An analysis of fluid loss during transcervical resection of submucous myomas

Objective: To determine the contribution of several variables to fluid loss during transcervical resection of submucous myomas.Design: An observational study using multiple linear regression analyses.Setting: A university-affiliated training hospital and a university department of clinical epidemiology and biostatistics.Patient(s): Patients with submucous myomas.Intervention(s): Transcervical resection of submucous myomas and monitoring of fluid loss.Main Outcome Measure(s): Patient age, uterine enlargement, treatment with GnRH analogues or 8-ornithine-vasopressin, type of anesthesia, number of myomas, intramural extension of the myoma (type of myoma), and operating time were tested as variables.Result(s): Only intramural extension of the myoma and operating time were obviously related to fluid loss. For the other variables, such a relation was weak at best. The relation between fluid loss and operating time was not modified by any of the other variables.Conclusion(s): Because fluid loss is an important limiting factor in the transcervical resection of submucous myomas, special attention should be paid to reduction of the operating time and preoperative assessment of the intramural extension of the myoma to guide appropriate patient selection.     

Pre- and post-transplant assessment of liver function in paediatric liver transplantation

The pre-operative risk of paediatric liver transplantation candidates (n=41) was assessed in a prospective study by means of clinical symptoms, conventional static and liver blood flow dependent dynamic liver function tests. Nine patients died during the 365-day waiting period. The data were subjected as covariates to a survival analysis in the Cox proportional hazards model. There was a significant relationsship between the results of mono-ethylglycinexylidide (MEGX) formation and ICG test and the 365-day survival rate. In the stepwise analysis, none of the remaining parameters improved the predictive ability when added to the dynamic liver function test results. The assessment of post-transplantation liver function was studied in 27 patients during the first 28 postoperative-day period. In addition, liver function was studied in a cross-sectional study 1–7 years after successful liver transplantation in children with complete or partial rehabilitation. In the early postoperative period severe organ damage was indicated by both static and dynamic liver function tests. In the later course after transplantation no deterioration of liver function measured with MEGX formation was to be observed. These findings demonstrate the usefulness of dynamic liver function tests in the pre- and post-transplant assessment of liver function.     

Choledochoenterostomy with an anti-reflux mechanism

A new technique of choledochoenterostomy was devised to solve some of the problems of enterobiliary anastomosis with a normal calibre. The distal extremity of the common bile duct is completely surrounded by the bowel mucosa to a length of 3 cm after seromyectomy of a bowel wall rectangle of 4 × 1 cm. Experimental studies in rats and dogs demonstrated that this procedure prevents the risks of anastomotic disruption and functions like a mechanical unidirectional valve, which has great efficacy in stopping enterobiliary reflux. Studies in ten patients with obstructive jaundice with an extrahepatic biliary dilation less than 1.2 cm diameter submitted to this procedure Confirmed the experimental results. All patients were asymptomatic, without jaundice and with normalization of the liver enzymes after 2 months. The permeability of the valvular anastomosis studied by cholangiography, the HIDA ^99mTc test and manometry was quite similar to other classical biliary-enteric anastomosis. In contrast, anti-reflux efficacy was only demonstrated in patients with a valvular anastomosis.     

