Roux-en-Y Reconstruction for Failed Fundoplication

Background

Redo fundoplication has acceptable outcomes in patients with failed previous fundoplications. However, a subset of patients require Roux-en-Y (RNY) reconstruction for symptom relief.

Aim

The aim of this study was to demonstrate safety and efficacy of RNY reconstruction for failed fundoplications.

Method

Retrospective review of data on patients who underwent short-limb RNY gastrojejunostomy (GJ) or esophagojejunostomy (EJ) between the years 2005 and 2007 was performed.

Results

Twenty-two patients underwent RNY reconstructions. Fourteen (64%) patients had one, six (27%) patients had two, and 2 (9%) patients had three previous anti-reflux procedures. RNY GJ was performed in 18 patients and EJ in four patients. Gastrectomy was performed in 13 of these patients. Seven patients (32%) had ten major or minor complications within the 30-day postoperative period, without any mortality observed. At a mean follow-up of 23 months, completed in 21 of these patients (95%), the average heartburn score was 0.38 (range, 0–2). The average regurgitation score was 0.23 (range, 0 to2) and the average dysphagia score was 0.7 (range, 0–2). The mean postoperative BMI was 25.4 compared to a preoperative BMI of 31.

Conclusion

RNY reconstruction with GJ or EJ for failed anti-reflux procedures is a safe, valid surgical option in difficult situations, where a redo fundoplication is either non-feasible or expected to fail. However, it is associated with higher morbidity.     

Effect of C-arm angiographic CT on transcatheter arterial chemoembolization of liver tumors

Rotational C-arm angiographic computed tomography (CT) with a flat-panel radiography unit permits three-dimensional (3D) reconstruction of soft tissues and blood vessels. The usefulness of this C-arm technique during transcatheter arterial chemoembolization (TACE) is unknown. The authors analyzed the role of the C-arm technique in 18 patients with unresectable liver tumors during TACE. The technique altered the catheter position anticipated by attending interventional radiologists in seven of the 18 patients (39%; 95% confidence interval [CI]: 20%, 61%) and improved the diagnostic confidence in the selected catheter position in 14 of the 18 patients (78%; 95% CI: 55%, 91%). The technique provides CT-like images that are useful to interventional radiologists during TACE.     

Cancer prognosis using support vector regression in imaging modality

The proposed techniques investigate the strength of support vector regression (SVR) in cancer prognosis using imaging features. Cancer image features were extracted from patients and recorded into censored data. To employ censored data for prognosis, SVR methods are needed to be adapted to uncertain targets. The effectiveness of two principle breast features, tumor size and lymph node status, was demonstrated by the combination of sampling and feature selection methods. In sampling, breast data were stratified according to tumor size and lymph node status. Three types of feature selection methods comprised of no selection, individual feature selection, and feature subset forward selection, were employed. The prognosis results were evaluated by comparative study using the following performance metrics: concordance index (CI) and Brier score (BS). Cox regression was employed to compare the results. The support vector regression method (SVCR) performs similarly to Cox regression in three feature selection methods and better than Cox regression in non-feature selection methods measured by CI and BS. Feature selection methods can improve the performance of Cox regression measured by CI. Among all cross validation results, stratified sampling of tumor size achieves the best regression results for both feature selection and non-feature selection methods. The SVCR regression results, perform better than Cox regression when the techniques are used with either CI or BS. The best CI value in the validation results is 0.6845. The best CI value corresponds to the best BS value 0.2065, which were obtained in the combination of SVCR, individual feature selection, and stratified sampling of the number of positive lymph nodes. In addition, we also observe that SVCR performs more consistently than Cox regression in all prognosis studies. The feature selection method does not have a significant impact on the metric values, especially on CI. We conclude that the combinational methods of SVCR, feature selection, and sampling can improve cancer prognosis, but more significant features may further enhance cancer prognosis accuracy.     

