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Colonic Decompression Reduces Proximal Acute Colonic Pseudo-obstruction and Related Symptoms.
Mankaney, GN, Sarvepalli, S, Arora, Z, Kamal, A, Lopez, R, Vargo, JJ, Burke, CA
Diseases of the colon and rectum. 2020;(1):60-67
Abstract
BACKGROUND Colonoscopic decompression is performed in inpatients for management of acute colonic pseudo-obstruction. Evidence for its efficacy is limited to small descriptive studies published before the use of neostigmine for acute colonic pseudo-obstruction. Furthermore, therapeutic end points were not defined. OBJECTIVE The aim was to compare the effectiveness of colonic decompression with standard medical therapy (supportive and pharmacologic therapy) to standard medical therapy alone. DESIGN This is a retrospective, propensity-matched study. SETTING The study was conducted at a tertiary care center. PATIENTS Inpatients with first diagnosis of acute colonic pseudo-obstruction between 2000 and 2016 were selected. INTERVENTIONS The intervention group received colonic decompression as well as supportive and/or pharmacologic therapy. The control group did not receive colonic decompression. MAIN OUTCOME MEASURES The primary outcome was the resolution of overall colonic dilation on imaging 48 hours following colonic decompression or the initiation of standard medical therapy alone. Secondary outcomes included symptom improvement, colonic segment diameter percentage change, perforation, 30-day readmission, and all-cause mortality. RESULTS The standard medical therapy and colonic decompression groups included 61 and 83 patients. Of the patients who underwent colonic decompression, 47.7% had complete resolution of acute colonic pseudo-obstruction versus 19.9% of patients who underwent standard medical therapy (p < 0.001). There were no significant differences in mid or distal colon diameter reduction between groups. The 30-day readmission rate was 15.7% in the colonic decompression group versus 26.2% in the standard medical therapy group. No immediate adverse events were noted in either group. Thirty-day all-cause mortality was 8.4% for the colonic decompression group and 14.8% in the standard medical therapy group. LIMITATIONS The study was a retrospective review on a highly comorbid population. CONCLUSIONS Colonic decompression is effective compared to standard medical therapy alone for proximal colonic dilation or symptoms associated with acute colonic pseudo-obstruction. On segmental analysis, colonic decompression does not provide any additional benefit over standard medical therapy in improving transverse or distal colonic dilation. See Video Abstract at http://links.lww.com/DCR/B32. LA DESCOMPRESIÓN COLÓNICA REDUCE LA PSEUDOOBSTRUCCIÓN COLÓNICA AGUDA PROXIMAL Y LOS SÍNTOMAS RELACIONADOS.: La descompresión colonica se realiza en pacientes hospitalizados para el tratamiento de la pseudoobstrucción colónica aguda. La evidencia de su eficacia se limita a pequeños estudios descriptivos antes del uso de neostigmina para la pseudoobstrucción colónica aguda. Además, los puntos finales terapéuticos no se definieron.El objetivo fue comparar la efectividad de la descompresión colónica mas el tratamiento médico estándar (tratamiento de apoyo y farmacológico) contra el tratamiento médico estándar solamente.Este es un estudio retrospectivo de propensión coincidente.El estudio se realizó en un centro de atención de tercer nivel.Pacientes hospitalizados con diagnóstico de pseudoobstrucción colónica aguda entre 2000 y 2016.El grupo de intervención recibió descompresión colónica, así como tratamiento de apoyo o farmacológica. El grupo control no recibió descompresión colónica.La medida de resultado primaria fue la resolución de la dilatación colónica general en la imagen 48 horas después de la descompresión colónica o el inicio del tratamiento médico estándar solo. Los resultados secundarios incluyeron mejoría de los síntomas, cambio porcentual en el diámetro del segmento colónico, perforación, reingreso a los 30 días y mortalidad por cualquier causa.La terapia médica estándar y los grupos de descompresión colónica incluyeron 61 y 83 pacientes, respectivamente. El 47,7% de los pacientes con descompresión colónica tuvieron una resolución completa de la pseudoobstrucción colónica aguda frente al 19,9% de los pacientes con terapia médica estándar (p < 0,001). No hubo diferencias significativas en la reducción del diámetro del colon medio o distal entre los grupos. La tasa de reingreso a los 30 días fue del 15,7% en el grupo de descompresión colónica frente al 26,2% en el grupo de tratamiento médico estándar. No se observaron eventos adversos inmediatos en ninguno de los dos grupos. La mortalidad por cualquier causa a los 30 días fue del 8.4% para la descompresión del colon y del 14.8% en los grupos de terapia médica estándar.El estudio fue una revisión retrospectiva en una población altamente comórbida.La descompresión colónica es efectiva en comparación con el tratamiento médico estándar solo para la dilatación del colon proximal o los síntomas asociados con la pseudoobstrucción colónica aguda. En el análisis segmentario, la descompresión colónica no proporciona ningún beneficio adicional sobre el tratamiento médica estándar para mejorar la dilatación colónica transversal o distal. Vea el resumen del video en http://links.lww.com/DCR/B32.
