Carpal tunnel release by the Agee endoscopic technique. Results at 4 year follow-up

Ninety-five hands (86 patients) were treated by endoscopic carpal tunnel release using the technique of Agee. They were the first ones operated on by the senior author (GF) using this technique. The patients were interviewed at a mean follow-up of 4.5 years: 72% of hands were free of symptoms and 94% were described by the patients as functionally normal. Seventeen hands (out of 27) with residual or recurrent symptoms were examined. Nine hands (nine patients) were only partially improved (mean 6.7 on a 10 point scale) and in eight hands (seven patients), some symptoms had recurred after a mean delay of 3.8 years. It was possible to find a second pathology in most of these cases. It is necessary to inform the patient before operation that incomplete relief or recurrence of symptoms can occur after endoscopic carpal tunnel release, as with conventional release.     

Impact of colour Doppler sonography on detection of thrombosis of the hepatic artery and the portal vein after liver transplantation

Sixty patients who received 75 consecutive liver grafts and had routine Doppler sonography monitoring in the early postoperative period (three times a day) were reviewed for vascular complications. Thrombosis of the hepatic artery was detected in seven patients (3, 4, 20, 24, 48, 70 and 84 h after liver transplantation) and was then confirmed by emergency laparotomy in six cases. In one patient, thrombosis was verified by angiography before laparotomy. In two patients thrombectomy was successful, in five patients retransplantation had to be performed. Portal vein occlusion was detected in three patients (24, 26 and 90 h after transplantation) and all were successfully treated by thrombectomy and partial arterialization of the portal vein. Colour Doppler sonography was associated with no false-positive or -negative results. The specificity was 100% for the diagnosis of hepatic artery and portal vein thrombosis. In our opinion colour Doppler sonography will be able to replace time-consuming angiography in vascular diagnostics in the early postoperative phase after liver transplantation. Furthermore, there is evidence that frequent use of this non-invasive technique permits early detection of clinically unsuspected vascular complications and subsequent immediate relaparotomy, which is linked to a reduction in the rate of retransplantation.

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Bedeutung der farbdopplersonographie für die entdeckung einer thrombose der A. hepatica und der V. portae nach Lebertransplantation

Zusammenfassung Bei 60 Patienten nach Lebertransplantation (75 Transplantate) wurde in der ersten postoperativen Woche dreimal täglich eine farbcodierte Dopplersonographie zum Ausschlu vaskulärer Komplikationen durchgeführt. Eine Thrombose der Leberarterie wurde bei 7 Patienten diagnostiziert (3, 4, 20, 24, 48, 70 und 84 h nach der Transplantation). Die Diagnose wurde intraoperativ bei Relaparotomie bestätigt, bei einem Patienten erfolgte vor der Revisionsoperation eine Angiographie. Zweimal war eine Thrombektomie der Leberarterie erfolgreich, bei fünf Patienten mute retransplantiert werden. Eine Pfortaderthrombose wurde bei drei Patienten (24, 26 und 90 h nach der Transplantation) diagnostiziert. Immer war eine Thrombektomie mit partieller Arterialisierung der Pfortader erfolgreich. Falsch negative bzw. falsch positive Befunde wurden nicht erhoben, so da die farbcodierte Dopplersonographie mit einer hohen Sensitivität bei einer Spezifität von 100% in der Diagnose von Gefäßkomplikationen nach Lebertransplantation verbunden ist. In der Diagnostik von Gefäßkomplikationen während der frühen postoperativen Phase nach Lebertransplantationen kann die Angiographie durch die farbcodierte Dopplersonographie ersetzt werden. Die Diagnose insbesondere von klinisch noch nicht manifesten Gefäßkomplikationen ist durch engmaschigen Einsatz der Methode möglich und kann durch frühzeitige Relaparotomie zu einer Senkung der Retransplantationsrate führen.

     

Risk factors for relapse in clinical stage I nonseminomatous testicular germ cell tumors: results of the German Testicular Cancer Study Group Trial.

