Hemodynamic changes during gaseous and gasless laparoscopic cholecystectomy

Abstract. Purpose: The main disadvantage of gaseous laparoscopic surgery is the need for CO₂ insufflation and the elevation of intra-abdominal pressure. Gasless laparoscopic surgery is an alternative to gaseous laparoscopic surgery, which avoids the hazardous effects of pneumoperitoneum. This study was conducted to investigate the hemodynamic effects of pneumoperitoneum and to compare gasless and gaseous laparoscopic cholecystectomy on a hemodynamic basis. Methods: The gasless laparoscopic procedure uses an electromechanical retractor system to lift the abdominal wall. We performed 20 gaseous and 11 gasless laparoscopic cholecystectomies in a collective total of 31 patients with symptomatic gallostones. The mean arterial pressure, heart rate, end diastolic index, systemic vascular resistance index, cardiac index (CI), ejection fraction (EF), and stroke index (SI) values were monitored noninvasively by thoracic electrical bioimpedance. Results: In the gaseous group, statistically significant changes were detected in CI, EF, and SI values after insufflation as compared to the values before pneumoperitoneum. In the gasless group, only minimal changes were detected in the SI values, which were not significant. Conclusion: Gasless laparoscopy has little effect on the hemodynamic parameters of patients and provides an alternative to the gaseous technique in selected cases. Received: December 6, 2000 / Accepted: January 8, 2002     

Use of laparoscopic splenectomy in developing countries: analysis of cost and strategies for reducing cost

BACKGROUND: In general, laparoscopic surgery is more expensive than open surgery. However, recent reports showed lower overall cost. PATIENT AND METHODS: Fourteen patients underwent laparoscopic splenectomy (LS) and 15 patients open splenectomy (OS). Patients were evaluated with regard to blood loss, complication rate, length of hospital stay, operative time, presence of accessory spleens, hospital cost, and total cost. For the OS group, there was no laparoscopic instrument cost, and the total cost was equal to the hospital cost. In the LS group, total cost was calculated by adding the hospital cost to the cost of laparoscopic instruments. RESULTS: The postoperative hospitalization was shorter in the LS group than the OS group (3.4 vs. 7.5 days), but the operating time was significantly longer for the LS group. The mean hospital cost was calculated as US $1,055 in the LS group and $1,664 in the OS group. The overall total cost was $1,664 for the OS group and $2,064 for the LS group. In the LS group, less morbidity and shorter postoperative hospital stay resulted in lower hospital cost. CONCLUSION: The cost for laparoscopic instruments is the main factor responsible for the high total cost of LS. Resterilization of disposable laparoscopic instruments is feasible and a more economic way of treatment compared with splenectomy with totally disposable laparoscopic instruments and has costs comparable to those of open surgery.     

Adrenomedullin and nitrite levels in children with primary nocturnal enuresis

Primary nocturnal enuresis (PNE) is the most common type of nocturnal enuresis in children, but its etiology remains unclear. Recent studies indicated the differences in urinary electrolytes in enuretic children, and stressed the existence of a renal tubular maturation defect. In this study, 30 children (aged 6-12 years) with PNE were investigated in comparison with 18 healthy controls. We evaluated plasma antidiuretic hormone, electrolytes, 24-h urine volume, osmolarity, and urinary electrolytes. Unlike other studies, we firstly assessed the plasma and urinary adrenomedullin (AM) and total nitrite levels, a stable product of nitric oxide (NO), and investigated their relationship with urinary electrolytes. The plasma AM and total nitrite levels were significantly lower than controls. Urine volume (24-h) and potassium excretion were higher than in controls. However, 24-h urinary osmolarity and excretion of AM were significantly lower than in controls. Our results indicate that there may be a problem in renal regulation of potassium in children with PNE. Although decreased levels of AM and total nitrite may be a compensatory response to abnormal potassium and water excretion, further investigations are required to exclude whether the renal synthesis of AM and NO are also deficient in these children.     

