Balloon Kyphoplasty for Managing Intractable Pain in Pediatric Pathologic Vertebral Fractures.

BACKGROUND: Vertebral compression fractures are a common result of osteoporosis and osteopenia secondary to steroid use and chemotherapy treatment. Balloon kyphoplasty is a treatment option with good to excellent results well described in adults. Although a few recent studies have been published regarding the use of kyphoplasty in children, no formal indication exists for the pediatric population. The purpose of this study is to describe the outcomes of 3 chronically ill children with intractable pain from vertebral compression fractures, managed with kyphoplasty. METHODS: We retrospectively reviewed 3 pediatric patients who underwent balloon kyphoplasty for vertebral compression fractures secondary to chronic illness. Patient variables included age, sex, primary diagnosis and treatments, levels of vertebral fracture, and time elapsed from initial therapy to fracture. A numeric rating scale of 0 to 10 was used for patient-reported pain, before and after kyphoplasty. Preoperative and postoperative analgesic use and physical function were also described. Surgical variables included levels of kyphoplasty, operative time, and procedure-related complications. RESULTS: The primary diagnoses were relapsed rhabdomyosarcoma, abdominal desmoplastic small round cell tumor, and IPEX-like (immune dysregulation, polyendrocrinopathy, enteropathy, X-linked) syndrome. All 3 patients were males, aged 12, 12, and 13, respectively, at the time of kyphoplasty. Pain scores were 8 to 9 preoperatively in 2 patients, severely affecting their physical function including independent walking. Excruciating back pain was a contributing factor to the respiratory distress of the third patient, who required elective intubation. All of the patients reported significant pain relief (range, 0 to 2) and improved physical function with kyphoplasty. The third patient was successfully extubated 1 week postoperatively and eventually returned to baseline activity. There were no complications related to kyphoplasty. CONCLUSIONS: Balloon kyphoplasty seems to be safe in terminally ill children and may be a useful tool for managing intractable pain due to vertebral compression fractures. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Recurrence of rib prominence following surgery for adolescent idiopathic scoliosis with pedicle screws and direct vertebral body derotation.

PURPOSE: Pedicle screw constructs combined with direct vertebral body derotation (DVBD) provide a powerful corrective force of the rib prominence associated with adolescent idiopathic scoliosis (AIS). We wished to evaluate the incidence and correlative factors associated with recurrence of rib prominence (RRP) developing postoperatively despite adequate initial correction. METHODS: 103 patients with AIS underwent pedicle screw fixation with DVBD without thoracoplasty and had postoperative scoliometer readings at 6, 12, and 24 months. Patients with RRP, defined as a postoperative scoliometer increase ≥5°, were compared to those without recurrence. RESULTS: The mean rib prominence measured 14.0 ± 4.3° preoperatively, with a correction of 50.3 ± 26.7 % at 6 months, 49.0 ± 39.0 % at 1 year, and 49.1 ± 26.7 % at 2 years. RRP was identified in 15.5 % of the patients with a correction of 57.5 ± 25.5 % at 6 months, 47.2 ± 42.5 % at 1 year, and 40.4 ± 21.6 % at 2 years. At 2 years, the RRP group demonstrated a significantly larger major coronal Cobb (p < 0.05) and a trend towards less curve correction (p = 0.09). Patients with open triradiates had a significantly higher rate of RRP compared to those with closed (p = 0.01). Worsening apical vertebral rotation at 2 years post-operation occurred in 43.8 % (7/16) of the patients with RRP. CONCLUSION: RRP after posterior fusion for AIS with all pedicle screw constructs and DVBD occurred in 15.5 % of patients in our study. Patients with open triradiate cartilage had a significantly higher rate of RRP, although most with RRP were skeletally mature. There was a trend towards loss of coronal correction and increased apical vertebral rotation at 2 years in patients with RRP. The potential for RRP after adequate initial correction should be discussed with patients. LEVEL OF EVIDENCE: 2.

