Penetrating Keratoplasty for Corneal Ectasia after Laser in Situ Keratomileusis

Purpose

To improve the visual acuity of patients with progressive keratectasia following laser in situ keratomileusis (LASIK).

Methods

Five eyes of four patients underwent penetrating keratoplasty for ectasia after LASIK. In one patient the second eye was operated on 10 months after the first keratoplasty. The pre- and postoperative refraction, best spectacle-corrected visual acuity, and topographic data were evaluated.

Results

The preoperative refraction was −20.0 diopters (D) with high cylindrical values in all eyes at the time of surgery. After penetrating keratoplasty, mean spherical equivalent was −13.08±3.62 (SD) and mean refractive cylinder was −3.87±1.12 (SD). In one eye Urrets-Zavalia syndrome was noted as an early postoperative complication. In the second operated eye of another patient, there had been graft rejection several times. In this patient, frequent steroid use led to secondary glaucoma and he required filtering surgery.

Conclusions

Penetrating keratoplasty is effective and successful in treating iatrogenic keratectasia after LASIK, but these patients need a close and lifelong follow-up to treat late-term complications such as graft rejection and secondary glaucoma.

Mild and Severe Anal Incontinence after Lateral Internal Sphincterotomy: Risk Factors, Postoperative Anatomical Findings and Quality of Life

<i>Aim:</i> This study aims to evaluate the risk factors for incontinence after lateral internal sphincterotomy (LIS) and assess quality of life in different levels of incontinence. <i>Methods:</i> All consecutive patients (n = 253) with chronic anal fissure who underwent LIS between 2003 and 2006 were retrospectively reviewed. All patients were questioned for possible anal incontinence according to the Wexner Incontinence Score (WIS). Demographics, vaginal delivery history, additional procedures and surgeon’s experience were evaluated as risk factors. Endoanal ultrasound (EUS) was performed in incontinent patients to assess the thickness of the remaining internal sphincter and to evaluate any injury in the external sphincter. Quality of life was questioned with SF-36. <i>Results:</i> Twenty-eight (11.7%) patients suffered from incontinence (mean WIS = 3.6 ± 2.5). The search for a risk factor was unsuccessful when continent and incontinent groups were compared. In subgroup analyses, patients were found to be suffering from mild (WIS <5, n = 19) or severe (WIS >5, n = 9) incontinence. Vaginal delivery history was found more often in the severely incontinent subgroup than in the continent group (p < 0.05). Also, vaginal delivery history and the additional procedures were more frequently observed in the severely incontinent subgroup than in the mildly incontinent subgroup. EUS did not find any external sphincter injury in these cases. WIS had negative correlations with the physical and mental component scores of SF-36. <i>Conclusion:</i> In our opinion, the threat for incontinence is unpredictable; however, vaginal delivery history may increase the risk of severe incontinence.

Apical lymph nodes at the root of the inferior mesenteric artery in distal colorectal cancer: an analysis of the risk of tumor involvement and the impact of high ligation on anastomotic integrity

BACKGROUND

What level of arterial ligation is best in left-sided colon cancer and rectal cancer remains controversial. This study aims to assess the necessity and risk of high ligation from an oncological and technical perspective.

METHODS

The lymph nodes at the origin of the inferior mesenteric artery (IMA) were separated as apical nodes in all patients operated for distal colorectal cancer in our department. The number and status of the nodes were prospectively assessed, and demographic and tumor-related variables were evaluated as risk factors for apical tumor invasion. Anastomotic leaks were also evaluated.

RESULTS

A hundred and three patients (52 [50.5%] males, 60.3+/-12.9 years old) were included. The number of non-apical lymph nodes harvested was 14.5+/-7.1 with an additional 4.4+/-3.2 apical nodes at the high ligation site. Tumor invasion of apical nodes was observed in 6 (5.8%) patients. Two of these (1.9%) had no other positive nodes (skip metastases). Although none of the variables evaluated was found significant for predicting apical node positivity, tumor invasion was detected in 8.5 and 22.2% of patients with pT3 and pN2 cancers, respectively. Among patients, who had an anastomosis (n = 84, 81.6%), anastomotic leak was observed in 7(8.3%) and 1 (1.2%) of these patients required emergency relaparotomy. There was no mortality related to high ligation.

CONCLUSIONS

High ligation of IMA may be routinely performed in patients with distal colorectal cancer, since tumor invasion of apical lymph nodes is neither rare (>5%) nor predictable, and skip metastases may also occur. This is especially true in case of an advanced disease for which apical node positivity peaks. The anastomotic leak rate is less than 10%, and mortality is low after high ligation of IMA.

