When should MRI be recommended for the accurate clinical staging of base of tongue carcinoma?

BACKGROUND AND PURPOSE: According to the American Joint Committee on Cancer (AJCC) cancer staging criteria (6th edition), cross-sectional imaging for base of tongue carcinoma is recommended when the deep tissue extent of a primary tumor is in question. The aim of this study was to establish which group of patients MRI might most benefit from accurate clinical staging of base of tongue carcinomas. PATIENTS AND METHODS: The clinical stagings of 33 patients with pathologically proven squamous cell carcinomas of the base of tongue were performed by two otorhinolaryngologic surgeons. Their results were compared with the results from MRI interpreted by a neuroradiologist and the numbers of patients being upstaged, downstaged or with an unchanged stage were recorded and analyzed. RESULTS: The tumor stages were changed in 13 of 33 patients (39.4%, 95% CI: 23.9-57.87%) and the overall stage groupings were changed in 10 (30.3 %, 95%CI: 15.6-48.7%) after performing MRI. Mis-staging by clinical examination in the overall stage grouping was as high as 83.3% (95%CI: 35.9-99.6%) in stages II and III and 85.7% (95% CI: 42.1-99.6%) in T3. CONCLUSION: MRI should be recommended in base of tongue carcinoma whenever clinical examination suggests overall stage groupings II, III or tumor stage T3.

Primary pull-through with modified Duhamel technique: 1 institution's experience.

BACKGROUND/PURPOSE: Primary pull-through for Hirschsprung disease has been reported to give comparable surgical outcomes to staged operations with less morbidity. The aim of this study was to review the early experiences in our institution with the primary pull-through option. METHODS: Medical records of 50 consecutive patients with Hirschsprung disease who underwent a modified Duhamel pull-through operation from 2001 to 2004 were retrospectively reviewed. For analysis, cases were divided into 2 groups: primary pull-through (group I, 30 patients), and patients with a previously established colostomy who underwent a staged operation (group II, 20 patients). Comparisons were made regarding operating time, operative morbidity, and medium-term functional outcomes. RESULTS: There was no difference between the groups with respect to median age and weight at time of surgery, sex ratio, presenting symptoms, and extent of aganglionosis. Seventy-four percent of the procedures were performed on infants (group I, 21 [70%] of 30 patients; group II, 16 [80%] of 20 patients). Acute postoperative complications were experienced by 4 (13.3%) of 30 patients in group I and 4 (20%) of 20 patients in group II (P <.05). Postoperative enterocolitis occurred in 11 (36.7%) of 30 patients in group I and in 7 (41.2%) of 17 patients in group II. CONCLUSIONS: Our experience indicates that the primary pull-through using a modified Duhamel technique gave neither difference in functional outcomes nor medium-term complications compared to a staged procedure. Considering a sparing of colostomy and a potential economic benefit, the procedure should be considered in selected patients.

Circumumbilicus incision for bleeding Meckel's diverticulectomy.

BACKGROUND/OBJECTIVE: With regard to the recent interest in minimally invasive surgery, the authors report on a technique of transumbilical incision for Meckel s diverticulum and appendectomy, which provides better cosmetic results and no increase in complications. MATERIAL AND METHOD: The case records of 18 consecutive Meckel's diverticulum (MD) patients who were treated at Songklanagarind Hospital in Thailand between 1996 and 2005 were reviewed. RESULTS: The male-female ratio was 14-4 (3.5:1). Of the 15/18 (83.3%) symptomatic cases, presenting symptoms were bleeding 10/15 (66.7%), gut obstruction 2/15 (13.3%), peritonitis 2/15 (13.3%), and intussusception 1/15 (6.7%). All bleeding patients were children (age 1-15 years), 9/10 (90%) Meckel scan positive and 10/10 (100%) ectopic-gastic tissue. Four children underwent a circumumbilical incision. There were no perioperative or long-term complications related to the transumbilical approach. CONCLUSION: The umbilical incision has all the benefits of a minimal access approach. Umbilical incision is a safe, inexpensive, cosmetically pleasing, and easy technique. This minimally invasive surgery does not require long-term specialized training or special equipment.

A randomized double-blind controlled trial comparing two forms of enema for flexible sigmoidoscopy.

