Towards a pituitary apoplexy classification based on clinical presentation and patient journey.

PURPOSE: The condition of pituitary apoplexia contains the clinical spectre from life-threatening emergency to asymptomatic self-limiting course, which partly determines diagnostic delay and management. Outcome evaluation of course and management of pituitary apoplexia is hampered by the diverse presentation of this condition and requires appraisal. This study aimed to describe the patient journey, clinical presentation, and management of various types of pituitary apoplexy in a new classification to facilitate future outcome evaluation and identify unmet needs in the care process. METHODS: A single-center retrospective patient chart study was conducted between 2005-2021 (N = 98). Outcome measures were clinical symptoms at first presentation in hospital, being headache, consciousness, visual acuity, visual field defects (VFD), ophthalmoplegia, nausea, vomiting, fever, and hypopituitarism and care process characteristics. RESULTS: Mean age was 47.6 ± 16.6 years (51.0% male). We describe their patient journey and identified three different types, differing in clinical presentation, in-hospital route, and final treatment, e.g., Acute (type A, 52%), Subacute (type B, 22.5%), and Non-acute (type C, 25.5%). Type A generally presents with acute onset headaches, VFD, or ophthalmoplegia emergency setting, with lowest mean visual acuity of both eyes and frequent hypocortisolism. CONCLUSIONS: Pituitary apoplexy can be approached as a spectrum of disease with 3 main subtypes, with a different initial presentation, different in-hospital route resulting in different management. Acknowledging subtypes with particular needs for (emergency) referrals to Pituitary Tumors Center of Excellence (PTCOE) will serve patient care improvements, outcome evaluations and address areas for improvement.

[An adolescent with inability to bear weight on his knee after a jump]. / Een jongen met een onbelastbare knie na een sprong.

A 15-year-old boy sustained a left tuberositas tibiae avulsion fracture as a result of jumping. This type of fracture typically occurs in adolescent boys during sports.

Morbidity and quality of life after continent ileostomy in the Netherlands.

BACKGROUND: Continent ileostomy (CI) after proctocolectomy is an alternative technique compared to an ileal pouch-anal anastomosis (IPAA). The question arises as to whether this technique is valuable. The aim of this study was to evaluate the role of the continent ileostomy, by patient follow-up satisfaction and quality of life assessment. METHOD: Twenty-eight patients with a continent ileostomy operated between 1996 and 2007 were compared with patients who received an IPAA or a conventional ileostomy. SF-36 and EORTC QLC-CR38 questionnaires and a specific continent ileostomy questionnaire were used to assess differences and patient satisfaction. RESULTS: The quality of life in patients with a CI is not significant better or worse than patients with either a conventional ileostomy or an IPAA. On three scales (sexual enjoyment, gastro-intestinal tract symptoms and male sexual problems) statistically significant differences were reported. Overall, nearly all patients are very satisfied with the CI. All patients would make the same decision again and would recommend this procedure to other patients. CONCLUSION: The continent ileostomy remains to be a suitable alternative for the preservation of continence after a proctocolectomy, especially when an ileal pouch-anal anastomosis is not an option. If a choice has to be made between a CI and conventional ileostomy good preoperative counselling is necessary to make a well founded decision. To minimize complications, these procedures have to be performed in centres with specific expertise. Therefore, knowledge about the CI should be preserved for the future.

Rupture of true aneurysms of the pancreaticoduodenal arcade: treatment with transcatheter arterial embolization.

We present 2 cases of ruptured true aneurysms of the pancreaticoduodenal arcade, underscoring the role of transcatheter arterial embolization (TAE) as the initial treatment of choice in pancreaticoduodenal arcade aneurysm. Ruptured true aneurysms of the pancreaticoduodenal artery (PDA) are uncommon and few cases have been reported, whereas false aneurysms are seen more often. The first patient we describe is a 63-year-old woman with an aneurysm of the PDA initially treated by TAE. The second case is a 67-year-old woman with an aneurysm of the inferior PDA post-operatively treated by TAE. In both patients TAE via a combined superior mesenteric artery and celiac axis approach was successful. Follow-up contrast-enhanced computed tomography showed prolonged occlusion of both aneurysms. A review of the literature concerning TAE supports our experience that TAE of ruptured aneurysms of the pancreaticoduodenal arcade, when feasible, is at least as effective as conventional surgery, but with lower morbidity and mortality. Therefore, TAE should be the initial treatment of choice in this group of patients.

The efficacy of robot-assisted versus conventional laparoscopic vascular anastomoses in an experimental model.

BACKGROUND: Robot-assisted surgery is thought to facilitate complex laparoscopic movements, enhancing advanced laparoscopic procedures. OBJECTIVE: To evaluate the benefit of robotic assistance for laparoscopic vascular surgery. DESIGN: Experimental study using prosthetic conduits in a laparoscopic training box. METHODS: Two surgeons each performed 40 laparoscopic vascular anastomoses alternating with and without robotic assistance. A Zeus-Aesop surgical Robotic system trade mark with 3-D visualisation was used. Each surgeon made 40 anastomoses in total, using different prostheses (5 mm PTFE and 16 mm Dacron) and suture material (Prolene and PTFE). A time-action analysis was performed to evaluate surgical performance. Primary efficacy parameters were quality and leakage of the anastomosis, total time and total number of actions. RESULTS: Equal quality scores and anastomotic leakage were achieved with both techniques. Robotic assistance resulted in significant longer suture and knot tying time and significant more actions were needed compared to the manual laparoscopic procedures. Significant more failures occurred during the robot-assisted procedures. CONCLUSION: In this study, robotic (Zeus-Aesop) assistance did not improve the laparoscopic performance of the surgeon whilst making vascular anastomoses.

Outcome of palliative embolization of bone metastases in differentiated thyroid carcinoma.

We investigated the effects of selective embolization in patients with symptomatic bone metastases of differentiated thyroid carcinoma. A total of 41 embolizations was performed in 16 patients. We studied the follow-up (range, 2 months to 8.6 yr) after the first embolization by evaluation of clinical symptoms and tumor dimensions. Success was defined as an improvement in clinical symptoms without tumor progression. The procedure was successful in 24 of 41 occasions (59%). Twenty-six embolizations were preceded or followed up by additional therapies, consisting of surgery (laminectomy), external irradiation, or radioiodine. Subgroup analysis revealed that these additional therapies did not influence the success rate; however, a potential effect on success duration may be present: for embolizations without additional radioiodine or external irradiation therapy, the median success duration was 6.5 months; for embolizations combined with additional radioiodine or external irradiation, this was 15 months (P = 0.0146). The ultimate outcome of the patients was unfavorable: nine patients died and five patients have progressive disease. We concluded that selective embolization of bone metastases may be considered a palliative therapy that may induce rapid, but transient, relief of symptoms. Combination with radioiodine or external irradiation may prolong the duration of success.