Breast cancer surgery decreases serum brain-derived neurotrophic factor concentrations in middle aged women: relationship to the serum C-reactive protein concentration.

The aim of this study was to establish the effect of breast cancer surgery in middle aged women on the serum (s) and plasma (p) brain-derived neurotrophic factor concentrations [BDNF]s and [BDNF]p, respectively, in relation to the serum C-reactive protein [CRP]s concentration measured before and at 24 hours after surgery. Eighteen patients with recently diagnosed breast cancer (mean ± SE): age 49.1 ± 1.6 years, body mass 69.8 ± 2.2 kg, BMI 25.8 ± 0.8 kg m-2, participated in this study. The [BDNF]s before the surgery amounted to 25 523 ± 1 416 pg ml-1. At 24 h after the surgery it decreased to 21 551 ± 998 pg ml-1 (P = 0.004). This decrease was accompanied by a significant (P = 0.001) decrease in the platelet count (PLT) from 254.7 ± 12.2 k µl-1 before, to 228.8 ± 9.7 k µl-1 after the surgery. The [CRP]s increased from 3.59 ± 0.79 mg l-1 before to 25.04 ± 4.65 mg l-1 after the surgery (P = 0.002). A significant positive correlation was found between the [BDNF]s and the PLT both before (P = 0.003) as well as after the surgery (P = 0.027). Moreover, a significant positive correlation (P = 0.046) was found between [BDNF]s and the [CRP] s before the surgery. At 24 h after the surgery the [BDNF]s and the [CRP]s still correlated positively (P = 0.044), despite the fact that the surgery significantlly decresed the [BDNF]s and increased [CRP]s. No significant effect of the surgery on the [BDNF]p was found. We have concluded that serum BDNF concentration in breast cancer patients positively correlates with serum CRP both before and at 24 h after the surgery. Moreover, breast cancer surgery decreases serum BDNF concentration at 24 h after operation and increases [CRP]s.

Surgical repair versus conservative treatment and subacromial decompression for the treatment of rotator cuff tears: a meta-analysis of randomized trials.

AIMS: The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff. MATERIALS AND METHODS: PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: Six studies were included. Surgical repair resulted in a statistically significantly better Constant-Murley Score (CMS) at one year compared with conservative treatment (mean difference 6.15; p = 0.002) and subacromial decompression alone (mean difference 5.81; p = 0.0004). In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair. CONCLUSION: The results of this review show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients. However, the magnitude of the difference in outcomes between surgery and conservative treatment may be small and the 'success rate' of conservative treatment may be high, allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery. Cite this article: Bone Joint J 2019;101-B:1100-1106.

Is sarcopenia a better predictor of complications than body mass index? Sarcopenia and surgical outcomes in patients with rectal cancer.

AIM: Sarcopenia, or a reduction of lean muscle mass, is associated with poorer outcomes in cancer patients. Few previous studies have examined this potentially correctable risk factor in patients with locally advanced rectal cancer. METHOD: Skeletal muscle mass index was measured retrospectively on initial staging CT scans of patients undergoing chemoradiation followed by radical resection for rectal cancer for the period 2007-2013. Patients were categorized as sarcopenic or nonsarcopenic and differences in terms of demographics, pre-, peri- and postoperative outcomes were examined. RESULTS: Forty-seven patients were included; their mean age was 59.3 (36-82) years and 61.7% were men. We considered that 55.2% of men and 44.4% of women were sarcopenic; the overall prevalence of sarcopenia was 51.1%. Age, preoperative haemoglobin and albumin were significantly related to sarcopenia. Body mass index (BMI) and obesity (BMI > 30 kg/m2 ) were not associated with sarcopenia. Blood transfusions were more frequent in sarcopenic patients (P = 0.001). Although readmissions and length of stay were not increased, overall postoperative complications were significantly higher in sarcopenic patients (P = 0.03). Neither BMI nor obesity was associated with postoperative complications. CONCLUSION: Sarcopenia was present in over 50% of patients with locally advanced rectal cancer at diagnosis. It was associated with a higher incidence of both blood transfusion and postoperative complications. BMI did not correlate with these negative outcomes. Sarcopenia may be a better predictor of surgical outcomes than BMI or obesity.

