The role of surgery in the management of gestational trophoblastic disease

Between November 1967 and December 1994, 242 patients with gestational trophoblastic disease (GTD) were treated with chemotherapy by the Gynecology Service of Memorial Hospital. Eighty-seven of the patients (35.9%) underwent at least one major operation during the course of their illness. Twenty-six patients underwent two major operations, and in five patients, three major operations were performed, for a total of 118 procedures. The most frequent procedures were: hysterectomy, 56 (47.4%); hysterotomy, 15 (12.7%); thoracotomy, 13 (11%); and craniotomy, 5 (4.2%). Twenty-nine additional procedures ranging in complexity from oophorectomy to segmental liver resection were also performed. Twenty-nine operations (24.5%) were considered to be beyond the scope of most gynecologic surgeons. The overall complete remission rate for 242 patients was 90.4%. The rate for patients who underwent a major surgical procedure was 79.3% compared to 96.7% for patients whose treatment was with chemotherapy alone.
The data demonstrate that the integration of surgery in the management of GTD patients often requires a multidisciplinary approach that in many cases can best be achieved at specialized treatment centers.     

Posterior segment eye-surgery in day care?

Day care is generally accepted in anterior segment eye-surgery. In the Rotterdam Eye Hospital this option was also considered for posterior segment surgery. We were interested in the opinion, of patients on this matter and therefore asked patients, who were admitted for posterior segment eye-surgery, to answer a questionnaire. The major question was: ‘If your physician had given his permission, do you think it would have been possible for you to go home on the evening after surgery?’. Other questions evaluated problems in organising assistance at home and transportation to the out-patient clinic as well as circumstances after the operation, such as pain, nausea, dizziness and anxiety. Eighty-one out of 87 patients responded: 56% answered ‘eyes’ and 44% ‘no’ to the major question. Relating the answer to the major question to medical data and to answers to the other questions, we found organizational problems at home and anxiety to have a statistical significant relation with a negative answer. Clinical factors like age, American Society of Anesthesiologists (ASA)-class, diabetes mellitus (including insulin-dependant), type of anesthesia, time of the day the surgery was finished, duration of surgery, pain, nausea or dizziness were not signficantly related. The number of patients involved in this study, however, is too small to draw conclusions on specific subgroups of patients.     

Neuropsychological correlates of intractable anxiety disorder before and after capsulotomy

A comprehensive neuropsychological test battery was administered to 10 consecutive patients undergoing neurosurgical intervention, capsulotomy, as a last resort treatment for chronic, incapacitating, and otherwise intractable illness, either obsessive-compulsive disorder (OCD; n= 5) or non-OCD anxiety disorder (n= 5). The aim was to study the neuropsychology of severe anxiety disorders before and after a defined neurosurgical intersection of connections between the frontal lobes and related brain regions. Although extremely disabled by their illness before surgery, the patients performed within the normal range on most tests. After capsulotomy, there was significant improvement on measures of clinical morbidity and of psychosocial functioning, and the general neuropsychological performance remained remarkably intact. In a subgroup of 5 patients, however, perseverative responses were more common postoperatively, possibly indicating dysfunction of systems involving the frontal lobes. Although admittedly sparse, these data can be interpreted as suggesting that in vulnerable individuals, capsulotomy may give rise to increased perseverative behaviour in the laboratory, and possibly in the real world as well. This risk must be weighed against the potential clinical benefit of capsulotomy in this extremely disabled, sometimes suicidal patient population.     

Comparison of local tumor recurrence following excision with the CO2 laser, Nd:YAG laser, and Argon Beam Coagulator

This study compares the incidence of local tumor recurrence following primary excision with the CO2 laser, Nd:YAG laser (contact), Argon Beam Coagulator, or electrocautery. One hundred eight Fisher 344 rats with R3230AC mammary tumors (1.6 +/- 0.04 [SD] cm diameter) were used. All animals were randomized into groups of similar tumor size. In groups C and CS, excision was performed with a Sharplan 1060 CO2 laser (TEMoo, 25 W, continuous wave [CW], 0.2-mm spot size). Wounds in group CS were "sterilized" (0.5-mm spot size, 25 W, CW) by gently heating the wound without causing blanching or charring. In group N, a 0.4-mm contact Laser Blade and a Cooper 8000 Nd:YAG laser at 20 W CW was used. In groups SA1 and SA2, tumors were excised with the scalpel, and hemostasis and wound "sterilization" were accomplished with the Bard System 6000 Argon Beam Coagulator (ABC) at 40 W and 4 liters/min argon gas flow in SA1 and 12 liters/min in SA2. In group E, excision was accomplished at 40 W blend mode, 10 W spray mode. In group EA, excision was accomplished at 60 W cutting current, and hemostasis was achieved with the ABC. The animals were examined for evidence of recurrence for 34 days postoperatively. Mortalities were excluded from analysis. The incidence of recurrence was 11/14 (79%) in C, 6/16 (38%) in CS, 10/14 (71%) in SA1, 6/13 (46%) in SA2, 6/15 (40%) in N, 7/10 (70%) in EA, and 3/15 (20%) in E. Group E is statistically different (P less than .01) from groups EA, C, and SA1. Group C was different (P less than .01) from groups E, CS, and N. These results demonstrate an inverse relationship between tumor recurrence and local thermal effects at the surgical site. The ABC did not increase tumor recurrence. Contact YAG surgery was similar to CO2 laser excision and "sterilization." An attempt to study the influence of gas flow and pressure on local tumor recurrence and metastases should be made.     

