Safety and clinical efficacy of Onyx for embolization of extracranial head and neck vascular anomalies.

BACKGROUND AND PURPOSE: Onyx was developed for embolization of central nervous system AVMs but is increasingly used extracranially because of its unique physical properties. We review our experience and results with the use of Onyx for the treatment of fast-flow extracranial vascular lesions. MATERIALS AND METHODS: We retrospectively analyzed clinical and imaging records of 22 patients who underwent 71 extracranial embolizations from March 2007 through January 2010. The diagnoses were the following: cervicofacial AVM (n = 18), traumatic fistula (n = 3), and vessel laceration (n = 1). In 62 of 71 procedures (87%), Onyx was the sole embolic agent; it was delivered transarterially in 67/71 and percutaneously in 4/71 procedures. Clinical goals included amelioration of pain and control of bleeding. The clinical efficacy of embolization was judged by symptom control, and adverse events were assessed by clinical examination and history, both postembolization and 4 weeks postprocedure. RESULTS: Cessation of acute bleeding was achieved in 13/14 cases, with 1 case of immediate recurrent massive epistaxis prompting reintubation and further embolization. Control of subacute bleeding episodes and pain was achieved for all patients. Following staged embolization, 7 patients underwent surgical resection without significant blood loss. Surgeons reported high satisfaction with the intraoperative handling properties of Onyx. Transient swelling, local tenderness, or numbness was encountered after 7 procedures. There were no stuck catheters, vessel dissections, or vessel ruptures and no skin discoloration. CONCLUSIONS: Staged Onyx embolization was clinically efficacious in managing extracranial fast-flow vascular malformations and lesions, with low associated morbidity.

Laparoscopic splenectomy for massive splenomegaly using a Lahey bag.

BACKGROUND: Although the recent development of hand-assisted laparoscopic surgery (HALS) has made the laparoscopic retraction of large spleens feasible, the laparoscopic removal of massively enlarged spleens (>1,000 g) remains a significant problem because these spleens do not fit into endoscopic bags. Consequently, in order to remove massive spleens either a large abdominal incision or morcellation of the spleen outside of an endoscopy bag is required. METHODS: Two patients, with spleens weighing 2,510 g and 1,720 g, underwent laparoscopic splenectomy using a hand port to ensure safe retraction. The massive spleen was placed into a Lahey bag that was inserted into the abdomen through the hand port site. While in the Lahey bag, the spleen was removed piecemeal through the hand port site. RESULTS: Both operations were completed laparoscopically without complications. The patients were discharged on postoperative day 2 and experienced minimal morbidity. CONCLUSIONS: The Lahey bag facilitates laparoscopic splenectomy for massive splenomegaly as even the most massive spleens will fit into a Lahey bag. A massive spleen may be removed piecemeal from the Lahey bag through the small hand port incision without risking a large abdominal incision, splenosis, or the insertion of a morcellator.

Lluis Barraquer-Roviralta (1855-1928): Spanish neurologist described progressive lipodystrophy.

Lluis Barraquer-Roviralta, a Spanish neurologist, described the syndrome of progressive lipodystrophy in 1907. This syndrome was subsequently known as Barraquer's syndrome. The main feature of Barraquer's syndrome is the progressive atrophy of the subcutaneous fat of the face. Plastic surgeons are familiar with Barraquer's name because they often correct the facial deformity associated with Barraquer's syndrome. Although plastic surgeons recognize Barraquer for his description of progressive lipodystrophy, his main contributions were to the field of neurology. Barraquer, who is considered the founder of the specialty of neurology in Spain, contributed to the start of neurosurgery in Spain, as well. Barraquer was an expert in diseases of the peripheral nervous system and developed medicines to treat tabes dorsalis. His drawings and photographs of the nervous system were unparalleled. His iconographic collection helped to define the anatomy and pathology of numerous neurological diseases. His pictures were featured in the main neurology textbook of the time and are presently housed in the Museum of Medical History in Spain. During his career at the University of Barcelona Barraquer was well known for his lecturing ability and for training the first neurologists in Spain. In addition to describing progressive lipodystrophy, Barraquer also was the first to describe the grasp reflex of the foot, now known as Barraquer's reflex. Of his remarkable accomplishments, Barraquer is best remembered for his description of two phenomena that now bear his name, Barraquer's reflex and Barraquer's syndrome. Although Lluis Barraquer-Roviralta's main contributions were to the field of neurology, his description of progressive lipodystrophy in 1907 will forever endear him to future generations of plastic surgeons.

Laparoscopically assisted ileocolectomy for Crohn's disease through a pfannenstiel incision.

Recently, laparoscopically assisted bowel resections have been shown to be less morbid than the traditional laparotomy, especially for benign conditions such as Crohn's disease. While reports describing laparoscopically assisted bowel resections use a small midline or right transverse incision, we describe a novel laparoscopically assisted approach employing a Pfannenstiel incision for Crohn's patients. We attempted the Pfannenstiel incision since it is well known to be associated with less postoperative pain, decreased ileus and hospital stay, and low rates of wound infection and incisional hernia, compared with midline or right transverse incisions. Furthermore, we found that the Pfannenstiel incision offers additional advantages that may be uniquely suited for Crohn's patients. First, the cosmetic position of the incision is particularly attractive to the young population affected by Crohn's. Second, the Pfannenstiel incision preserves fresh tissue in the midline, right, and left lower quadrants in the event that reoperation or stoma placement are required in the future owing to recurrent disease. We describe our technique in 10 consecutive patients undergoing ileocolectomy for Crohn's disease. Our patients experienced minimal morbidity and were pleased with the cosmetic results of their incisions.