PURPOSE: To prospectively assess potential risk factors for relapse in clinical stage I nonseminomatous germ cell tumors of the testis (CS I NSGCT). PATIENTS AND METHODS: From September 1996 to May 2002, 200 patients with CS I NSGCT were prospectively assigned to retroperitoneal lymph node dissection (RPLND), and risk factor assessment was performed within a multicenter protocol. One hundred sixty-five patients had an adequate minimum follow-up of 12 months (mean, 34.5 months) or had pathologic stage II. RESULTS: Pathologic stage II disease was found in 27.9% of patients. Only 0.6% of patients relapsed in the retroperitoneum after confirmation of pathologic stage I disease. With reference pathology, vascular invasion (VI) was most predictive of stage in multifactorial analysis (accuracy, 65.1%). However, the positive predictive value (PPV) of VI to predict patients who have metastatic disease or relapse during follow-up was only 52.7%. With absent VI, low-risk patients had a negative predictive value (NPV) of 76.9%. With a combination of several risk factors, the PPV increased to 63.6% and the negative predictive value increased to 86.5%. CONCLUSION: Even with an optimal combination of prognostic factors and reference pathology, more than one third of patients predicted to have pathologic stage II or relapse during follow-up will not harbor metastatic disease and, therefore, would be overtreated with adjuvant therapy. However, patients at low risk may be predicted at an 86.5% level, and thus, surveillance in highly compliant patients would be a valuable option. For high-risk patients, further reduction of adjuvant treatment is necessary.     

Mechanisms for the formation of glycoxidation products in end-stage renal disease

BACKGROUND: Advanced glycation end products (AGEs) accumulate on tissue and plasma proteins in patients with renal failure far in excess of normal aging or diabetes. The aim of these studies was to elucidate the nature of the precursors and the pathways that lead to an accelerated formation of two structurally identified AGEs [pentosidine and Nepsilon(carboxymethyl)lysine (CML)] in the uremic milieu. METHODS: Serum levels of the glycoxidation products, pentosidine and CML, were quantitated by high-performance liquid chromatography in uremic patients treated by dialysis. The formation of early glycation products (as furosine) and late glycoxidation products was modeled in uremic serum and in spent peritoneal dialysate. RESULTS: Clinical factors that affect circulating levels of AGEs included dialysis clearance and dialyzer membrane pore size, but not the presence or absence of diabetes. Both pentosidine and CML form at an accelerated rate in serum from uremic patients. Chelating agents most effectively slow the formation in vitro. In uremic fluids, the primary mechanism of formation of pentosidine is through the Amadori pathway. The primary mechanism of formation of CML is through metal-chelated autoxidation of reducing sugars generating reactive carbonyl precursors. In uremic serum, the presence of an unidentified reactive low molecular weight precursor accelerates the formation of pentosidine. CONCLUSIONS: The formation of the two glycoxidation products, pentosidine and CML, proceeds by different pathways and is enhanced by different precursors in the uremic milieu. The formation of both AGEs is markedly enhanced by metal-catalyzed reactions, evidence for the presence of increased metal-ion mediated oxidant stress in uremia.     

The effect of smoking on placental and fetal zinc status

Previous studies have reported a cadmium/zinc interaction in cadmium-exposed pregnant animals that results in (1) increased placental cadmium levels, (2) increased placental zinc levels, and (3) decreased placental zinc transport. This study was carried out to determine whether zinc status would be affected in pregnant women exposed to cadmium through cigarette smoke. Atomic absorption spectroscopy was used to determine the levels of cadmium and zinc; 65 pregnant women who smoke and 84 who do not smoke were studied. Our data reveal that increased cadmium levels in pregnant women as the result of smoking increase placental zinc levels and decrease cord red blood cell zinc levels. Significantly higher levels of both cadmium and zinc were found in the placentas of pregnant women who smoke; moreover, stepwise multiple regression showed that maternal whole blood cadmium levels predicted placental zinc levels. In regard to cord blood, a significant 9% decrease in the red blood cell zinc level was observed in infants of mothers who smoke and this decrease was correlated with smoking activity, as evaluated by measuring plasma levels of thiocyanate. Also cord red blood cell zinc levels were found to correlate with placental zinc levels in nonsmokers but not in smokers. Overall, our data show that a cadmium/zinc interaction does take place in the maternal-fetal-placental unit of pregnant women who smoke and results in less favorable zinc status in the infants.