bluuebunny/crossref_metadata_2025 huggingface dataset:
Intraoperative Manometry during Laparoscopic Operation for Esophageal Achalasia: Does Pneumoperitoneum Affect Manometry?
Authors: Kamiike Wataru , Taniguchi Eiji , Iwase Kazuhiro , Ito Toshinori , Nezu Riichirou , Nishida Toshirou , Inoue Masahiro , Ohashi Shuichi , Matsuda Hikaru
Published: August 2002

The effects of pneumoperitoneum on the lower esophageal sphincter (LES) were evaluated during laparoscopic operation for esophageal achalasia. Intraoperative manometry was performed in three patients who underwent laparoscopic cardiomyectomy with Dor’s fundoplication and five patients who underwent laparoscopic cholecystectomy (LC). The LES pressure and the length of the high‐pressure zone (HPZ) did not change during pneumoperitoneum in either the achalasia and the LC group. In the achalasia group the LES pressure was sufficiently decreased following completion of cardiomyectomy, and the length of the HPZ was found to be sufficiently long after completion of fundoplication. The postoperative courses of the achalasia patients were uneventful, and they have had no symptoms of achalasia or gastroesophageal reflux since the operation. Accordingly, intraoperative manometry during 12 mmHg pneumoperitoneum was considered to be available for laparoscopic surgery for esophageal achalasia.
Technical Difficulties and Complications during Laparoscopic Cholecystectomy: Predictive Use of Preoperative Ultrasonography
Authors: Santambrogio Roberto , Montorsi Marco , Bianchi Paolo , Opocher Enrico , Schubert Luca , Verga Maurizio , Federico Luca , Spina Gianpaolo
Published: August 2002

The aim of this study was to evaluate ultrasound findings as predictors of potential operative difficulties and complications during laparoscopic cholecystectomy (LC). From October 1993 to June 1995 a total of 143 patients with symptomatic cholelithiasis (50 males, 93 females, mean age 49.5 ± 15 years) were evaluated by ultrasound (US) the day before LC. The US examination assessed six parameters: gallbladder (GB) volume, GB wall thickness, GB neck position, GB stone mobility, stone maximum size, and GB adhesions. On the basis of these US findings, a predictive judgment of technical difficulties was expressed by degree: easy, difficult, and very difficult. Altogether 101 patients presented with uncomplicated symptomatic cholelithiasis, and 42 had acute cholecystitis. The operation was predicted to be easy in 38% of cases, difficult in 49%, and very difficult in 13% with a good correlation with the surgeon’s intraoperative judgment (r= 0.66). A significant association was found between stone mobility (r= 0.37), presence of adhesions (r= 0.36), and the difficulty of the procedure. The predictive US evaluation was significantly correlated with some intraoperative technical steps [dissection of Calot’s triangle (r= 0.41), dissection of the gallbladder bed (r= 0.41)], and intraoperative bleeding (r= 0.27). Our results suggest that preoperative US is a useful screening test for patients undergoing LC, and it can help predict technical difficulties. On the other hand, a relevant number of cases still exist wherein the concordance between the preoperative US classification and the surgical findings is unsatisfactory. In this group the surgeon cannot safely rely on the US examination alone.
Protective Effects of Antithrombin III Supplementation on Warm Ischemia and Reperfusion Injury in Rat Liver
Authors: Okano Keiichi , Kokudo Yasutaka , Okajima Kenji , Hossain Mohammad Akram , Ishimura Ken , Yachida Shinichi , Tsubouchi Taijirou , Wakabayashi Hisao , Maeba Takashi , Maeta Hajime
Published: August 2002

