Ruptured infective native thoracic aortic aneurysm treated by endovascular repair as a bridge therapy to open repair.

We report the case of a 70-year-old woman who presented with a ruptured infective native thoracic aortic aneurysm (INTAA), associated with spondylodiscitis and posterior mediastinitis. She underwent a staged hybrid repair: urgent thoracic endovascular aortic repair was first performed as a bridge therapy in the context of septic shock. Allograft repair using cardiopulmonary bypass was performed five days later. Given the complexity of INTAA, multidisciplinary teamwork was paramount to determine the most appropriate treatment strategy, including procedure planning with multiple operators as well as perioperative care. Therapeutic alternatives are discussed.

Isthmic spondylolisthesis treated with circumferential arthrodesis (ALIF and posterior fixation): correction, fusion and indirect decompression.

There is no consensus regarding the choice of the surgical technique for isthmic spondylolisthesis treatment, although they all aim to a common goal, achieving fusion at the index level while restoring an appropriate lordosis and remove potential radicular compression. Analyze outcome of circumferential arthrodesis (CA) with ALIF (Anterior Lumbar Interbody Fusion) and pedicle screw fixation for the treatment of all-grade isthmic spondylolisthesis, with indirect neurological decompression. Retrospective study of isthmic spondylolisthesis treated with CA, with one-year follow-up. Clinical scores were collected at one year: VAS-L, VAS-R and ODI. Pelvic parameters, L4-S1 lordosis and at index and adjacent levels, and lumbo-sacral angle (LSA) were measured pre- and post-operatively and at last follow-up. Foraminal surface and diameters were measured pre- operatively and at follow-up on CT-Scan. Level of evidence: IV. 87 patients were included. Mean VAS-L was 2.3, mean VAS-R was 1, and mean ODI was 13.8%. 10% of the patients presented a high-grade spondylolisthesis and 50% a grade II. Mean lordosis at index level shifted from 6° to 18°, L4-S1 lordosis increased from 37 to 45° and LSA shifted from 116 to 125° (p<0.001). The foraminal surface increased from 50mm 2 to 70mm 2 at last follow-up mostly through the supero-inferior diameter, shifting from 7.4mm to 9.5mm (p<0.001). In LSA<90° group, mean correction was 20° at index level, 13° at L4-S1 and 21° for LSA versus 11°, 8° and 8° respectively in LSA>90° group (p<0.001). Fusion rate was estimated at 96.5%. One infection, 5 sympathetic dysfunctions, one retrograde ejaculation, one iliac vein injury, one incisional hernia, one lateral femoral cutaneous nerve injury and two adjacent syndromes have been noted. CA is an efficient technique for the treatment of isthmic spondylolisthesis of all grades, with an acceptable rate of complications. It allows a restoration of the regional lordosis as well as a foraminal widening, avoiding additional decompression.

Drain or No Drain Following Pancreaticoduodenectomy: The Unsolved Dilemma.