Is there a role for the 5-degree rule in adolescent idiopathic scoliosis?

BACKGROUND: Nonstructural curves are defined in the Lenke classification system for adolescent idiopathic scoliosis as bending out to <25 degrees. A caveat in the original paper states, however, that if the difference in Cobb magnitude between the major and minor curves is <5 degrees, then the minor curve should be considered structural, regardless of its Cobb magnitude. It is unclear whether following this rule affects patient outcomes. METHODS: A multicenter retrospective study using a prospectively collected database was performed on surgical adolescent idiopathic scoliosis patients, with 2 years of minimum follow-up. All the lumbar curves measured <25 degrees on bending x-ray. Curves (major and minor) that were within <5 degrees of each other were analyzed in 2 treatment subsets: nonselective fusion (NS) and selective thoracic fusion (STF1), and compared with similar selective fusion cases with false double major curves with a lumbar curve between 5 and 10 degrees less in magnitude than the thoracic curve magnitude (STF2). Preoperative and 2-year postoperative radiographic and SRS-22 parameters were compared. RESULTS: Of 58 patients, there were 14 NS, 11 STF1, and 33 STF2. NS had larger preoperative curves than STF1, but achieved better lumbar correction (58%) than STF1 (32%) or STF2 (41%) (P=0.004). STF1 tended to have more preoperative coronal imbalance than STF2 (-2.26 vs. -1.12 cm) (P=0.066) but were similar at 2 years. Preoperative thoracic rib prominence measures were similar for all groups, but NS had significantly worse rib prominence than STF1 (NS: 8.4 vs. STF1: 4.4, P=0.046) at 2 years. There were no differences among the 3 groups in SRS-22 scores preoperatively and at 2 years. CONCLUSIONS: Almost half of the cases with curves within <5 degrees of each other did not follow the 5-degree rule, suggesting that there is variability among surgeons in their definition of what is truly structural. Selective thoracic fusion cases behaved similarly regardless of whether or not the curves were within 5 degrees of each other. The results of our analysis of the 5-degree caveat challenge its utility as a criterion for defining structural curves. LEVEL OF EVIDENCE: Level II.

Is there a "July effect" in surgery for adolescent idiopathic scoliosis?

BACKGROUND: Prior studies in various medical and surgical specialties have suggested that the changeover of medical trainees in the United States at the end of the academic year, or so-called "July effect," negatively impacts the quality of patient care, including increasing morbidity and decreasing efficiency. We analyzed whether the outcomes of surgery for adolescent idiopathic scoliosis involving physicians-in-training as first assistants were affected by the time of year the surgery was performed. METHODS: We performed a multicenter retrospective study with use of a prospectively collected database to examine outcomes following instrumented posterior spinal fusion in patients with adolescent idiopathic scoliosis. The minimum duration of follow-up was two years. The outcomes of procedures performed by twelve surgeons whose first assistants were all surgeons-in-training were analyzed on the basis of the month of year that the surgery was performed. Variables assessed included blood loss, operative time, length of hospitalization, radiographic outcomes, Scoliosis Research Society (SRS-22) scores, and complications. RESULTS: Five hundred and seventy-five surgical procedures for adolescent idiopathic scoliosis were performed, most in June (14%) and July (13%) (p ≤ 0.001). Preoperative radiographic characteristics were similar across all months as were postoperative radiographic outcomes. Preoperative and two-year SRS-22 scores were also similar across all months, with the exception of scores in the preoperative pain domain, which showed worse pain for patients who underwent surgery in February. No significant differences in blood loss, operative time, or length of hospital stay were observed when these variables were analyzed on the basis of the month in which the surgery was performed. The rate of patients experiencing any complication (23.5% overall) was not associated with the month of surgery, nor were the rates for the specific subcategories of neurologic, pulmonary, gastrointestinal, instrumentation, or surgical site-related complications. With the exception of three gastrointestinal complications that were observed in July, the odds of a patient having a complication from surgery in July/August were unchanged from other months. CONCLUSIONS: Overall, the data did not provide evidence to support a July effect. Our results suggest that surgery for adolescent idiopathic scoliosis during July and August yields safety and outcomes equal to that of other months.