The effect of antithrombin III (AT III) supplementation on energy status, microcirculation, cytoprotection, and prostacyclin (PGI2) production during and after a period of warm ischemia of the rat liver was investigated. AT III supplementation (250 units/kg) stimulate prostaglandin I2 (PGI2) production from 1 hour after administration, with maximal production observed at 3 hours. Ischemia was induced by occluding the hepatoduodenal ligament for 30 minutes, and experiments were continued for 60 minutes after reperfusion. The rats received AT III (250 units/kg IC) 30 minutes before induction of liver ischemia (AT III group). In the AT III group, recovery of the β‐ATP/inorganic phosphate ratio measured by 31P nuclear magnetic resonance showed significant improvement (p< 0.01), and the recovery of tissue blood flow markedly improved (p< 0.01) compared to the saline‐treated group (control group). Leakages of aspartame aminotransferase, alanine aminotransferase, and lactate dehydrogenase were mitigated in the AT III group (p< 0.05). Ultrastructural alterations of sinusoidal endothelial cells were markedly reduced in the AT III group. The PGI2level at the end of reperfusion was significantly elevated (p< 0.01) in the AT III group compared to the control group. The results of this study indicated that pretreatment with AT III significantly improved the energy status and microcirculation, as well as histologic damage, after liver ischemia and reperfusion. One of the fundamental effects of AT III might be mediated through the production of prostacyclin.
Role of Splenectomy in Hematologic Disorders
Authors: Schwartz Seymour I.
Published: August 2002

There has been an increase in the indications for splenectomy for hematologic diseases. It is a consequence of expanding the list of disorders and liberalizing the indications for splenectomy for many diseases. Hereditary spherocytosis is the most frequently encountered congenital anemia for which splenectomy is curative. Splenectomy is generally advised for warm antibody acquired hemolytic anemia if conventional medical therapy fails. Idiopathic thrombocytopenic purpura (ITP) remains the most common hematologic disorder for which splenectomy is therapeutic. A variety of thrombocytopenias are improved by splenectomy. The myeloproliferative disorders constitute a spectrum of disease potentially improved by splenectomy, but preoperative management should be modified in this group. Splenectomy in patients with chronic leukemias and lymphomas are often palliative and facilitate chemotherapy. There are no specific requirements preoperatively other than the administration of pneumoccocal andHemophilus influenzaevaccines. Platelets are not administered to patients with ITP. An integral part of the procedure is the search for accessory spleens. The postoperative complication of overwhelming postsplenectomy sepsis must be considered; it occurs more frequently in association with specific basic diseases and can be obviated by appropriate treatment.
Iodide or l‐Thyroxine to Prevent Recurrent Goiter in an Iodine‐Deficient Area: Prospective Sonographic Study
Authors: Feldkamp J. , Seppel T. , Becker A. , Klisch A. , Schlaghecke R. , Goretzki P.E. , Röher H.D.
Published: August 2002

In a randomized study, prevention of goiter recurrence with l‐thyroxine was compared with pure iodide substitution after thyroid surgery for nodular goiter in an iodine‐deficient area. Altogether 107 patients were followed up for 52 weeks after thyroid resection. The thyroid volume was determined sonographically. Free thyroxine, total thyroxine, thyrotropin, thyroglobulin, and antibodies to thyroglobulin and thyroid peroxidase were measured. The thyroid volume decreased slightly over the course of a year in the two therapy groups. There was no significant difference between the two groups. Recurrences were seen with both l‐thyroxine medication and iodide substitution. The thyroglobulin levels fell significantly over the 52‐week follow‐up period in the iodide group. Antibody formation was not observed under iodine substitution. In an area of iodine deficiency, substitution with iodide is just as effective as medicating the patients with l‐thyroxine for preventing recurrences.
Diagnostic Dilemma of Small Incidentally Discovered Adrenal Masses: Role for 131I‐6β‐Iodomethyl‐norcholesterol Scintigraphy
Authors: Kloos Richard T. , Gross Milton D. , Shapiro Brahm , Francis Isaac R. , Korobkin Melvyn , Thompson Norman W.
Published: August 2002

Incidentally discovered adrenal masses are detected in 0.35% to 5.00% of patients imaged with computed tomography (CT) for reasons other than suspected adrenal pathology. Most small adrenal masses are benign, although malignant tumors ≤ 3 cm in diameter are well described. In the setting of normal adrenal hormonal secretion, the preferential accumulation of 131I‐6β‐iodomethyl‐norcholesterol (NP59) by adrenocortical tissues allows the distinction of adenomas from other space‐occupying or destructive lesions, with diagnostic images being obtained in 100% of lesions > 2 cm. Although some lesions ≤ 2 cm have yielded nondiagnostic images, the frequency of this phenomenon and thus the utility of NP59 scintigraphy for the evaluation of small adrenal lesions has remained incompletely characterized. Between January 1976 and December 1994 a total of 166 patients with nonhypersecretory unilateral adrenal masses ≤ 3 cm in maximal diameter, discovered incidentally during CT examinations of the abdomen or chest for reasons other than clinically suspected adrenal disease, were studied with NP59 scintigraphy. Nonhypersecretory masses ≤ 1 cm, > 1 to ≤ 2 cm, and > 2 to ≤ 3 cm yielded diagnostic images in 52%, 89%, and 100% of patients, respectively. Lesions other than adenomas, including malignancies, > 1 to ≤ 2 cm and > 2 to ≤ 3 cm were present in 9% and 10% of patients, respectively. These findings emphasize the need to determine the nature of small incidentally discovered adrenal masses whose management may alter patient care and confirm the utility of NP59 scintigraphy to evaluate nonhypersecretory adrenal masses regardless of size.
Clinicopathologic Differences between Long‐Term and Short‐Term Postoperative Survivors with Advanced Gallbladder Carcinoma
Authors: Chijiiwa Kazuo , Yamaguchi Koji , Tanaka Masao
Published: August 2002