Optimal debulking following chemotherapy of advanced-stage epithelial ovarian carcinoma

We reviewed the records of 110 consecutive patients with advanced-stage epithelial ovarian carcinoma treated at the Soroka Medical Center, Beer-Sheva, Israel, from 1961-1987. Twenty patients (18.1%) had optimal debulking at initial laparotomy, 30 patients (27.2%) had nonoptimal debulking at initial laparotomy, 20 patients (18.1%) had an "inoperable" disease at initial laparotomy, and 40 patients (36.3%) had such poorly written records that no information about the degree of resectability at initial laparotomy could be obtained. Four patients, in whom the residual tumor left at initial laparotomy had responded to chemotherapy, had a second laparotomy. In all four patients optimal debulking surgery at second laparotomy was easy to perform and was successful. The value of a second laparotomy after a few cycles of chemotherapy in order to optimally debulk the residual tumor left at initial laparotomy is discussed. It is concluded that a second attempt of debulking surgery after chemotherapy has a respectable place in the management of patients with advanced-state epithelial ovarian carcinoma, but further research is needed.     

The external laryngeal nerve: surgical and anatomic considerations. Report of 50 total thyroidectomies

This surgical anatomy study aimed to evaluate the possibility of identifying the external laryngeal nerve during thyroid surgery and the possible variations of nerves at risk. Fifty patients underwent total thyroidectomies during a period of 12 months. Using a neurostimulator, the distal motor branch of the external laryngeal nerve was searched. Electrical stimulation of a nervous branch aimed to provoke a global contraction of the cricothyroid in order to identify with certitude the external laryngeal nerve. The external laryngeal nerve was identified in 20% of cases. Its course was, with almost equal frequency, either (1) between the vessels of the superior thyroid pedicle or (2) superficial and anterior to the fascia of the cricothyroid muscle. The external laryngeal nerve is hard to find during thyroid surgery, even with a neurostimulator. It can be vulnerable during thyroid surgery but only in cases of anatomic variations. Searching for the nerve systematically during thyroid surgery does not seem to be useful. Several precautions when dissecting the superior pole of the thyroid gland seem to be necessary and sufficient to respect the external laryngeal nerve.     

Regulation of cytokine synthesis in cardiac surgery: Role of extracorporeal circuit and humoral mediators <Emphasis Type="Italic">in vivo</Emphasis> and <Emphasis Type="Italic">in vitro</Emphasis>

Objective and design: Cardiopulmonary bypass (CPB) impairs monocyte and neutrophil proliferation, cytokine synthesis, and antigen presentation. This study compares in vivo data with results from an extracorporeal circulation (ECC) model, distinguishing direct effects on cytokine synthesis from regulatory mechanisms. Patients and methods: Whole blood from 18 patients prior to, during and after CPB was stimulated with lipopolysaccharide (LPS). Tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-8 levels were measured. Additionally, blood from 4 volunteers was circulated in an ECC model. Cytokine levels were measured before and during mock ECC. Results: LPS-induced cytokine synthesis was reduced after CPB (TNF-α: 11 %; IL-6: 29 %; IL-8: 48 % of preoperative values, all p < 0.001). In mock ECC, cytokine production (except IL-8) was suppressed: TNF-α production was lowest 60 min after starting ECC, IL-6 synthesis was lowest at 90 min (33 % and 15 % vs. pre-ECC levels; both p < 0.001). Patient sera contained cytokine-inhibitory activity after CPB, an activity not found in mock ECC. Conclusions: (1) In patients, CPB induces early transient LPS hyporesponsiveness; (2) blood contact with foreign surfaces induces LPS hyporesponsiveness; (3) serum cytokineinhibitory activities are released after CPB, but not in mock ECC. Impaired leukocyte function may explain increased susceptibility to infections after CPB. Received 16 September 2006; accepted without revision by K. Visvanathan 18 October 2006     

The Graz learning and training model for arthroscopic surgery

Summary Up to 30% of all operative procedures in orthopaedic surgery are performed arthroscopically. Because of the steadily increasing number of residents, it seems to be difficult both to maintain high standards and to guarantee an adequate training in arthroscopic surgery. However, in contrast to many other surgical techniques it is possible to learn and practice arthroscopy using artificial models and cadaver joints, provided that experienced surgeons and anatomists act as supervisors and instructors. The aim of this paper is to assess practice models and training programs which should guarantee sufficient practical experience during the training period.

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Modèle d'apprentissage et d'entraînement à la chirurgie sous arthroscopie

Résumé Jusqu'à 30% de toutes les techniques opératories en chirurgie orthopédique sont réalisées sous arthroscopie. En raison du nombre croissant de résidents, il semble difficile de maintenir à la fois le haut niveau de formation et de garantir un entraînement adéquat à la chirurgie sous arthroscopie. Toutefois, contrairement à de nombreuses autres techniques chirurgicales, il est possible d'apprendre à pratiquer l'arthroscopie en utilisant des modèles artificiels ou des articulations de cadavres, dans la mesure où des chirurgiens et des anatomistes expérimentés agissent comme enseignants et tuteurs. Le but de ce travail était d'évaluer les modèles pratiques et les programmes d'entraînement pouvant garantir une expérience pratique suffisante durant la période d'apprentissage.