BACKGROUND AND AIMS: There is no consensus regarding the routine placement of intra-abdominal drains after pancreaticoduodenectomy. We aim to determine the effects of intraperitoneal drain placement during pancreaticoduodenectomy on 30-day postoperative morbidity and mortality. METHODS: Patients who underwent pancreaticoduodenectomy for pancreatic tumors were identified from the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database. Univariate and multivariate analyses adjusting for known prognostic variables were performed. A subgroup analysis was performed based on the risk for development of postoperative pancreatic leak determined by the pancreatic duct caliber, parenchymal texture, and body mass index. RESULTS: A total of 6858 patients with pancreatic tumors who underwent pancreaticoduodenectomy were identified in the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database dataset. In all, 87.4% of patients had intraperitoneal drains placed. A 30-day mortality rate was higher in the no-drain group (2.9% vs. 1.7%, P = 0.003). Patients in the drain group had a higher incidence of overall morbidity (49.5% vs. 41.2%, P = 0.0008), delayed gastric emptying (18.1% vs. 13.7%, P = 0.004), pancreatic fistulae (19.4% vs. 9.9%, P ⩽ 0.0001), and prolonged length of hospital stay over 10 days (43.7% vs. 34.9%, P < 0.0001). Subgroup analysis based on risk categories revealed a higher 30-day mortality rate in the no-drain group among patients with high-risk features (3.1% vs. 1.6%, P = 0.02). Delayed gastric emptying and pancreatic fistula development remained significantly higher in the drain group only in the high-risk category. Prolonged length of hospital stay and composite morbidity remained higher in the drain group regardless of the risk category. CONCLUSION: To our knowledge, this is the largest study to date that aims at clarifying the pros and cons of the intraperitoneal drain placement during pancreaticoduodenectomy for pancreatic tumors. We showed a higher 30-day mortality rate if drain insertion was omitted during pancreaticoduodenectomy in patients with softer pancreatic textures, smaller pancreatic duct caliber, and body mass index over 25. Postoperative 30-day morbidity rate was higher if a drain was inserted regardless of the risk category. Further randomized controlled trials with prospective evaluation of stratification factors for fistula risk are needed to establish a clear recommendation.

Do Curve Characteristics Influence Stenosis Location and Occurrence of Radicular Pain in Adult Degenerative Scoliosis?

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The aim of this study was to describe the various locations of spinal stenosis (LSS) in lumbar scoliosis and its related clinical symptoms. INTRODUCTION: Adults with lumbar scoliosis often present with pain and disability. Association of scoliosis and stenosis is not rare, but remains sparsely explored. Consequences of scoliosis on stenosis location and treatment remain debatable. METHODS: Patients operated for symptomatic LSS with lumbar scoliosis (Cobb angle >20°) from 2015 to 2016 were included. All patients completed preoperative clinical and neurologic examination. Coronal and sagittal radiographic parameters, rotatory subluxation (RS), and spondylolisthesis were analyzed on full spine radiographs. Computed tomographic scan multiplanar reconstructions were performed to measure central, foraminal, and lateral recess stenosis, from T10 to the sacrum. RESULTS: A total of 76 patients were included (69 ± 9 years old, 77% female). Sixty percent had neurogenic claudication, and L5 was the most common radicular pain (41%). The mean Cobb angle was 33° ± 16°. Overall, 35 (46%) patients had coronal malalignment; in 69%, side of the coronal tilt corresponded to side of the concavity of the lumbosacral curve. Sixty patients had RS (most frequent level L3-L4). In 50% of the cohort, RS was located at the junction between the lumbar and lumbosacral curves. In 70% (n = 53) of the patients, central stenosis occurred at the junction between the lumbar and lumbosacral curves. Foraminal and lateral stenosis were most frequently observed in the concavity of the distal lumbosacral curve. L5 radicular pain was significantly more frequent in case of lumbosacral contra-curve and right coronal malalignment. CONCLUSION: LSS is frequent in lumbar scoliosis. Relationships exist between curve characteristics and symptomatic LSS in lumbar scoliosis; especially, concavity of the lumbosacral contra-curve and the junctional level between the lumbar curve and the lumbosacral contra-curve. Therefore, accurate analysis of stenosis in ASD seems mandatory, to at least perform decompression because perfect planned treatment for stenosis and scoliosis correction might not always be possible because of the patient's general health status. LEVEL OF EVIDENCE: Level 4.

Change of signs, symptoms and voice quality evaluations throughout a 3- to 6-month empirical treatment for laryngopharyngeal reflux disease.