Evaluation of portal MR angiography using superparamagnetic iron oxide

The purpose of our research was to determine the effects of superparamagnetic iron oxide on MR imaging of the portal venous system. Eight piglets were examined in deep anaesthesia and respiratory arrest using a time-of-flight magnetic resonance fast low angle shot, two-dimensional angiography sequence at 1.5T. MR angiograms were acquired precontrast and after intravenous administration of a cumulative dose of 10, 20 and 40 μmol/kg SHU 555A, a superparamagnetic iron oxide contrast agent for MR imaging with a particle size of 60 nm. For each dose, two subsequent sets of scans were obtained and reconstructed by a maximum-intensity-projection algorithm. Hepatic parenchymal and portal venous signal intensities were measured, and portal vein contrast calculated for each set of scans. All examinations were visually rated as to portal vein contrast and homogeneity by two blinded observers. Receiver operating characteristics of both observers were analyzed. The contrast agent reduced hepatic parenchymal signal in a dose-dependent way. After a cumulative dose of 10 μmol iron oxide, hepatic parenchymal signal intensity decreased to 63 ± 6% (average of measurements at 4 and 14 minutes, mean ± standard error of the mean), after 20 μmol to 24 ± 3%, and after 40 μmol to 12 ± 1% of control. Intra-vascular signal in the left main portal vein branch increased to 117 ± 6%, 127 ± 10%, and 133 ± 9% of control, respectively. The contrast-to-noise ratio of the portal vein improved (521 ± 90%, 891 ± 178%, and 995 ± 201% of control in the left portal vein main branch). Intravascular signal intensities increased slightly. The combined effect improved contrast of the portal vein stem and its branches. Receiver operating characteristics analysis documented dose-dependency of contrast medium effects on portal venous contrast and intravascular homogeneity. Visual rating also indicated a positive effect on portal venous contrast. The superparamagnetic iron oxide agent improved portal venous contrast with surrounding hepatic parenchyma in this normal animal model, and could potentially result in more accurate diagnosis of portal venous pathology.     

PULMONARY RESECTION FOR METASTATIC BREAST CANCER

Background : A patient with a solitary pulmonary metastasis who had breast cancer in the past may benefit from pulmonary resection. Methods : Between 1984 and 1996, 17 patients underwent metastatectomy for metastatic breast cancer. There were 15 females and two males whose average age was 59 (range: 40–74 years). The median tumour-free interval after the primary breast-cancer operation was 5.1 years (range: 8 months-18.2 years). Sixteen patients had complete resections, which included six lobectomies and 10 lesser resections. Results : The postoperative mortality was nil and the morbidity rate was 6%. Follow-up was complete in all patients. Recurrent disease developed in four patients and two patients died of their disease. The 5-year survival was 62%. Conclusion : An aggressive surgical approach is warranted in patients with isolated resectable pulmonary metastases from breast cancer.     

Segmental hyperintensity on T1-weighted MRI of the liver: Indication of segmental cholestasis

The purpose of this study was to determine the relationship between segmental hyperintensity of the liver on T1-weighted images and segmental cholestasis in patients with obstructive jaundice. T1-weighted and T2-weighted MR images were obtained of 73 patients with obstructive jaundice caused by various diseases. Fat-suppressed T1-weighted images were also obtained of 10 patients. Eleven patients with segmental intra-hepatic bile duct dilatation (cholestasis) showed segmental hyperintensity on T1-weighted images and/or fat-suppressed T1-weighted images and no signal intensity difference on T2-weighted images. Sixty-two patients with widespread intrahepatic bile duct dilatation showed no intensity difference on T1-weighted and T2-weighted images (P < .01). Segmental hyperintensity on T1-weighted images was correlated with intrahepatic cholestasis.     

Potassium permanganate resistant amyloid in fine-needle aspirate of the liver

A case of primary amyloidosis, initially detected by fine-needle aspiration of the liver, is reported here. Amorphous acellular metachromatic material was seen extracellularly in between the hepatocytic cords compressing them. This material showed typical apple-green birefringence under crossed bipolars after alkaline Congo-red staining proved its amyloid nature. It was resistant to potassium permanganate pretreatment, indicating it to be of the AL type. © 1994 Wiley-Liss, Inc.     