Same-day and delayed hospital discharge are associated with worse outcomes following total knee arthroplasty.

AIMS: To evaluate the influence of discharge timing on 30-day complications following total knee arthroplasty (TKA). PATIENTS AND METHODS: We identified patients aged 18 years or older who underwent TKA between 2005 and 2016 from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. We propensity score-matched length-of-stay (LOS) groups using all relevant covariables. We used multivariable regression to determine if the rate of complications and re-admissions differed depending on LOS. RESULTS: Our matched cohort consisted of 76 246 TKA patients (mean age 67 years (sd 9)). Patients whose LOS was zero and four days had an increased risk of major complications by an odds ratio (OR) of 1.8 (95% confidence interval (CI) 1.0 to 3.2) and 1.5 (95% CI 1.2 to 1.7), respectively, compared with patients whose LOS was two days. Patients whose LOS was zero, three, and four days had an increased risk of minor complications (OR 1.8 (95% CI 1.3 to 2.7), 1.2 (95% CI 1.0 to 1.4), and 1.6 (95% CI 1.4 to 1.9), respectively), compared with patients whose LOS was two days. In addition, a LOS of three days increased the risk of re-admission by an OR of 1.2 (95% CI 1.0 to 1.3), and a LOS of four days increased the risk of re-admission by an OR of 1.5 (95% CI 1.3 to 1.6), compared with a LOS of two days. CONCLUSION: Patients discharged on days one to two postoperatively following TKA appear to have reduced major and minor complications compared with discharge on the day of surgery, or on days three to four. Prospective clinical data are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B(7 Supple C):70-76.

Duration of surgery affects the risk of complications following total hip arthroplasty.

AIMS: The aim of this study was to assess the influence of operating time on 30-day complications following total hip arthroplasty (THA). PATIENTS AND METHODS: We identified patients aged 18 years and older who underwent THA between 2006 and 2016 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We identified 131 361 patients, with a mean age of 65 years (sd 12), who underwent THA. We used multivariable regression to determine if the rate of complications and re-admissions was related to the operating time, while adjusting for relevant covariables. RESULTS: The mean operating time decreased from 118.3 minutes (29.0 to 217.0) in 2006, to 89.6 minutes (20.0 to 240.0) in 2016. After adjustment for covariables, operating times of between 90 and 119 minutes increased the risk of minor complications by 1.2 (95% confidence interval (CI) 1.1 to 1.3), while operating times of between 120 and 179 minutes increased the risk of major complications by 1.4 (95% CI 1.3 to 1.6) and minor complications by 1.4 (95% CI 1.2 to 1.5), and operating times of 180 minutes or more increased the risk of major complications by 2.1 (95% CI 1.8 to 2.6) and minor complications by 1.9 (95% CI 1.6 to 2.3). There was no difference in the overall risk of complications for operating times of between 20 and 39, 40 and 59, or 60 and 89 minutes (p > 0.05). Operating times of between 40 and 59 minutes decreased the risk of re-admission by 0.88 (95% CI 0.79 to 0.97), while operating times of between 120 and 179 minutes, and of 180 minutes or more, increased the risk of re-admission by 1.2 (95% CI 1.1 to 1.3) and 1.6 (95% CI 1.3 to 1.8), respectively. CONCLUSION: These findings suggest that an operating time of more than 90 minutes may be an independent predictor of major and minor complications, as well as re-admission, following THA, and that an operating time of between 40 and 90 minutes may be ideal. Prospective studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B(6 Supple B):51-56.

Influence of Polypharmacy on the Quality of Life in Stable Kidney Transplant Recipients.