The correlation among tissue, serum adiponectin levels and histopathological variables in gastric cancer patients

e22199

Background: Adiponectin is a new peptide hormone secreted from the adipose tissue, affecting the proliferation and insulin sensitivity in different cell types.The previous studies showed that the serum levels of adiponectin are decreased in patients with endometrial and breast cancer.In our study, demographic features and histopathological variables and the relationship among adiponectin levels of serum and gastric tissue were analyzed in gastric cancer patients. Methods: Thirty-five consecutive patients with gastric cancer included in this study.The serum levels of glucose, insulin, c-peptide, HbA1c, lipids and adiponectin were measured in patients.In addition, normal and tumor tissue levels of adiponectin were also detected.We analyzed the correlation among these parameters and patients demographic features, such as age, gender, body mass index (BMI) and histopathological variables. Results: Patients characteristics included 24 males (68.5%), 11 females (31.5%); median age was 64 (range:41–85). The mean serum, normal and tumor tissue levels of adiponectin were 49.4±0.8, 48.2±4.2, 48.6±2.9 ng/ml, respectively. There was no relationship among serum, normal and tumor tissue adiponectin levels (p>0.05).There was inverse correlation between the normal tissue levels of adiponectin and insulin (p=0.002).The serum adiponectin levels were significantly associated with tumor localization (p=0.03).However, there was inverse correlation between serum adiponectin levels and perineural invasion (p=0.02).In subgroup analysis, the serum, normal and tumor tissue levels of adiponectin in woman were not different compared with those in male patients (p>0.05).No relations were detected among tumor stage, grade, nodal status, lymphatic and vascular invasion, the other insulin-resistant status parameters and the levels of serum, normal and tumor tissue adiponectin (p>0.05). Conclusions: Our results suggest that no correlations among the levels of serum adiponectin,normal tissue and tumor tissue adiponectin levels,patients demographic features and histopathological variables except for the association of serum adiponectin with tumor localization and perineural invasion detected in gastric cancer patients.

No significant financial relationships to disclose.

Comparison of cecal abrasion and multiple-abrasion models in generating intra-abdominal adhesions for animal studies

BACKGROUND

The formation of postoperative adhesions is a common problem in abdominal surgery that may lead to serious complications. Appropriate animal adhesion models are essential for the investigation of adhesiogenesis and the development of new anti-adhesive products. Although animal models have been developed to study the process of adhesion formation in the abdomen, they are not effective in generating adhesions located over small bowel where adhesions are most commonly observed in clinical practice.

METHODS

Twenty-nine Sprague Dawley rats were subjected to standardized cecal abrasion (group 1; n=9), or two types of multiple abrasion, in which cecal and 3 or 5 abrasions were performed on small bowel (group 2, n=10; and group 3, n=10). An observer blinded to the randomization assessed the difficulty of adhesiolysis on a 6-point scale, and the locations of the adhesions were recorded 21 days after the initial surgery.

RESULTS

Adhesiolysis was significantly more difficult in group 3 than in group 1 (p=0.01). The number of animals that had adhesions between the small bowel segments and the total number of locations where small bowel adhered were significantly greater in group 2 and 3 than in group 1 (p<0.05 for all comparisons).

CONCLUSIONS

Abrasions to the small bowel created consistent adhesions that have clinical characteristics of intra-abdominal adhesions as compared to the standard cecal abrasion model and that can be used in future animal studies on adhesions.

Meshless repair of perineal hernia after abdominoperineal resection: case report

Perineal hernia is a rare complication after major pelvic surgery. Placing non-biodegradable mesh across the pelvic inlet is the best method of repair. A 72-year-old man presented with a perineal hernia 8 years after undergoing an abdominoperineal resection because of rectal cancer. During the repair operation, intestinal spillage occurred, making it impossible to place permanent mesh as planned. Instead, we used the bladder to cover the pelvic inlet. The patient recovered well and after 35 months of follow-up, there was no evidence of hernia recurrence. When mesh placement is not feasible, this bladder mobilization technique can replace it.

Benefits of 'clean sweep' in Peutz-Jeghers patients

OBJECTIVE

Laparotomy is the treatment of choice in Peutz-Jeghers Syndrome (PJS) patients for endoscopically irretrievable symptomatic polyps and polyp-related complications. During the last decade, we have operated on majority of the PJS patients with the purpose of removing all the gastrointestinal polyps (clean sweep), when an operation was indicated. The aim of this study is to evaluate the effect of clean sweep technique on the need for repeated surgery compared to a problem focused approach.