OBJECTIVE: To assess the usefulness of voice quality measurements as a treatment outcome in patients with laryngopharyngeal reflux (LPR)-related symptoms. DESIGN: Prospective uncontrolled multi-centre study. MATERIAL AND METHODS: A total of 80 clinically diagnosed LPR patients with a reflux finding score (RFS)>7 and a reflux symptom index (RSI)>13 were treated with pantoprazole and diet recommendations during 3 or 6 months, according to their evolution. RSI; RFS; blinded Grade, Roughness, Breathiness, Asthenia, Strain and Instability (GRBASI) and aerodynamic and acoustic measurements were evaluated at baseline, 3 months (n = 80), and 6 months (n = 41) post-treatment. We conducted a correlation analysis between the adherence to the diet, and the evolution of both signs and symptoms and between videolaryngostroboscopic signs and acoustic measurements. RESULTS: Reflux symptom index, RFS, perceptual voice quality evaluations (dysphonia, roughness, strain and instability), and aerodynamic and acoustic measurements (ie, percent jitter and percent shimmer) were significantly improved at 3 months post-treatment but not at 6 months. Percent jitter was the most useful outcome for evaluating the clinical evolution of patients throughout the treatment course. A significant relationship between globus sensation and posterior commissure hypertrophy was documented; both seemed to significantly improve from 3 to 6 months. The correlation analysis revealed correlations between adherence to diet recommendations and the improvement of symptoms and between posterior commissure granulation severity and acoustic measurement impairments. CONCLUSION: Voice quality improved in a manner similar to both signs and symptoms throughout a 6-month empirical treatment with better improvement the 3 first months. Voice quality assessments can be used as indicators of treatment effectiveness in patients with LPR-related symptoms.

Isolated and stable gallbladder perforation in a 5 year old child after blunt abdominal trauma.

Isolated gallbladder injury, secondary to a blunt abdominal trauma, is a rare finding in children. The presence of vague symptoms and the unknown dynamic of the trauma may increase the diagnostic challenge especially in pediatrics. A conservative management has been proposed in some particular cases in adults, but remains controversial in children. We report a case of a 5 year old boy who presented an isolated gallbladder lesion secondary to a blunt abdominal trauma. The surgical treatment was delayed for non-medical reasons, which gave us the possibility to try a conservative approach.

Neurological deficit secondary to a pre-sacral abscess with epidural extension up to L3: A case report and literature review.

Isolated epidural abscesses are uncommon lesions. Surgical treatment may be difficult due to the extension of these lesions. We present a case of a pelvic abscess spreading along the path of the sciatic nerve to the gluteus muscles and the lumbar canal, causing neurological compression; requiring surgical treatment with three simultaneous approaches.

Safety of a thickened extensive casein hydrolysate formula.

OBJECTIVES: Cow's milk allergy (CMA) is treated in formula-fed infants with an extensive protein hydrolysate. This study aimed to evaluate the nutritional safety of a non-thickened and thickened extensively casein hydrolyzed protein formula (NT- and T-eCHF) in infants with CMA. METHODS: Infants younger than 6 mo old with a positive cow milk challenge test, positive IgE, or skin prick test for cow milk were selected. Weight and length were followed during the 6 mo intervention with the NT-eCHF and T-eCHF. RESULTS: A challenge was performed in 50/71 infants with suspected CMA and was positive in 34/50. All children with confirmed CMA tolerated the eCHF. The T-eCHF leads to a significant improvement of the stool consistency in the whole population and in the subpopulation of infants with proven CMA. Height and weight evolution was satisfactory throughout the 6 mo study. CONCLUSIONS: The eCHF fulfills the criteria of a hypoallergenic formula and the NT- and T-eCHF reduced CMA symptoms. Growth was within normal range.

Opioid-free anesthesia: what about patient comfort? A prospective, randomized, controlled trial.