The objective of this study was to determine histopathologic factors that influence the failure or success of extended cholecystectomy and more aggressive surgery to attain long‐term survival in patients with advanced carcinoma of the gallbladder. Of 46 patients with carcinoma of the gallbladder who had undergone surgical resection, 36 had advanced carcinoma invading to or beyond the subserosal layer. Among these 36 patients were 10 long‐term survivors (> 5 years) and 11 short‐term survivors who died of recurrence (< 37 months) after extended cholecystectomy or more extensive surgery. Factors were compared between the two groups. Significant factors observed in the long‐term survivors were the depth of invasion limited to the subserosal layer (p< 0.05), hepatic infiltration < 5 mm (p< 0.01), histologic grade of papillary or well differentiated adenocarcinoma (p< 0.01), absent or minimal venous, lymphatic, and perineural invasion (p< 0.01), and lymph node metastasis limited to the hepatoduodenal ligament (p< 0.05). It was concluded that the patients with subserosal invasion have a hope for long‐term survival by extended cholecystectomy or more aggressive surgery when hepatic infiltration and venous, lymphatic, and perineural invasion are absent or minimal, the histologic grade is papillary or well differentiated adenocarcinoma, and lymph node metastasis is limited to the hepatoduodenal ligament.
High‐Resolution Ultrasonography: Highly Sensitive, Specific Technique for Preoperative Localization of Parathyroid Adenoma in the Absence of Multinodular Thyroid Disease
Authors: Gofrit Ofer N. , Lebensart Penchas D. , Pikarsky Alon , Lackstein Dror , Gross David J. , Shiloni Eitan
Published: August 2002

The objective of this prospective study was to evaluate the role of preoperative ultrasonography (US) for parathyroid lesion localization in patients with primary hyperparathyroidism (PHPT) prior to initial surgery. Fifty‐two consecutive patients with PHPT, diagnosed in our institution within a period of 2 years, were referred for preoperative US and subsequently for bilateral surgical neck exploration. The combination of a confirmatory pathologic report and normalization of blood calcium concentration for a period of at least 3 months was considered an operative success. In 50 patients (96.2%) a single parathyroid adenoma was excised, and in one patient (1.9%) hyperplasia of three glands was found at surgery. In the one surgical failure, no parathyroid pathology was identified in the neck; therefore the operative success in this series was 98%. The sensitivity of preoperative US was 83% with a specificity of 100%. In the absence of thyroid multinodular disease (MND), the sensitivity of preoperative US increased to 90%, whereas in patients with MND the sensitivity was only 64%. Our findings support the notion that patients with PHPT should be investigated with US before initial surgery. Bilateral surgical exploration is warranted in patients with MND. In the absence of such thyroid pathology, an US finding positive for adenoma should allow the surgeon to perform unilateral neck exploration only, with consequent reduction of operation time and postoperative complications.
Resection of Liver Metastases of Colorectal Carcinoma
Authors: Nakamura Satoshi , Suzuki Shohachi , Baba Shozo
Published: August 2002