PATIENTS AND METHODS

All patients with PJS treated in our institution since 1964 were studied. They were placed into two groups; those who had a problem-focused operation and those who were operated with the purpose of removing all small and large intestinal polyps. Demographics, presentation, follow-up period and the need for recurrent surgery were compared.

RESULTS

We identified 11 patients (4 males, 7 females). Eight patients (5 females; median age 18.5) had problem-focused surgery for bleeding-anaemia (n = 3) or obstruction-intussusception (n = 5). These patients required 23 further operations within 87 patient-follow-up-years (2.64 operations per 10 years). Three patients (2 females; median age 6) were operated for bleeding-anaemia (n = 1) or obstruction-intussusception (n = 2) using the 'clean sweep' approach. These patients did not require any further surgery within 21 patient-follow-up-years. The gender, presentation and follow-up periods were similar between the groups. However, the 'clean sweep' technique appears to have reduced the need for further operations when it is compared with problem-focused approach (P = 0.01).

CONCLUSION

To reduce the need for abdominal surgery and consequent problems in PJS patients, an attempt to remove all detected polyps (clean sweep technique) may be beneficial in these patients.

Small bowel perforation due to blunt trauma directly to the inguinal region: A case report

We report on a patient with intestinal perforation caused by direct blunt trauma to the inguinal region. The patient had been previously diagnosed with an inguinal hernia. The perforation was managed surgically, and he subsequently underwent hernia repair. In our opinion, intestinal perforation caused by inguinal region trauma in patients with inguinal hernias is a rare and unfortunate situation but one that reveals the importance of inguinal hernia repair.

Excision and marsupialization versus sinus excision for the treatment of limited chronic pilonidal disease: a prospective, randomized trial

The treatment techniques for pilonidal disease are either associated with high recurrence rates or complex procedures. This prospective randomized study compared the outcome of excision and marsupialization technique with sinus excision technique. A total of 40 consecutive patients with limited, chronic pilonidal sinus disease were operated with either excision and marsupialization technique (Group 1, n=20) or sinus excision technique (Group 2, n=20). The demographics, perioperative data, complications and recurrences were recorded. Patient satisfaction was evaluated with a specific questionnaire 16-18 weeks after surgery. Demographic data, preoperative symptoms and the acute disease history were similar between the groups. Operation time, hospital stay and work-off periods were significantly shorter and the number of out-patient procedures was significantly more in Group 2. Although satisfaction scores were similar between the groups, the patients who had no complaint, were "completely satisfied" or would "absolutely recommend the operative technique to other patients" were significantly more in Group 2. In conclusion, the sinus excision technique requires a shorter operation time, hospital stay and work-off period than excision and marsupialization in the treatment of limited, chronic pilonidal disease. The sinus excision technique can be performed as an out-patient procedure in most cases, and seems to be associated with better patient satisfaction.

The effectiveness of systemic antibiotics in preventing postoperative, intraabdominal adhesions in an animal model

OBJECTIVE

Postoperative intraabdominal adhesions can be prevented by antibiotic lavage. We assessed whether systemic antibiotics could prevent adhesion formation in a rat model.

METHODS

Cecal abrasion was performed in the peritoneal cavities of 40 Wistar albino rats. Twenty rats were treated with a 5-day course of cefepim and metronidazole; the remaining animals were given saline injections. The animals were sacrificed 14 days after surgery. Adhesion severity scores and histopathologic findings were compared.

RESULTS

The median adhesion severity score was 2 (0-3) in the antibiotic group and 2.5 (1-4) in the controls (P = 0.03). In tissue specimens from controls, the adhesions were marked by mature collagen bundles. In treated rats, the adhesions were immature, characterized by early inflammatory cells, less collagen formation, and no collagen bundles.

CONCLUSIONS

Postoperative systemic antibiotics slow adhesion formation and reduce the severity of the adhesions.

Intravitreal penetration of oral pefloxacin in humans

We measured vitreous and serum levels of pefloxacin after oral administration. Twenty patients with retinal detachments undergoing vitrectomy were recruited into this study. Each patient received 400 mg pefloxacin orally 1 to 12 hours before vitrectomy. Vitreous fluid (0.1 mL) was aspirated at surgery. Vitreous levels of pefloxacin were determined by high-performance liquid chromatography. Six hours after oral administration, an average level of 1.37 microgram/mL of pefloxacin was measured in the vitreous samples. These levels were well above the minimum inhibitory concentration (MIC) for most organisms termed sensitive to pefloxacin. Oral administration of pefloxacin may play an important role in the prevention or management of endophthalmitis.