BACKGROUND: We investigated the effect of a pern-operative opioid-free approach on postoperative patient comfort in patients undergoing breast cancer surgery. SUBJECTS AND METHODS: From September 2014 to July 2015, 66 female patients of the Belgian Oncology Institut Jules Bordet were recruited. They were randomized into two groups: the first group received anesthesia with opioids for their breast cancer surgery, and the second group received opioid-free anesthesia. Patient comfort was evaluated 24 hours postoperatively through the QoR-40 score, with a difference of 15 points considered as being clinically relevant. Postoperative analgesia was provided through a piritramide patient-controlled analgesia device, during the first 24 hours. The hypothesis of this study was that opioid-free anesthesia would improve quality of recovery after anesthesia. RESULTS: A statistically significant difference in postoperative QoR-40 score was observed between groups [Mean (SD) QoR-40 of 182.1/200 (13.9) in the opioid-free group, and 175.6/200 (14.80) in the opioid group; P = 0.04]. The clinical relevance of this finding is questionable, insofar as the difference of 15 points was not met. A statistically significant difference in postoperative piritramide usage was observed (8.1 (6.6) in the opioid-free group, and 13.1 (9.4) in the opioid group; P = 0.03). CONCLUSIONS: This randomized controlled trial shows, for the first time, equal comfort during the immediate postoperative period in patients having received opioid-free and conventional anesthesia for their breast cancer surgery. Opioid-free anesthesia in this indication appears safe, and may be associated with slightly reduced pain during the first 24 postoperative hours.

Solitary cavernous lymphangioma of the duodenum: a case report.

Duodenal lymphangioma is an extremely rare benign tumor of the gastrointestinal tract. In this case report, we describe the case of a 39-year-old Lebanese female with cystic lymphangioma of the duodenum diagnosed by exploratory laparotomy and immunohistochemical analysis. Herein our findings are described.

Portomesenteric venous gas: A late complication of pneumatosis intestinalis.

BACKGROUND: The pneumatosis intestinalis is an entity with multiple aetiologies and may be associated with a fatal outcome when present on plain radiographs. When associated with the presence of portomesenteric venous gas (PMVG) it is typically the result of bowel ischaemia. METHODS AND RESULTS: We are presenting a case of a 43 year old male who presented with a two days history of haematemesis, generalised abdominal pain and distension. Computed tomography (CT) scan revealed a gross amount of air within the portal venous system and small bowel dilatation to the level of distal ileum was also seen with associated pneumatosis intestinalis. Emergency laparotomy was conducted which demonstrated a simple band adhesion resulting in bowel ischaemia. The patient was making a good post-operative recovery complicated only by sub-therapeutic treatment of schizophrenia. CONCLUSION: The presence of gas within the portal venous system and PI in adults can indicate severe life-threatening disease. This requires early surgical intervention in those patients with a clinical suspicion of bowel ischaemia, and with radiological signs. This may avoid significant mortality.

[Transgender voice and communication treatment: Review of the literature]. / La prise en charge communicationnelle chez les patients transsexuels.

Transgender persons constitute a small but growing population in ENT department: as a matter of fact, many voice parameters significantly contribute to the perception of gender (fundamental frequency, supraglottic resonance patterns, etc.). The persons involved in transition processes may therefore aim at changing their own voice properties, either by means of speech therapy or by medical intervention (hormonotherapy and/or surgery). The current voice assessment and outcome measures for this population before and after treatment are nevertheless still lacking validity. A well-accepted general framework including self-perception, subjective assessment of the practitioner and objective measures is not well documented. This review is therefore meant as a contribution to the development of a state of the art in the field.

[Pathophysiology, assessment and treatment of laryngopharyngeal reflux]. / Physiopathologie, évaluation et traitement du reflux laryngopharyngé.

Laryngopharyngeal reflux is a prevalent, yet incompletely understood, ENT disorder accounting for 8 to 10% of patients consulting ENT. This clinical entity, increasingly considered as different from gastroesophageal reflux disease, may greatly affect the quality of life of patients through vocal and digestive symptoms. Debate persists concerning pathophysiology, diagnosis, and treatment. The aim of this review is to study the current literature about the pathophysiology, diagnosis, treatment, and the outcomes in the follow-up.

Hip fracture incidence in Lebanon: a national registry-based study with reference to standardized rates worldwide.