Hepatic metastasis of colorectal cancer is a life‐threatening prognostic factor. The present review revealed that hepatic resection is the best treatment modality, although the overall survival rate after hepatectomy for metastatic colorectal cancer is still low (20–40%). Various prognostic factors analyzed by many authors are controversial. The number of hepatic metastases and the surgical margin were the most important prognostic factors, as seen in 10 papers previously reported including our data. A clear surgical margin is achievable, but the prognosis of patients with four or more metastatic nodules in the liver remains poor. Repeat hepatectomy is also evaluated and is believed by many surgeons to have acceptable mortality. It improved survival to a certain extent. Analysis of the biologic characteristics of primary and metastatic tumors is extremely important and is urgently indicated.
Stereotactic Breast Biopsy as an Alternative to Excisional Biopsy
Authors: Park Soon‐Tae , Galbo Claudia , Ghosh Bimal C.
Published: August 2002

The current widespread use of modern mammography has increased the detection of suspicious mammographic lesions, which has led to a greater number of diagnostic surgical biopsies. Most of these lesions referred for surgical biopsy have been benign. The reduction in the number of benign surgical biopsies can reduce medical costs and unnecessary invasive breast surgery. Stereotactic large‐core needle biopsies in patients with suspicious mammographic lesions can preselect the breast lesions that need further evaluation with surgical excisional biopsy. Our results with stereotactic large‐core needle biopsies support this alternative approach to the workup of suspicious mammographic lesions.
Peripancreatic Fluid Cytology: Detection of Early Rejection versus Graft Pancreatitis after Canine Pancreatic Transplantation
Authors: Suzuki Yasuyuki , Kuroda Yoshikazu , Tanioka Yasuki , Matsumoto Shin‐ichi , Kim Yongsik , Ku Yonson , Tsukamoto Ryuko , Saitoh Yoichi
Published: August 2002

It is particularly difficult to distinguish between early rejection and graft pancreatitis when early rejection produces an elevated serum amylase level. In this study we determined whether peripancreatic fluid cytology (PFC) can differentiate early acute rejection and graft pancreatitis as an alternative diagnostic tool to graft biopsy that has the potential of pancreatic fistula and hemorrhage. Sixty‐two dogs received either a segmental pancreas allograft (n= 25) or autograft (n= 37) heterotopically in the neck. This study included five groups: allografts without immunosuppression (group A,n= 12), allografts with immunosuppression (group B,n= 13), autografts without immunosuppression (group C, n= 11), autografts with immunosuppression (group D, n= 12), and autografts treated by 45 minutes of pretransplant warm ischemia to induce acute graft pancreatitis (group E, n= 14). A closed suction drainage catheter was placed next to the graft to collect peripancreatic fluid daily after the transplant. PFC was performed using May‐Gruenwald‐Giemsa double‐staining technique and compared to the corresponding histology through the observation period. In analyses of 50 functioning grafts, PFC performed on day 1 showed similar neutrophil accumulations in all groups. In sharp contrast, on days 3 and 6, group A had dramatically increased mononuclear cell concentrations in PFC, whereas groups B, C, and D showed significantly lower concentrations, the percent of mononuclear cells among total leukocytes being 47.3 ± 23.4%, 11.8 ± 4.9%, 4.3 ± 1.8%, and 6.4 ± 2.4% (day 3); and 32.7 ± 9.8%, 10.5 ± 4.8%, 7.2 ± 4.2%, and 8.6 ± 6.4% (day 6) in groups A, B, C, and D, respectively. On the other hand, in group E numerous degenerating neutrophils with a marked to moderate increase in necrotic tissue fragments were observed by PFC on days 3 and 6. In terms of graft histology on days 3 and 6, group A showed interstitial mononuclear cell infiltration indicating an acute rejection process, whereas groups B, C, and D had minimal inflammatory cell infiltration. In group E graft pancreatitis was histologically confirmed on days 3 and 6. These results suggest that PFC after pancreas transplantation could be a safe, simple, useful diagnostic tool for discriminating early graft rejection from graft pancreatitis.
Delayed Xenograft Rejection
Authors: Hancock Wayne W.
Published: August 2002

