The open peritoneal cavity: etiology correlates with the likelihood of fascial closure

The use of laparostomy in damage control surgery and uncontrolled intra-abdominal infection has been well described. We examined 71 patients who required laparostomy to see if trends in management and outcome could be identified based on the underlying disease state. The underlying etiology included gastrointestinal sepsis (n = 25), pancreatitis (n = 21), or trauma (n = 25). Pancreatitis patients required more operations per patient (P < 0.05). The likelihood and type of closure (fascial, mesh, or none) was related to the underlying etiology: trauma patients were more likely to have fascial closure (P < 0.02), patients with GI sepsis were more likely to require mesh closure, and pancreatitis patients were more likely to have no formal closure (P < 0.02). Only 29 per cent of patients achieved definitive fascial closure. Mortality in trauma patients was 20 per cent, 36 per cent for GI sepsis, and 43 per cent in patients with pancreatitis. Complications of laparostomy included enterocutaneous fistula (16.9%) and abscess formation (7%). Though the use of laparostomy has become more prevalent, it is still associated with significant hospital stay, morbidity, and mortality. In our study, the number of operations and likelihood of abdominal closure appears to correlate with the etiology of the underlying disease requiring use of laparostomy.     

Iliac compression syndrome and recanalization of femoropopliteal and iliac venous thrombosis: a prospective study with magnetic resonance venography

OBJECTIVES: Poor iliac vein recanalization has been associated with compression of the left common iliac vein by the right common iliac artery (RCIA/LCIV compression); however, this finding has been difficult to confirm. In a baseline study, RCIA/LCIV compression was detected with magnetic resonance imaging in patients with deep venous thrombosis. We compared recanalization of left femoropopliteal and iliac thrombosis with and without RCIA/LCIV compression. METHODS: This was a prospective blinded study carried out in a 1355-bed university hospital. Thirty-one patients were recruited from consecutive cohorts of patients with iliofemoral and femoropopliteal DVT who underwent direct thrombus magnetic resonance imaging, venous enhanced peak arterial magnetic resonance venography, and magnetic resonance arteriography as part of the baseline study relating RCIA/LCIV compression to extent of thrombosis. Magnetic resonance venography was performed 6 weeks, 6 months, and 1 year after diagnosis of deep venous thrombosis. Femoropopliteal and iliac venous segments that were occluded at diagnosis were classified as occluded, partially occluded, or patent on follow-up scans. RESULTS: At 6-week follow-up, recanalization of all segments was incomplete. At both 6-month and 1-year follow-up, recanalization of left iliac segments associated with RCIA/LCIV compression was poorer compared with recanalization of left iliac segments not associated with compression (6 of 6 occluded vs 1 of 6 occluded and 1 of 6 partially occluded at 6 months, P =.015; 6 of 6 occluded vs 5 of 5 patent at 1 year, P = .002). This was due to complete failure of recanalization of left common iliac veins associated with RCIA/LCIV compression in 6 of 6 cases. All other iliac and femoropopliteal segments including left external iliac veins associated with RCIA/LCIV compression had high rates of recanalization at both 6 months and 1 year. CONCLUSION: RCIA/LCIV compression is associated with persistent occlusion of the left common iliac vein. The recanalization rate for all other femoropopliteal and iliac segments was high.     

Donor Kidney Exchanges

Kidney transplantation from live donors achieves an excellent outcome regardless of human leukocyte antigen (HLA) mismatch. This development has expanded the opportunity of kidney transplantation from unrelated live donors. Nevertheless, the hazard of hyperacute rejection has usually precluded the transplantation of a kidney from a live donor to a potential recipient who is incompatible by ABO blood type or HLA antibody crossmatch reactivity. Region 1 of the United Network for Organ Sharing (UNOS) has devised an alternative system of kidney transplantation that would enable either a simultaneous exchange between live donors (a paired exchange), or a live donor/deceased donor exchange to incompatible recipients who are waiting on the list (a live donor/list exchange). This Regional system of exchange has derived the benefit of live donation, avoided the risk of ABO or crossmatch incompatibility, and yielded an additional donor source for patients awaiting a deceased donor kidney. Despite the initial disadvantage to the list of patients awaiting an O blood type kidney, as every paired exchange transplant removes a patient from the waiting list, it also avoids the incompatible recipient from eventually having to go on the list. Thus, this approach also increases access to deceased donor kidneys for the remaining candidates on the list.     

