Showing papers in "International Surgery in 1997"

MRI and ultrasonographic findings in the investigation of lymphedema and lipedema.

Abstract: METHODS Twenty-four healthy subjects and 16 patients with lymphedema and lipedema were studied with MRI and ultratomography. RESULTS In chronic lymphedema, ultrasonography revealed a statistically significant increase of the subcutaneous fat without difference in skin thickness as compared to the healthy subjects. MRI revealed in lymphedema a statistically significant increase of skin thickness + subcutaneous tissue + muscular mass (p = 0.048); in lipedema, a statistically significant increase of skin thickness and subcutaneous tissue (p < 0.0001) as compared to the healthy controls. CONCLUSIONS MRI offers strong qualitative and quantitative parameters in the diagnosis of lymphedema and lipolymphedema, while ultrasonography is expected to improve its diagnostic efficiency with the aid of high frequency echo with more sophisticated resolution apparatus. Age, weight and height of the patient as well as duration of the disease do not seem to affect the above-mentioned parameters.

Preoperative natural killer cell activity: correlation with distant metastases in curatively research colorectal carcinomas.

Abstract: The authors investigated whether host immunity contributes to the development of asynchronous distant metastases in colorectal carcinomas. The host immunity was examined 8 times, pre- and postoperatively during a one year period in 77 curatively operated cases. A prospective study was performed using obtained personal data. During the mean follow-up period of 920 days, 13 patients developed distant metastases. Among the immunological parameters, the preoperative natural killer (NK) cell activity differed significantly between the metastases positive and negative groups. On univariate analysis, dichotomous NK activity, presence of nodal metastases, and venous invasion correlated with metastases. The hazard ratios on multivariate analysis were 4.53, 3.82, and 4.81, respectively. No correlation was noted between NK activity and the progression stages of colorectal carcinomas. These data suggested that attenuated preoperative NK activity is an important background factor for the development of asynchronous distant metastases following curative resection of colorectal carcinomas.

Complications of thyroid surgery.

Abstract: The current study reports complications from thyroidectomy in 253 consecutive patients from 1988 to 1992. There were 10 temporary cases of hypoparathyroidism. After total thyroidectomy, one of 34 patients (3.2%) developed permanent hypoparathyroidism. Complications of recurrent laryngeal nerve (RLN) injury or hypoparathyroidism were no more common following completion thyroidectomy than total thyroidectomy. Unplanned RLN injury was seen in 13 patients of which 7 were permanent (2.1% of 334 nerves at risk). All 13 patients with RLN injury experienced a reduction in speech "loudness", but only 3 reported "hoarseness". The RLN may be injured without serious vocal disability. Eleven of 171 right RLN's at risk were injured as compared to 2 of 163 left RLN's. The volume of thyroid tissue resected was positively associated with RLN injury (p < 0.05) and not hypoparathyroidism. These findings are discussed. Hypoparathyroidism, not "symptomatic" RLN injury, is the most problematic complication impacting on the decision whether or not to perform total or completion thyroidectomy.

Clinical presentations and predictive variables of thyroid microcarcinoma with distant metastasis

Abstract: BACKGROUND: Thyroid microcarcinoma is not an uncommon disorder. The purpose of this study is to analyze the clinical presentation and predictive factors for patients with thyroid microcarcinomas who have distant metastases. METHODS: We retrospectively reviewed and analyzed the clinical variables of 97 patients with thyroid microcarcinoma during the period from 1977 to 1995. The patients were divided into 2 groups representing patients with and without distant metastases. These data were analyzed by the Mann-Whitney U, chi 2 and Fisher's exact tests. RESULTS: Of the 97 patients with thyroid microcarcinomas, there were 6 (6.2%) cases (F/M = 5/1) with distant metastases. Among them, 4 cases were papillary carcinomas and 2 cases were follicular carcinomas. The parameters: age at diagnosis (P = 0.0137), one month postoperative serum thyroglobulin (Tg) level (P = 0.0215), cervical lymph node metastasis (P = 0.0097), and follicular cell type (P = 0.0079), were determined to be factors predictive for distant metastases by statistical analysis. There were no statistical differences between gender (P = 0.5781), postoperative 131I uptake (P = 0.1238), tumor size (P = 0.0571), preoperative thyroid function (P = 0.4425), fine-needle aspiration cytology (FNAC) (P = 0.9723), preoperative thyroid scan (P = 0.9765), and operative methods (P = 0.1060) between these two groups. CONCLUSIONS: Most thyroid microcarcinomas presented with relatively benign clinical courses, but patients with adverse predictive factors need more aggressive interventions to improve outcome.