BACKGROUND: Kidney transplant recipients are frequently treated for other medical conditions and experience polypharmacy. The aim of our study was to evaluate quality of life in relation to medicines' burden in these patients. METHODS: We studied 136 unselected patients with mean post-transplant time of 7.2 ± 4.6 years. Quality of life was evaluated using a validated Polish version of the Kidney Disease Quality of Life-Short Form questionnaire. Data concerning the type (generic name) and number of currently prescribed medications were collected by interview survey. The participants were divided into 3 groups: group 1, patients with a maximum of 4 different medications (n = 37); group 2, patients with 4 to 9 medications (n = 76); and group 3, patients receiving at least 10 different medications (n = 23). RESULTS: The number of medicines taken regularly ranged from 2 to 16. Patients with ≥10 drugs had the highest body mass index and lowest estimated glomerular filtration rate. Patients treated with ≥10 drugs, compared to patients from the 2 other groups, had presented lower subscales results concerning the physical functioning (65.9 vs 84.5 in group 1 and 83.4 in group 2, P < .001 for both comparisons), pain (57.2 vs 82.7 and 76.5, respectively, P < .001 for both), social function (66.8 vs 82.1 and 80.4, respectively, P = .04 for both), and energy/fatigue (54.8 vs 67.7, P = .03 and 65.4, P < .05). Multivariate regression analysis revealed that the number of drugs independently influenced physical functioning, pain, and social function subscales. CONCLUSIONS: Polypharmacy is associated with lower quality of life in patients after successful kidney transplantation. The negative impact of polypharmacy is particularly seen regarding physical functioning and pain severity.

Parylene-based flexible neural probes with PEDOT coated surface for brain stimulation and recording.

Implantable neural prosthetics devices offer a promising opportunity for the restoration of lost functions in patients affected by brain or spinal cord injury, by providing the brain with a non-muscular channel able to link machines to the nervous system. Nevertheless current neural microelectrodes suffer from high initial impedance and low charge-transfer capacity because of their small-feature geometry (Abidian et al., 2010; Cui and Zhou, 2007). In this work we have developed PEDOT-modified neural probes based on flexible substrate capable to answer to the three critical requirements for neuroprosthetic device: efficiency, lifetime and biocompatibility. We propose a simple procedure for the fabrication of neural electrodes fully made of Parylene-C, followed by an electropolymerization of the active area with the conductive polymer PEDOT that is shown to greatly enhance the electrical performances of the device. In addition, the biocompatibility and the very high SNR exhibited during signal recording make our device suitable for long-term implantation.

Exogenous melatonin abolishes mechanical allodynia but not thermal hyperalgesia in neuropathic pain. The role of the opioid system and benzodiazepine-gabaergic mechanism.

Melatonin (MT) is a neurohormone synthesized and secreted by the pineal gland. MT plays an important role in the regulation of physiological and neuroendocrine functions. The purpose of this study was to assess the overall effect of melatonin on neuropathic pain, the type of melatonin receptor involved, and potential role of the opioid system and GABA(A) receptors. The experiments were conducted by using the animal neuropathic pain model (CCI). The rats with CCI showed the characteristic for the mechanical allodynia and thermal hyperalgesia signs that were calculated by using the von Frey's and Hargreaves' tests. The conducted studies measured the effects of intraperitoneal administration of naloxone (opioid antagonist), prazosin (MT3 antagonist), luzindole (MT1/MT2 receptor antagonist), picrotoxin (GABA(A) antagonist) and flumazenil (benzodiazepine antagonist) on the antinociceptive effects caused by melatonin. Melatonin caused the increase in the pain threshold of the mechanical allodynia and the slight increase in the threshold of the thermal hyperalgesia. The pre-treatment with naloxone completely abolished the antinociceptive effects of melatonin in von Frey's test, but not thermal sensation in the Hargreaves's test. Prazosin did not have any effects, while administration of luzindole significantly suppressed the antinociceptive effect of melatonin. The antiallodynic effect of MT was also abolished by flumazenil and picrotoxin. Melatonin influences the mechanical allodynia but not thermal hyperalgesia via activation of opioid system and benzodiazepine-GABAergic pathway. Antinociceptive effects of melatonin are mostly related to the MT1/MT2 receptors interaction.

