The role of complete surgical resection in stage IV neuroblastoma

The purpose of this study was to examine the outcome of attempted radical surgical resection in patients with stage IV neuroblastoma. Between 1989 and 2003, 20 (median age 2.4 years, range 0.5–8.7 years) children with stage IV neuroblastoma were treated at the Department of Pediatrics. Surgery was performed in 7 consecutive children (6 male and 1 female) between July 1997 and February 2002 at the Department of Urology in Bonn. Mean age at diagnosis was 57 months (21–104 months). Mean age at the time of surgery was 54 months (8–390 months). Follow-up was available for all patients (100%) and mean follow-up after the operation was 32.5 months (4–56 months). Primary localization of the tumor was retroperitoneal in all cases; 4 out of 7 patients (57%) also had additional adrenal, 3 out of 7 (42%) paraganglion and 1 out of 7 (14%) thoracic primaries. Bone marrow and lymph node metastases were found in all patients (100%). Surgery led to complete tumor resection in 6 out of 7 patients (85%). Surgical approach was abdominal (chevron incision) in 6 out of 7 (85%) of the patients, in one patient the approach was thoraco-abdominal. After induction chemotherapy and delayed surgery, 6 out of 7 (86%) patients showed a complete remission (CR) and the mean CR lasted for about 27.7 months (range 3.1–55.4 months). At the last time of follow-up 5 out of 7 (71%) patients were alive, 2 had died due to recurrent disease. Mean time to recurrent disease was 24 and 51 months, respectively. Mean overall survival time since diagnosis was 38.3 months (11–64 months) and mean event-free survival was 34.5 months (11–60.3 months). The final outcome, overall survival and event-free survival time was influenced by metastatic or local relapse. Tumor resection is beneficial but the value of surgery can only be judged when we are able to control metastatic disease in stage IV neuroblastoma. The final outcome may rely on the extent of complete surgical resection, but is also related to treatment of metastases. A longer follow-up period is indicated to detect long term outcome.     

Split-liver transplantation in the United States: outcomes of a national survey

OBJECTIVE: Assess application and outcomes of split-liver transplantation within the United States. SUMMARY BACKGROUND DATA: While a theoretically attractive mechanism to increase cadaver organ supply, split-liver transplantation has been infrequently applied. The American Society of Transplant Surgeons, in an attempt to gather preliminary data on split-liver transplantation, performed a data protected survey of transplant centers participating in the U.S. Scientific Registry for Transplant Recipients. METHODS: Between April 2000 and May 2001, 89 surgical teams were surveyed. Elicited data included graft type, recipient status, procurement method, graft sharing, graft outcomes, recipient outcomes, and experience with cadaver, whole-organ transplantation. RESULTS: Eighty-three surgical teams reported data on 207 left lateral segment, 152 right trisegment, 15 left lobe, and 13 right lobe grafts. The split procedure was performed ex vivo in 54% and in situ in 46% of grafts. Complications were frequent in all graft types with biliary and vascular complications equally distributed between grafts procured by either technique. Primary nonfunction, graft failure, and recipient death correlated with transplant status. CONCLUSIONS: Split-liver transplantation has been principally applied to adult-child pairs with at least one recipient critically ill. Biliary and vascular complications account for the majority of morbidity in grafts procured by either split technique with graft failure and recipient death observed more frequently in critically ill recipients. Enhanced utilization and improved results may be possible through improved information sharing and modification of allocation criteria.     

The reference point to measure the anterior intermeniscal ligament's thickness: an MRI study

The purpose of this study was to identify a reliable reference point for measuring anterior intermeniscal ligament thickness and to investigate the morphological characteristics of the ligament at its attachment site to anterior horns of both menisci by MRI. MRI was performed in 98 knees of randomly chosen patients. The anterior intermeniscal ligament was detected in 61 knees (62.2%). The average ligament length was 29.8 mm. Men had significantly longer anterior intermeniscal ligament than women patients (32.5 vs. 27.8 mm). The thickness of anterior intermeniscal ligaments at their attachment sites to menisci was usually less than 3 mm; a thickness of 3 mm or more at the attachment site to anterior horns of the meniscus was defined as "cordlike." It is suggested that the "cordlike" pattern is a variation of the anterior intermeniscal ligament's attachment characteristics, and that this might have a significant role in meniscal translations during knee motion, and also that the "cordlike" pattern could be clinically important with respect to its relationship to the anterior horn of medial meniscus. The attachment site of the ligament is a reliable reference point for measuring its thickness.     

The gluteal perforator-based flap in repair of pressure sores.

The gluteal perforator-based flap is designed according to the localisation of sacral perforator vessels. These vessels penetrate the gluteus maximus muscle and reach the intrafascial and suprafascial planes, and the overlying skin forming a rich vascular plexus. The gluteal perforator-based flaps described in this paper are highly-vascularised, have minimal donor site morbidity, do not require the sacrifice of the gluteus maximus muscle and rarely lead to post-operative complications. We believe these easy-to-perform flaps might be considered as the first choice in the repair of gluteal pressure sores.     