Complications and contraindications of thoracoscopy.

Abstract: In many instances surgical intervention in the chest has been replaced by the minimally invasive thoracoscopic or VATS approach. With such a technique there are disadvantages, complications and contraindications that develop or exist. Disadvantages include the loss of tactile sensation and the cost of the procedural equipment. Absolute contraindications include a fused lung, markedly unstable patient, shock or cardiac arrest, and an individual unable to tolerate partial or complete unilateral collapse of the lung. Lesser contraindications include the patient with bleeding tendencies or under anticoagulant therapy. The few major complications we have seen include prolonged air leak, pulmonary atelectasis and respiratory failure, the "down" lung syndrome or retained secretions. Technical complications including inability to locate the lesion because of its small size, penetration of the lung or inadequate resection of a tumor with subsequent seeding of the tract through the pleural and chest wall have been reported. Major bleeding has not occurred in our institution. Mortality has been seen only in the preterminal malignancy patient.

Role of steroid in childhood haemangioma : A 10 years review

Abstract: 1195 cases of various type of haemangioma were treated with various steroid modalities. The response to intralesional steroids was excellent in strawberry and mixed haemangiomas. The response to oral steroids was also good in these two types. The response of cavernous variety was poor with either modality used alone but with combined modality, a moderate response can be obtained.

Thoracoscopic dissection of the esophagus for cancer.

Abstract: Eighteen patients affected by a resectable intramural tumor of the esophagus have undergone esophagectomy with thoracoscopic dissection of the esophagus in the last 4 years. All patients had a relative contraindication to transthoracic esophagectomy with radical lymphadenectomy. All esophagectomies were completed thoracoscopically and reconstruction of the digestive tract was performed in 17 cases through cervical gastroplasty and in 1 case through cervical coloplasty. One cirrhotic patient died in the postoperative period due to cervical anastomotic leak. Six other patients experienced a postoperative complication (mortality rate 5.5%; morbidity rate 33.3%). After a median follow up of 17 months, 14 patients are alive without evidence of disease. One patient, who had excision of a cutaneous metastasis at a trocar insertion site 6 months postoperatively, eventually died with locoregional recurrence 14 months postoperatively. Another patient died 20 months after surgery with mediastinal recurrence. One patient died 28 months postoperatively after massive hematemesis with a suspect abdominal recurrence. The results of the present series and those reported by other authors do not seem to indicate presently evident advantages from the minimally invasive procedure during resection of the esophagus for cancer. At the present time, no indication to this procedure exists for standard clinical use; wider randomized trials and longer follow-up to be performed only in selected centers are needed to further evaluate the procedure.

Total thyroidectomy or lobectomy in benign nodular disease of the thyroid: changing trends in surgery.

Abstract: Methods Over a 23-month period (January 1994-December 1995) in the era of fine needle aspiration (FNA), 344 thyroid surgery operations were performed for benign diseases of the thyroid. Of these 55 total thyroidectomies or lobectomies were evaluated. Mean age was 43.6 + 9.7 and the female/male ratio was 47/8 (5.8). All cases were operated on with the consensus of the surgery + endocrinology + pathology council according to a protocol based on FNA, thyroid function tests, scintigraphy and ultrasound. Suspected FNA or suspected nodules during the surgery were verified by frozen section also. Of these 55 benign nodules, 7 (12.7%) had total bilateral, 48 (87.3%) unilateral lobectomies. Results Postoperatively 3 cases (5.8%) of seroma, one transient hypoparathyroidism (1.8%) and one unilateral vocal cord paralysis (1.8%) were seen as complications. Conclusions In our center, FNA cytology has been a routine procedure since 1992. Surgery for benign thyroid disease has been reduced 50% since than. This study was started after two years of the FNA procedure. Resident nodules are the most common cause of recurrence in nodular thyroid disease, so some cases need radical surgery when it is decided to operate. Morbidity of surgery for recurrent disease is unacceptably high and is comparable to lifelong supplement therapy.