The efficacy of rib-based distraction with VEPTR in the treatment of early-onset scoliosis in patients with arthrogryposis.

BACKGROUND: Although arthrogryposis multiplex congenital (AMC) is a rare condition, rapidly progressive scoliosis is common in children with AMC. Only a limited number of studies characterize the nature of these curves, and even fewer describe surgical outcomes. To determine efficacy or rib-based distraction in these patients, we reviewed the outcomes of the use of the Vertical Expandable Prosthetic Titanium Rib (VEPTR) device in what we believe is the first study to report this. METHODS: Search of the Chest Wall Spinal Deformity Study Group database identified 10 children with AMC and early-onset scoliosis who were treated with the VEPTR device at 6 different pediatric health centers. The 7 female and 3 male patients had their initial surgery at an average age of 5 years. Mean follow-up was 4.2 years. RESULTS: The most common curve was from T5 to L2. After initial VEPTR insertion, the scoliosis decreased from a mean of 67 to 43 degrees (37% correction) and kyphosis from 65 to 48 degrees (29% correction). The mean proximal junctional kyphosis after initial insertion was 33 degrees. At final follow-up, scoliosis and kyphosis were 55 degrees (17% correction) and 62 degrees (8% correction), respectively. Spinal growth during the treatment period showed a mean T1-S1 increase of 4.2 cm or approximately 1 cm/y. In the 62 procedures performed over the course of the study period, 6 complications occurred in 4 patients: 3 infections, 2 rib failures, and 1 implant failure. Six patients had proximal junctional kyphosis of ≥45 degrees at the last follow-up. CONCLUSIONS: In children with AMC, rib-based distraction using the VEPTR is an effective treatment method for controlling scoliosis and kyphosis and maintaining thoracic growth, but proximal junctional kyphosis remains a problem.

The posterior pedicle screw construct: 5-year results for thoracolumbar and lumbar curves.

OBJECT: Several studies of the outcomes of patients with adolescent idiopathic scoliosis (AIS) with thoracolumbar and lumbar curves after treatment with posterior pedicle screws have been reported, but most of these studies reported only 2-year follow-up. The authors analyzed the radiographic and clinical outcomes of patients with thoracolumbar and lumbar curves treated with posterior pedicle screws after 5 years of follow-up. METHODS: A multicenter database was retrospectively queried to identify patients with AIS who underwent spinal fusion for Lenke 3C, 5C, and 6C curves. Radiographs from the following times were compared: preoperative, first follow-up visit, 1-year follow-up visit, 2-year follow-up visit, and 5-year follow-up visit. Chart review included scoliometer measurements, Scoliosis Research Society (SRS)-22 questionnaires, and complications requiring return to the operating room. RESULTS: Among 26 patients with Lenke 3C, 5C, and 6C curves, the mean (± SD) age was 14.6 ± 2.1 years. From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal lumbar Cobb angles (p < 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the lumbar curve remained stable (p = 0.14). From the time of the preoperative radiographs to the 5-year follow-up radiographs, there was a statistically significant improvement in the mean coronal thoracic Cobb angles (p < 0.0001), and from the time of the first postoperative radiographs to the 5-year follow-up radiographs, the thoracic curve remained stable (p = 0.10). From the first postoperative visit to the 5-year follow-up visit, the thoracic kyphosis (T5-12) remained stable (p = 0.10), and from the time of the preoperative radiographs to the 5-year follow-up radiographs, the lumbar lordosis (T-12 to top of sacrum) remained stable (p = 0.44). From the preoperative visit to the 5-year follow-up visit, the coronal balance improved significantly (p < 0.05) and remained stable from the first postoperative visit to the 5-year follow-up visit (p = 0.20). The SRS-22 total scores improved significantly from before surgery to 5 years after surgery (p < 0.0001). No patients required reoperation because of complications. CONCLUSIONS: Correction of the coronal, sagittal, and axial planes in this cohort of patients was maintained from the first follow-up measurements to 5 years after surgery. In addition, at 5 years after surgery total SRS-22 scores and inclinometer readings were improved from preoperative scores and measurements.

