Anatomic bases for liver transplantation

Summary This study gathers the anatomic implications for a good liver transplantation. During hepatic removal a left hepatic a.exists in 20% of cases; a right hepatic artery originating from the superior mesenteric a. (SMA) can be the only arterial supply in 9% of cases; the whole lesser omentum has to be removed and the SMA from 6 cm to its origin. The SMA must be freed from the celiac ganglia and its ostium removed with the celiac trunk in an aortic patch cut on the anterior side in order to avoid the renal ostia. During total hepatectomy, dissection of the portal triad is often difficult because of portal hypertension dilating accessory portal veins (parabiliary arcade) and pedicular lymphatics. Nerve plexuses are thick in front of the hepatic artery or behind the portal triad. Transection of triangular ligaments leads to the retrohepatic inferior vena cava (IVC) that must be freed from its posterior tributaries (right suprarenal vein and inferior phrenic veins flowing either into the IVC or into the hepatic veins). One big problem during hepatic replacement is the biliary anastomosis which must be well irrigated. In the recipient, dissection up to the hilum preserves hepatic and pancreatico-duodenal pedicles. The biliary tract of the graft must be cut low, behind the pancreas, and several centimeters of the gastroduodenal artery must be preserved to save hepatic and gastroduodenal pedicles.

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Bases anatomiques de la transplantation hépatique

Résumé Ce travail rassemble les notions anatomiques nécessaires au bon déroulement d'une transplantation hépatique. Le prélèvement du greffon doit enlever tout le petit omentum contenant une éventuelle a. hépatique gauche née de l'a. gastrique gauche (20%) et emporter l'a. mésentérique supérieure jusqu'à 6 cm de son origine pour ne pas oublier une a. hépatique droite née de cette dernière: son ostium est pris avec le tronc clique dans un patch aortique découpé sur la face antérieure. Lors de l'hépatectomie totale, la dissection du pédicule hépatique est rendue délicate par l'hypertension portale qui dilate les veines portes diets accessoires (arcade parabiliaire) et les lymphatiques pédiculaires. Les plexus nerveux sont riches devant l'artère hépatique et derrière le pédicule. La section des ligaments triangulaires droit et gauche amène à la veine cave inférieure (VCI) rétro-hépatique qu'il faut libérer de ses afférences postérieures (en particulier la veine surrénale principale droite toujours haut située et les veines phréniques inférieures qui s'abouchent soit dans la VCI soit dans les veines hépatiques du carrefour). Lors du remplacement, l'anastomose biliaire doit être vascularisée. Chez le receveur la dissection jusqu'au hile permet de conserver les pédicules. La voie biliaire du greffon doit être coupée bas derrière le pancréas et les premiers centimètres de l'artère gastro-duodénale conservés pour préserver les pédicules hépatique et pancréaticoduodénal.

     

Molecular epidemiology of Legionella species by restriction endonuclease and alloenzyme analysis.

As part of an ongoing investigation into nosocomial Legionella infections at Stanford University Medical Center (SUMC), we applied the technique of restriction endonuclease analysis (REA) to determine strain differences among three species, including Legionella pneumophila, Legionella dumoffii, and Legionella micdadei. A total of 26 human and environmental water isolates from SUMC were selected for REA and compared with control strains that were not epidemiologically linked to SUMC. REA results were compared with results of alloenzyme typing, typing by monoclonal antibodies, and plasmid fingerprinting in all but L. micdadei strains. REA and alloenzyme typing showed that SUMC patient isolates were derived from distinct strains of three species. L. pneumophila strains from SUMC patients were genotypically identical to those isolated from potable water. REA was especially useful in proving that SUMC L. dumoffii patient isolates were derived from a single strain and that patients may have been exposed to a common source(s). REA typing correlated well with alloenzyme typing. These methods complement serologic typing of L. pneumophila and provide discriminating capability between strains of other Legionella species such as L. dumoffii, for which serologic types have not been identified. In addition, REA typing is somewhat easier to perform than alloenzyme typing and can be done in clinical laboratories.     

