The posterior intrahepatic approach for hepatectomy or removal of segments of the liver.

We have described herein an anterior and posterior perihilar intrahepatic approach to the hepatic sheaths of the segments of the liver. This approach allows early delineation of the anatomy of the liver and we believe it is a useful addition to the techniques available for operating on the liver.     

Surgical resection of hepatocellular carcinoma in the cirrhotic liver.

A total of 80 patients with asymptomatic small hepatocellular carcinoma (HCC) associated with liver cirrhosis underwent a liver resection. The patients were divided into 4 groups according to the location of their tumor: group A (n = 9): left lateral segmentectomy or left hepatectomy, group B (n = 42): atypical partial hepatectomy on the lateral aspect of the right lobe, group C (n = 25): subsegmentectomy on either the anterior or the posterior surface of the right lobe, group D (n = 4): subsegmentectomy in the hilar area. There were two postoperative deaths (both in group D) and five cases of hospital mortality (1 case due to myocardial infarction in group C; 1 case due to bleeding esophageal varices in group B and 2 cases in group C; and 1 case due to fulminating hepatitis in group B). There was no any significant difference in tumor size, the preoperative serum bromosulfaphthalein retention rate or the postoperative peak serum conjugated bilirubin level among all the groups (p less than 0.05). The weights of the resected specimens were higher in groups A and B (259 +/- 58 g, 230 +/- 154 g) than in groups C and D (54 +/- 32 g, 37.5 +/- 15.0 g) (p less than 0.05). The amount of blood required for transfusion during surgery in group D (3,625 +/- 3,146 mL) was significantly greater than in the other three, groups (p less than 0.05); and was also greater in groups B and C (1,649 +/- 880 mL, 1,635 +/- 1,156 mL), than in group A (444 +/- 273 mL; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Assessment of pattern and treatment of intrahepatic recurrence after resection of hepatocellular carcinoma.

From 1980 to 1988, 161 patients underwent total extirpation of primary hepatocellular carcinoma. There were 18 operative or hospital deaths. Recurrence of tumor was diagnosed in 69 of the remaining 143 patients during follow-up treatment with monthly serum alpha-fetoprotein measurements and imaging studies that were performed every three months. There were 61 men and eight women whose ages ranged from 33 to 78 years. The histologic factors noted were cirrhosis of the liver in 60 patients and chronic hepatitis in nine. There were multiple or diffuse recurrences (Type A) in 34 instances, one to three nodular recurrences (Type B) in 21, marginal recurrences (Type C) in 11 and a mixed form of the latter two in three instances. Two-thirds of the recurrences were found within 1.5 years and the second peak was noted between 2.0 and 2.5 years. Sex of patient, hepatitis B virus, type of tumor, capsule, extent of hepatic resection and postoperative chemotherapy did not influence the rate of recurrence, but cirrhotic livers had a significantly higher recurrence rate. A second hepatic resection was performed upon 20 patients with a five year survival rate of 26.8 per cent. Good results were obtained by chemoembolization of the hepatic artery. Prevention and adequate treatment of intrahepatic recurrence are of paramount importance in achieving better surgical results for hepatocellular carcinoma.     

Modified technique of Pringle's maneuver in resection of the liver.

Crushing of the hepatic parenchyma with hepatic clamps to minimize blood loss during resection of the liver leads to mechanical damage of hepatocytes. Pringle's maneuver may precipitate liver failure by hepatic warm ischemia as well. Therefore, we controlled bleeding from the surface of the resection by using light compression on the hepatic parenchyma with a band while applying a hepatic arterial clamp at the hepatic hilus. This vascular control method can be done because the portal pressure is about one-tenth of the hepatic artery pressure and provides an efficient and harmless transection of the liver.     

Surgical approach to segment I for malignant tumors of the liver.

Seven complete and 13 partial resections of segment I (caudate lobe) were performed for malignant tumors. In all except one instance, removal of segment I was combined with other types of hepatic resection for technical or carcinologic reasons. Six were iterative hepatic resections for recurrent hepatic metastases. In two, the future remaining left lobe was hypertrophied by right portal venous embolization preoperatively. Hepatectomies were performed with intermittent portal triad clamping (mean total duration of 63 minutes, range of 20 to 120 minutes) and after preparation for total vascular exclusion. Associated partial resection of the inferior vena cava was necessary in three instances. Mean duration of operation was 285 minutes (range of 60 to 540 minutes) and mean blood loss was 1,749 milliliters (range of 200 to 5,200 milliliters). There was no postoperative mortality and the morbidity rate was low. Surprisingly, we discovered retrospectively that free margins were small (less than 5 millimeters) in 83 percent of the patients. Regardless of limited free margins and six iterative hepatectomies, eight patients were free of disease with a mean follow-up examination period of 19.2 months. Technical problems were different for each patient and a patient by patient adaptation was necessary. Left, right and central approaches were used accordingly. If resection of segment I associated with a right or left hepatectomy can be currently considered as a standard hepatic resection, isolated complete resection of segment I remains a real technical challenge.     