Treatment of experimental suprachoroidal hemorrhage with subconjunctival injection of tissue plasminogen activator: a negative report

Suprachoroidal hemorrhage was created in 10 albino rabbit eyes. Five eyes were treated with subconjunctival injections of 40,000 IU of tissue plasminogen activator (tPA) daily for 6 days; five eyes served as controls. It took approximately the same amount of time for the suprachoroidal hemorrhages to clear in both the control and treatment eyes. We conclude that subconjunctival injection of tPA does not accelerate the clearance of suprachoroidal hemorrhage.

Treatment of experimental suprachoroidal hemorrhage with intravenous tissue plasminogen activator

Suprachoroidal hemorrhages were created in 15 albino rabbit eyes by injecting 0.1 cc of autologous blood into the suprachoroidal space. One day later, 10 of these eyes were treated with intravenous tissue plasminogen activator (TPA). Doses of 1 mg per kg were given to each rabbit over 2 to 3 hours by intravenous infusion. Five eyes served as control. The rate of clearance of hemorrhage was compared in the two groups. Average day of clearance was 14 days for the treated group, and 20.2 for the untreated control group. In this study, TPA given intravenously appears to accelerate the clearance of suprachoroidal hemorrhage.

Calcein angiography: a preliminary report on an experimental dye

Calcein is a new experimental dye for fundus angiography. Injected intravenously, calcein shares most of the characteristics of sodium fluorescein, but it also has some advantages over fluorescein because it lasts longer in the circulatory system. Calcein may be useful in experimental and clinical angiography of the fundus. This study gives the results of angiograms taken with a standard fundus camera after calcein injection.

Measurement of retinal blood velocity and flow rate in primates using a liposome-dye system

A recently developed liposome-dye method was used to make quantitative measurements of blood velocity and volumetric flow rates in the retina of the rhesus monkey. After systemic injection of a liposome-encapsulated fluorescent dye (calcein), the release of a bolus of the dye in the retina was triggered by an ophthalmic argon laser. Initially, calcein was entrapped at a high concentration and the fluorescence of the dye in the lipid vesicle was quenched. After laser exposure, the liposomes released a bolus of dye at the laser exposure site in a specific vessel of the retina. The released dye formed a well-defined, fluorescent wavefront in the exposed artery or vein. By measuring the distance the dye traveled in the vein over a set time interval, it was possible to measure blood velocity in retinal vessels of various diameters, and to calculate volumetric flow rates in those vessels.

External limbal sclerostomy with contact Nd:YAG laser versus surgical knife

An ab externo limbal sclerostomy was made into the anterior chamber using either a contact neodymium: yittrium aluminum garnet (Nd:YAG) laser probe or a surgical superblade. 5-fluorouracil was injected subconjunctivally as an antiproliferative agent to prevent or decrease cell proliferation and scar formation. The contact Nd:YAG laser use was accompanied by minimal complications. The intraocular pressure was lowered for a longer period in the contact Nd:YAG group compared with the other (knife) group. External sclerostomy with an Nd:YAG laser may offer an alternative in the surgical management of recurrent or intractable glaucoma.

Repetitive, selective angiography of individual vessels of the retina

Recent experiments have shown the feasibility of using laser or microwave energy for the externally controlled release of both dyes and drugs from temperature-sensitive liposomes (lipid vesicles). In the present study, calcein, a fluorescent dye, was used to improve the in vivo capabilities of this controlled release system. In vitro studies showed that the encapsulation efficiency was improved when compared to carboxyfluorescein, the fluorescent dye used previously. The improved liposome and dye system was used to obtain repetitive, "selective angiograms" in isolated segments of the retina in rabbits and in a nonhuman primate (Macaca mulatta) over a period of up to 2 hours after a single liposome injection. Conventional fluorescein angiography of the primate retina one week after the end of the experiments showed no visible damage, even after more than 400 individual laser exposures.

Tissue plasminogen activator in the treatment of experimental retinal vein occlusion

The thrombolytic effect of recombinant tissue plasminogen activator was studied in 28 randomly selected rabbit eyes to lyse photochemically induced retinal vein occlusion. Occlusion was confirmed histologically and assessed by fluorescein angiography. Sixteen eyes were treated with recombinant tissue plasminogen activator given intravenously and 12 control eyes were given similar volumes of normal saline solution. Fluorescein angiography was performed before and at various intervals after treatment. Four hours after treatment, the retinal vein was patent in 16 eyes (100%) treated with recombinant tissue plasminogen activator, as opposed to one eye (8.3%) treated with normal saline. The results indicate that tissue plasminogen activator is effective in lysing experimentally induced retinal vein thrombi.