Replantation in children

The rates of survival of the amputated part and the functional outcomes were studied retrospectively after 13 replantations and 12 revascularizations in 25 children. The ages of the patients ranged from 2 to 15 years (mean, 6.4 years). The average duration of follow-up was 4.2 years (range, 2 to 7 years). The survival rate was higher after revascularization (94.6%) than after replantation (84.6%). Sensory recovery of all digits was satisfactory. The mean growth rate of replanted digits relative to contralateral digits was 80%. Functional results were rated as excellent in 11 cases, good in 8 cases, moderate in 2 cases, and poor in 1 case. In order to prevent functional and growth disturbances and due to cosmetic reasons, replantation or revascularization should definitely be tried for children. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:410–413, 1998     

Chemoprevention of fibroid tumors by [−]-epigallocatechin-3-gallate in quail

Spontaneous leiomyomas of the oviduct are common tumors of the Japanese quail (Coturnix coturnix japonica), and fibroid tumors in the laying hen are similar to human fibroid tumors with respect to estrogen and progesterone receptors. This makes the quail a good animal model for screening potential agents for that aid in the prevention and treatment of human myoma uteri. We have previously reported a decreased incidence of leiomyomas in the oviduct of Japanese quail with antioxidant supplementation, for example, lycopene and soy isoflavones. Most of the health benefits associated with green tea consumption is attributed to EGCG, one of 4 major catechins found in green tea. This study investigated the effects of epigallocatechin-3-gallate supplementation on the development of leiomyomas in the oviduct of Japanese quail. We also measured serum and tissue levels of malondialdehyde and TNF-α. One hundred eighty quail (8 months old) were assigned to 3 treatment groups consisting of 6 replicates of 10 quail in each group. Animals were fed either a basal diet (control group) or the basal diet supplemented with 200 or 400 mg of EGCG/kg of diet. The animals were euthanized at the end of the 12-month study period, and the tumors were characterized. Epigallocatechin gallate supplementation significantly decreased the number of leiomyomas as compared with the controls (P = .001). The tumors in the EGCG fed birds were smaller than those found in the control birds (P = .001). Serum and liver malondialdehyde and TNF-α concentrations decreased (P = .001) with EGCG supplementation. The results indicate that dietary supplementation with EGCG reduces the incidence and size of spontaneously occurring leiomyoma of the oviduct in Japanese quail. Clinical trials should be conducted to investigate the efficacy of EGCG supplementation in the prevention and treatment of uterine leiomyoma in humans.     

Occult Intrabiliary Rupture of Hydatid Cysts in the Liver

The aim of this study was to investigate the effects of various surgical modalities directed at the cavity of hydatid cysts in patients with occult intrabiliary rupture. In this respect, 324 patients with hydatid cyst of the liver operated on during 1983-2003 were analyzed; among them, 39 patients with occult intrabiliary rupture were included in the study. Clinical symptomatology, physical examination, laboratory findings, results of imaging studies, the localization and size of the cyst, and operative findings were reviewed. Twelve patients had complications, and there was no mortality. The most common complication was bile fistula. The average postoperative hospital stay was 7.0 ± 3.8 days for patients with omentoplasty and 6.0 ± 2.5 days for those who underwent cavitary drainage. For patients who do not have bile-stained cystic fluid, the utilization of scolicidal agents is appropriate. Although the opening of the duct is sutured when it is identified, the risk of biliary fistula is not clearly correlated with this approach. In such cases, omentoplasty provides a good alternative to cavitary drainage.     

Plasma and urinary adrenomedullin levels in children with renal parenchymal scar and vesicoureteral reflux

Adrenomedullin (AM) is a strong vasodilator peptide with proven antimitogenic and antiproliferative effects in renal mesangial cells, as well as diuretic and natriuretic actions. Its gene expression is stimulated by endotoxins (lipopolysacharides) and cytokines. Consequently, its plasma and urinary levels are known to deviate from normal levels in many renal diseases. The purpose of this study is to determine plasma and urinary AM levels in children with renal parenchymal scar (RPS) and vesicoureteral reflux (VUR). The study was carried out on 74 children with recurrent urinary tract infections, arranged in groups: 25 patients with RPS with VUR (group I), 16 patients with RPS without VUR (group II), 12 patients with VUR without RPS (group III) and 21 healthy children as the control group. Plasma and urinary AM concentrations were both determined by high performance liquid chromotography (HPLC). Plasma AM was measured as picomoles per milliliter (pM/ml) and urinary AM as pM/mg urinary creatinine. In addition, serum creatinine, creatinine clearance and fractional sodium excretion (FE_Na) were measured. All cases with RPS and VUR had normal blood pressure levels. The plasma AM levels were higher, although not significantly, in the control group (56.2±14.0 pM/ml) than in group I (50.6±4.2 pM/ml), group II (49.6±3.7 pM/ml) and group III (50.6±3.6 pM/ml) ( P =0.162). The urinary AM levels were higher in the control group (80.1±33.9 pM/mg) than in the three study groups (52±7.6 pM/mg, 58.6±7.5 pM/mg and 44.2±6.4 pM/mg; P =0.003, P =0.002 and P =0.002, respectively). There were no differences among the 4 groups (group I, group II, group III and the control group) in terms of FE_Na and creatinine clearance ( P >0.05 and P >0.05, respectively). The finding that diminished urinary AM levels in patients with RPS and VUR implies that AM can be a prognostic factor in the long-term follow-up of cases with these diseases.     