Raman microspectroscopy of organic inclusions in spodumenes from Nilaw (Nuristan, Afghanistan).

The color varieties of spodumene (green spodumene, kunzite) from Nilaw mine (Nuristan, Afghanistan) have been investigated by microthermometry and Raman spectroscopy analyses. These minerals are rich in primary and secondary fluid inclusions. Measured values of temperature homogenization (T(h)) and pressure (P) for selected fluid-inclusion assemblages (I-IV) FIA in green spodumene and (I-II) FIA in kunzite ranges from 370 to 430°C, 1.16 to 1.44 kbar and 300 to 334°C, 0.81 to 1.12 kbar, respectively. The brine content and concentration varies from 4.3 to 6.6 wt.% eq. NaCl. Numerous and diverse mineral phases (quartz, feldspars, mica, beryl, zirconium, apatite, calcite, gypsum) present in this mineral as solid inclusions were studied by Raman microspectroscopy. Raman spectra of selected fluid, organic and solid inclusions were collected as line or rectangular maps and also depth profiles to study their size and contents. There appeared very interesting calcite (156, 283, 711 and 1085 cm(-1)), beryl (324, 397, 686, 1068 and 3610 cm(-1)), topaz (231, 285, 707, 780 and 910 cm(-1)) and spodumene (355, 707 and 1073 cm(-1)) inclusions accompanied by fluid and/or organic inclusions (liquid and gas hydrocarbons) with bands at 2350 cm(-1) (CO(2), N(2)), 2550 cm(-1) (H(2)S) and 2900 cm(-1) (C(2)H(6)-CH(3)). Some solid inclusions contain carbonaceous matter (D-band at ca. 1320 cm(-1) and/or G-band at ca. 1600 cm(-1)).

[An interesting case: recovery of a transmurally penetrated abdominal pad by the means of laparoscopy]. / Der interessante Fall: Laparoskopisch unterstützte Bergung eines transmural penetrierten Bauchtuches.

Lymphangiomas are rare benign tumors. In most cases, resection is necessary to obtain a precise histopathological analysis. There are capillary, caverous and cystic lymphangiomas. The therapy of choice is a complete excision. Recurrence has been reported after incomplete resection. We present the case of a 45-year-old man with a lymphangioma of the omentum minus and -review the literature.

Dementia in a retired world boxing champion: case report and literature review.

OBJECTIVE: Dementia in retired boxers, also referred to as "dementia pugilistica" (DP), is usually attributed to repeated concussive and subconcussive blows to the head. We report the case of a former world boxing champion whose progressive cognitive decline could be ascribed to DP, cerebral infarcts and Wernicke-Korsakoff syndrome. This case demonstrates that dementia in retired boxers may be caused and/or exacerbated by etiologic factors other than DP. MATERIALS AND METHODS: We correlated the clinical features with the histochemical and immunohistochemical changes observed on autopsy brain material from a retired boxer, reviewed the literature on boxing-related dementia, and compared our findings with previous reports on DP. RESULTS: Neuropathologic examination revealed numerous neurofibrillary tangles (NFTs), rare neuritic plaques (NPs), multiple cerebral infarcts, fenestrated septum pellucidum, atrophic and gliotic mamillary bodies, and pale substantia nigra and locus ceruleus. CONCLUSIONS: Our neuropathologic data confirmed the notion that dementia in retired boxers could be due to several factors such as DP, multiple cerebral infarcts and Wernicke-Korsakoff syndrome. Our findings illustrate the need to comprehensively examine former boxers with dementia as well as carefully evaluate the neuropathologic changes that may cause or contribute to the patient's cognitive and behavioral symptoms. Such an approach is crucial in order to provide prompt and more definitive therapies.