Adolescent scoliosis classification and treatment.

Adolescent idiopathic scoliosis (AIS) affects up to 3% of the population. It can be stratified by curve type according to the Lenke classification. This classification system incorporates curve magnitude, flexibility, the lumbar modifier, and the sagittal plane. The Lenke classification serves as a guide for selection of levels for surgical treatment of AIS. Surgical treatment of AIS includes anterior and posterior approaches; most AIS is treated through a posterior approach. Surgical goals include maximizing correction in the coronal, sagittal, and axial planes.

Variations in the iliolumbar vein during the anterior approach for spinal procedures.

STUDY DESIGN: Retrospective study from data from a single access surgeon at 2 hospitals. OBJECTIVE: To increase the surgeon's awareness of iliolumbar vein (ILV) variants during the anterior approach to the lumbar spine. SUMMARY OF BACKGROUND DATA: Although there are many advantages to using the anterior approach, serious risks are involved, namely, vascular injury. The ILV is especially vulnerable when exposing the L4 and L5 vertebrae, and its ligature is recommended to avoid massive hemorrhage from its disruption. Cadaver studies on ILV variants have mainly analyzed drainage patterns. To our knowledge, however, no studies on ILV variants have been conducted on live humans during anterior spinal surgical procedures. METHODS: A total of 159 patients who underwent anterior spinal surgery of at least the L4-L5 levels were included. Cases not involving the L4-L5 level were excluded. Frequency of anomalous ILVs and their possible association with diagnosis (spondylolisthesis, herniated nucleus pulposus, degenerative disc disease, and stenosis), sex, comorbidities, and pelvic history was evaluated. ILV was classified into 5 types: type 0 (missing ILV), type 1 (single ILV), type 2 (2 ILVs), type 3 (3 ILVs), and type 4 (>3 ILVs). RESULTS: Most patients had a single ILV (73%, N = 116). Multiple ILVs were found in 25.8% of cases: 27 cases (17%) for type 2, 11 cases (6.9%) for type 3, and 3 cases (1.9%) for type 4. A higher frequency of multiple ILVs was found in males (32%) than in females (19.2%) (P = 0.034). Diagnosis, comorbidity, and pelvic surgical history were not associated with the number of ILVs. CONCLUSION: The high frequency of multiple ILVs found during the anterior approach is crucial knowledge for access surgeons, as it will help them anticipate such anomalies and thus avoid the potentially catastrophic complications of an avulsion of an unexpected extra vein.

Risk of recurrence of non-metastatic breast cancer in women under 40 years: a population-registry cancer study in a European country.

UNLABELLED: Breast cancer in young patients is relatively uncommon. There is no consensus about the impact of young age on prognosis. The aim of this study was to analyze the effect of young age over the risk of recurrence of breast cancer using a population-registry cancer database in Spain. A retrospective study case-control type was designed. A total of 1,210 patients fulfilled the inclusion criteria. A cutoff at 40 years was used to define two groups of patients: group A, ≤40 years (n = 111); and group B, >40 years (n = 1,099). Younger women showed a higher rate of undifferentiated tumors; a higher percentage of positive lymph nodes; lower rate of positivity of estrogen receptor, higher rate of nonconservative surgery and higher proportion of adjuvant therapies. The risk of recurrence was higher for women ≤40 years: HR =2.59 (95% CI: 1.60-4.18). CONCLUSION: Breast cancer diagnosed at a young age (≤40 years) is correlated with higher recurrence rates.

