Bioartificial liver support devices: historical perspectives

Fulminant hepatic failure (FHF) is an important cause of death worldwide. Despite significant improvements in critical care therapy there has been little impact on survival with mortality rates approaching 80%. In many patients the cause of the liver failure is reversible and if short-term hepatic support is provided, the liver may regenerate. Survivors recover full liver function and a normal life expectancy. For many years the only curative treatment for this condition has been liver transplantation, subjecting many patients to replacement of a potentially self-regenerating organ, with the lifetime danger of immunosuppression and its attendant complications, such as malignancy. Because of the shortage of livers available for transplantation, many patients die before a transplant can be performed, or are too ill for operation by the time a liver becomes available. Many patients with hepatic failure do not qualify for liver transplantation because of concomitant infection, metastatic cancer, active alcoholism or concurrent medical problems. The survival of patients excluded from liver transplantation or those with potentially reversible acute hepatitis might be improved with temporary artificial liver support. With a view to this, bioartificial liver support devices have been developed which replace the synthetic, metabolic and detoxification functions of the liver. Some such devices have been evaluated in clinical trials. During the last decade, improvements in bioengineering techniques have been used to refine the membranes and hepatocyte attachment systems used in these devices, in the hope of improving function. The present article reviews the history of liver support systems, the attendant problems encountered, and summarizes the main systems that are currently under evaluation.     

Holmium laser prostatectomy

There are three very different topics presented in this section. The authors from Tauranga, New Zealand, who write about holmium laser prostatectomy, have the largest series in the world and were the instigators of this type of treatment for BPH. They address the pros and cons of treating prostatic enlargement in this way and update the reader on the results. Urinary markers for urothelial cancer have been introduced in some numbers in recent years. That so many have been developed leaves one with the feeling that none is completely reliable. The importance to urologists of a urinary marker of any malignancy is clear, and the authors from Ankara review this interesting topic. The management of erectile dysfunction is gradually becoming less invasive and less complicated for patients, but is still very important to urologists worldwide. Many new types of treatment have been recently introduced, and there appear to be more on the way. The authors from New York review the newer agents used for the treatment of sexual dysfunction.     

Transurethral resection vs microwave thermotherapy of the prostate: a cost-consequences analysis

OBJECTIVE: To compare the costs and outcome of high-energy transurethral microwave thermotherapy of the prostate (HE-TUMT) with transurethral resection of the prostate (TURP), as the former is considered to be the best minimally invasive method for managing lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: Between January 1996 and March 1997, 144 patients were randomized to treatment with HE-TUMT (78) using the Prostatron device and Prostasoft 2.5 software (EDAP Technomed, Lyon, France), or TURP (66). At baseline and during the annual follow-up, patients were evaluated by the International Prostate Symptom Score and uroflowmetry (maximum flow rate and postvoid residual volume). Kaplan-Meier survival analyses were used to calculate the cumulative risk of re-treatment. A cost-consequences analysis was performed based on the prospective measurement of healthcare use, with costs expressed as Netherland guilders (NLG). RESULTS: During a 3-year follow-up period, the mean (95% confidence interval) risk of re-treatment was 22.9 (12.5-33.2)% and 13.2 (4.5-21.9)% for HE-TUMT and TURP, respectively (P = 0.215). The mean direct cost of treatment was 3450 (3444-3456) and 6560 (5992-7128) NLG for HE-TUMT and TURP, respectively. The mean total (including re-treatments), discounted (4%) 3-year cost for the HE-TUMT and TURP group was 5300 (4692-5908) and 7800 (7118-8482) NLG, respectively. CONCLUSIONS: In this prospective randomized trial, HE-TUMT and TURP had a comparable 3-year risk of re-treatment. Healthcare expenditure on HE-TUMT, mainly because it is an outpatient treatment, was significantly lower than for TURP.     

