Laparoscopic management of benign solid and cystic lesions of the liver

OBJECTIVE: The authors present their experience in the laparoscopic management of benign liver disease. The aim of the study is to analyze technical feasibility and evaluate immediate and long-term outcome. SUMMARY BACKGROUND DATA: Indications for the laparoscopic management of varied abdominal conditions have evolved. Although the minimally invasive treatment of liver cysts has been reported, the laparoscopic approach to other liver lesions remains undefined. METHODS: Between September 1990 and October 1997, 43 patients underwent laparoscopic liver surgery. There were two groups of benign lesions: cysts (n = 31) and solid tumors (n = 12). Indications were solitary giant liver cysts (n = 16), polycystic liver disease (n = 9), hydatid cyst (n = 6), focal nodular hyperplasia (n = 3), and adenoma (n = 9). Only solid tumors, hydatid cysts, and patients with polycystic disease and large dominant cysts located in anterior liver segments were included. All giant solitary liver cysts were considered for laparoscopy. Patients with cholangitis, cirrhosis, and significant cardiac disease were excluded. Data were collected prospectively. RESULTS: The procedures were completed laparoscopically in 40 patients. Median size was 4 cm for solid nodules and 14 cm for solitary liver cysts. Conversion occurred in three patients (7%), for bleeding (n = 2) and impingement of a solid tumor on the inferior vena cava (n = 1). The median operative time was 179 minutes. All solitary liver cysts were fenestrated in less than 1 hour. There were no deaths. Complications occurred in 6 cases (14.1%). Two hemorrhagic and two infectious complications were noted after management of hydatid cysts. There were no complications after resection of solid tumors. Three patients received transfusions (7%). The median length of stay was 4.7 days. Median follow-up was 30 months. There was no recurrence of solitary liver or hydatid cysts. One patient with polycystic disease had symptomatic recurrent cysts at 6 months requiring laparotomy. CONCLUSION: Laparoscopic liver surgery can be accomplished safely in selected patients with small benign solid tumors located in the anterior liver segments and giant solitary cysts. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Hydatid disease is best treated through an open approach.     

The lateral pectoral flap

The lateral pectoral flap is a new pedicled flap based on the superficial thoracic artery which arises from the subscapular artery and courses along the lateral border of pectoralis major. The flap consists of skin, subcutaneous tissue and the underlying pectoral epimysium. It has been used successfully to resurface contralateral soft tissue defects over the fingers, thumb and dorsum of the hand in eight cases. The advantages of this flap are that it provides reliable soft tissue cover to the hand, which can be kept in an elevated position resting comfortably on the contralateral pectoral region with the forearm and arm aligned conveniently in the cross-chest position. It does not interfere with clothing and dressing the lower part of the body in contrast to the groin, hypogastric or lower abdominal flaps, and it allows early ambulation. Primary closure of the donor site in the majority of cases is an added benefit.     

"False inhibition" of demand pacemaker due to leakage of fluid into the pacemaker lead socket

"False inhibition" of a demand pacemaker usually occurs with a microfracture of the lead system resulting in a galvanic potential at the site of the fracture or with sensing of myopotential with exercise. An increase in the slope of the leading half edge of the pulse contour is generally considered diagnostic of lead fracture. We report the case of a patient in whom "false inhibition" at rest and an increase in the slope of the leading half edge of the pulse contour were caused by leakage of fluid into the pacemaker lead socket.     

Activation of striatal dopamine receptors induces pain inhibition in rats

Summary In the rat, elevating dopamine content in corpus striatum with electrical stimulation of substantia nigra or direct administration of apomorphine (50–200g) into the lateral cerebral ventricle or apomorphine (2–10g) into the caudate-putamen complex decreased pain sensitivity (as shown by an increase in the latency to hind-paw lick in the hot plate test). Furthermore, the decreased pain sensitivity after the central administration of apomorphine was antagonized by pretreatment with haloperidol (a dopamine antagonist). On the other hand, lowering dopamine content in corpus striatum with electrolytic destruction of substantia nigra and 6-hydroxydopamine lesions to the substantia nigra, as well as direct injection of haloperidol into the lateral cerebral ventricle or caudate-putamen complex increased pain sensitivity. The data indicate that activation of striatal dopamine receptors in rat brain induces pain inhibition.     