Un método para individualizar el riesgo de una errónea clasificación ganglionar negativa en el cáncer de colon / A method for individualising the risk of a negative lymph node classification error in cancer of the colon

Introducción y objetivos: En el cáncer de colon, el número de ganglios linfáticos que se deberían analizar antes de clasificar a un paciente como libre de afectación ganglionar ha sido ampliamente discutido. Se propone un modelo matemático basado en el teorema de Bayes para calcular la probabilidad de error (PE) similar al utilizado habitualmente para la evaluación de una prueba diagnóstica pero adaptado a una variable cuantitativa como es un recuento ganglionar. Métodos: Se revisaron las historias clínicas de 480 pacientes intervenidos de forma programada de cáncer de colon con intención curativa, excluyendo los casos que presentaban metástasis de cualquier tipo. Con el fin de calcular las PE, para la serie completa y para diversos subgrupos de pacientes (tumores T2, T3, y T4) se aplicó la fórmula que proponemos basada en dicho teorema de Bayes. Resultados: Para las probabilidades de error al clasificar un paciente como N negativo que oscilaran entre un 5% hasta un 1‰ (próximo o prácticamente 0), la mínima cifra de ganglios negativos necesarios para analizar fluctuó entre 7 y 17 respectivamente para la serie completa. Esta cifra mínima también fue cambiante para los diversos subgrupos (tumores T2, T3, y T4) considerados. Fundamentalmente, tales cifras dependen de las características de la casuística de un grupo de trabajo concreto en cuanto a prevalencia de casos N+ que manejen, y de su capacidad históricamente demostrada para recolectar e identificar ganglios positivos en los pacientes que los presentaran. Conclusión: Desde el punto de vista matemático, el número mínimo de ganglios que se deberían analizar en el cáncer de colon para clasificar a un paciente como N negativo no es una constante. Este depende del error que se esté dispuesto a asumir para tal diagnóstico, puede estar en función de ciertos rasgos del tumor, y además, se debería adaptar a la casuística de cada grupo de trabajo (AU)

Introduction: In cancer of the colon, the number of lymph nodes that should be analysed before a patient is classified as free of lymph node involvement has been widely discussed. A mathematical model is proposed which is based on the Bayes Theorem for calculating the probality of error (PE) similar to that normally used to evaluate a diagnostic test, but adapted to a quantitative variable, the lymph node count. Methods: The clinical histories of 480 patients routinely operated on in attempt to cure cancer of the colon were reviewed. Cases with any kind of mesttasis were excluded. The proposed formula based on the Bayes Theorem was applied with the aim of calculating the PEs for the complete series and for different patient sub-groups (T2, T3, and T4 tumours). Results: For the probabilities of error of classifying a patient as N negative, which varied between 5% and 1% (near or practically 0), the minimum number of negative lymph nodes required for analysis fluctuated between 7 and 17, respectively, for the complete series. This minimum figure was also variable for the different sub-groups (T2, T3, and T4 tumours) studied. These numbers mainly depended on the case characteristics of a specific study group as regards the prevalence of the N+ cases that they dealt with, and of its historically demonstrated ability to collect and identify positive lymph nodes in those patients that had them. Conclusion: From a mathematical point of view, the minimum number of lymph nodes that have to be analysed in cancer of the colon in order to classify a patient as N negative is not a constant. This depends on the error that is prepared to be assumed for that diagnosis, possibly depending on certain tumour traits, and also may be adapted to the cases of each study group (AU)

[A method for individualising the risk of a negative lymph node classification error in cancer of the colon]. / Un método para individualizar el riesgo de una errónea clasificación ganglionar negativa en el cáncer de colon.