Activity and localization of cathepsin B, D and G in aortic aneurysm.

Abstract: The activities of cathepsin B, D and G, and their distribution in the walls of normal aorta and those of aneurysms of abdominal aorta were studied. The immunohistochemical reaction for these cathepsins was positive in the aneurysm wall both in the cells and in the extracellular matrix. It was more apparent than in normal aortas. The activities of cathepsin B, D and G in aneurysm were 1.5 times higher than in normal aortas. It may be suspected that besides the action of collagenases and elastases the cathepsins participate in an enhanced degradation of collagen and elastin fibers of aneurysm wall.

Peritoneal cytology and its prognostic value in endometrial carcinoma.

Abstract: BACKGROUND There has been a controversy about the prognostic significance of positive peritoneal cytology in endometrial carcinoma. MATERIALS AND METHODS Peritoneal cytology was obtained at the time of surgery, including systematic retroperitoneal lymph node dissection, in 114 patients. RESULTS The incidence of positive peritoneal cytology was 35.1%. The 5-year survival rates of the stage IIIA and IIIC (FIGO, 1988) cases were 82.8% and 58.3%, respectively. In pathological stage I (the disease was histologically confined to the uterine corpus), there was no significant difference in 5-year survival rates between patients with and without positive peritoneal cytology. Though the patients in stage IIIA who had only positive peritoneal cytology were given no postoperative therapy unless they had extrauterine disease, no patients developed recurrence. In stages IIIC and IV, the prognosis was significantly poorer for patients with positive peritoneal cytology than for those with negative cytology. CONCLUSION Positive peritoneal cytology is not an adverse prognostic factor endometrial carcinoma if disease is limited to the uterus.

Gallbladder carcinoma: a 28 year experience.

Abstract: BACKGROUND Despite the fact that several studies have been conducted to demonstrate advancements in the treatment and prognosis of gallbladder carcinoma, no standard method of treatment has been identified or agreed upon. OBJECTIVE The aim of this study were to review the presentation, staging, treatment and prognosis of subjects with cancer of the gallbladder at Howard University and its affiliated Institutions over the last three decades to see if there were any improvement in the survival. METHODS A retrospective analysis of a 28 year experience at Howard University was performed. Patient gender, age, symptoms, signs, the diagnostic tests, pathology reports, operative and adjuvant treatments of each case were reviewed. A review of the English literature on the subject of gallbladder carcinoma covering the last twenty years using a Medlars search of the subject was also performed. An attempt was made to determine the utility of the various radiological tests used to diagnose and stage gallbladder, cancer. RESULTS Patients with Stage I tumors using the Nevin classification had a 100% survival at 5 years. Patients with Stage V had 0% survival at 5 years. Stages II, III and IV had survivals of 51%, 12% and 10% respectively. The most common presenting symptom was abdominal pain which was present in 45% of cases. Gallbladder ultrasound studies had a sensitivity of 50% while the CT scanning had a sensitivity of 40% for disease detection. ERCP, when used, had a sensitivity of 75%. Radio and chemotherapy did not influence the survival of patients in this series. The most common surgical procedure performed was cholecystectomy with or without an associated hepatic resection for stage II and III, combined with adjuvant chemotherapy. CONCLUSIONS The current prognosis of individuals with gallbladder carcinoma is dismal, nevertheless a slightly improvement over the last three decades has been achieved particularly regarding the sensitivity of the radiological tests to diagnosis GBC. Five fluorouracyl may be promising as adjuvant therapy associated with radiotherapy. Consideration should be given to a more aggressive screening with the up-to-date radiological tools, of high risk individuals and early resection of the gallbladder in high risk cases with any findings suggestive of gallbladder cancer.

Biliary enteric fistulas.