Temporary cardiopulmonary bypass and isolated lung ventilation for tracheal stenosis and reconstruction

A 27-yr-old lady with a past history of prolonged ventilationpresented with worsening respiratory distress caused by trachealstenosis. She required urgent tracheal resection and reconstruction.Because of the risk of an acute respiratory obstruction, spinalanaesthesia was used to establish cardiopulmonary bypass bycannulating the femoral artery and femoral vein. Adequate gasexchange was possible with full flow rate. Thoracotomy was thencarried out to mobilize the left main bronchus. After successfullysecuring an airway by intubation of the left main bronchus,cardiopulmonary bypass was discontinued and tracheal resectionand anastomosis was done under conventional one lung anaesthesia. Br J Anaesth 2003; 91: 742–4     

Esthesioneuroblastoma: the Northwestern University experience

OBJECTIVE: To review our experience with esthesioneuroblastoma, a rare malignancy of the head and neck. STUDY DESIGN: Retrospective review of Tumor Registry data. METHODS: We performed a computerized search of the Northwestern Memorial Hospital Tumor Registry database from 1981 to 2000. RESULTS: Sixteen patients with esthesioneuroblastoma were identified and analyzed. Their mean age was 42 years. Eleven of 16 patients (69%) had Kadish stage C; 8 patients (50%) had brain involvement at presentation. Craniofacial resection was performed in 13 patients (81%). Fourteen patients received either preoperative or postoperative therapy; radiation therapy was employed in 11 cases and chemotherapy in 4. The actuarial 5-year survival was 60%, and the actuarial 5-year disease-free survival was 33%, with a median follow-up of 4.3 years. Recurrences occurred at a median time of 11 months after diagnosis (2.5 mo-18 y). The first site of failure was locoregional alone in 10 of 12 patients who progressed, and in 6 patients involved the brain or the meninges. Two patients were successfully salvaged. Patients with high-grade tumors had a trend toward work survival. CONCLUSIONS: Esthesioneuroblastoma is a rare tumor that is potentially curable by surgical resection and radiation therapy. However, the rate of local failure is high, and late recurrences are not uncommon. The role of chemotherapy warrants further investigation.     

Otoplasty: an analysis of technique over a 33-year period

OBJECTIVE: To compare the merits of otoplasty technique with a diverse patient population as experienced spanning a period greater 30 years. STUDY DESIGN: A review of a series of otoplasty cases that occurred in two distinctly different clinical settings during a 33-year period. METHODS: A retrospective analysis of 211 patients undergoing otoplasty from 1969 to 1982 in a military hospital setting was compared with 118 patients receiving otoplasty from 1982 to 2002 in a university/private practice setting. The patient population consisted of 180 adults and 149 children. RESULTS: Otoplasty patients in the military setting were primarily adults, whereas those in the university/private practice setting were primarily children. In the adult population, 98.9% of patients required use of lateral conchal cartilage resection combined with a mattress suture technique. In the pediatric population, all patients required use of a mattress suture technique and in 83.2% of selected cases limited lateral conchal cartilage resection was required. CONCLUSION: Otoplasty technique involving lateral conchal cartilage resection, mattress suture fixation, or a combination of both is applicable to diverse patient populations.     

Tracheal autotransplantation as a new and reliable technique for the functional treatment of advanced laryngeal cancer

OBJECTIVES/HYPOTHESIS: Tracheal autotransplantation allows for reconstruction of extended hemilaryngectomy defects (including half of the cricoid cartilage) after resection of laryngeal or hypopharyngeal cancer. A series of 38 patients underwent the operation. The technique involved a two-stage procedure (stage 1, tracheal revascularization; stage 2, hemilaryngectomy and tracheal autotransplantation) because the trachea requires at least 2 weeks for revascularization. The objective was to improve the oncological reliability of the procedure by performing a one-stage tumor resection. STUDY DESIGN: Five patients who underwent a one-stage tumor resection are presented. They had T2 (n = 3) to T3 (n = 2) N0 laryngeal tumors. METHODS: Neck dissection, tumor resection, and tracheal revascularization were all performed during the first operation. The radial forearm fascia flap was designed with a distal fascial paddle and a proximal skin paddle. A 4-cm segment of cervical trachea was wrapped with the fascial paddle for revascularization, and the skin paddle was used for temporary closure of the extended hemilaryngectomy defect. The definitive reconstruction consisted of tracheal autotransplantation and was performed 4 months after the first procedure. Medical records were reviewed to determine time to oral intake, time to decannulation, length of hospital stay, and postoperative complications. RESULTS: After the first operation the skin paddle of the radial forearm flap succeeded in a restoration of the sphincteric function. The mean time to oral intake for solids was 9.0 days (SD = 2.6 d) and the mean length of hospital stay was 11.2 days (SD = 2.2 d). All patients were able to speak with the tracheal cannula in place. All laryngeal functions were restored after the second operation. The mean time to oral intake for solids was 8.2 days (SD = 5.2 d). The mean time to oral intake for liquids was 16.6 days (SD = 6.3 d), and the mean length of hospital stay was 9.6 days (SD = 2.3 d). The mean time to closure of the tracheostomy and removal of the gastric tube was 27.0 days (SD = 5.8 d). CONCLUSION: Tracheal autotransplantation allows for a functional treatment of advanced laryngeal cancers and is compatible with a one-stage tumor resection.     