Effects of adenosine 3′, 5′-cyclic monophosphate on thermoregulation in both rats and rabbits

Summary The effects of intraventricular administration of dibutyryl adenosine 3, 5-cyclic monophosphate (db cyclic AMP) on the thermoregulatory responses of unanesthetized rats and rabbits to different ambient temperatures (T_a) were assessed. Administration of db cyclic AMP (10–60 mM) produced dose-dependent hypothermia in both rats and rabbits at T_a 2–22 °C. The hypothermia in response to db cyclic AMP was due to decreased metabolic heat production and cutaneous vasodilatation. There was no change in respiratory evaporative heat loss. In contrast, in the heat (30–32 °C), db cyclic AMP administration produced dose-dependent hyperthermia in these animals. The hyperthermia was due to increased metabolism (due to muscular shivering) and decreased heat losses. The reduction in heat losses was shown by a decrease in both cutaneous circulation and respiratory evaporative heat loss. The data demonstrate that the thermoregulatory responses induced by central administration of db cyclic AMP are T_a-dependent.     

Three-dimensional computed tomography

Three-dimensional images were generated by reformating data from an axial image set. Separate contours were generated for bone and for tumor. The contour representing the tumor was generated by tracing the tumor using a cursor on the CRT. The contours showed the relationship of the tumor to the skull base. Three-dimensional imaging by this method is more of a communication tool than a diagnostic tool. The information on such images can be derived from close analysis of the axial image set. Indeed, determination of the position of the tumor relative to very precise structures requires analysis of the original images. The three-dimensional imaging does orient the observer and give an overall view of the position of the tumor. Because the contour of the tumor is traced, the final image represents the opinion of the radiologist. Various technical considerations and artifacts are discussed.     

Complications of preoperative balloon test occlusion of the internal carotid arteries: experience in 300 cases

Treatment of some tumors and aneurysms of the skull base may require internal carotid artery (ICA) sacrifice. Preoperatively to determine the dependence of the cerebral blood flow on a particular vessel, we perform a balloon test occlusion (BTO) by temporarily occluding the vessel in an awake patient. During occlusion, clinical evaluations and cerebral blood flow measurements are assessed. We have performed 300 BTOs. Eleven patients (3.7%) have had complications. Six (2%) were asymptomatic dissections. Five (1.7%) had neurologic deficits that persisted beyond the test period. Of these five, one was back to baseline in less than 24 hours, one recovered completely in a week, and one (0.33%) had a minimal but persistent dysphasia. These latter three cases are unexplained but might have resulted from unrecognized dissections or embolic events. Finally, one patient with a persistent deficit required energency surgery for reasons unrelated to the BTO and was therefore difficult to assess, and one required emergency middle cerebral artery embolectomy and repair of the dissection. The preoperative knowledge of carotid dependence in cases in which the ICA is at risk is essential, since vascular grafts or alternative surgical approaches are necessary in patients unable to tolerate carotid sacrifice. Since approximately 15 to 20% of the population falls into this category, a preoperative BTO appears justified.     

Modification of vascular response to synthetic oxytocin by oestrogen in rabbit

Intravenously administered oxytocin caused a dose-related fall in blood pressure of the rabbit. When oxytocin was administered in oestrogen-primed animals, the depressor response was converted to a pressor one "Oxytocin reversal". The "oxytocin reversal." was abolished after treatment with dihydroergotamine, hexamethonium or adrenalectomy. The "oxytocin reversal" did not appear in reserpinized animals.     

Concurrent cisplatin and radiotherapy in advanced head and neck cancer

Management of Head and Neck Cancers poses a challenge inspite of several advances because of poor success in terms of response rate, survival and reduced morbidity of the patients. In the present study 30 untreated histologically proven cases of head and neck cancers were subjected to weekly radiotherapy with adjuvant chemotherapy (cisplatin 30 mg/m² intravenously). This study group was compared with a group of 30 patients who were given only radiotherapy. Results have shown that combination of chemotherapy with radiotherapy gives a significantly better results in tumour as well as nodal response with minimal toxicities.