Abstract: Thirty-one patients with biliary enteric fistula who were operated on over a 19-year period (1976-1994) with an incidence of 0.74% in all biliary tract operations were reviewed retrospectively to identify etiologic factors, types of fistulas, signs and symptoms, methods of diagnosis, management and prognosis of the cases. Most common symptoms were abdominal pain, nausea, vomiting and jaundice. Two patients had gallstone ileus. The majority of the patients had severe concomitant medical illnesses. The exact preoperative diagnosis of a biliary enteric fistula was established in only five (16%) patients. In 81% of the cases fistula was secondary to chronic calculous biliary tract disease. Postoperative complications included wound infection in six (19%), biliary fistula in two (6%) and erosive gastritis in one (3%) patient. Two patients died of intra-abdominal sepsis and two of cardiac failure, with an operative mortality of 13%. Early elective cholecystectomy is recommended to avoid complications of chronic calculous cholecystitis such as bilioenteric fistulas and their increased mortality and morbidity.

Cytokine activation in patients undergoing open or laparoscopic cholecystectomy.

Abstract: BACKGROUND Laparoscopic surgery is estimated to produce a minor surgical injury in comparison with open and laparoscopic cholecystectomies. Studies in the past compare almost data of the first hours until day two. However, the surgical injury and the wound healing metabolism has to be detected. METHODS A prospective study was designed to investigate cytokine responses after surgical injury. Twenty-three patients with symptomatic cholelithiasis were admitted to the study. Eleven patients underwent conventional (open) and twelve patients laparoscopic cholecystectomy. Circulating concentrations of cytokines-including Interleukin-6 (IL-6), Tumor necrosis factor-alpha (TNF-alpha) and neopterin, were compared between both groups. In addition, association of the cytokines with clinical parameters including leucocytes, urea, fever and C-reactive protein (CRP) were assessed. We are using ELISA-test of Medgenix GmbH, Ratingen, Germany and BRAHMS Diagnostica, Berlin, Germany. RESULTS Enhanced cytokine responses were observed in the conventional group compared to the laparoscopic group. On day 3 after operation, the second increase in cytokine levels (but smaller than the first increase) were observed in both groups. In the conventional group, a slightly high correlation ratio between the urea and cytokine levels was found. However, only neopterin and urea association on postoperative day 3 (r = 0.65) was significant (p < 0.05). There was no significant association between CRP and cytokine levels in both groups. CONCLUSIONS Cytokine response after cholecystectomy demonstrates the lesser degree of surgical injury in the laparoscopic group, however, TNF-alpha demonstrates on day 4 a similar increase in both groups. This is a new result of studies working in this field. In conclusion, the benefit of laparoscopic surgery results only in the minimal access to the abdominal cavity, the wound healing metabolism is at last the same in both groups.

Thoracoscopic resection of benign tumours of the esophagus.

Abstract: Thoracoscopic excision of an esophageal leiomyoma was successfully performed in 5 patients. The tumours were enucleated easily without intraoperative complications. A patient in whom the muscular layer was not sutured after removal of the myoma, one year after the operation presented an esophageal pseudodiverticulum requiring a thoracotomy for resection. This new procedure which reduces the operative trauma and postoperative pain and allows quick recovery is described.

Sigmoid perforation, an exceptional late complication of peritoneal prosthesis for treatment of inguinal hernia.

Abstract: Two cases of sigmoid perforation and fistula occurred as late complications after insertion of a nonresorbable prosthesis by the open preperitoneal inguinal route. These infrequent complications are favoured by peritoneal defects and use of materials which can cause extensive sclerous reactions. Indications for this type of mesh are increasingly common with the intraperitoneal laparoscopic approach, so that careful peritoneal dissection and closure are required.

Groin lymphorrhea postoperative nuisance.

Abstract: Lymphorrhea is defined as the flow of lymph from disrupted lymphatic channels that drains externally or is contained within a wound. It complicates approximately 2% of vascular incisions in the groin. Of 116 patients who underwent different arterial reconstructions involving 186 groin wounds, lymphorrhea developed in 4 patients (3.4%) including 4 groins (2.1%). They have been managed in the Division of Vascular Surgery at King Khalid University Hospital (KKUH) in Riyadh, during a 3-year period ending in February 1996. There were 105 (90.5%) males and 11 (9.5%) females. The ages ranged from 32 to 96 years with a mean age of 63 years. All the 4 cases complicated with lymphorrhea were managed conservatively for a period of three to five weeks. In 2 cases, the lymphatic leak stopped and the patients discharged without other local complications. In the other 2 cases, lymphatic leakage stopped immediately and permanently following direct surgical ligation. The use of isosulphane blue for localization of the site of the lymphatic leak was a simple, reliable and accurate method during wound exploration. Follow-up of all cases for 6 months showed no recurrence, no sepsis and patent vascular graft.