The physiological importance of cervical secretion and its role in reproduction

The physiological importance of cervical mucus is major and essential. Sterility is often due to some kind of disorder in this short genital tract, linking the vagina with the uterine cavity. The major factors facilitating the transport of spermatozoa into the uterine cavity are: 1) protection against the strong acid conditions of the vagina; 2) penetrability of the mucus only during the days in which impregnantion is possible; 3) asepsis of the uterine cavity and of the upper genital tract by means of lactoferrine, peroxidase and lysozyme; 4) selection of spermatozoa, favoring the strongest and most mobile ones; 5) selection of spermatozoa carrying the "Y" chromosome; 6) providing spermatozoa with the best possible milieu from which to draw energy; 7) protection of the male gametes against eventual phagocytosis from leucocytes; 8) creation of an intracervical reserve of spermatozoa. All these factors contribute to favor the meeting of the gametes at the best possible moment, in the best possible conditions.     

Techniques of ultrasonic dissection in resection of the liver

The ultrasonic device allows dissection of hepatic parenchyma without damage to vascular or ductal structures. With it, both standard hepatic resections and more radical ones are made safer. It is an instrument useful for hepatic operations.     

The importance of a positive approach to sexuality in sexual health programmes for unmarried adolescents in Bangladesh

This article explores the mismatch that exists between what unmarried adolescents in Bangladesh experience, want and need in regard to their sexuality and what they receive from their society, which negatively impacts on their understanding of sexuality and their well-being. The findings provide a picture of Bangladeshi adolescents' (12–18 years) sexual feelings, experiences, behaviours, anxieties and concerns – in particular in relation to desire, pleasure, sexual power, masturbation, virginity, romantic love and dating, and arranged marriage – and how socio-sexual norms and taboos influence these. Curiosity of boys and girls about sex was driven by a need and desire to know and understand, but also because it was exciting to read about and talk about sex. Young people are not just passive recipients of adult norms and messages around sexuality, but agents who actively construe meanings and navigate between what is expected from them and what they want, need and feel themselves. Adolescents have a need for information and support – long before they ever have sex. We call for a positive, rights-based approach to sexuality education for adolescents and a focus beyond health outcomes alone to support adolescents and young people to make sense of the multiplicity of messages they encounter and reduce unnecessary feelings of guilt and anxiety.     

Medical egg freezing: the importance of a patient-centered approach to fertility preservation

Purpose

This binational qualitative study of medical egg freezing (MEF) examined women’s motivations and experiences, including their perceived needs for patient-centered care in the midst of fertility- and life-threatening diagnoses.

Methods

Forty-five women who had undertaken MEF were interviewed in the USA (33 women) and in Israel (12 women) between June 2014 and August 2016. Interviews lasted approximately 1 h and were conducted by two senior medical anthropologists, one in each country. Women were recruited from four American IVF clinics (two academic, two private) and two Israeli clinics (both academic) where MEF is being offered to cancer patients and women with other fertility-threatening medical conditions.

Results

Women who undertake MEF view their fertility and future motherhood as important components of their identities and recovery and, thus, are grateful for the opportunity to pursue fertility preservation. However, women who undergo MEF have special needs, given that they tend to be a “vulnerable” population of young (age <?30), unmarried, resource-constrained women, who are facing not only fertility loss but also the “double jeopardy” of cancer. Through in-depth, qualitative interviews, these women’s MEF stories reveal 10 dimensions of care important to fertility preservation, including five “system factors” (information, coordination and integration, accessibility, physical comfort, cost) and five “human factors” (adolescent issues, male partner involvement, family involvement, egg disposition decisions, emotional support). Together, these dimensions of care constitute an important framework that can be best described as “patient-centered MEF.”

Conclusions

Women pursuing MEF have special medical needs and concerns, which require particular forms of patient-centered care. This study outlines 10 dimensions of patient-centered fertility preservation that are appropriate for MEF patients. This approach may help IVF clinics to be better prepared for delivering top-quality care to mostly young, single women facing the daunting prospect of fertility loss and life-threatening medical diagnoses.

     

The banding method as a simplified technique for resection of the liver

Application of the Insulok band is a simple, rapid and reliable technique to minimize excessive blood loss during hepatic resection. It is especially appropriate when the hepatic lesion is peripherally located, whether resection is done by an anatomic or nonanatomic technique. The availability of the band, the minimal hepatic manipulation needed in its application and the reduction of operative transfusion requirement suggest this is a useful operative adjunct for hepatic resection.