The use of human dura mater as an interposition graft in the treatment of vesicovaginal fistula

PURPOSE: In this prospective study we aimed to describe our new technique; dehydrated human dura mater as an interposition graft in patients undergoing benign vesicovaginal fistula repair (VVF). PATIENTS AND METHODS: Eleven patients with benign VVFs aged 38-73 years were operated with dura mater interposition technique at our institution between July 1996 and February 2002. In all patients fistula were secondary to abdominal hysterectomies with benign diseases and two had undergone previous transvaginal surgery. Patients were operated 8-15 (mean 12) weeks after previous surgery. A suprapubic cystotomy was performed and the fistula was not excised. The bladder wall is widely dissected from underlying vagina. Dura-mater was placed over the vaginal suture line to close the fistulous tract, cytostomy was inserted and the bladder was closed. An 18 F Foley catheter was left in the bladder for 5 days. A successful repair is defined as no leakage by cystogram at 14 days postoperatively and completely dry by patient report. RESULTS: An overall success rate of 100% was achieved in all patients. All patients remain dry at the follow-up which ranges from 7 to 60 (mean 26) mounts. Patients were discharged at 14 to 26 (mean 16) days postoperatively. No major complications or side effects were observed during the follow-up period. CONCLUSIONS: The use of human dura mater as an interposition graft in the treatment of vesicovaginal fistula is an alternative for VVF repairs because of its excellent tissue compability, stability, good elasticity and absorbability.     

Predictors of survival after liver transplantation for hepatocellular carcinoma associated with Hepatitis C.

The efficacy of orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) associated with hepatitis C virus (HCV) is not well defined. This study examines the variables that may determine the outcome of OLT for HCC in HCV patients. From 1990 to 1999, 463 OLTs were performed for HCV cirrhosis. Of these patients, 67 with concurrent HCC were included in the study. Univariate and multivariate analyses considered the following variables: gender, pTNM stage, tumor size, number of nodules, vascular invasion, incidental tumors, adjuvant chemotherapy, preoperative chemoembolization, alpha-fetoprotein (AFP) tumor marker, lobar distribution, and histological grade. Overall OLT survival of HCV patients diagnosed with concomitant HCC was significantly lower when compared to patients who underwent OLT for HCV alone at 1, 3, and 5 years (75%, 71%, and 55% versus 84%, 76%, and 75%, respectively; P < 0.01). Overall survival of patients with stage I HCC was significantly better than patients with stage II, III, or IV (P < .05). Eleven of 67 patients developed tumor recurrence. Sites of recurrence included transplanted liver (5), lung (5), and bone (1). Twenty-four of 67 patients (36%) died during the follow-up time. Causes of deaths included recurrent HCC in 8 of 24 patients (12%) and recurrent HCV in 3 of 24 patients (4.5%), whereas 13 (19.5%) patients died from causes that were unrelated to HCV or HCC. Both univariate and multivariate analysis demonstrated that pTNM status (I versus II, III, and IV; P < .05) was a reliable prognostic indicator for patient survival. Presence of vascular invasion (P = .0001) and advanced pTNM staging (P = .038) increased risk of recurrence. Multivariate analysis showed that pretransplant chemoembolization and adjuvant chemotherapy reduced risk of death after OLT in HCC recipients. In conclusion, this study demonstrates the effectiveness of OLT for patients with HCC in a large cohort of chronic HCV patients. Advanced tumor stage, and particularly vascular invasion, are poor prognostic indicators for tumor recurrence. Early pTNM stage, adjuvant chemotherapy, and preoperative chemoembolization were associated with positive outcomes for patients who underwent OLT for concomitant HCV and HCC.     

Does the complication rate increase in laparoscopic cholecystectomy for acute cholecystitis?

BACKGROUND: Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy for the treatment of gallbladder disease. Despite the well-accepted success of LC in chronic cholecystitis, the efficacy of this technique has been subject to some debate in acute cholecystitis (AC). This study was designed to evaluate our institution's experience with LC for AC and chronic symptomatic calculous cholecystitis (CC), based on complication and conversion rates to open surgery. PATIENTS AND METHODS: The records of 1158 patients with LC from September 1991 to December 2001 were analyzed. The parameters of age, gender, early and late complication rates, and conversion rates from LC to open cholecystectomy were compared in patients with AC and CC. RESULTS: During the study period, LC was performed in 1158 patients. Of these, 162 patients had AC (group 1) and 996 patients had CC (group 2). The conversion rates were 4.3% (7/162) in group 1 and 2.4% (24/996) in group 2. The complication rates were not significantly different (5.6% in group 1, 5.1% in group 2, P > 0.05). Difficulty in dissection around Calot's triangle and obscure anatomy were the main reasons for conversion to conventional open surgery. The mortality rate was 1.2% in group 1 and 0.01% in group 2. CONCLUSION: LC appears to be a reliable, safe, and effective treatment modality for AC and CC. The surgical approach should be performed carefully because of the spectrum of potential hazards of the laparoscopic procedure. Conversion and complication rates are similar in both AC and CC groups, and improve as surgeons gain experience.     

The sinus node artery: anatomic investigations based on injection-corrosion of 60 sheep hearts

The purpose of this study was to investigate the sinus node artery in the sheep heart to establish adequate baseline information for use in cardiovascular research, and to compare this information with similar data for man. The coronary arteries were exposed by using injection-corrosion casting technique in 60 sheep hearts. Polyester and diluted sulfuric acid were used. When the corrosion was completed, the specimens were photographed. The sinus node artery was single in 59 specimens, and double in one specimen. The artery originated from the right coronary artery (in 42 specimens), left coronary artery (in 16 specimens), and right aortic sinus (in 1 specimen). In the majority of specimens, sinus node artery corresponded to the right superior (anterior) atrial artery. Pericaval termination was common. Mean measurements about the sinus node artery were tabulated. According to the present study, we can state that the sinus node artery in sheep heart is similar to that of humans. Because of the importance of animal research, we suggest that experimental surgical studies of the sinus node artery should be performed on the sheep heart.