A splenic-inferior mesenteric venous anastomosis prevents gastric congestion following pylorus preserving pancreatoduodenectomy with extensive portal vein resection for cancer of the head of the pancreas

Abstract: BACKGROUND In order to prevent gastric congestion after both of the splenic and coronary veins were taken as part of extensive portal vein resection in pylorus preserving (PP) pancreatoduodenectomy (PD), we made a splenic-inferior mesenteric venous (SpIMV) anastomosis. MATERIALS AND METHODS Four patients underwent PP subtotal PD with such extensive portal vein resection under the diagnosis of pancreas head cancer. The portal vein was reconstructed by end-to-end anastomosis, and the coronary vein was ligated. Since the stump of the splenic vein could not be approximated to the portal or superior mesenteric vein, shunting the splenic venous flow to the inferior mesenteric vein was attempted by making a SpIMV anastomosis in 3 patients and by preserving the SpIMV confluence in a patient. Postoperative celiac angiography showed that venous outflow from the stomach, spleen and remnant pancreas collected into the splenic vein and passed through the SpIMV anastomosis or confluence, and finally drained into the portal vein by inferior mesenteric to superior mesenteric collateral. RESULTS No remarkable congestion of the stomach was observed. CONCLUSIONS In conclusion making a SpIMV anastomosis or preserving the SKpIMV confluence is beneficial for preventing gastric congestion following PP PD with extensive portal vein resection for cancer of the head of the pancreas.

Pyogenic liver abscess: the role of surgical treatment.

Abstract: MATERIALS AND METHODS We present an analysis of 48 patients with pyogenic liver abscess (PLA) that were treated according to a protocol between 1975 and 1993. In this period, 35 patients with PLA were treated by surgical drainage (SD). The indication for surgical treatment of the abscess were patients in septic conditions, underlying intra-abdominal surgical disease and the failure/contraindication of other therapeutic methods. Thirty-one patients were submitted to surgical treatment as the initial procedure and four patients unsuccessfully treated by percutaneous drainage, underwent SD. RESULTS The surgical approach was indicated in patients with severe disease and presented 91.5% of good results, and a mortality rate of 8.5%. CONCLUSIONS These results suggest that surgical treatment is a good alternative as a first step not only for the treatment of the primary cause of the abscess but also in septic patients with severe disease where a delay in adequate drainage, frequent in percutaneous management, can lead to high morbidity and mortality rates.

Laparoscopic cholecystectomy in Brazil: analysis of 33,563 cases.

Abstract: The authors present the results obtained in 33,563 laparoscopic cholecystectomies performed in Brazil from 1990 to 1995. Data were obtained by mailing questionnaires to 220 Services, 118 of which responded. The features included the year when the service started its activities, patient distribution by sex and age, surgical indications, prophylaxis with antibiotics, use of nasogastric and vesical catheters, technique used to produce pneumoperitoneum, intraoperative cholangiography, management of choledocholithiasis, necessity and causes of conversion to open surgery, surgical time, intra and postoperative complications, time of hospitalization, mortality, patient return to normal activities, and laparoscopic cholecystectomy in pregnancy. Analysis of the results demonstrated that the data are equivalent to those obtained in leading world countries and at times even better in terms of lesion of the main bile duct, time of hospitalization, etc.