[A rare splenic involvement by Echinococcus multilocularis - case report]. / Ein aussergewöhnlicher Milzbefall durch Echinococcus multilocularis - eine Kasuistik.

In the present case an 81-year-old patient was operated upon for a suspected atraumatic spleen rupture. During the operation a spleen abscess was found. Histological examination of the removed spleen revealed an Echinococcus multilocularis infection. There was no sign of further organ involvement: surprisingly the liver was not affected. Case history, clinical outcome and the prescribed treatment are described. A short overview of the Echinococchus multilocularis syndrome is presented.

Low plasma dehydroepiandrosterone sulfate level and its relationship to adiponectin in hemodialysis patients.

The aim of the present study was to assess the relationship between plasma DHEA-S and adiponectin concentrations in hemodialyses patients (HD). Plasma adiponectin, DHEA-S, cholesterol, and albumin levels were estimated in 94 HD and 46 healthy subjects (HS). In HD, a significantly lower plasma DHEA-S concentration (2.5+/-0.2 vs. 4.7+/-0.4 micromol/L respectively; p = 0.002) but significantly higher plasma adiponectin level (15.0+/-0.7 vs. 8.7+/-0.8 microg/mL respectively; p = 0.004) than in HS were found. Only in uremic patients was a significant negative correlation found between plasma adiponectin and DHEA-S concentrations (tau = -0.210; p = 0.001). Decreased plasma DHEA-S level is associated with increased adiponectinemia in uremic patients.

Melatonin and serotonin effects on gastrointestinal motility.

The gastrointestinal tract represents the most important extra pineal source of melatonin. Presence of melatonin (M) suggests that this hormone is somehow involved in digestive pathophysiology. Release of GI melatonin from serotonin-rich enterochromaffin EC cells of the GI mucosa suggest close antagonistic relationship with serotonin (S) and seem to be related to periodicity of food intake. Food deprivation resulted in an increase of tissue and plasma concentrations of M. Its also act as an autocrine and paracrine hormone affecting not only epithelium and immune system but also smooth muscle of the digestive tract. Low doses M improve gastrointestinal transit and affect MMC. M reinforce MMCs cyclic pattern but inhibits spiking bowel activity. Pharmacological doses of M delay gastric emptying via mechanisms that involve CCK2 and 5HT3 receptors. M released in response to lipid infusion exerts a modulatory influence that decreases the inhibitory effects of the ileal brake on gastric emptying. On isolated bowel S induces dose dependent increase in tone and reduction in amplitude of contraction which is affected by M. M reduced the tone but not amplitude or frequency of contraction. M is a promising therapeutic agent for IBS with activities independent of its effects on sleep, anxiety or depression. Since of its unique properties M could be considered for prevention or treatment of colorectal cancer, ulcerative colitis, gastric ulcers and irritable bowel syndrome.

Crossmodal audio-visual interactions in the primary visual cortex of the visually deprived cat: a physiological and anatomical study.

