Surgical resection for non-Asian intrahepatic lithiasis: The Brazilian experience

BackgroundIntrahepatic lithiasis (IHL) is a rare disease in the western world. Complications associated with IHL include acute cholangitis, liver atrophy, secondary biliary cirrhosis, and risk for intrahepatic cholangiocarcinoma. Liver resection is considered the treatment of choice for IHL. The objective of this study was to analyze patients who underwent liver resection for non-Asian hepatolithiasis.Methods127 patients with symptomatic non-Asian hepatolithiasis underwent resection in six institutions. Demographic data, clinical presentation, diagnosis, classification according to stone location, presence of atrophy, bile duct stricture, biliary cirrhosis, incidence of cholangiocarcinoma, treatment and postoperative course were evaluated.Results52 patients (40.9%) were male and the mean age was 46.1 years. Sixty-six patients (51.9%) presented with history of cholangitis. Stones were located in the left lobe in 63 (49.6%), and right lobe in 28 patients (22.0%). Atrophy was observed in 31 patients (24.4%) and biliary stenosis in 18 patients (14.1%). The most common procedure performed was left lateral sectionectomy in 63 (49.6%) patients, followed by left hepatectomy in 36 (28.3%), right hepatectomy in 19 (15.0%), and associated hepaticojejunostomy in 28 (22.0%). Forty-two patients (33.0%) presented postoperative complications and the most common were biliary fistula (13.3%) and surgical site infection (7.0%). Postoperative mortality was 0.7%. Intrahepatic cholangiocarcinoma was observed in 2 patients (1.5%). Recurrence was identified in 10 patients (7.8%), mostly with bilateral stones and/or hepaticojejunostomy.ConclusionLiver resection is the standard treatment for symptomatic unilateral or complicated IHL with good operative results. Risk of cholangiocarcinoma was low in non-Asian patients.     

Analysis of C-myc messenger-RNA expression in primary breast carcinomas with clinical follow-up

The level of c-myc messenger RNA was measured in 105 primary breast carcinoma samples and matched normal breast tissue from the same patients. Only tumors showing a greater than 2-fold increase in c-myc levels were considered to be overexpressed. Overexpression of c-myc mRNA was identified in 27.6% of tumor samples analysed and was significantly correlated with mitotic grade (p=0.05) and intense lymphocytic infiltrate (p=0.026) but not with other clinical and pathological variables such as size, necrosis, lymph node involvement, estrogen or progesterone receptor status, menopausal status, age or staging of the patients and increased risk of relapse or overall survival. Approximately 25% of the tumors contained overexpression of c-erbB-2 mRNA and simultaneous overexpression of the two oncogenes was seen in only five samples. Disease-free survival was significantly shorter in these patients (p=0.02) and this reduction remained significant after adjustment for nodal status. However, simultaneous overexpression of c-myc and c-erbB-2 did not improve significantly the prediction of risk of death.     

Construction,quality assurance and calibration of spherical isotropic fibre optic light diffusers

Spherical isotropic fibre optic light diffusers are used in photodynamic therapy either as a light source or as a light detector. The construction of light diffusers using different materials is described, viz. an optical method involving local polymerization of a dental fissure sealant, which is referred to as the Henderson method, and a second method using plastic or ceramic pre-fabricated spheres. Quality tests necessary for reliable clinical use are presented for the mechanical strength, output power and isotropy. The maximum pull-off force and blow-off output power for the different kinds of diffusers were determined. The calibration procedures are given for measurement of the output power and wavelength of the light emitted by a diffuser and for measurement of the fluence rate by a light-detecting diffuser, using a compact integrating sphere device. With all types of diffusers described, an isotropy can be obtained of better than ± 20% measured over a 320° angle for spheres as small as 1 mm. Larger ceramic diffusers are particularly suitable for delivering high output powers. A 3-mm-diameter ceramic diffuser mounted on a 600-m-core fibre can emit up to 5 W of continuous wave (CW) visible light in air. Diffusers used for light detection can measure the light fluence rate in tissue with 15% accuracy or better if calibration factors are determined for each individual probe.     

Emerging infectious diseases in the realm of complexity: implications for scientific and technological policies

The current emergence and global dissemination of some new and resurgent infectious diseases have surpassed national frontiers, increasingly affecting developing and also developed countries. This study stresses that this outburst is affecting the predictability of dominant health transition approaches. This paper analyses, from epistemological and policy viewpoints, alternative approaches in order to confront these new global epidemiological trends.     