Is the rectum a conduit or storage organ

Abstract: The rectum is claimed to be a conduit; as it receives the stools, the rectoanal inhibitory reflex is evoked and defecation occurs. However, in many healthy subjects, stools could be palpated in the rectum by digital rectal examination (DRE) without the subject feeling the desire to defecate. The purpose of this communication is to study whether the rectum is a conduit or a storage organ. The study comprised 48 healthy volunteers (mean age 38.4 +/- 15.8 SD years; 30 men, 18 women). Number of stools per week was recorded and DRE was carried out followed by air enema radiography. The subjects had a normal stool frequency of 7.8 +/- 1.4 per week. Most of them last defecated a mean of 6.2 +/- 3.4 hours prior to the test. Stools were palpated in the lower rectum by DRE in 31/48 subjects and by radiography in 12/16. DRE correlated with radiologic examination in 9/12 subjects; in 3 of them, DRE revealed an empty rectum while radiography showed stools in the upper rectum. The 17 subjects with an empty rectum had their last defecation 5.2 +/- 3.6 hours before DRE, and the 31 subjects with palpable stools 15.6 +/- 12.9 hours. In conclusion, the rectum might be considered not simply as a conduit for stools but also as a storage organ. This occurs when it receives from the sigmoid colon an amount of stools too small to evoke the defecation reflex, or when this reflex is neglected due to unfavorable circumstances of defecation.

The effect of corticosteroids and pentoxifylline in caustic esophageal burns. A prospective trial in rats.

Abstract: Background Caustic Esophageal Burns (CEB) usually results in scatritial tissue and stricture formation. Management requires preventing the massive inflammatory process that ensues in its early phase and decreasing bacterial complications. Methods An animal model was created to investigate the effect of corticosteroids and pentoxifylline in CEB using 52 male Wistar rats. The injury was produced using an indwelling esophageal catheter through which 3N of 12% sodium hydroxide was infused. The rats were grouped as control, CEB, CEB and ceftazidime (CEB-C, 100 mg/kg/day im. bid. 10 days), CEB and ceftazidime plus dexamethasone (CEB-CD, 0.1 mg/kg/day im. bid. 4 weeks) and CEB and ceftazidime plus pentoxifylline (CEB-CP, 50 mg/kg/day im. tid. 4 weeks). The groups were evaluated making use of esophagograms, hydroxyproline (OH-P) contents and histologic examination of the specimens 28 days after injury. Results No significant statistical differences were observed among the dexamethasone (CEB-CD), pentoxifylline (CEB-CP), antibiotics (CEB-C) and the untreated CEB groups.

Methylene blue localizations of pulmonary nodules under CT-guidance: a new procedure used before thoracoscopic resections.

Abstract: With the expending use of video-assisted thoracoscopy for a wide range of indications, we present our experience of CT-guided localizations of pulmonary nodules with methylene blue injections before their thoracoscopic resections. This technique was developed for deep non-palpable nodules of small size. Forty seven nodules in 44 patients were preoperatively localized under CT guidance and marked with methylene blue injections. The localizations under CT guidance of the 47 nodules were successful in all cases. The surgeon confirmed accurate localization of 46 nodules. In one case, the injected methylene blue could not be identified during thoracoscopy. Complications of this technique included 7 cases of asymptomatic pneumothorax, 5 cases of local and asymptomatic pulmonary hemorrhage, and 2 cases of fits of coughing. Because of this technique, 46 diagnostic thoracotomies could be avoided. CT guided localization with methylene blue injection is a simple and rapid technique enabling good thoracoscopic surgery results.

Percutaneous large core needle biopsy versus surgical biopsy in the diagnosis of breast lesions

Abstract: OBJECTIVE To value LCNB accuracy in the determination of morphobiological parameters and as an alternative to the open SB diagnostic procedure of breast lesions. SETTING University Hospital, Italy. SUBJECTS From May 1992 to February 1995 196 biopsies have been performed. The diameter of the neoplasms examined varied from 0.6 to 7 cm with an average of 1.9 cm. MAIN OUTCOME MEASURES The accuracy of the two methods in the evaluation of histological degree, receptor state, protein c-erb B2 and p53 were compared. RESULTS No inadequate sampling were ever recorded. LCNB has shown values of 97% sensitivity and 100% specificity. The positivity and negativity predicted values obtained were 100% and 89% respectively. Retrospectively 70 sample-cases of carcinoma were selected and the morphobiological parameters evaluated. The correlation coefficients for the data obtained with SB and LCNB in the evaluation of Progesteron and Oestrogen receptor expression, protein c-erb B2 and p53 were excellent. Furthermore it was noted that LCNB allows a saving of at least 1/3 of the cost vs intraoperative SB. CONCLUSIONS Percutaneous LCNB has high diagnostic accuracy for histological classification. LCNB has the same accuracy as SB for morphobiological parameters. The cost of LCNB is markedly lower than SB.