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Short-term outcomes of a self-expandable metallic stent as a bridge to surgery vs. a transanal decompression tube for malignant large-bowel obstruction: a meta-analysis.
Matsuda, A, Yamada, T, Matsumoto, S, Sakurazawa, N, Kawano, Y, Sekiguchi, K, Matsutani, T, Miyashita, M, Yoshida, H
Surgery today. 2019;(9):728-737
Abstract
PURPOSE Preoperative intestinal decompression, using either a self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) or a transanal decompression tube (TDT), provides an alternative to emergency surgery for malignant large-bowel obstruction (MLBO). We conducted this meta-analysis to compare the short-term outcomes of SEMS placement as a BTS vs. TDT placement for MLBO. METHODS We conducted a comprehensive electronic search of literature published up to March, 2018, to identify studies comparing the short-term outcomes of BTS vs. TDT. Decompression device-related and surgery-related variables were evaluated and a meta-analysis was performed using random-effects models to calculate odd ratios with 95% confidence intervals. RESULTS We analyzed 14 nonrandomized studies with a collective total of 581 patients: 307 (52.8%) who underwent SEMS placement as a BTS and 274 (47.2%) who underwent TDT placement. The meta-analyses showed that the BTS strategy conferred significantly better technical and clinical success, helped to maintain quality of life by allowing free food intake and temporal discharge, promoted laparoscopic one-stage surgery without stoma creation, and had equivalent morbidity and mortality to TDT placement. CONCLUSIONS Although the long-term outcomes are as yet undetermined, the BTS strategy using SEMS placement could be a new standard of care for preoperative decompression to manage MLBO.
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Bilateral Common Peroneal Nerve Entrapment After Excessive Weight Loss: Case Report and Review of the Literature.
Margulis, M, Ben Zvi, L, Bernfeld, B
The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2018;(3):632-634
Abstract
We report a case of excessive weight loss causing bilateral common peroneal nerve entrapment in a 60-year-old patient. The bilateral peroneal involvement suggested a systemic cause. Excessive weight loss during a relatively short period can cause changes in the tissues surrounding the common peroneal nerve and lead to its entrapment in the peroneal tunnel. Our patient underwent successful surgical decompression with significant improvement.
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4.
Chronic Pancreatitis: Diagnosis and Treatment.
Barry, K
American family physician. 2018;(6):385-393
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Abstract
Chronic pancreatitis is an irreversible and progressive disorder of the pancreas characterized by inflammation, fibrosis, and scarring. Exocrine and endocrine functions are lost, often leading to chronic pain. The etiology is multifactorial, although alcoholism is the most significant risk factor in adults. The average age at diagnosis is 35 to 55 years. If chronic pancreatitis is suspected, contrast-enhanced computed tomography is the best imaging modality for diagnosis. Computed tomography may be inconclusive in early stages of the disease, so other modalities such as magnetic resonance imaging, magnetic resonance cholangiopancreatography, or endoscopic ultrasonography with or without biopsy may be used. Recommended lifestyle modifications include cessation of alcohol and tobacco use and eating small, frequent, low-fat meals. Although narcotics and antidepressants provide the most pain relief, one-half of patients eventually require surgery. Therapeutic endoscopy is indicated to treat symptomatic strictures, stones, and pseudocysts. Decompressive surgical procedures, such as lateral pancreaticojejunostomy, are indicated for large duct disease (pancreatic ductal dilation of 7 mm or more). Resection procedures, such as the Whipple procedure, are indicated for small duct disease or pancreatic head enlargement. The risk of pancreatic cancer is increased in patients with chronic pancreatitis, especially hereditary pancreatitis. Although it is not known if screening improves outcomes, clinicians should counsel patients on this increased risk and evaluate patients with weight loss or jaundice for neoplasm.
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Histological fibrosis may predict the failure of core decompression in the treatment of osteonecrosis of the femoral head.