INTRODUCTION: In cancer of the colon, the number of lymph nodes that should be analysed before a patient is classified as free of lymph node involvement has been widely discussed. A mathematical model is proposed which is based on the Bayes Theorem for calculating the probability of error (PE) similar to that normally used to evaluate a diagnostic test, but adapted to a quantitative variable, the lymph node count. METHODS: The clinical histories of 480 patients routinely operated on in attempt to cure cancer of the colon were reviewed. Cases with any kind of metastasis were excluded. The proposed formula based on the Bayes Theorem was applied with the aim of calculating the PEs for the complete series and for different patient sub-groups (T2, T3, and T4 tumours). RESULTS: For the probabilities of error of classifying a patient as N negative, which varied between 5% and 1% (near or practically 0), the minimum number of negative lymph nodes required for analysis fluctuated between 7 and 17, respectively, for the complete series. This minimum figure was also variable for the different sub-groups (T2, T3, and T4 tumours) studied. These numbers mainly depended on the case characteristics of a specific study group as regards the prevalence of the N+ cases that they dealt with, and of its historically demonstrated ability to collect and identify positive lymph nodes in those patients that had them. CONCLUSION: From a mathematical point of view, the minimum number of lymph nodes that have to be analysed in cancer of the colon in order to classify a patient as N negative is not a constant. This depends on the error that is prepared to be assumed for that diagnosis, possibly depending on certain tumour traits, and also may be adapted to the cases of each study group.

Demographic factors affect Scoliosis Research Society-22 performance in healthy adolescents: a comparative baseline for adolescents with idiopathic scoliosis.

STUDY DESIGN: Prospective analysis. OBJECTIVE: The purpose of this study was to: (1) evaluate the influence of variable demographic factors on the Scoliosis Research Society (SRS)-22 performance and (2) evaluate SRS-22 performance in normal adolescents without scoliosis to establish a comparative baseline for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The SRS-22 instrument has been used widely to evaluate patients with scoliosis but no study has characterized how variable patient demographics in normal, unaffected individuals may influence SRS-22 scores. METHODS: Healthy adolescents at a high school clinic and at referring pediatricians' private offices were asked to anonymously complete the SRS-22 instrument: 22 questions scaled 1-5 (highest). Additional questions assessed household income, race (white, Hispanic, African-American, other), gender, household status (single vs. dual parent), and body mass index. ANOVA and multivariate regression analyses were used to identify statistically significant factors (P < 0.05). RESULTS: Four hundred fifty unaffected adolescents completed the SRS-22 (62% female, 38% male; mean age 16 (range, 9.3-21.8), mean body mass index 22.8 (range, 13.5-47.5). Mean SRS-22 performance was 4.1 ± 0.5 (Activity: 4.0 ± 0.6; Pain: 4.3 ± 0.6; Image: 4.2 ± 0.6; Mental: 3.8 ± 0.8, Mean: 4.1 ± 0.5). Whites scored higher in the activity domain than Hispanic and other ethnicities, while African Americans scored higher in the pain domain than Hispanics (P < 0.05 for both). From the lowest income range to 125,000 dollars/yr, household income had a positive effect on the activity, image and mean SRS-22 score (P < 0.05 for all). Males scored higher than females in the mental health domain and mean SRS-22 (P < 0.0001). Dual parent versus single parent households had higher activity and mean SRS-22 scores (P < 0.005). CONCLUSION: We report that male gender, dual parent household, white race and increased household income were predictive of higher SRS-22 scores in healthy adolescents without scoliosis. The impact of these factors represents a meaningful clinical difference in SRS-22 performance.

Percutaneous drainage treatment of traumatic pancreatic rupture with pancreatic transection

Management of traumatic pancreatic pseudocyst associated with pancreatic duct laceration is controversial. Surgical therapy has been clasically considered the treatment of choice for those pseudocysts. However, several authors have published good results with percutaneous drainage. Percutaneous drainage can be performed easily, with minimal complication and may facilitate the resolution of a pseudocyst.We present a case of a 16-year-old boy who sustained blunt abdominal trauma in a vehicle accident. A large pancreatic pseudocyst developed, with complete disruption of the main pancreatic duct. Percutaneous drainage under ultrasound guidance was performed and was associated with the administration of octreotide (to inhibit exocrine pancreatic secretion). The drainage flow decreased gradually until ceasing, and the pseudocyst disappeared(AU)