New approaches in laparoscopically assisted radical vaginal hysterectomy.

Abstract: Background To illuminate our new approaches in laparoscopically assisted radical vaginal hysterectomy. Methods Twenty-four women underwent laparoscopically assisted radical vaginal hysterectomies during the period from March 1994 to May 1995 in our institute. Indications for this surgery, including cervical carcinoma stage 1A to 2A, were the same as for abdominal radical hysterectomy. The procedure was performed under general endotracheal anesthesia through means of the technique of videolaparoscopy. Two new approaches were recruited in these procedures including using middle upper abdomen as the primary trocar site and using ureteral stent or illuminator as a ureter marker. Results All of these patients completed the procedures without exception. The mean hospital stay was 8.2 +/- 3.2 days. The average blood loss was 540 +/- 210 ml with a range from 100 to 1800 ml. Operating time was from 220 to 420 minutes with a mean time of 325 minutes. In all cases pelvic lymphadenectomy was performed without exception, yielding an average of 13.2 macroscopic nodes. Two of them metastatic lymph nodes were noted. No ureteral injury occurred after using the ureteral stent as a marker. Conclusions In this preliminary result, using middle upper abdomen as the primary trocar site could provide the surgeon with a wider and familiar visual angle, thus making the pelvic or para-aortic lymphadenectomy much easier. Moreover, using the ureteral illuminator as a marker during unroofing the ureter laparoscopically is helpful to prevent the ureteral injury and facilitating the procedures in laparoscopically radical hysterectomy.

Pathologic intrathyroidal parathyroid glands.

Abstract: Background Parathyroid glands originate from the third and fourth branchial pouches and migrate caudally to their final positions. Aberrations during migration result in anomalous locations. Intrathyroidal location is not common. Methods We reviewed cervical explorations performed from 1974 to 1993 in hyperparathyroidism patients. Results We found pathological intrathyroidal glands in six patients. Three patients had adenomas (left superior, left inferior and right inferior glands). The hyperplastic glands were left inferior in one patient and right inferior in the remaining two. Intraoperative diagnosis was made in three cases in which palpation of the thyroid gland showed a nodule that was suspected to be the parathyroid missing gland. In three patients it was a finding in thyroidectomy or hemithyroidectomy specimens, two of them with associated thyroid nodular disease. Conclusions Ipsilateral thyroidotomy on the side of a palpable thyroid mass or blind hemithyroidectomy are justified if a presumably pathological intrathyroidal gland is suspected, when all other sites in the neck have been excluded.

Videoassisted transhiatal esophagectomy for cancer

Abstract: Blunt transhiatal esophagectomy is largely performed in selected cases of esophageal cancer according to the experience of Mark Orringer. We have recently performed eleven consecutive videolaparoscopy assisted transhiatal esophagectomies in order to help esophageal dissection and to avoid injuries to mediastinal structures. In our experience the routine use of laparoscopic assistance during transhiatal esophageal dissection improves the safety of this technique and lowers postoperative complications. The results of neoadjuvant treatments (radio-chemotherapy) recently reported emphasize the role of transhiatal esophagectomy for cancer.

Malignant peritoneal mesothelioma. Case-report demonstrating pitfalls of diagnostic laparoscopy.

Abstract: Patients with peritoneal mesothelioma present with abdominal distension and clinical syndrome of debilitating ascites. Cytology of the peritoneal fluid obtained by laparocentesis often does not result in a diagnosis. Laparoscopy with biopsy of peritoneal nodules is a valuable method by which a histological diagnosis is established. However laparoscopy can greatly complicate the management of peritoneal mesothelioma by facilitating tumor dissemination to port sites. The patient presented was treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Although palliation of intra-abdominal tumor and ascites was achieved, port sites-disease required extensive resection of the abdominal wall. Our experience with this patient suggests that if a malignant source of ascites is suspected and a diagnosis is not obtained by paracentesis, laparoscopy should be used to establish a diagnosis. However, trocars should only be placed along the midline of the abdominal wall so that port sites can be excised at the time of cytoreductive surgery. This diagnostic strategy is applicable to the majority of patients undergoing laparoscopy when there is known or suspected intraabdominal malignancy.