OBJECTIVE: To compare bowel preparation quality and patient tolerance of two common enema solutions for flexible sigmoidoscopy. MATERIAL AND METHOD: Three hundred adults were randomized to receive a hypertonic sodium chloride or hypertonic sodium phosphate enema regime, each consisting of two enemas administered 60 and 30 min before the procedure. Patients completed surveys on preparation comfort. Patients and endoscopist were blinded to the preparation used During the procedure, the endoscopist took pictures of the mucosa and intraluminal content. All pictures were later evaluated by a single doctor who graded the quality of the preparation. RESULTS: There were no serious complications during or following the procedures. The preparation quality was rated as excellent or good by 76.9% of the hypertonic sodium chloride group and 72.9% of the hypertonic sodium phosphate group (p = 0.423). The hypertonic sodium chloride enema was associated with more abdominal discomfort (p = 0.018). CONCLUSION: Both enemas were safe for all patients with no statistical difference between the qualities of the two bowel preparations. Both preparations performed their bowel-cleaning function well and were suitable for the preparation of patients before flexible sigmoidoscopy. The less expensive hypertonic sodium chloride solution may be an option for hospitals where budgetary considerations are important.

Terminal warm blood cardioplegia in mitral valve replacement: prospective study.

Terminal warm blood cardioplegia has had a profound impact on cardiac surgery, especially in coronary artery bypass surgery, but there have been few studies on its use in mitral valve replacement. The purpose of this study was to determine whether terminal warm blood cardioplegia offers any advantages in mitral valve replacement. Forty patients with mitral valve disease were prospectively randomized to one of two groups of 20 with different techniques of myocardial protection: group A had cold blood cardioplegia, and group B had cold blood cardioplegia with terminal warm blood cardioplegia. Intraoperative and postoperative variables were used to assess primary outcomes. Postoperative troponin T release was measured as a secondary outcome. Improved spontaneous recovery of sinus rhythm was observed in group B, but the difference was not significant. The maximum doses of inotropics, duration of inotropic support, intensive care unit stay, and postoperative left ventricular ejection fraction were similar in both groups. Troponin T release at 0 and 6 h postoperatively was not different between the two groups. This study did not find any benefit of terminal warm blood cardioplegia in either clinical outcome or troponin T release after mitral valve replacement.

Repair of extra-cranial internal carotid artery aneurysm with application of modified carotid shunt: a case report.

Aneurysms of the extracranial internal carotid artery (ICA) are uncommon. These lesions usually present with symptoms of transient ischemic attacks (TIA) from emboli and cranial nerve dysfunction from compression. The primary objective of treatment is to prevent a permanent neurologic deficit arising as a result of atheroembolism. The resection of an ICA aneurysm with restoration of flow is the preferred method of treatment. The authors present the case of a 32-year-old woman diagnosed with an ICA aneurysm. The patient underwent aneurysmectomy using an autologous saphenous vein graft with ICA blood flow being maintained using a carotid-to-carotid shunt, which was modifiedfrom an intravenous catheter set. This modified carotid shunt is easy to prepare for use and is of low cost. The authors do not expect this shunt to represent the standard commercially available shunt; but in some institutes, where commercial shunts are not available, this shunt may be suitably used.

Non-shaved ventriculoperitoneal shunt in Thailand.

The objective of this study was to determine whether non-shaved patients undergoing ventriculoperitoneal shunt operations would experience a significantly increased shunt infection rate as compared to shaved patients. Clinical trials of non-shaved scalp preparation were performed in ventriculoperitoneal shunt procedures at Songklanagarind Hospital from January 1994 to December 1999. Exclusion criteria were poor scalp condition, previous shunt procedures and immunocompromised hosts. Statistical analysis using univariate, multivariate and logistic regression was used. One hundred and nineteen patients were included in the study. Thirty-six cases were in the non-shaved group. Thirty-eight of 119 cases were less than one year of age and congenital hydrocephalus was the most common problem. The only notable risk factor for shunt infection was an operation lasting more than 59 min. The shunt infection rate in the non-shaved and shaved groups was 6.25% and 14.94%, respectively (p>0.05). In conclusion, leaving the hair intact for ventriculoperitoneal shunt surgery is safe and not associated with increased risk of shunt infection. The non-shaved method may encourage quicker restoration of the patients' self-image and facilitate their early return to normal life.