Contribution to the study of the tributaries and the termination of the external jugular vein

Summary The dissection of 100 external jugular veins in 50 cadavers was the object of this anatomic study. A certain number of notions concerning the afferent veins, the mode of termination and the valvular system of this vessel were defined. 1)Afferent veins. Along its pathway toward the deep venous system, the external jugular vein successively received: the transverse cervical vein in 88 cases (88%), usually opposite the intersection of the external jugular vein with the dorsal border of the sterno- cleidomastoid muscle; the suprascapular vein in 47 cases (47%); the anterior jugular vein in 46 cases (46%); the cervical vein or anastomosis with the latter in 13 cases (13%). 2)Mode of termination. Forty-three subjects presented a symmetric mechanism. 100 anastomoses can be classed into three types: in 60 cases (60%), the external jugular vein flowed into the jugulo-subclavian venous confluence; in 36 cases (36%), in to the subclavian vein at a distance from its junction with the internal jugular vein; in 4 cases (4%) in to the trunk of the internal jugular vein. 3)Study of the valves. There were studied in 25 subjects (50 external jugular veins). The valves were found in the ostial and paraostial position in 49 out of 50 veins.

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Contribution à l'étude des afférences et de la terminaison de la veine jugulaire externe

Résumé Cette étude anatomique repose sur la dissection de 100 vv. jugulaires externes chez 50 cadavres. Elle a permis de préciser un certain nombre de notions concernant les veines afférentes, le mode de terminaison et le système valvulaire de ce vaisseau. 1)Veines afférentes. Le long de son trajet vers le sytème veineux profond, la v. jugulaire externe reçoit successivement: la v. cervicale transverse dans 88 cas (88 %), habituellement en regard du croisement de la v. jugulaire externe avec le bord dorsal du m. sterno-cléido-mastoïdien ; la v. supra-scapulaire dans 47 cas (47 %); la v. jugulaire antérieure dans 46 cas (46 %) ; la v. céphalique ou une anastomose avec celle-ci dans 13 cas (13 %). 2)Mode de terminaison. Quarante trois sujets présentent un dispositif symétrique. Les 100 abouchements peuvent être classés en trois types : dans 60 cas (60 %) la v. jugulaire externe se déverse dans le confluent veineux jugulo-subclavier ; dans 36 cas (36 %), dans la v. subclavière à distance de sa réunion avec la v. jugulaire interne ; dans 4 cas (4 %) dans le tronc de la v. jugulaire interne. 3)Etude des valvules. Recherchées chez 25 sujets (50 vv. jugulaires externes), les valvules ont été retrouvées dans 49 cas sur 50 en position ostiale ou paraostiale.

     

The ileoanal J pouch: radiographic evaluation

Endorectal ileoanal pull-through offers an attractive alternative to proctocolectomy and ileostomy for patients with ulcerative colitis, Gardner syndrome, and familial polyposis. To our knowledge, a careful radiographic analysis of the ileum, ileal pouch, and ileoanal anastomosis after ileoanal pull-through has not been reported. Thirty-two patients with ulcerative colitis, Gardner syndrome, and familial polyposis underwent colectomy, mucosal proctectomy, and endorectal ileoanal pull-through of a 15-cm ileal "J" pouch and loop ileostomy. Twenty-five (78%) of 32 of all the pouches radiographically demonstrated spiral folds extending from the middle of the pouch to the pectinate line. Other radiographic features included a mesenteric mass effect, pseudopolyps, and a central lucency that indicated intrapouch sutures. Radiographs provide useful information in the postoperative management of the ileal pull-through.     

Interorganizational exchanges as performance markers in a community cancer network.