Present day concepts of thoracoscopy as a modality in pediatric cancer management.

Abstract: Recent improvements in video imaging and instrumentation have encouraged a wider use of thoracoscopy as a modality for diagnostic procedures Its utility for resection is still being reviewed To assess the utility, diagnostic accuracy, and morbidity of thoracoscopy in children with cancer, we reviewed the experience at our institution Between January 1991 and July 1995 sixty-four (64) procedures were performed either to diagnose pulmonary nodules of indeterminate origin (n = 42) or mediastinal masses (n = 11) or to evaluate pulmonary infiltrates in leukemia (n = 11) Thoracoscopy yielded a successful diagnosis in 90% of the cases Conversion to open thoracotomy was necessary in 11 patients Thoracoscopy in the management of children with cancer is useful for staging, obtaining diagnostic tissue, and is associated with a low morbidity

Short-term restorative nutrition in malnourished patients: pro's and con's of intravenous and enteral alimentation using compositionally matched nutrients.

Abstract: In a prospective controlled clinical study 30 patients with moderate degree of malnutrition, normal liver and kidneys, and a functioning gastrointestinal tract were randomized to receive a free amino acid and small peptide enteral diet (15 patients) or an isonitrogenous isocaloric parenteral support for at least 10 days (total energy: 2900 kcal, nitrogen: 14.5 g, carbohydrates: 380 g, fat: 112 g, N/non protein calories: 1/175). The parenteral and enteral diets had the same protein/lipid/carbohydrate composition. The data indicated that both routes led to positive nitrogen balance. Nitrogen equilibrium was achieved by day 3 in the TPN group and by day 5 in the enteral group. There were no significant changes in serum albumin within either group. Serum level of transferrin reached a significant increase in both groups (p = 0.003). Thyroxine-binding prealbumin rose significantly in both groups as well (p = 0.019 and 0.004 respectively). Statistically significant rises in lymphocyte counts (p = 0.003 and 0.001 respectively), in levels of C3 (p = 0.009 and 0.001 respectively), IgA (p = 0.002), IgG (p = 0.004 and 0.003 respectively) and IgM (p = 0.004) occurred in either treatment group. There was a high incidence of negative skin tests at the start of the study in the enteral group (73.3%) and the TPN group (60%). By the end of the study the incidence of negative results for this test was 40.0% and 26.6% respectively. Despite maintenance of similar glucose levels in both groups, TPN led to significantly (p = 0.000) higher serum insulin levels. The serum insulin increased almost linearly over the study period, and eventually prevented fat mobilization and lipolysis, so that free fatty acid levels had fallen significantly (p = 0.000). A significant elevation of the liver enzymes over the study period occurred in the TPN group, but not in the enterally fed patients. The present findings provide no evidence that semi-elemental diets are in any way inferior to isonitrogenous isocaloric regimes parenterally given for a short period of time.

CEA, TPA, CA 19–9, SCC and CYFRA at diagnosis and in the follow-up of anal canal tumors

Abstract: The authors evaluated serum CEA, TPA, CA19-9, SCC and CYFRA at diagnosis and in the follow-up of 18 anal canal tumors. Sensitivity at diagnosis was 38.8% for CEA, 55.5% for TPA, 16.6% for CA19-9, 50% for SCC and 5.5% for CYFRA. In the follow-up CEA showed 0% sensitivity and 73.3% specificity, TPA 33.3% sensitivity and 86.6% specificity, CA19-9 0% sensitivity and 80% specificity, SCC 0% sensitivity and 93.3% specificity, CYFRA 0% sensitivity and 100% specificity. The authors consider the usefulness of serum SCC and TPA at diagnosis of squamocellular anal cancer and of CEA in the diagnosis of cloacogenic tumors. Nevertheless these serum markers did not detect recurrences in the follow-up.