Rare tumor of the posterio-superior mediastinum. Therapeutic approach. Apropos of a case. Review of the literature]

The authors report an exceptional case of giant cell tumour of the third thoracic vertebra revealed by its mediastinal development. Despite intimate involvement of the large mediastinal vessels, a double surgical approach, starting with sternotomy to ensure vascular control then anterolateral thoracotomy, allowed curative resection of this tumor. Treatment was completed by a second neurosurgical operation followed by 5,000 rads of radiotherapy. Based on a review of the literature, the authors discuss the pathogenesis and consider the various therapeutic problems raised by giant cell tumours of the vertebrae (situated above the sacrum).     

Selective surgical therapy of the Budd-Chiari syndrome provides superior survivor rates than conservative medical management

The Budd-Chiari syndrome is an unusual form of portal hypertension caused by hepatic vein occlusion, which results in centrilobular congestion and necrosis. Its overall mortality rate exceeds 50% at 2 years, and optimal treatment remains controversial. To determine optimal therapy on the basis of clinical and angiographic data, we retrospectively analyzed 30 patients with this disease treated at the University of California, Los Angeles or the University of Southern California School of Medicine between 1955 and 1985. Twelve patients were treated conservatively with diuretics, anticoagulants, paracentesis, and/or peritoneal-venous shunt. Eighteen patients were treated by definitive surgery: side-to-side portocaval shunt (four), mesocaval shunt (four), side-to-side splenorenal shunt (one), liver transplantation (two), transatrial membranotomy (TM) (two), TM followed by inferior vena cava reconstruction (IVCR) (one), TM followed by mesocaval shunt (one) simultaneous IVCR and side-to-side portocaval shunt (one), IVCR (one), and azygousatrial shunt followed 4 years later by a splenopulmonary shunt (one). Overall the surgical group had survival rates superior to the medical group, with a 2-year survival rate of 54% for the surgical group vs. 9% for the medical group (p less than 0.089). On the basis of these data we conclude that surgical therapy is superior to medical therapy for the Budd-Chiari syndrome. However, the operation must be tailored to treat the specific anatomic and clinical abnormality. Guidelines to select the proper surgical procedure are given.     

Variables influencing the outcome following orthotopic liver transplantation

Seventy-two patients who underwent orthotopic liver transplantation (OLT) were studied to identify perioperative variables that would predict survival and intraoperative blood loss. Survival and intraoperative blood loss were not affected by encephalopathy, length of donor liver ischemia, or any of the preoperative laboratory values studied. Survival was significantly decreased in patients requiring postoperative dialysis (41%) and in patients who had severe rejection requiring retransplantation (33%). Intraoperative blood loss was significantly greater in patients over 50 years of age (11.6 blood volumes) and patients with biliary atresia (8.7 blood volumes). These results may aid in choosing future recipients for orthotopic liver transplantation and in anticipating the postoperative support needed.     

Tolerability and serum levels of benoxaprofen in healthy volunteers

Tolerability, serum levels and urinary excretion of benoxaprofen (B) in therapeutic doses of 400 or 600 mg as a capsule were studied in 22 healthy volunteers after single or multiple doses. B was determined by a HPLC procedure. Apart from a skin reaction in one patient, no major problems were encountered by patients. Mean serum peak values after 400 and 600 mg were 49.84 and 94.54 micrograms/ml respectively. Mean time to peak was 5.6 hours and mean half-life ranged between 45.38 (400 mg regimen) and 63.48 hours (600 mg regimen). Urinary excretion was only a fraction of the doses ingested: 14.39% after a single dose; 35.5% after multiple doses. This may depend on other pathways of elimination of the drug because steady state is reached according to half-life.     

One-stage repair of colovaginal fistula complicating acute diverticulitis

Fourteen patients with colovaginal fistula secondary to sigmoid diverticulitis were seen between 1964 and 1988. Thirteen had undergone prior hysterectomy. Three different operative approaches were used. Three patients were treated with colostomy alone; one died and the fistula persisted in one. Five patients underwent staged procedures. One patient died of complications after the second stage of a planned three-stage procedure. Four patients underwent a two-stage procedure (fistula takedown, colectomy with colostomy and colostomy closure), all with good results. Six patients were treated with one-stage fistula takedown, colectomy and primary anastomosis, without major complication. We advocate this as the procedure of choice and emphasize the following principles of epidemiology and management: 1) colovaginal fistula complicates diverticulitis in elderly women usually following hysterectomy; this association may be a factor in etiology; 2) vaginography is useful in diagnosis; and 3) planned one-stage repair is the best surgical approach.     

Randomized prospective trial of OKT3 for early prophylaxis of rejection after liver transplantation

A group of 52 liver transplant patients was prospectively randomized to receive prophylactic immunosuppressive therapy consisting of either Orthoclone OKT3 for 14 days, azathioprine, and steroids (25 patients); or cyclosporine, azathioprine, and steroids (27 patients). The groups were similarly matched for age, diagnosis, and Child's classification. The patients were studied to determine the effect of these two regimens on the incidence of rejection, infection, renal dysfunction, and mortality. Seven rejection episodes, as determined by clinical and histological criteria, occurred in seven of 25 patients (28%) receiving OKT3 compared with 18 episodes in 27 patients (67%) receiving cyclosporine during the first 14 days after transplantation (P less than 0.02). In 20% of the OKT3 patients, CD3+ levels of greater than 10% developed during therapy, and 16% of the patients developed anti-OKT3 antibodies during OKT3 treatment. Five patients were retreated with OKT3 for steroid-resistant acute rejection episodes; all had resolution of the rejection episode. Infectious complications were similar in each group. Renal function, as measured by serum creatinine, was significantly better with OKT3 than with cyclosporine (P less than 0.003) at 14 days. We conclude that prophylactic OKT3 is effective in reducing the number of early rejection episodes after liver transplantation; after 14 days the incidence of rejection is similar; reuse of OKT3 has been successful in liver transplant patients; infectious complications are similar between OKT3 and cyclosporine; and OKT3 preserves renal function better than cyclosporine and is thus indicated in patients with compromised preoperative renal function.