"Very Late" isolated para-aortic nodal recurrence of carcinoma cervix mimicking radiation-induced sarcoma

Only a minority of the patients who develop recurrence after definitive treatment for cervical cancer are detected after 5 years (late recurrence); the numbers are lesser still after 10 years (very late recurrence). Among the infrequent cases that do develop "late" and "very late" recurrence, the commonest site is the pelvis. We report an unusually rare recurrence of treated cervical cancer confined to the para-aortic nodal group after a protracted disease-free interval of 13 years. On the basis of the long disease-free interval, location of the mass at the periphery of the radiation field, and aggressive imaging appearance, a diagnosis of radiation-induced sarcoma was considered. However, the final diagnosis of isolated para-aortic nodal recurrence of cervical cancer was rendered based on the histopathological and immunohistochemistry findings, supported by the absence of disease elsewhere on whole-body imaging.     

Does laparoscopic surgery decrease the risk of atrial fibrillation after foregut surgery?

Background  Atrial fibrillation, which occurs in 12% of all major foregut surgeries, can prolong hospital stay and increase morbidity. Minimally invasive techniques in foregut surgery have been suggested to cause less tissue trauma. We examined the factors associated with new-onset atrial fibrillation after foregut surgery at our institution. Methods  We retrospectively examined the records of 154 adult patients who underwent major foregut surgery which included esophagectomy, partial or total gastrectomy, redo Heller myotomy, redo or transthoracic fundoplications. Univariate and multivariate logistic regression analysis with standard modeling techniques were performed to determine risk factors for new-onset atrial fibrillation. Results  Of the 154 patients, 14 patients developed new-onset atrial fibrillation with a higher mean age of 67.1 years (±8.8 years) versus 56.4 years (±14.1 years) (p = 0.006). Laparoscopic (p = 0.004) and nonthoracic surgeries (p = 0.01) were associated with lower risk of atrial fibrillation. Patients with atrial fibrillation had received more fluid (6.5 ± 2.8 liters versus 5.3 ± 2.0 liters) and had longer operations (370 ± 103 min versus 362 ± 142 min), none of which were statistically significant. The average intensive care length of stay of patients was longer: 7.5 ± 6.8 days versus 4.0 ± 7.1 days (p = 0.004). Multivariate analysis revealed an association of atrial fibrillation with age (OR 1.08, 95% CI 1.02–1.14, p = 0.01), and laparoscopic surgery (OR 0.09, 95% CI 0.01–0.95, p = 0.04) after adjusting for surgery type. Conclusions  Laparoscopic surgery is associated with lower risk of atrial fibrillation in foregut surgery. Development of atrial fibrillation is associated with increased length of intensive care stay. We recommend a prospective trial to confirm our findings.     

Use of the Ponseti method for recurrent clubfoot following posteromedial release

Background:

A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.

Materials and Methods:

A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.

Results:

Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.

Conclusion:

The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.     

Coupling between slow waves and sharp-wave ripples engages distributed neural activity during sleep in humans

Hippocampal-dependent memory consolidation during sleep is hypothesized to depend on the synchronization of distributed neuronal ensembles, organized by the hippocampal sharp-wave ripples (SWRs, 80 to 150 Hz), subcortical/cortical slow-wave activity (SWA, 0.5 to 4 Hz), and sleep spindles (SP, 7 to 15 Hz). However, the precise role of these interactions in synchronizing subcortical/cortical neuronal activity is unclear. Here, we leverage intracranial electrophysiological recordings from the human hippocampus, amygdala, and temporal and frontal cortices to examine activity modulation and cross-regional coordination during SWRs. Hippocampal SWRs are associated with widespread modulation of high-frequency activity (HFA, 70 to 200 Hz), a measure of local neuronal activation. This peri-SWR HFA modulation is predicted by the coupling between hippocampal SWRs and local subcortical/cortical SWA or SP. Finally, local cortical SWA phase offsets and SWR amplitudes predicted functional connectivity between the frontal and temporal cortex during individual SWRs. These findings suggest a selection mechanism wherein hippocampal SWR and cortical slow-wave synchronization governs the transient engagement of distributed neuronal populations supporting hippocampal-dependent memory consolidation.