Removal of dairy soil from heated stainless steel surfaces: use of ozonated water as a prerinse.

Square (2.54 x 2.54 cm2) 304 stainless steel metal plates were cleaned, passivated, and soiled by autoclaving (121 degrees C at 15 psi for 15 min) with reconstituted nonfat dry milk (20% solids). Fifteen-minute treatments using either warm water (40 degrees C) or ozonated cold water (10 degrees C) were conducted to compare prerinse cleaning potential of soiled metal plates. The chemical oxygen demand determination was performed on extracted organic material from treated metal plates. Results indicated that the ozone treatment removed 84% of soil from metal plates versus 51% soil removal by the warm water treatment, but the effectiveness of the two treatments did not differ (P > 0.05). Cleaning effects were visualized using scanning electron microscopy at 200x and 2000x magnification. The amount of soil film present on stainless steel metal surfaces was visibly lower on ozonated treatments versus on warm water treatments.

Organic acids and volatile flavor components evolved during refrigerated storage of kefir.

Kefir samples were prepared and transferred to sterile jars for storage at 4 degrees C. After 0, 7, 14, and 21 d of storage, the pH, organic acid, and volatile flavor component content were determined to monitor possible flavor changes during storage. Stored samples were analyzed for organic acid (orotic, citric, pyruvic, lactic, uric, acetic, propionic, butyric, and hippuric) content by HPLC with UV detection at 275 nm. Acetoin, ethanol, acetaldehyde, and diacetyl were monitored using gas chromatography equipped with a headspace autosampler. There was no significant decrease in average pH of samples between d 0 and 21 of storage (P>0.05). Lactic acid concentration increased during storage, reaching a maximum of 7739 ppm by d 21. Orotic and citric acids increased slightly during storage. Although pyruvic and hippuric acids are produced during fermentation, neither was detected during storage. Acetic, propionic, and butyric acids were not detected during kefir storage. Ethanol concentrations increased during storage and reached 0.08% by d 21. The amounts of acetaldehyde and acetoin, common flavor substances in many cultured dairy products, increased during fermentation. Acetaldehyde content in kefir samples doubled from d 0 to 21, reaching a final concentration of 11 microg/g. During storage, the concentration of acetoin decreased from 25 ppm on d 0 to 16 ppm on d 21. However, diacetyl, another common flavor component in cultured dairy products, was not detected during fermentation or storage.

Is sestamibi-guided parathyroidectomy really cost-effective?

BACKGROUND: Sestamibi-guided limited neck explorations are an alternative to the standard bilateral neck exploration for patients with primary hyperparathyroidism. A recently published meta-analysis by Denham and Norman (JACS vol.186, 1998) suggested that a sestamibi-directed approach offers a cost benefit because it decreases operative and recovery room times, hospital stay, and the number of frozen sections needed. METHODS: We reviewed 41 bilateral neck explorations for primary hyperparathyroidism and compared our results with those reported by the meta-analysis to determine whether a sestamibi-directed approach is cost effective. RESULTS: Operative and recovery room times averaged 60.3 +/- 19.3 and 45 minutes, respectively. Forty six percent of the patients were treated as outpatients, and 1.21 +/- 0.57 frozen sections were obtained per case. Our standard bilateral exploration cost 47% less than the bilateral approach and 17% less than the sestamibi-directed operation calculated in the meta-analysis. There were no cases of nerve injury or permanent hypocalcemia, 98% of patients were cured, and 61% of patients did not require narcotics postoperatively. CONCLUSIONS: Sestamibi-guided parathyroidectomy may not offer any advantage over the standard bilateral exploration. In our experience, a bilateral neck exploration can be performed on an outpatient basis and at low cost, with a high success rate and minimal morbidity. Most patients do not require narcotics, and the cosmetic results are excellent.

A comparison of ozonation and chlorination for the disinfection of stainless steel surfaces.

Ozonated water and chlorinated sanitizer were compared for effectiveness against biofilms of milk spoilage bacteria. Stainless steel plates were incubated in UHT-pasteurized milk inoculated with pure cultures of either Pseudomonas fluorescens (ATCC 949) or Alcaligenes faecalis (ATCC 337). After incubation, the plates were removed and rinsed in sterile PBS. A control rinsed stainless steel plate was swabbed and plated on standard plate count agar. A second rinsed stainless steel plate was covered and treated for 2 min with a commercial chlorinated sanitizer (dichloro-s-triazinetrione), prepared according to the manufacturer's recommendations; after treatment, the plate was rinsed twice in sterile PBS, swabbed, and plated on standard plate count agar. A third rinsed stainless steel plate from the culture was placed in ozonated deionized H2O (.5 ppm of ozone) for 10 min, rinsed twice as described, swabbed, and plated. Both ozonation and chlorination reduced bacteria populations by > 99% at initial cell densities in the range of approximately 1.24 x 10(5) to 8.56 x 10(5) cfu/cm2 for P. fluorescens and 1.53 x 10(4) to 8.56 x 10(5) cfu/cm2 for A. faecalis in milk films on stainless steel surfaces.