Two-stage reconstruction of four-digit amputation: distal ulnar artery flap and combined second- and third-toe transfer

We report a case of combined two toe transfer after distal ulnar artery fasciocutaneous flap in a 10-year-old boy who has four-digit amputation. Four years after the operation, satisfactory results were obtained both functionally and cosmetically.     

Sodium hyaluronate in trabeculectomy: effect on early complications

PURPOSE: To evaluate the effect of sodium hyaluronate on the early complications of trabeculectomy. METHODS: In this prospective study, trabeculectomy was performed in 51 eyes of 51 patients with different types of glaucoma. Patients were divided into two groups randomly. In 24 eyes (study group) sodium hyaluronate was injected into the anterior chamber after suturing the scleral flap. In the remaining 27 eyes (control group) only balanced salt solution was injected. Visual acuities, intraocular pressures and early complications were evaluated. RESULTS: Preoperative mean intraocular pressures were similar in the two groups (34.5 +/- 18.7 mmHg in the study group and 37.2 +/- 18.1 mmHg in the control group). In the first postoperative day mean intraocular pressure difference was significant (16.8 +/- 7.1 mmHg in the study group and 9.0 +/- 6.6 mmHg in the control group, P < 0.01). There was significant difference in occurrence of hypotony (8.3% study vs. 40.7% control), anterior chamber shallowing (8.3% study vs. 37% control) and choroidal detachment (none in study vs. 33.3% control) between the two groups (P < 0.01). Early intraocular pressure peak, occurred more common in the study group (20.8%) than in the control group (11.1%), but the difference was not significant (P > 0.01). Hyphema occurred in two (8.3%) eyes in the study group, and three (11.1%) in the control group. This was not significant (P > 0.01). The clearance time of blood from the anterior chamber (less than 1 week) was also similar in the two groups. CONCLUSION: Sodium hyaluronate-assisted trabeculectomy decreased the incidence of early postoperative complications like anterior chamber shallowing, choroidal detachment and hypotony, but it did not have any effect on hyphema or its clearance.     

Effects of iron deficiency versus iron deficiency anemia on brainstem auditory evoked potentials in infancy

There has been little or no evidence of brainstem auditory evoked potentials (BAEPs) among infants with iron deficiency (ID) that is not severe enough to cause anemia. To our knowledge, the effect of ID on auditory functions and/or potentials has not been investigated previously, though it seems reasonable that it should be associated with BAEP measures intermediate between those observed in iron deficiency anemia (IDA) and in iron sufficiency, considering the role of iron in myelin formation and maintenance. We therefore aimed in this study to investigate the effect of ID on BAEPs by comparing three groups of infants with ID, IDA and iron sufficiency (control) both before and after iron treatment (in iron-deficient groups). Three groups of infants (IDA, n = 25; ID, n = 24; Control, n = 44) were compared on the basis of hematological laboratory parameters and BAEP measurements both at entry into and after (12 weeks treatment with oral iron in IDA and ID groups) the study. BAEP measurements recorded at 85 dB both at entry into and after the study were not significantly different among the groups, although a sufficient response to iron treatment was achieved in iron-deficient groups (Group I and Group II). The only positive finding determined in our study was a slight decrease in latencies obtained at the end of the study when compared to the pre-study values in all three groups of the study in accordance with the expected age-dependent developmental changes. Although no negative electrophysiological effect of ID on brainstem auditory functions was found in the present study, further longer term (late childhood or adult) studies are necessary to elucidate the relationships among anemia (maybe other than IDA), ID and auditory functions, and clinical implications of hearing loss (if any) should be questioned.