Memory consolidation involves the transformation of newly encoded representations into long-term memory (1–3). During non-rapid eye movement (NREM) sleep, hippocampal representations of recent experiences are reactivated (4, 5), along with transient synchronization of distributed subcortical and cortical neuronal populations (6, 7). It is hypothesized that the oscillatory synchrony facilitates connections between the neuronal ensembles, stabilizing memory representations (8). The selection and synchronization of distant neuronal populations that participate in hippocampal-dependent memory consolidation are proposed to depend on the interaction between hippocampal sharp-wave ripples (SWRs, 80 to 150 Hz), traveling subcortical/cortical slow-wave activity (SWA, 0.5 to 4 Hz), and sleep spindles (SP, 7 to 15Hz), but the underlying mechanisms subserving this network engagement are unclear. Here, we investigated how hippocampal SWRs and subcortical/cortical slow waves and spindles coordinate distributed neuronal populations during memory consolidation in NREM sleep.Hippocampal SWRs are transient local field potential oscillations (20 to 100 ms; 80 to 150 Hz in humans) implicated in planning, memory retrieval, and memory consolidation (9). Several lines of evidence highlight the role of SWRs in sleep-dependent memory consolidation. First, memory reactivation in the hippocampus, cortical, and subcortical structures peaks during SWRs (4–7, 10, 11). Second, hippocampal–subcortical/cortical functional connectivity, the prerequisite for binding of anatomically distributed reactivated memory traces is enhanced around SWRs (7, 12–15). Finally, SWR suppression interferes with, while prolongation of SWR duration improves hippocampal-dependent memory consolidation (16, 17).While research converges on the notion that SWR output modulates neuronal activity across brain regions during NREM sleep, SWR events are temporally biased by phases of SWA and SWA-nested SP (18–20). SWA and SP are present in cortical and subcortical structures (21, 22), originate in frontal areas, and traverse in an orderly succession to temporal lobes and subcortical structures, including the hippocampus (18, 22–24). Indeed, SWA synchrony increases following learning, and the reduction of SWA synchrony is correlated with memory impairment (25). Finally, although SWA is ubiquitous, individual SWA trajectories are usually limited to a subset of cortical/subcortical areas, with ∼80% of these events detected in less than half of recorded locations in humans (22). Therefore, each SWR-associated SWA event could recruit and index a unique sequence of cortical and subcortical populations.In this study, we used the broadband high-frequency activity (HFA, 70 to 200 Hz) recorded from human intracranial electrodes as a metric of subcortical/cortical activity. HFA is an indirect measure of multiunit spiking from the population surrounding the electrode contact (26), estimated in the range of several hundred thousand neurons. Consistent with the hypothesized role of SWR in synchronizing distributed memory traces, we found HFA power modulation during hippocampal SWR events in ∼30% of extrahippocampal recording sites. Given the critical role of SWA in facilitating hippocampal-dependent memory consolidation (13) and their confinement to local regions (22), we hypothesize that interplay between SWA and SWRs organizes hippocampal–cortical and cortical–cortical interactions during SWR events. Indeed, we found a strong association between SWR phase locking to extrahippocampal SWA or SP and HFA modulation in the same recording site. Interestingly, while the SWR–SWA phase locking was present bilaterally, the SWR–SP phase locking was limited to the hemisphere of SWR origin. These findings suggest that coupling between the hippocampal SWRs and extrahippocampal SWA/SP drives the selection of cortical populations to participate in hippocampal–cortical communication. In addition, theoretical constructs of memory consolidation predict transient synchronization of neuronal populations in distant cortical regions during hippocampal SWRs. Based on the widespread presence of SWA during NREM sleep, SWA–SWR temporal coupling, and ability of SWA to synchronize large cortical areas, we hypothesized that the pairwise phase relation between the SWA in different cortical locations could predict the functional coupling between the local cortical populations during SWR windows. In support of the cooperative role of SWR and SWA in orchestrating cortical–cortical communication, we found that SWA phase alignments between two distant cortical sites predicted their neuronal population synchronization during individual SWR windows, manifested by temporal HFA power correlations. The amplitude of individual SWRs was another strong predictor of cortico–cortical coupling, while the combination of SWA phase difference and SWR amplitude outperformed the predictive accuracy of the phase difference or SWA amplitude individually. These results imply a recruitment mechanism by which interplay of SWA and SWRs provides communication windows for long-range interactions between distributed neuronal populations, critical for hippocampal-dependent memory consolidation.