Results of decompression of four medial ankle tunnels in the treatment of tarsal tunnels syndrome.

Controversy surrounds the surgical approach and efficacy for tibial nerve compression at the ankle. The hypotheses tested are that the poor published results are due to failure to recognize that the tarsal tunnel is analogous to the forearm, not the carpal tunnel, and that postoperative ankle immobilization contributes to poor results by permitting fibrosis of the tibial nerve branches. From January of 1987 through December of 1994, a consecutive series of 77 patients with tarsal tunnel syndrome was accrued, 10 of whom had the condition bilaterally. The surgical approach included a neurolysis of the tibial nerve in the tarsal tunnel and the medial, lateral plantar, calcaneal nerves in their own tunnels. Postoperatively, immediate weight bearing and ambulation were permitted in a bulky cotton dressing. The dressing was removed at 1 week. For the 87 legs, mean follow-up after surgery was 3.6 years. Utilizing the traditional postoperative assessment, there were 82% excellent, 11% good, 5% fair, and 2% poor results. Utilizing a numerical grading scale, there was a statistically significant improvement at the P<0.001 level for sensory and also for motor impairment. Recognition that decompression of four medial ankle tunnels and immediate postoperative mobilization of the tibial nerve through ambulation is necessary results in a high level of success for patients with tarsal tunnels syndrome.

Altered expression of TFF-1 and CES-2 in Barrett's Esophagus and associated adenocarcinomas.

Identification of biomarkers to recognize individuals with Barrett's esophagus (BE) predisposed to develop malignancy is currently a pressing issue. We utilized gene expression profiling to compare molecular signatures of normal esophagus and stomach, BE, and adenocarcinoma (AC) to identify such potential biomarkers. Over 22,000 genes were analyzed by oligonucleotide microarrays on 38 unique RNA Unsupervised and supervised clusterings were performed on a subset of 2849 genes that varied most significantly across the specimens. Immunohistochemistry (IHC) for two of the significantly differentially expressed gene products was performed on tissue microarrays. Unsupervised clustering identified two discernable molecular BE profiles, one of which was similar to normal gastric tissue ("BE1"), and another that was shared by several of the AC specimens ("BE2"). The BE1 profile included expression of several genes that have been described as tumor-suppressor genes, most notably trefoil factor 1 (TFF-1). The BE2 profile included expression of genes previously found overexpressed in cancers, such as carboxylesterase-2 (CES-2). IHC demonstrated the loss of TFF-1 late in the progression of BE to AC. It also revealed CES-2 as being upregulated in AC documented to have arisen in the presence of BE. These potential biomarkers, as well as the relative expression of genes from BE1 versus those from BE2, may be validated in the future to aid in risk stratification and guide treatment protocols in patients with BE and associated AC.

Prospective evaluation of pancreatic sphincterotomy as a precut technique for biliary cannulation.

BACKGROUND & AIMS: Pancreatic sphincterotomy has been described as an effective technique to obtain biliary access after standard methods fail. This prospective study evaluates its efficacy and compares its complication rate to conventional biliary sphincterotomy (BS). METHODS: Between January 2001 and January 2004, patients in whom biliary cannulation failed underwent a pancreatic precut sphincterotomy (PPS) and were analyzed prospectively. Multivariate analysis was performed on the following variables with regard to their ability to predict successful biliary cannulation: age, gender, time to access bile duct after precut (< or =10 or >10 minutes), final diagnosis, and operator. Complications of PPS were then compared with those resulting from endoscopic retrograde cholangiopancreatography with BS in 120 patients examined during the same period of time and matched by sex, gender, and disease process. RESULTS: One hundred sixteen patients (50 male), mean age 58 +/- 16 years, underwent PPS. Immediate biliary access was achieved after pancreatic precut in 99 cases (85%). Complications occurred in 14 patients (12%): 3 (2.6%) postsphincterotomy bleeding, 9 (8%) pancreatitis (8 mild, 1 moderate), and 2 (1.7%) retroperitoneal perforation managed conservatively. The factor statistically associated with successful biliary cannulation was the amount of elapsed time between completing the PPS and obtaining biliary access. No statistical difference was identified in the complication rate of pancreatitis between the PPS and BS groups. CONCLUSIONS: PPS is an effective precut technique to facilitate biliary cannulation. Success is correlated to the speed of biliary access after precut. In expert hands, its rate of pancreatitis is similar to endoscopic retrograde cholangiopancreatography with BS.

Safety and efficacy of ERCP in pregnancy.

BACKGROUND: Choledocholithiasis during pregnancy increases the risk of morbidity and mortality for both fetus and mother because of cholangitis and pancreatitis. ERCP has been advocated as safe and effective in pregnant women, but fetal radiation exposure is not routinely monitored. The aim of this study was to record fetal exposure to ionizing radiation during ERCP and to assess outcome. METHODS: Seventeen ERCPs were performed in pregnant women between January 1995 and August 2003. Techniques to minimize fluoroscopy were used, and fluoroscopy times were recorded. Thermoluminescent dosimeters affixed to the skin of the mother were used to estimate fetal radiation exposure. OBSERVATIONS: Mean gestational age was 18.6 (8.9) weeks (range 5-33 weeks). Mean fluoroscopy time was 14 (13) seconds (range 1-48 seconds). Estimated fetal radiation exposure was 40 (46) mrad (range 1-180 mrad). There was a correlation between fluoroscopy time and radiation exposure, but there was a wide range of radiation exposure for individual fluoroscopy times. Complications included post-sphincterotomy bleeding in one patient (controlled by hemoclip placement) and post-ERCP pancreatitis in one patient that necessitated 3 days of hospitalization. Two women developed third-trimester preeclampsia, and labor was induced in both. Thirteen of the 15 patients who delivered were contacted and they confirmed that their child was in good health. CONCLUSIONS: ERCP with modified techniques is safe during pregnancy. Dosimetry should be routinely recorded.

Total knee arthroplasty for patellofemoral arthritis.

BACKGROUND: Multiple treatment methods have been advocated for patellofemoral arthritis. The purpose of the present study was to report on our experience with the use of total joint replacement for the treatment of primarily severe patellofemoral arthritis of the knee in patients more than fifty-five years of age. METHODS: Between January 1980 and December 1994, thirty knee replacements were performed in twenty-seven patients for the treatment of arthritis that primarily involved the patellofemoral joint. The Ahlbück radiographic evaluation scale was used to grade the severity of arthritis; the mean score was 4.83 points (range, 4 to 5 points) for the patellofemoral compartment and 0.6 point (range, 0 to 1 point) for both the medial and lateral compartments. The patients included eighteen women and nine men who had a mean age of seventy-three years (range, fifty-nine to eighty-eight years). None of the patients had had any prior procedures on the knee, but all had been treated for a minimum of six months with nonoperative measures. The mean preoperative Knee Society score was 50 points (range, 20 to 64 points). RESULTS: At a mean duration of follow-up of eighty-one months (range, forty-eight to 133 months), there were twenty-eight excellent, one good, and one poor result. The mean Knee Society objective score was 93 points (range, 67 to 100 points). The poor result was in a patient who sustained a rupture of the patellar tendon postoperatively as the result of a fall, which necessitated a tendon reconstruction. CONCLUSION: Total knee arthroplasty was found to be a viable treatment option in patients more than fifty-five years of age with primarily severe patellofemoral disease.