Sadile, F, Bernasconi, A, Carbone, F, Lintz, F, Mansueto, G
International journal of surgery (London, England). 2017;:303-308
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Abstract
PURPOSE Osteonecrosis of femoral head (ONFH) is histopathologically characterized by necrotic areas associated with reactive fibrosis, trabecular bone remodeling and thickening zones. Our double goal was to evaluate if: 1) main ONFH risk factors were related to specific histological specimen patterns 2) different histological patterns were related to the final outcome after a core decompression (CD) procedure. METHODS This observational longitudinal cohort study respected the STROBE statement. We described a series of 41 ONFH (Ficat stage I and II) treated by CD. Specimens from core biopsies were scored according to the extension of necrosis, fibrosis, trabecular bone remodeling and thickening, and were correlated (multivariate analysis) to clinical, biological and radiological factors (age, delay between symptoms onset and surgery, alcohol, steroids, smoking, related disease, cholesterol, triglycerides, x-ray and MRI findings). Prospectively, differences in survivorship among different histological patterns were assessed (log-rank test on Kaplan-Meier curves). Minimum follow-up was 3 years. RESULTS Risk factors did not correlate with the histological pattern. The CD survival rate was progressively decreased at 36 months after surgery, thereafter, remained relatively constant (59% at 1 year, 46% at 2 years, 37% at 3 and 5 years). A survival sub-analysis showed a higher CD survivorship in patients with lower extension of fibrosis on core biopsies than patients with high fibrosis levels (log rank p = 0.019). CONCLUSIONS The extension of fibrosis on specimens from biopsies in ONFH is a predictor of the outcome of the CD, therefore it may be considered a prognostic variable. However, it did not correlate with any risk factor. Different ONFH risk factors background did not correlate with specific histological patterns.
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Update on Graves disease: advances in treatment of mild, moderate and severe thyroid eye disease.
Strianese, D
Current opinion in ophthalmology. 2017;(5):505-513
Abstract
PURPOSE OF REVIEW To report the most recent therapeutic advances of thyroid eye disease (TED) and offer general recommendations for management of TED. RECENT FINDINGS Treatment of Graves ophthalmopathy is traditionally based on the use of high doses of corticosteroids and/or radiotherapy (RT) to decrease the activity of the disease, with the subsequent proptosis, strabismus and eyelid deformites treated with different surgical procedures. In recent years, the evidence that oxidative stress plays a relevant role in exacerbating TED severity has encouraged the use of antioxydative agents such as selenium, which has shown a capacity in limiting the disease progression. In addition, reports have shown the effectiveness of biological immunosuppressive agents in the management of TED. The main advantage of these medications seems to be the long lasting effects, which may reduce recurrence, and effectiveness in steroid-resistant cases. The reported increased accuracy of imaging techniques in evaluating fat and muscle volumes may provide useful information for surgical management. SUMMARY The use of selenium, in mild TED, seems to limit disease progression without carrying the risk of relevant side-effects. Biological agents may provide an effective and long lasting block of the inflammatory activity of TED, with a possible lower risk of recurrence and reduction in the need for surgical intervention in moderate-to-severe disease. The accurate evaluation of fat and muscle volume, using a recently published algorithm for imaging, gives relevant information for preoperative assessment, allowing the customization of orbital decompression.
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Comparison Between Acrylic Cage and Polyetheretherketone (PEEK) Cage in Single-level Anterior Cervical Discectomy and Fusion: A Randomized Clinical Trial.
Farrokhi, MR, Nikoo, Z, Gholami, M, Hosseini, K
Clinical spine surgery. 2017;(1):38-46
Abstract
STUDY DESIGN Prospective, single-blind randomized-controlled clinical study. OBJECTIVE To compare polyetheretherketone (PEEK) cage with a novel Acrylic cage to find out which fusion cage yielded better clinical outcomes following single-level anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA ACDF is considered a standard neurosurgical treatment for degenerative diseases of cervical intervertebral disks. There are many options, including bone grafts, bone cement, and spacers made of titanium, carbon fiber, and synthetic materials, used to restore physiological disk height and enhance spinal fusion, but the ideal device, which would provide immediate structural support and subsequent osteointegration and stability, has not been identified yet. To overcome this, we designed a new, inexpensive Acrylic cage. MATERIALS AND METHODS A total of 64 patients were eligible to participate and were randomly allocated to undergo ACDF either with Acrylic interbody fusion cage filled with bone substitute (n=32) or PEEK cage (n=32). Nurick's grading was used for quantifying the neurological deficit. Clinical and radiologic outcome was assessed preoperatively, immediately after surgery, and subsequently at 2, 6, and 12 months of follow-up using Odom's criteria and dynamic radiographs (flexion-extension) and computed tomography scans, respectively. RESULTS There was a statistically significant improvement in the clinical outcomes of the Acrylic cage group compared with the PEEK cage group (mean difference: -0.438; 95% confidence interval, -0.807 to -0.068; P=0.016). There was a statistically significant difference in disk space height increase between the 2 groups at the 6- and 12-month follow-up. The Acrylic cage achieved higher fusion rate (good fusion) than the PEEK cage (96.9% vs. 93.8%). Intervertebral angle demonstrated a significant difference among the 2 treated groups throughout the follow-up period. CONCLUSION This study suggests that the use of Acrylic cage is associated with good clinical and radiologic outcomes and it can be therefore a good substitute for bone graft and other cages in ACDF.