Blind individuals often demonstrate enhanced non-visual perceptual abilities. Neuroimaging and transcranial magnetic stimulation experiments have suggested that computations carried out in the occipital cortex may underlie these enhanced somatosensory or auditory performances. Thus, cortical areas that are dedicated to the analysis of the visual scene may, in the blind, acquire the capacity to participate in other sensory processing. However, the neural substrate that underlies this transfer of function is not fully characterized. Here we studied the synaptic and anatomical basis of this phenomenon in cats that were visually deprived by dark rearing, either early visually deprived after birth (EVD), or late visually deprived after the end of the critical period (LVD); data were compared with those obtained in normally reared cats (controls). The presence of synaptic and spike responses to auditory stimulation was examined by means of intracellular recordings in area 17 and the border between areas 17 and 18. While none of the cells recorded in control and LVD cats showed responses to sound, 14% of the cells recorded in EVD cats showed both subthreshold synaptic responses and suprathreshold spike responses to auditory stimuli. Synaptic responses were of small amplitude, but well time-locked to the stimuli and had an average latency of 30+/-12ms. In an attempt to identify the origin of the inputs carrying auditory information to the visual cortex, wheat germ agglutinin-horseradish peroxidase (WGA-HRP) was injected in the visual cortex and retrograde labeling examined in the cortex and thalamus. No significant retrograde labeling was found in auditory cortical areas. However, the proportion of neurons projecting from supragranular layers of the posteromedial and posterolateral parts of the lateral suprasylvian region to V1 was higher than that in control cats. Retrograde labeling in the lateral geniculate nucleus showed no difference in the total number of neurons between control and visually deprived cats, but there was a higher proportion of labeling in C-laminae in deprived cats. Labeled cells were not found in the medial geniculate nucleus, a thalamic relay for auditory information, in either control or visually deprived cats. Finally, immunohistochemistry of the visual cortex of deprived cats revealed a striking decrease in pavalbumin- and calretinin-positive neurons, the functional implications of which we discuss.

["Iatrogenic acute coronary syndrome"--59 year old patient with adenocarcinoma of ascending colon and stenocardia while receiving adjuvant chemotherapy with 5-fluorouracil]. / ,,Das iatrogene akute Koronarsyndrom"--59-jähriger Patient mit Adenokarzinom des Colon ascendens und Stenokardien unter adjuvanter Chemotherapie mit 5-Fluorouracil.

Fluorouracil-associated cardiotoxic adverse events represent a relevant but underestimated problem in 5-fluorouracil treatment. After right hemicolectomy for adenocarcinoma of the rightsided colonic flexure a 59-year old patient was referred to our hospital for adjuvant chemotherapy according to MOSAIC-protocol with oxaliplatin and 5-fluorouracil. The patient's history was unremarkable for any cardiopulmonary disease and for any cardiovascular risk factors. 24 hours after completing the first cycle the patient was readmitted to our emergency department because of thoracic pain combined with significantly elevated cardiac enzymes and ischaemic changes in ECG. Coronary angiography was performed revealing no coronary artheriosclerosis. Clinical symptoms and pathological ischaemic serum parameters returned to normal range within 12 hours. Diagnosis of 5-FU-induced acute coronary syndrome could be made. Because of the high rate of recurring cardiotoxicity the patient's chemotherapy was modified to an alternative regimen containing raltitrexed instead of 5-fluorouracil. Immediate diagnosis of 5-FU-induced cardiotoxicity and differentiation from preexisting coronary heart disease is still a major problem in daily oncological practice.

[Prospective multicenter trial of gastric cancer surgery--a contribution to clinical research on quality control]. / Prospektive Multizenterstudie zur Chirurgie des Magenkarzinoms--Ein Beitrag zur klinischen Versorgungsforschung.

By the mean of a prospective multicenter observational study (East German Gastric Cancer Study - EGGCS), 1 139 consecutive patients with gastric cancer were enrolled in 80 East German surgical departments from January 1 to December 31, 2002. Out of them, 1,031 (90.5%) underwent surgical intervention. The resection rate was 86.4% (n = 891); the R0 resection rate (n = 726) was 81.5%. Gastrectomy was performed in 79.8 % (n = 649) of subjects with radical resections (n = 813). In approximately 70 % of the interventions with curative intention, lymph node resection of the D2 compartment was carried out. The postoperative hospital mortality was 8.3%. The results were compared with the data obtained in the German Gastric Cancer Study (GGCS 1992); relevant differences and aspects were discussed.

Slow adaptation in fast-spiking neurons of visual cortex.