The triumph of genetic engineering in overcoming hyperacute rejection (HAR) of a discordant organ xenograft is clear, but the promise of clinical application of xenotransplantation remains unfulfilled as further immunologic barriers are defined that lead to rejection of a vascularized xenograft within days of transplantation. This report describes the features of this second set of immunologic responses, collectively termed delayed xenograft rejection (DXR). DXR is a syndrome seen in xenograft recipients in which HAR has been avoided or suppressed by antibody depletion or blockade of complement activation. DXR may result, at least in part, from the persisting activation of those pathways first encountered during the HAR phase. Serial studies over several days after transplant show that, histologically, xenografts undergoing DXR demonstrate varying combinations of (1) progressive infiltration by activated macrophages and natural killer (NK) cells, (2) platelet aggregation and fibrin deposition throughout the microvasculature, and (3) endothelial activation. In various experimental models, DXR is T cell‐independent and can occur in the absence of demonstrable xenoreactive antibodies. Hence DXR is probably best regarded as arising from the activation of innate host defense mechanisms coupled with failure of normal regulatory mechanisms due to manifold molecular incompatibilities. Although DXR‐like features can be seen in concordant models, T cell involvement in the latter is probably requisite. Similarly, in a much muted form, aspects of a DXR‐like process may contribute to numerous inflammatory processes, including allograft rejection. The importance of DXR in xenotransplantation is that its development appears resistant to all but the most dense and toxic forms of immunosuppression, which prolong xenograft survival at the expense of inducing host leukopenia, thrombocytopenia, and coagulopathies. It is likely that until the basis of DXR is more clearly understood there can be no further significant progress toward clinical xenotransplantation. However, as the mechanisms responsible for DXR are dissected and understood, still further genetic engineering of donor pigs, involving the introduction of additional or multiple genes to regulate macrophage and NK cell responses, local coagulation, and endothelial cell activation, may once again prove to be an attractive, practical, powerful therapeutic option.
Laboratory Studies in Cross‐Species Lung Transplantation
Authors: Kamholz Stephan L. , Brewer Robert J. , Grijalva Galo , Burack Joshua , Del Rio Michael J. , Vaynblatt Michael , Lawson Nuria , Squinto Steve , Fodor William L. , Norin Allen J.
Published: August 2002

The lack of sufficient suitable human donor lungs for the many patients requiring pulmonary transplantation as life‐saving therapy for end‐stage lung diseases has generated extensive interest in cross‐species lung transplantation. Ethical concerns and those of animal rights advocates have prompted studies of nonprimate species as potential solid organ donors for humans. This paper provides an overview of some of the laboratory studies of cross‐species pulmonary transplantation performed over the past 20 years and focuses, in particular, on more recent work (from our laboratory and others) in the area of porcine‐to‐primate pulmonary xenotransplantation.
Carnitine Contents in Remnant Liver, Kidney, and Skeletal Muscle after Partial Hepatectomy in Rats: Randomized Trial
Authors: Lai Hong‐Shiee , Chen Yun , Chen Wei‐Jao
Published: August 2002

Carnitine, an important carrier of free fatty acid that is transported into mitochondria for beta‐oxidation, was thought to be one of the key factors in the regulation of liver regeneration. If the carnitine content is insufficient in the hepatocyte, it might impair the energy substrate's transport and the energy charge required for cell regeneration. The purpose of this study is to evaluate the changes of carnitine content in remnant liver, kidney, and skeletal muscle simultaneously after partial hepatectomy in rats. Partial hepatectomy with resection of the median and left lateral lobes was performed on male Wistar rats. Rats with a sham operation comprised a control group. This study was an experimental randomized trial. Ten rats from each group were sacrificed before the operation and at 6, 24, 48, and 72 hours after the operation. The carnitine content, as total and free forms, in remnant liver, kidney, and skeletal muscle were quantified by high‐performance liquid chromatography. The carnitine contents in the remnant liver increased significantly at 6, 24, and 48 hours after partial hepatectomy (p < 0.01). The increase of total carnitine content was more obvious than that of the free form. In contrast, the decreasing concentrations of total carnitine and free carnitine in the kidney were significant (p < 0.01). In skeletal muscle the total carnitine content decreased to a small extent, and it was observed only at 6 hours after partial hepatectomy (p < 0.05). It is suggested that remnant liver promoted the generation of carnitine, whereas kidney and skeletal muscle released their stored carnitine at an early stage after partial hepatectomy. As a result, the influx of the carnitine into hepatocytes increased at the regenerative stage. The carnitine content of remnant liver is sufficient during the early posthepatectomy stage.
Tertiary Peritonitis: Clinical Features of a Complex Nosocomial Infection
Authors: Nathens Avery B. , Rotstein Ori D. , Marshall John C.
Published: August 2002