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[Graves' ophthalmopathy].
Eckstein, A, Dekowski, D, Führer-Sakel, D, Berchner-Pfannschmidt, U, Esser, J
Der Ophthalmologe : Zeitschrift der Deutschen Ophthalmologischen Gesellschaft. 2016;(4):349-64; quiz 465-6
Abstract
Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease and the full clinical picture can impair the quality of life of the patients considerably. Active inflammation can often be effectively treated by intravenous steroids/immunosuppression, however does not lead to full remission, since inflammation rather quickly results in irreversible fibrosis and increase of orbital fat. Very important is the control of risk factors (smoking cessation, good control of thyroid function, selenium supplementation) to prevent progression to severe stages. Treatment should rely on a thorough assessment of activity and severity of GO. Rehabilitative surgery (orbital decompression, squint surgery, eyelid surgery) is needed in many patients to restore function and appearance. Anti-thyroid-stimulating hormone (TSH) receptor antibodies do specifically occur in these patients and correlate to the course of thyroid and eye disease. The levels of these antibodies can be used for treatment decisions at certain time points of the disease.
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No difference in long-term development of rotator cuff rupture and muscle volumes in impingement patients with or without decompression.
Ketola, S, Lehtinen, J, Elo, P, Kortelainen, S, Huhtala, H, Arnala, I
Acta orthopaedica. 2016;(4):351-5
Abstract
Background and purpose - Arthroscopic acromioplasty is still commonly used in the treatment of shoulder impingement syndrome, even though its benefits are questioned; randomized controlled studies have not shown any benefits when compared to non-operative treatment. In this randomized study, we investigated whether operative treatment protects from later rotator cuff rupture and whether it has any effect on the development of rotator cuff muscle volume. Patients and methods - 140 stage-II impingement patients were randomized to a structured exercise group (n = 70) or to an operative group (n = 70). In the operative group, arthroscopic acromioplasty was performed, after which a similar structured exercise program was begun. MRI of the shoulder was done at baseline and at 5 years. Results - There were no statistically significant differences in either the amount of perforating ruptures of the supraspinatus tendon or in the changes in muscle volume at 5 years. The grading of muscle fatty degeneration showed worse results in the operative group, but this difference was not statistically significant. Interpretation - In this study, we found that arthroscopic acromioplasty does not have any long-term benefit based on radiological findings of muscle volumes. Also, the frequency of later rotator cuff rupture was similar irrespective of whether or not surgery was performed. Acromioplasty is not justified as a treatment for dynamic shoulder impingement syndrome.
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Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression.
Kraeutler, MJ, Reynolds, KA, Long, C, McCarty, EC
Journal of shoulder and elbow surgery. 2015;(6):854-9
Abstract
BACKGROUND The purpose of this study was to compare the effect of compressive cryotherapy (CC) vs. ice on postoperative pain in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. A commercial device was used for postoperative CC. A standard ice wrap (IW) was used for postoperative cryotherapy alone. METHODS Patients scheduled for rotator cuff repair or subacromial decompression were consented and randomized to 1 of 2 groups; patients were randomized to use either CC or a standard IW for the first postoperative week. All patients were asked to complete a "diary" each day, which included visual analog scale scores based on average daily pain and worst daily pain as well as total pain medication usage. Pain medications were then converted to a morphine equivalent dosage. RESULTS Forty-six patients completed the study and were available for analysis; 25 patients were randomized to CC and 21 patients were randomized to standard IW. No significant differences were found in average pain, worst pain, or morphine equivalent dosage on any day. CONCLUSION There does not appear to be a significant benefit to use of CC over standard IW in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Further study is needed to determine if CC devices are a cost-effective option for postoperative pain management in this population of patients.