Fast-spiking (FS) neurons are a class of inhibitory interneurons classically characterized as having short-duration action potentials (<0.5 ms at half height) and displaying little to no spike-frequency adaptation during short (<500 ms) depolarizing current pulses. As a consequence, the resulting injected current intensity versus firing frequency relationship is typically steep, and they can achieve firing frequencies of < or =1 kHz. Here we have investigated the properties of FS neurons discharges on a longer time scale. Twenty second discharges were induced in electrophysiologically identified FS neurons by means of current injection either with sinusoidal current or with square pulses. We found that virtually all FS neurons recorded in cortical slices do show spike-frequency adaptation but with a slow time course (tau = 2-19 s). This slow time course has precluded the observation of this property in previous studies that used shorter pulses. Contrary to the classical view of FS neurons functional properties, long-duration discharges were followed by a slow afterhyperpolarization lasting < or =23 s. During this postadaptation period, the excitability of the neurons was decreased on average for 16.7 +/- 6.8 s, therefore rendering the cell less responsive to subsequent afferent inputs. Slow adaptation is also reported here for FS neurons recorded in vivo. This longer time scale of adaptation in FS neurons may be critical for balancing excitation and inhibition as well as for the understanding of cortical network computations.

Long-term follow-up and patient satisfaction after surgery for thoracic outlet syndrome.

The purpose of this study was to review the long-term outcomes, particularly patient satisfaction, of patients surgically treated for thoracic outlet syndrome (TOS). All patients who had undergone surgery for TOS at the University of Iowa Hospitals and Clinics between 1988 and 1999 were reviewed. A retrospective chart review of 29 patients (36 operations) was performed. In addition, 20 (69%) of the patients were able to be contacted for a phone survey. There was no operative mortality. Specific neurologic complications occurred in 4/36 operations (11%) including one brachial plexus traction palsy, two phrenic nerve palsies, and one long thoracic nerve palsy. All nerve palsies were either mild or temporary. Mean follow-up was 4 years. On phone survey, 80% of the patients were actively employed. Twenty-seven percent reported that they had an excellent result, 58% reported they had a good result, 8% reported that they had a fair result, and 8% had a poor result. If they had it to do over again, 85% of the patients would have the same surgery again for relief of TOS.

Ambulatory 24-hour double-probe pH monitoring: the importance of manometry.

OBJECTIVE: Historically, manometry has been used for sphincter localization before ambulatory 24-hour double-probe pH monitoring to ensure accurate placement of the probes. Recently, direct-vision placement (DVP), using transnasal fiberoptic laryngoscopy (TFL), has been offered as an alternative technique. Presumably, DVP might be used to precisely place the proximal (pharyngeal) pH probe; however, using DVP, there appears to be no way to accurately position the distal (esophageal) probe. The purpose of this study was to evaluate the accuracy of DVP for pH probe placement using manometric measurement as the gold standard. METHODS: Thirty patients undergoing pH monitoring participated in this prospective study. Each subject underwent manometric examination of the esophagus to determine the precise location of the upper and lower esophageal sphincters (UES and LES). In addition, external anatomic landmarks were used to estimate interprobe distances. A physician blinded to the manometry results then placed a pH catheter using DVP so that the proximal probe was located just above the UES. The results were recorded and compared with those obtained by manometry. RESULTS: Accurate DVP of the proximal pH probe was achieved in 70% (23 of 30) of the subjects. The use of external anatomic landmarks to estimate interprobe distance resulted in accurate positioning of the distal probe in only 40% (12 of 30) of the subjects. Using fixed interprobe distances of 15 cm and 20 cm, distal probe position accuracy was 3% (1 of 30) and 40% (12 of 30), respectively. Therefore, using DVP, the distal esophageal probe was in an incorrect position in 60% to 97% of subjects. CONCLUSION: For double-probe pH monitoring, the proximal probe can be accurately positioned by DVP; however, there is no precise way to determine the interprobe distance required to correctly position the distal pH probe. Failure to accurately position the distal probe results in grossly inaccurate esophageal acid-exposure times. Thus, manometry is needed to ensure valid double-probe pH monitoring data.