El manejo de pseudoquistes pancreáticos de origen traumático asociados con el desgarro del conducto pancreático es polémico. Tradicionalmente, el abordaje de elección para dichos pseudoquistes ha sido el tratamiento quirúrgico. No obstante, varios autores han publicado buenos resultados con el drenaje percutáneo. El drenaje percutáneo se puede realizar de forma sencilla, con mínimas complicaciones y podría ayuda a resolver el pseudoquiste. Presentamos el caso de un joven de 16 años que sufrió traumatismo abdominal contuso en un accidente de coche. Se desarrolló un pseudoquiste pancreático de grandes dimensiones que causó trastorno absoluto del conducto pancreático principal. Se realizó drenaje percutáneo bajo vigilancia ecográfica junto con la administración de octreótida para inhibir la secreción exocrina del páncreas. El flujo del drenaje descendió de forma gradual hasta su cese completo y la desaparición del pseudoquiste (AU)

Percutaneous drainage treatment of traumatic pancreatic rupture with pancreatic transection.

Management of traumatic pancreatic pseudocyst associated with pancreatic duct laceration is controversial. Surgical therapy has been clasically considered the treatment of choice for those pseudocysts. However, several authors have published good results with percutaneous drainage. Percutaneous drainage can be performed easily, with minimal complication and may facilitate the resolution of a pseudocyst. We present a case of a 16-year-old boy who sustained blunt abdominal trauma in a vehicle accident. A large pancreatic pseudocyst developed, with complete disruption of the main pancreatic duct. Percutaneous drainage under ultrasound guidance was performed and was associated with the administration of octreotide (to inhibit exocrine pancreatic secretion). The drainage flow decreased gradually until ceasing, and the pseudocyst disappeared.

Treatment of morbid obesity and hiatal paraesophageal hernia by laparoscopic Roux-en-Y gastric bypass.

Obesity has been proven to be a significant independent risk factor for hiatal hernia. In morbidly obese patients, the usual techniques to improve gastroesophageal reflux after hiatal hernia repair could have poorer outcomes than in the general population. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be an effective procedure in controlling symptoms and complications of gastroesophageal reflux in these patients. Therefore, LRYGBP is one of the most frequent procedures performed in bariatric surgery. The authors report a case of a 41-year-old man with a body mass index (BMI) of 44.6 kg/m(2) who was diagnosed with giant type III hiatal hernia. A laparoscopic approach for both hiatal hernia repair and LRYGBP was performed. At 6 months follow-up, the patient has lost 30% of excess body weight (BMI 34.4), and there is no evidence of recurrence of the esophageal hernia.

Debating the mathematical model to validate the sentinel lymph biopsy techniques in breast cancer patients. The danger of bias and its practical implications.

BACKGROUND: Sentinel node biopsy (SNB) is an effective alternative to axillary lymph node dissection (ALD) for axillary staging. SNB (test) needs a validation period in which ALD (the gold standard) is always performed. Sensitivity, specificity and predictive values (PV) are used to define the accuracy of the procedure. We hypothesise that, during the period of validation, a bias is produced if the result of SNB is included as a part of the ALD. PATIENTS AND METHODS: A hypothetical population of 350 patients was analysed. First analyses were performed by including the sentinel lymph node as a part of 'the rest of the axilla'. Second analyses were re-done according to our theory, and sentinel lymph node was considered outside 'the rest of the axilla'. Sensitivity, specificity and PV were compared for both models. RESULTS: First group (classic) - sensitivity: 94%; specificity: 100%; positive PV: 100%; negative PV: 97%. Second group (new proposed model) - sensitivity: 87%; specificity: 81%; positive PV: 44%; negative PV: 97%. CONCLUSION: The classic concept of sentinel lymph node to calculate sensitivity, specificity and positive PV can result in a bias. The magnitude of this bias will vary in terms of the obtained values, but its direction is always optimistic.

Peritonitis por quiste mesentérico / Peritonitis due to a mesenteric cyst

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