Comparison of the precision of two standardized co-ordinate systems for the quantitation of brain anatomy: preliminary results

We assessed reproducible definition of two standardized co-ordinate systems for intersubject analysis of brain images. The baselines in the two co-ordinate systems were a modification of the canthomeatal (inCM) line and the anterior-posterior commissural )AC-PC) line. Axial spin-echo MR images of four subjects at 1.5T were used. Operator error was computed from the replicate analyses of two operators. The mCM line was determined by the lens of the eye and the internal auditory canal, and the AC-PC line was determined by the intersection of the AC and PC with the interhemispheric fissure. Reproducibility of the mCM markers (SD=0.59 mm) did not differ significantly from that of the AC-PC line (SD=0.68 mm). The measurement error of the angle of the baseline (), however, was more than 7 times as large for the AC-PC line as for the mCM line. An additional error affecting the rostrocaudal rotation of the co-ordinate systems, attributable to the distance between the anatomic markers, was 2.1 and 3.6° (3 mm and 5 mm slice thickness) for the mCM co-ordinate system and 8.2 and 11.0° (3 mm and 5 mm slice thickness) for the AC-PC system. The AC-PC line based co-ordinate system is therefore, less reproducible than the mCM line based system. this could be improved if a combination of axial and sagittal images were used for the definition of the AC-PC line.     

Meckel diverticulum as a possible source of complications]

The authors performed a retrospective analysis of 108 operations performed because of Meckel's diverticulum from Jan. 1, 1980 until Dec. 31, 1997. 87 incidental operations were performed (80.55%) and 21 operations were performed (19.54%) because of complications of Meckel's diverticulum. Of the 87 incidental cases, 44 were males and 43 were females. The diverticulum was resected in 70 cases, was inverted in 16 patients and was left untouched in 1 patient. There were postoperative complications in 10 cases (11.5%), however, only one complication was related to the diverticulum operation. There was one death due to pneumonia in the incidental group (1.14%). Of the 21 cases having complications there were 5 females and 16 males. The following complications were observed: 4 cases of ileus, 7 cases of perforation (a foreign body was found in two cases) and 10 cases of inflammation. The Meckel's diverticulum was resected in 19 cases and the small intestine was resected in 2 cases. Postoperative complications occurred in 3 cases (14.3%), however these were not related to the diverticulum operations. There were 2 deaths due to pneumonia and pulmonary embolism (9.5%). Histological examination revealed 7 cases of heterotopic gastric mucosa in both the incidental group and the group with complications. There was one case of heterotopic pancreatic tissue in the group with complications. The incidence of heterotopy in the incidental group was 8%, whereas in the group with complications the incidence was 33.3%. Histological examination also revealed reflux gastritis-like diverticulitis in 5 of the patients with heterotopic gastric mucosa. Meckel's diverticulum was diagnosed in 2 patients preoperatively by upper gastrointestinal series.     

Why laparoscopic cholecystectomy today?

Traditional open cholecystectomy became the gold standard of surgical treatment for symptomatic gallstone disease during the last century. In spite of its good results, clinicians have been trying to establish effective nonsurgical methods of eliminating gallstones. Although oral, percutaneous, or retrograde litholysis can be used effectively for cholesterol stones, these represent only 10% of all gallstones. Moreover, intracorporeal lithotripsy is an invasive method, and while extracorporeal shock wave lithotripsy is a promising procedure, even after careful selection, only 70%–80% of the patients become stone-free within 1 year. In fact, none of the methods which leave the gallbladder intact are free of complications, and they are followed by 50% stone recurrence within 5 years. Since 1987, laparoscopic cholecystectomy has become the procedure of choice as it is safe and only minimally invasive. We believe that the laparoscopic technique is a promising way to the surgery of the future.     

