antibodies. Flow cytometric analysis of pancreas (PN) and peri-pancreatic lymph nodes (PLN) revealed that CD4 and CD8 T cells build up in the PLN while mostly CD8 infiltrate intra-islet locations, which first causes glucose intolerance, and later on diabetes. Animals spontaneously show hyperglycemia of >250 mg/dl at approximately eight weeks of age. Without intervention, animals develop the classic complications observed in human diabetes (i.e., retinopathy, nephropathy, and neuropathy). To date, all complications of diabetes have been observed in our model (1). Our humanized transgenics develop diabetic retinopathy. Diabetic mice develop a significant increase of acellular capillaries in the retina as compared to non-diabetic controls as early as 6 months. Ocular tomography revealed that total retinal thickening was reduced in diabetic mice. Fundoscopic retinal images also revealed vascular leakage only in diabetic mice. Six-month-old diabetic mice also show advanced features of diabetic nephropathy like focal segmental/global glomerular sclerosis and focal tubular atrophy. Basal glomerular membrane doubles in size at three months as shown by electron microscopy as compared to non-diabetic controls. Moreover, our humanized mice also show diabetic neuropathy. Optic nerves of 6-month-old diabetic mice show an increase in the refractory period of the second compound action potential (CAP) as compared to non-diabetic mice (p < 0.05). This increase in the refractory period of CAP in the diabetic optic nerves is consistent with the reduced conduction velocity over non-diabetic controls. Conclusively, our humanized mice model is the closest one to human diabetes and is not just suitable for therapies to halt diabetes and its development but also to address the physiopathology and treatment of diabetes complications. 1) U.S. Provisional Patent #62/713,827 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Le système d’arthrodèse percutanée WSH®

BACKGROUND AND PURPOSE

The purpose of this study was to report our initial experience with a new percutaneous spine fixation system, avoiding open exposure, excessive blood loss and extensive muscle dissection. With the specially designed plates, this system can be used whatever the conformation of the segment instrumented is kyphotic or lordotic.

METHODS

Sixteen patients (9 men and 7 women ranging in age from 27 to 78 years, mean 54.9) underwent percutaneous pedicle fixation using this device. Twelve patients underwent single level fusions (discogenic lowback pain in 6 cases, spondylolisthesis in 1), and 4 underwent two-level fusions (2 for lumbar fracture and 2 for spondylolisthesis). TLIF by intersomatic cages were inserted at the same time in two patients with spondylolisthesis. The follow-up period ranged from 3 to 15 months (mean 5 months).

RESULTS

Improvement in pain control was assessed using a specially designed scale, allowing qualitative self-evaluation of pain control. Pain control was excellent in 12 patients, good in 3 and poor in one case due to loss of independence related to multiple associated disabling conditions.

CONCLUSIONS

Percutaneous pedicule screw insertion using this device is a safe and reliable technique. Further improvements in the system which allows a certain degree of spinal mobility after screw placement are in process. Early results shown in this study illustrate the perspectives.

A staged approach to long gap esophageal atresia employing a spiral myotomy and delayed reconstruction of the esophagus: an experimental study

In beagle dogs, the cervical esophagus was divided 5 cm cranial to the thoracic inlet employing a stapler. The distal esophageal stump was attached to the external surface of the trachea. A spiral myotomy (2 1/2 revolutions) was made in a 3-cm long segment constituting the distal end of the proximal esophageal segment. This was twisted on a bias with the muscle edges approximated by interrupted stitches to cover the denuded submucosal layer. With moderate traction, this segment could be elongated to a length of 5 cm. A subcutaneous tunnel was created in the anterior chest to accommodate the reconstructed proximal esophageal segment (under slight traction), with its distal end forming a cutaneous esophagostomy. A gastrostomy was created using a Gauderer button (Bard Interventional Products, Billerica, MA) for feeding. After 3 weeks, the proximal esophageal segment was mobilized and removed from the subcutaneous tunnel. The distal esophageal segment was freed from the trachea and 5 to 8 cm of its proximal end was excised. The proximal (myotomized) esophagus was brought down to the stump of the remaining distal esophagus and an anastomosis formed in an end-to-end fashion. Oral feeding was reestablished within 1 week. Prolonged ingestion, observed soon after operation, gradually improved. During a period of 1 to 6 months after the operation, motility of the myotomized segment was tested by barium swallow and manometry. There was neither diverticulum formation nor stenosis. Transit of contrast material in the myotomized segment was smooth and rapid. Manometry demonstrated preservation of motility in the myotomized segment of the esophagus.(ABSTRACT TRUNCATED AT 250 WORDS)