Upper tract surveillance in primary bladder cancer follow-up

OBJECTIVE: To determine if there is national variation in regimens of upper urinary tract surveillance in patients with primary bladder cancer. METHODS: A questionnaire was sent to 470 consultant urologists from a British Association of Urological Surgeons list in the UK; 301 anonymous replies were received. Two replies were incomplete and therefore the results of 299 questionnaires (64%) were analysed. RESULTS: Of the 299 surgeons, 19 (6%) use no form of upper urinary tract surveillance; 162 (54%) use surveillance in selected patients, i.e. those with carcinoma in situ (47%), multiple bladder tumours at first presentation (39%) and after cystectomy (70%), and 118 (39%) use upper tract surveillance on all patients with a history of bladder cancer. The median (range) screening interval was 24 (12-60) months and surveillance continued for a median of 10 (2 to indefinite) years, continuing for an indefinite period in 33%. CONCLUSIONS: Most urologists use upper tract surveillance in patients with bladder cancer but there is wide variation in the duration and interval for which it continues, and in the type of patient selected for surveillance. Some patients at high risk of upper tract tumour are not being screened. Asymptomatic upper tract tumours may not be diagnosed because the intervals between surveillance are too long, and the duration for which it continues inadequate. There is a need for multidisciplinary national guidelines to reduce variation in practice.     

The association of radial deficiency with thumb hypoplasia

BACKGROUND: Congenital longitudinal deficiencies of the radius and thumb are known to be associated with one another; however, the details of their relationship are unknown. The purpose of this study was to determine whether increased severity of radial deficiencies is associated with increased severity of thumb deficiencies and to review the relationship between radial deficiency and reconstructibility of a hypoplastic thumb. METHODS: Radiographs and charts of 227 affected upper extremities of 139 patients with radial longitudinal deficiency were reviewed. The associated thumb deficiency was classified according to a modification of the Blauth and Schneider-Sickert scheme and the radial deficiency was classified according to a modification of the Bayne and Klug criteria for 191 extremities of 119 patients. RESULTS: The severity of the thumb deficiency was directly proportional to the severity of the radial deficiency (p < 0.0001). Half of the extremities had either a thumb deficiency or thumb and carpal deficiencies without radial deficiency. Two-thirds (sixty-three) of the ninety-five limbs with a normal radius had a thumb that could be surgically reconstructed. Seventy-one (91%) of seventy-eight extremities with a thumb amenable to surgical reconstruction had a radius that did not require surgical reconstruction. All extremities with a radial and/or carpal deficiency had a thumb deficiency. Forty-eight (94%) of fifty-one extremities with complete absence of the radius had a thumb that was not reconstructible. CONCLUSIONS: This study supports the growing body of evidence that the components of radial longitudinal deficiency represent a progressive spectrum of upper extremity abnormalities, and a distal progression of severity, with distal structures likely to be more involved than proximal structures.     

Early prediction of IgA nephropathy progression: proteinuria and AOPP are strong prognostic markers

BACKGROUND: Inflammation and oxidative stress have been incriminated in the pathogenesis of IgA nephropathy (IgAN). The aim of the present study was to assess whether markers reflecting these pathophysiologic processes, namely C-reactive protein (CRP) and advanced oxidation protein products (AOPP), would allow-in conjunction with clinical and histopathologic parameters-to predict disease progression. METHODS: Between 1994 and 1997, 120 adult patients with biopsy-proven IgAN were included in a prospective cohort study, and followed until the end of 2002 or start of dialysis. In every patient, we determined plasma levels of CRP and AOPP. These parameters were included, together with clinical data, in a multivariate Cox proportional hazard regression analysis, with halving of baseline creatinine clearance as the primary renal end point. RESULTS: A total of 51 patients reached the renal end point, including 30 who had to start dialysis. With multivariate analysis, the most potent independent risk factors of poor renal outcome were proteinuria > or =1 g/day [proportional hazard risk (HR) = 23.7, P= 0.0001], hypertension (HR = 8.13, P= 0.008), and AOPP plasma level (HR = 1.09 per 10 micromol/L, P= 0.042), whereas angiotensin II inhibitors were protective (HR = 0.19, P= 0.001). CONCLUSION: Our data support the role of oxidative stress in the pathogenesis of IgAN and suggest that patients with proteinuria > or =1 g/day should be eligible for early implemented antioxidant and/or anti-inflammatory therapeutic strategies, with AOPP plasma level as a surrogate marker to evaluate their effects.     

IL-12 cDNA direct injection: antimetastatic effect from a single injection in a murine hepatic metastases model