Early experience with laparoscopic abdominoperineal resection

Background: Laparoscopic abdominoperineal resection (LAPR) has not been fully evaluated as a technique in the treatment of rectal and anal cancer or inflammatory bowel disease. The purpose of our study was to evaluate the early experience with laparoscopic abdominoperineal resection at Washington University Medical Center. Methods: A prospective analysis was performed on the first 21 patients undergoing the procedure at Washington University Medical Center. Indications for surgery included rectal cancer (14 patients), anal squamous cell cancer (four patients), inflammatory bowel disease (two patients), and anal melanoma (one patient). Results: The procedure was converted to open procedure in four patients (19%). The mean (±SEM) operative time and blood loss for completed and converted LAPR were 239 ± 11 min and 424 ± 43 ml, respectively. Postoperative hematocrit dropped a mean of 8.3% ± 1.2% SEM; five patients required blood transfusion (24%). Wound complication occurred in four patients (19%; three perineal, one trocar site). Bowel function returned after a mean of 3 days, and mean postoperative hospital stay for the completed LAPR group was 5 days. Mild pain was experienced by 81% of patients (17/21) while 19% (4/21) noted moderate pain, usually of the perineal wound. The mean duration of patient-controlled analgesia use was 2 days. During the 1–44-month follow-up, six patients (29%) died from cancer (stage III or IV at operation) and only one patient developed local recurrence in the pelvis (5%). There were no trocar-site implants of cancer. Furthermore, there was no relationship between prior abdominal operations, the amount of blood loss, postoperative drop of hematocrit, or blood transfusion requirement and the length of hospitalization or complication rates. Conclusion: Laparoscopic abdominoperineal resection is a feasible alternative to the conventional open technique in both cancer and colitis patients. Received: 23 April 1996/Accepted: 8 July 1996     

Expression of cell-matrix molecules and integrin receptors in human liver grafts during chronic rejection

Abstract The inflammatory response of immune cells to target cells and cell-matrix molecules is regulated by several receptor-ligand molecules. As fibrosis develops in ongoing chronic rejection after liver transplantation, it is of interest to analyze patterns of integrin receptors and cell-matrix molecules in order to study the relation between immune cells and the stromal and parenchymal cells. In the present study, we demonstrated the expression of these molecules in chronic rejected human liver grafts using immunohistochemical techniques. The results showed a differential expression and induction of integrin receptors and cell-matrix molecules on resident liver cells, especially on sinusoids, reflecting a state of chronic inflammation and a specific interaction between integrin receptors and cell-matrix molecules. The patterns of induced integrin receptors on graft-infiltrating cells was closely related to the local production of cell-matrix molecules and reflected the final sequence of a stepwise progress of the inflammatory reaction.     

Surgical relevance of diagnostic imaging techniques in pretherapeutic staging of carcinoma of the esophagus, stomach, colon and rectum

Summary. The increasing spectrum of therapeutic options for tumors of the gastrointestinal tract has resulted in a refinement of the pretherapeutic diagnostic strategies. The diagnostic approach in surgical institutions that are focused on primary surgical resection will therefore be much less sophisticated than in institutions who propose a selective therapeutic approach based on the pretherapeutic tumor stage and prognostic parameters. Pretherapeutic assessment of the depth of tumor infiltration, i. e. the T-category, is essential because most further diagnostic and therapeutic decisions are based on this information. This can today be achieved with a high degree of accuracy by endoscopy and endoscopic ultrasonography. Early T-stages (T1–2) are usually an indication for primary surgical resection and, after exclusion of distant metastases, no further diagnostic studies are required. In patients with locally advanced esophageal, gastric or rectum tumors (T3–4) multimodal therapeutic concepts should be considered. This usually requires additional diagnostic studies. None of the available diagnostic imaging modalities today allows satisfactory pretherapeutic assessment of lymph node metastases. The assumed nodular status should therefore currently not influence therapeutic decisions. Essential is, however, the assessment of distant metastases, since the documentation of distant tumor spread will change the therapeutic approach to a palliative situation. Detailed histologic and molecular-biologic assessment of tumor characteristics is growing in importance. This not only provides therapeutically relevant information regarding tumor grading, but opens the door towards a modern molecular diagnostic approach. It can be expected that in the near future a vast amount of relevant prognostic information can be obtained from endoscopic tumor biopsies, which may soon alter our therapeutic concepts.