Phenotypic differences in survival to an experimental acute carbon monoxide intoxication

Male and female 45-day-old mice of two inbred (CBA and C57B1) and of one outbred (OF₁), SPF (specific pathogen free), strains, LD_12:12 (L = 150 lx) synchronized, were submitted to an acute carbon monoxide challenge giving an overall survival close to 50%. Under these conditions significantly (P < 0.001) less CBA survived than the two other strains. A sex-related significant (P < 0.001 difference was observed in OF₁. Strain survival differences are independent of body weights and of respiratory and displacement activity, but appear to be related to behavior reactions towards environmental stresses. These phenotypic differences are similar to previous findings obtained with these three strains of mice submitted to a 50% survival acute hypoxic hypoxia (M. Stupfel, A. Perramon, P. Merat, J. M. Faure, and H. Masse, 1979, Comp. Biochem. Physiol., 64A, 317–323).     

Bedside Percutaneous Tracheostomy: Prospective Evaluation of a Modification of the Current Technique in 100 Patients

Percutaneous dilatational tracheostomy (PDT) is being increasingly used. Concerns have been raised as to its safety, especially when it is done at the bedside. A prospective evaluation was conducted of 100 consecutive, unselected critically ill patients with PDT. The mean intensive care unit (ICU) stay before PDT was 12 days. One surgeon performed PDT alone (5 cases) or assisted residents (95 cases) in all operations; 84 were performed at the ICU bedside. Only the first six patients were taken to the operating room solely for tracheostomy. A modified technique was used: (1) the endotracheal tube was left in place during sequential dilations; (2) dilators were inserted in a 60-degree cephalad orientation to the skin and directed caudally after penetration of the anterior tracheal wall; (3) a digit was inserted through the tracheal opening to guide withdrawal of the endotracheal tube to the level of the vocal cords; and (4) size 8 tracheostomy cannulas were inserted over 28F dilators. The average time from skin incision to insertion of the tracheostomy tube was 12 minutes (< 10 minutes, 41 patients; 10 to 15 minutes, 37 patients; > 15 minutes, 22 patients). Sixty-five percent had unfavorable anatomic conditions due to spinal precautions or diffuse neck edema. Postoperative complications occurred in four patients; surgical emphysema after tracheal lacerations in three, cannula dislodgment in one. All complications were successfully managed without an operation by tube exchange (n= 3) or observation (n= 1); there was no procedure-related mortality. Forty patients were available for long-term follow-up (6–18 months after tracheostomy) by telephone; one had persistent hoarseness without respiratory difficulty. We concluded that bedside PDT is safe and easy to teach when performed with a technique that ensures correct instrumentation.     

Management of soft tissue sarcomas (STS) in first isolated local recurrence: a retrospective study of 83 cases.

PURPOSE: To analyze the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcomas (trunk or extremities) and to identify prognosis factors. METHODS AND MATERIAL: Between 1980 and 1999, 83 adult patients were included in the study. Mean age was 61 years. Mean tumor size was 6 cm. Most sarcomas were located in extremities (n=74), were deep (n=60), and proximal (n=53); 30 involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histiocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (29 cases), marginal resection (43 cases), 5 patients requiring amputation. Final results were R0 (n=33), R1 (n=47) or R2 (n=3) resection. Besides surgery, 6 patients received neo-adjuvant and 7 others adjuvant chemotherapy. Twenty three patients received post-operative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial 192Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated. RESULTS: Mean follow up was 13 years. Thirty-seven (45%) patients relapsed, 62% of whom presenting an isolated local recurrence. Nineteen patients developed distant metastases. Multivariate analysis showed only tumor depth (P=0.05) and re-resection for primary R1 resection (P=0.018) being independent prognosis factors for tumor control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis (P=0.05). Overall survival rate was 73%, 54%, and 47% at, respectively, 3.5 and 10 years, and was 65%, 35% and 32% after a further local recurrence. Multivariate analysis showed trunk (P=0.0001) or inferior extremity locations (P=0.023), symptomatic (P=0.001), high grade (P=0.01), deep (P=0.01) tumors, and the occurrence of a further local failure (P=0.004) as unfavorable characteristics for overall survival. CONCLUSIONS: A first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, BCT being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumors, at best performed in centers that have expertise in this field.