BACKGROUND: Interleukin 12 (IL-12) gene therapy is an effective antitumor agent in local and metastatic murine tumor models. We sought to evaluate the antimetastatic effect of IL-12 cDNA in a liver metastases model. MATERIALS AND METHODS: A liver metastases model was induced by creating a "primary" splenic tumor through inoculation of 1 x 10(5) TS/A adenocarcinoma cells directly into the inferior pole of the spleen in female BALB/c mice. On day 4, 50 microg of IL-12 cDNA or control plasmid DNA was injected into splenic tumor, followed by splenectomy on day 8. Mice were sacrificed on day 25 to assess liver tumor burden. IL-12 mRNA and mIL-12 and IFN-gamma protein levels were assessed after IL-12 injection. Peripheral blood CD4+, CD8+, and NK cells were quantified on day 14 using FACS. To determine the significance of site of cytokine DNA injection, IL-12 cDNA was injected on day 4 into splenic tumor or into the non-involved spleen after isolation of the inferior and superior portions of the spleen, respectively, with surgical clips. Splenectomy was performed on day 8 and sacrifice was performed on day 25. RESULTS: IL-12 mRNA was detected in the liver 8 h after injection, with a peak at 24 h. After splenic injection, protein levels of IL-12 and IFN-gamma were detectable in the liver and spleen 24 h after treatment. IL-12 and IFN-gamma were not detectable in control animals. In the peripheral blood, there was a marked increase in NK cells (13% of total lymphocytes versus 4%, control) and in the CD4+/CD8+ ratio (5.5 versus 1.9). At day 25, there was a marked antimetastatic effect after IL-12 injection into either splenic tumor [liver:body weight, 6.2 versus 10.9 (control), P = 0.007] or non-involved spleen (6.8 g versus 10.7 g, P = 0.005). There was no difference in the antimetastatic effect between animals injected into splenic tumor or non-involved spleen (P = 0.3). CONCLUSION: Injection with a single dose of IL-12 cDNA into splenic tumor or non-involved spleen resulted in a profound antimetastatic effect. Splenic IL-12 injection results in mRNA expression in the liver, protein expression in the liver and spleen, and a marked increase in NK cells and the CD4+/CD8+ ratio in peripheral blood.     

Review of a routine test of cardiac function before aortic aneurysm surgery

The majority of vascular surgeons employ tests of cardiac function prior to embarking on elective abdominal aortic aneurysm (AAA) repair. This study reviewed the value of measuring preoperative ventricular ejection fraction (VEF). The records of the 207 patients considered for elective AAA repair between 1994 and 2000 were reviewed. In patients who underwent surgery, morbidity and mortality data were retrieved from the vascular department database. These outcomes were correlated with the measured VEFs. In patients turned down for surgery, the reasons were determined from patients' notes, and the role that VEF played in the decision was evaluated. Low VEF did not correlate with postoperative cardiac morbidity or mortality. The range of VEF values in patients turned down for surgery was not significantly different from those who underwent AAA repair. VEF was pivotal in the decision not to operate in only one patient over the 6-year interval. This review found no evidence that routine measurement of VEF prior to elective AAA repair was valuable either in making the decision whether to operate or in predicting outcome and complications. Little or no information was added that could not be gained on simple clinical evaluation of cardiac function.     

Significance of Toll-like receptors in the pathophysiology of surgical sepsis

The discovery of Toll-like receptors has substantially changed our knowledge of pathogen recognition. 11 Toll-like receptors have so far been described in humans. These recognize distinct pathogen associated molecular patterns, as well as endogenous ligands and small molecular synthetic compounds. TLRs have a multifunctional role in pathogen-triggered immune responses and represent an important connection between the "innate" and "adaptive" immunity. The role of the TLRs in the recognition of pathogens renders them a key figure in the activation of the immune response during surgical sepsis. However, emerging evidence points to a fundamental role in tumorigenesis, transplantation, wound healing, atherogenesis and inflammatory bowel disease. The aim hence was to review experimental data pertaining to the activation of TLR signalling pathways in conditions associated with surgical sepsis. A systematic review of the literature was undertaken by searching the MEDLINE database for the period 1966-2004 without language restriction. The paper also analyses the possible therapeutic utilization of the TLR signalling pathways in surgical sepsis.     

Is surgery necessary for asymptomatic tethered cord in anorectal malformation patients?

Background

Evidence supporting routine surgery for asymptomatic tethered cord in patients with anorectal malformation (ARM) is, at best, speculative. The authors therefore examined whether untethering is indicated for asymptomatic tethered cord in patients with ARM.

Methods

A retrospective analysis of all patients with ARM (n = 223) between 1992 and 2002 was conducted. During the same period, 435 patients had surgery for tethered cord.

Results

Tethered cord was detected radiologically in 22 (9.8%); 8 patients with a low conus, and 14 with a low conus with and thickened filum. Seven of 22 patients underwent untethering; 3 prophylatic (14%) and 4 for neuro/motor function deficits (18%). All 4 symptomatic patients had significant clinical improvement in their neuro/motor functions after surgery. However, bowel and urinary functions remained unchanged in all 7 patients with a mean follow-up of 6.4 years (range, 4 to 8 years). Fifteen patients with radiologically diagnosed tethered cord remain asymptomatic with a mean follow-up of 2.7 years (range, 8 months to 10 years).

Conclusions

Neuro/motor functions clearly improved with surgery in symptomatic patients. However, bowel and urinary functions remained unchanged after surgery. Only 4 ARM patients with tethered cord required surgery, whereas prophylactic surgery appears to have minimal benefit. Expectant conservative approach in the management of asymptomatic tethered cord patient appears to be safe.