Multiple intracranial aneurysms: A high risk condition

Summary There is still a relative silence in the literature on what policy should be followed in treating multiple aneurysms. The main risks are: bleeding of a formerly asymptomatic aneurysm during the haemodynamic tides of the peri-operative period; aneurysm(s) can be hidden on angiograms and tend to be overlooked easier in case of an already revealed aneursym; misjudgement of the ruptured one as a silent additional aneurysm, therefore left for second stage surgery.This paper, based on a material of 330 operations for multiple aneurysms, focuses on these problems. It advocates the one stage complete repair of all lesions using both options of bilateral pterional craniotomies or the contralateral approach. But it also describes those silent aneurysms which safely could be clipped later. Hazards and disadvantages concerning the more aggressive surgery proved to be less significant than the natural history of multiple aneurysms represents.Presented at the EANS Wintermeeting on High Risk Neurosurgery, Budapest, February 20–23, 1991.     

Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients

OBJECTIVE: To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device. SUMMARY BACKGROUND DATA: In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases. METHODS: A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy. RESULTS: Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%. CONCLUSIONS: The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.     

Prenylated isoflavonoids from the root bark of Erythrina vogelii

Four new prenylated isoflavonoids, vogelins D-G (1-4), were isolated from the CH2Cl2 extract of Erythrina vogelii root bark in addition to the known compounds isolupalbigenin (5), ficuisoflavone (6), ulexone (7), isochandalon (8), and isoderrone (9). The structures 1-4 were elucidated by spectroscopic and chemical methods. The absolute configuration of compound 1 was determined on the basis of its CD spectrum. Possible biogenetic relationships among the E. vogelii isoflavonoids are briefly discussed.     

Response of reperfusion-salvaged, stunned myocardium to inotropic stimulation

The purpose of this study was to determine whether myocardium salvaged by reperfusion following coronary occlusion could respond to inotropic stimulation by dopamine. Mongrel dogs underwent a 2-hour occlusion of the proximal left anterior descending coronary artery, followed by reperfusion for 5 or 28 hours. Dopamine (5 to 10 micrograms/kg/min) or dextrose was administered 1 hour or 24 hours after the onset of reperfusion. Serial, computer-assisted, two-dimensional echocardiographic determination of percentage of systolic wall thickening (%SWT) and cross-sectional ejection fraction (% delta area) were used to evaluate the response to treatment. Myocardium in the region of central ischemia contracted poorly after 1 hour of reperfusion (mean %SWT = 1.3 +/- 13.3% [mean +/- SD] compared to preocclusion value of 43.6 +/- 18.5%, p less than 0.001) and tended to thin at 24 hours of reperfusion (mean %SWT = -6.0 +/- 12.3%, p less than 0.001). After 1 hour of reperfusion, dopamine produced a greater than fourfold improvement in %SWT within the reperfused zone (to 15.3 +/- 7.3%, p less than 0.05). After 24 hours of reperfusion, dopamine again produced an improvement in %SWT (to 5.8 +/- 12.5%, p less than 0.05). There were no significant changes in %SWT with dextrose infusion. Thus, dopamine stimulates the reperfusion-salvaged but noncontracting (stunned) myocardium to contract as early as 1 hour after reperfusion.     

Liver dysfunction in Pennsylvania's multitransfused hemophiliacs

Transaminase values [alanine amino transferase (ALT) and aspartate amino transferase (AST)] and markers for hepatitis B were serially determined in 558 hemophiliacs exposed to blood products. Hepatitis B surface antigen (HB_sAg) persistent for over 12 months was present in 6% of the patients. Antibody to hepatitis B surface antigen (anti-HBs) was noted in 90% of the 259 patients treated with factor VIII or IX concentrates but in only 49% of the 43 patients treated with fresh frozen plasma (FFP) or cryoprecipitate. Persistently abnormal transaminase values were noted in 31% of the patients treated with commercial concentrates but in only one (2%) of the patients exposed to cryoprecipitate or FFP. This difference continued even when the two groups of patients were matched for the amount of blood products, up to 50, 000 units, which they had received in the study period. In the concentrate-treated patients, no correlation could be found between transaminase values and the number of units of factor VIII or IX they had received during the six years of the study (1973–1978).Supported in part by the Pennsylvania Hemophilia Centers and the Pennsylvania State-Wide Hemophilia Program.