Esthesioneuroblastoma: the University of Iowa experience 1978-1998

OBJECTIVE: Esthesioneuroblastoma is rare and the best treatment has yet to be defined. The purpose of this study is to analyze the natural history, treatment, and patterns of failure of esthesioneuroblastoma treated at one institution. METHODS: Between 1978 and 1998, 13 patients with esthesioneuroblastoma were identified using the University of Iowa Tumor Registry. All patients were staged according to Kadish criteria. Mean follow-up was 6.3 years. Six patients had 5 or more years of follow-up and four had follow-up exceeding 9.5 years. One patient was lost to follow-up at 36 months. RESULTS: No patients had Kadish stage A disease, five were stage B, and eight stage C. Overall actuarial 5- and 10-year survival rate was 61% and 24%, respectively. Disease-free survival rate at 5 and 10 years was 56% and 42%, respectively. Seven patients have died, three of intercurrent disease and three of disease progression, one with an unknown disease status. Six patients remain alive, three without evidence of disease and three have experienced a local or regional recurrence. Five patients who were initially controlled developed recurrence, three local only, one locoregional, and one regional and distant. Median time to failure was 96 months. All patients with follow-up exceeding 12 years have experienced either a local or regional recurrence. Survival after salvage therapy in these patients ranged from 3 to 12 years. CONCLUSION: Esthesioneuroblastoma has a long natural history characterized by frequent local or regional recurrence after conventional treatment. Successful retreatment can lead to prolonged survival.     

Early complications following total gastrectomy for gastric cancer

BACKGROUND: The study shows operative results with complications occurring in first 30 days after total gastrectomy for stomach cancer. METHODS: A retrospective analysis was performed using medical documentation and histological findings for 76 patients after total gastrectomy was done between 1990 and 1997. Mortality and postoperative complications were analyzed. Complications were sorted as specific and nonspecific. All operations were performed either for intestinal gastric cancer located in proximal stomach or for diffuse stomach cancer. All anastomoses were hand sewn. RESULTS: There were 43 male and 33 female patients. Postoperative mortality was 14.4%. The most frequent complications were dehiscence of the oesophago-jejunal anastomosis in 15.8% of operated patients, postoperative temperature without apparent infection in 5.2%, thrombophlebitis in 5.2%, pneumothorax in 3.9%, hepatic necrosis in one patient (1.3%), and perforation of jejunal loop with nasogastric tube in another (1.3%) ended fatally. The average postoperative intra-hospital treatment lasted 12.3 days. Dehiscence of the oesophago-enteric anastomosis, resulted in generalized peritonitis in 66.6%. Six patients succumbed as a consequence, while two survived with subphrenic and interenteric abscesses. Pneumothorax in combination with total gastrectomy was always fatal. CONCLUSIONS: Routine use of stapling surgery, subspecialization in surgery, and better early intensive care monitoring and treatment could reduce the mortality rate.     

Osteoid osteoma: technique of computed tomography-controlled percutaneous resection using standard equipment available in most orthopaedic operating rooms

Symptoms of osteoid osteoma are cured by removing the nidus. ‘En-bloc’ resection is often not successful because the nidus is hard to find and remove totally. Recently, minimally invasive procedures have been advocated for the resection of osteoid osteoma. Preceding investigators have used a set of special instruments. The nidus is best localized with computed tomography (CT). Surgery under CT control is only possible with minimal invasive procedures. A technique using standard equipment usually available in the operating room can be used successfully for CT-guided removal of the nidus. We report our preliminary results with 17 patients (12 men, 5 women) with an average age of 22 years (range 6–57 years). All patients were pain-free immediately after the operation. The average follow-up was 8.4 months (range 1–22 months) and the average operating time 75 min (range 50–130 min). Ten patients could be treated as outpatients. The average time in hospital after surgery was 1.5 days (range 1–3 days). There were two complications, one superficial wound infection and one change of operative technique to an open procedure due to a technical problem. The diagnosis could be confirmed histologically. Received: 26 July 2000