OBJECTIVE. This study examines how "strategic partnerships" between community-based consortia of oncologists and hospitals (CCOPs) and clinical cooperative groups emerge, develop, and influence patient accruals (i.e., the number of patients enrolled in clinical trials) over time. DATA SOURCES AND STUDY SETTING. Study analyses are based on 65 pairwise relationships that 38 CCOPs established with eight clinical cooperative groups in September 1983 and maintained through February 1989. Data are drawn from grantee applications and progress reports. STUDY DESIGN. The study examines how different types of CCOP-cooperative group exchange relate to one another and to CCOP patient accruals over six time points. Key independent variables include resource dependence, information exchange (i.e., meeting attendance and committee membership), and protocol exchange (i.e., the number of different protocols used). DATA COLLECTION METHODS. Data extracted from secondary sources were entered in a data base. PRINCIPAL FINDINGS. The number of CCOP physicians and support staff who attend cooperative group meetings during the first two years of a clinical research partnership has a significant influence on meeting attendance and protocol use in later years. Two-thirds or more of the variance in patient accruals at each time point can be explained by the number of different protocols used and the number of CCOP representatives serving on cooperative group committees (or attending cooperative group meetings). CONCLUSIONS. The findings highlight the importance of historical relationships and anticipated resource dependence in shaping initial exchange patterns. They also suggest that strategic partnerships need to emphasize structures and processes that encourage early involvement in collaborative activities and that reward participants for maintaining high levels of interaction.     

Dietary intake of Americans reporting adherence to a low cholesterol diet (NHANES II).

We studied the dietary intake of persons age 18 and over participating in the 1976-80 National Health and Nutrition Examination Survey (NHANES II). We compared the diets of those on a "low cholesterol" diet (dieters, n = 296) with the diets of individuals not following a special diet (non-dieters, n = 10,052). Dietary intakes were assessed by 24-hour recall and food frequency reports and were adjusted for differences in age, sex, race, education, smoking, and socioeconomic status by multivariate statistical techniques. Dieters consumed 16 percent (99% confidence interval(-) -24, -9 fewer calories than non-dieters, and had decreased intake of saturated fat by 25 percent (-34, -15) and cholesterol by 21 percent (-32, -10). However, their intake of vitamin A, thiamine, riboflavin, niacin, calcium, and iron were not significantly different from non-dieters and their ascorbic acid intake was 18 percent (1, 36) higher. The nutrient density (nutrient/1000 kcal) among dieters was increased over non-dieters by 35 percent (-3, 72) for vitamin A, 35 percent (1, 70) for thiamine, 30 percent (-4, 65) for riboflavin, 27 percent (9, 44) for niacin, 60 percent (40, 80) for vitamin C, 14 percent for calcium (-5, 32), and 15 percent for iron (6,25). Compared with non-dieters, dieters consumed 27 percent (9, 45) more poultry and 39 percent (12, 66) more fish, but consumed 30 percent (-44, -16) less eggs and 15 percent (-24, -6) less meat.     

Incidence of childhood brain and other non-haematopoietic neoplasms near nuclear sites in Scotland, 1975-94

OBJECTIVES: To examine the risk of cancers other than leukaemia and non- Hodgkin's lymphoma in children resident in the vicinity of nuclear sites in Scotland. METHODS: The study dataset comprised registrations of cancer other than leukaemia and non-Hodgkin's lymphoma diagnosed in children aged under 15 in the period 1975-94. These were validated for completeness and accuracy and analysed in two groups: (a) tumours of the central nervous system and (b) other malignant tumours (excluding leukaemia and non-Hodgkin's lymphoma). Around each nuclear site observed cases (O) were enumerated and expected numbers (E) calculated with adjustment for age, sex, deprivation, and an urban-rural category. Stone's maximum likelihood ratio test (MLR) was used to determine whether there was any evidence of increased risk of these neoplasms among children living within 25 km of one of the nuclear sites investigated. The significance level of each MLR statistic was estimated by simulation. RESULTS: More tumours of the central nervous system were observed than expected within 25 km of Dounreay (O/E = 1.14), Hunterston (1.14), and Rosyth (1.22). These results were based on 2, 26, and 136 observed cases, respectively. The unconditional MLR was significant only for Rosyth (p = 0.006). The conditional application of the MLR test for Rosyth was not significant (p = 0.771). For the group of other malignant neoplasms, the unconditional MLR test was not significant for any of the seven sites. CONCLUSIONS: There was no evidence for generally increased risk of either tumours of the central nervous system or other malignant tumours in children living near nuclear sites. The significant excess of tumours of the central nervous system around Rosyth is likely to be due to the high incidence of these tumours in east central Scotland. Further investigations in this area are warranted.