UNLABELLED: Crude incidence rates for hip fractures in individuals aged 50 and above in Lebanon were determined using data from the national hip fracture registry. For the years 2006-2008, crude rates varied between 164 and 188/100,000 for females and between 88 and 106 per 100,000 for males. Using the US 2000 white population as a reference, the calculated age-standardized rates were closest to rates derived for southern Europe. INTRODUCTION: Owing to the demographic explosion, it is projected that the rates of hip fractures would increase the most in the Middle East and Asia. Few are the population-based studies investigating the incidence of hip fractures in the region. METHODS: Using the Ministry of Health registry data, this population-based study evaluated the incidence of hip fractures in individuals aged 50 and above in Lebanon for the years 2006, 2007, and 2008. RESULTS: Hip fracture crude incidence rates varied across the years between 164 and 188 per 100,000 for females and between 88 and 106 per 100,000 for males, with a female/male ratio of 1.6-2.1. The overall mean age (SD) for hip fractures was 75.9 (9.2), 76.8 (9.0), and 77.0 (9.9) years in females in 2006, 2007, and 2008, respectively, and 74.4 (11.6), 76.3 (10.3), and 74.0 (12.1) years in males, respectively. Using the US 2000 white population as a reference, the age-standardized rates were 370.4, 335.1, and 329.0 for females and 109.7, 134.1, and 128.7 for males, for the years 2006, 2007, and 2008, respectively. CONCLUSIONS: The hip fracture age-standardized incidence rates in the Lebanese subjects receiving Ministry of Health coverage were lower than those found in northern Europe and the US and closest to rates derived for southern Europe.

2009 Melbourne metropolitan sewerage strategy: a portfolio of decentralised and on-site concept designs.

The bulk and retail water companies of the greater Melbourne area are developing the 2009 Metropolitan Sewerage Strategy to provide sustainable sewerage services to 2060. The objective of the strategy is to establish long term principles and near term actions to produce a robust sewage management system for Melbourne. Melbourne's existing sewerage system is largely centralised and discharges to two major treatment plants. Several small satellite treatment plants service local urban areas generally more distant from the centralised system. Decentralised and on-site wastewater systems are options for future sewage management and could play a role in local recycling. A portfolio of 18 on-site and decentralised concept designs was developed, applicable to the full range of urban development types in Melbourne. The concepts can be used in evaluation of metropolitan system configurations as part of future integrated water cycle planning. The options included secondary and tertiary treatment systems incorporating re-use of water for non potable uses, urine separation, black and greywater separation and composting toilets. On-site and cluster treatment systems were analysed. Each option is described by its indicative capital and operating costs, energy use and water and nutrient balances. This paper summarises and compares the portfolio mix of decentralized and on-site options in Melbourne's context.

Organ donation after cardiac death in the Middle East.

INTRODUCTION: The shortage of organ donors along with the increased number of waiting recipients have created the need for new strategies to expand the organ pool: living donors, split livers, domino livers, and organs from donations after cardiac death (DCD). The purpose of this article was to focus upon aspects of DCD application in the religious, traditional, ethical, and legal aspects of the Arab world. BACKGROUND: DCD can increase the donor pool by 15%-25%. Several ethical, legal, and social concerns need to be addressed to make DCD more widely accepted by the general population in Western countries as well as in the Middle East. Organs from DCD donors have been transplanted since the 1960s. As soon as brain death criteria were published in 1968, organ retrieval from cadaveric heart-beating donors predominated. Donation after brain death (DBD) almost completely replaced DCD. In the 1990s, the organ shortage led to DCD in many countries, but not in the Arab world. DCD is still not accepted by most in the Arab world due to religious, ethical, social, and legal issues. CONCLUSION: DCD in the Arab world is more complicated than in Western countries. It should be re-evaluated and thoroughly reviewed with the new criteria for DCD and its implementation in our region.