The objective of this study was to define risk factors for and the clinical course of recurrent or tertiary peritonitis. Intensive supportive care of patients with life‐threatening intraabdominal infections has led to the emergence of a new clinical syndrome, tertiary peritonitis, defined as the persistence or recurrence of intraabdominal infection following apparently adequate therapy of primary or secondary peritonitis. We undertook a retrospective study of 59 patients admitted with intraabdominal infection to a surgical intensive care unit (ICU). Tertiary peritonitis developed in 74% (44/59) of patients. Despite comparable premorbid health status, source of peritonitis, and admission APACHE II scores, patients with tertiary peritonitis had a significantly longer ICU stay (21.8 ± 14.9 vs. 8.5 ± 7.9 days), more advanced organ dysfunction reflected in higher organ dysfunction scores (13.3 ± 5.1 vs. 7.7 ± 3.3), and higher ICU mortality (64% vs. 33%) than patients with uncomplicated secondary peritonitis. The most common infecting organisms in patients with tertiary peritonitis were Enterococcus,Candida, Staphylococcus epidermidis, andEnterobacter. Infectious foci were rarely amenable to percutaneous drainage and were found to be poorly localized at laparotomy. Recurrent, or tertiary, peritonitis is a common complication of intraabdominal infection in patients admitted to an ICU. It differs from uncomplicated secondary peritonitis in its microbial flora and lack of response to appropriate surgical and antibiotic therapy. Like nosocomial pneumonia in the critically ill patient, the syndrome appears to be more a reflection than a cause of adverse outcome.
Sepsis: Stimulation of Energy‐Dependent Protein Breakdown Resulting in Protein Loss in Skeletal Muscle
Authors: Hasselgren Per‐Olof , Fischer Josef E.
Published: August 2002

Muscle catabolism is a characteristic metabolic response to sepsis, severe infection, and injury. In patients with severe and protracted sepsis, the catabolic response results in muscle wasting and fatigue, which may adversely affect the outcome in these patients. An understanding of the regulation of muscle protein breakdown during sepsis and the mechanisms involved is important from a clinical standpoint and is essential for the development of new therapeutic modalities to prevent protein loss from muscle tissue. Studies in septic patients and experimental animals have provided evidence that the myofibrillar proteins actin and myosin are particularly sensitive to the effects of sepsis. Among the factors that regulate muscle protein breakdown during sepsis, the proinflammatory cytokines tumor necrosis factor and interleukin‐1, together with glucocorticoids, are the principal mediators. Intracellular protein breakdown is regulated by multiple proteolytic pathways. Among these, the energy‐ubiquitin‐dependent pathway accounts for a major portion of muscle protein breakdown during sepsis. The development of specific proteasome inhibitors may make it possible in the future to target the molecular mechanisms of sepsis‐induced increase in muscle proteolysis. Such treatment may prove an important avenue to reduce the metabolic cost in patients with severe infection or sepsis.
Nutritional Support and Infection: Does the Route Matter?
Authors: Minard Gayle , Kudsk Kenneth A.
Published: August 2002

Questions regarding the effects of the route of nutrition began to surface shortly after the introduction of total parenteral nutrition (TPN). Although TPN has become a life‐saving therapy for patients who cannot tolerate enteral nutrition, it is not the panacea it was hoped to be. It appears that the enteral route of nutrition decreases rates of infectious complications compared with parenteral feeding. Reasons for this phenomenon are not clear, but it seems that enteral nutrition supports the gut barrier and gut‐associated lymphoid tissue, which may have effects on infections at distant sites such as the lung. These effects do not appear to be due solely to prevention of malnutrition, as the infectious complications develop early after injury or illness. However, the lack of understanding of the mechanisms does not negate the fact that in many clinical studies the enteral route of nutrition is superior to the parenteral route in terms of reducing infectious complications in critically ill or injured patients.
Typhoid Intestinal Perforations in Nigerian Children
Authors: Meier Donald E. , Tarpley John L.
Published: August 2002

This study was a retrospective analysis of 75 children with perforated typhoid enteritis treated at the Baptist Medical Centre in Ogbomoso, Nigeria over a 4‐year period. The mean age was 11.4 years. The usual symptoms were fever and abdominal pain, with a mean duration of 10.5 days. The diagnosis of perforation was usually based on the history and physical examination alone. The time interval from hospital presentation to operation was 11 hours, during which intravenous crystalloid and antibiotics were administered. Among the 75 children, 53 (71%) had a single perforation, and 22 had multiple perforations. Débridement and two‐layered closure was performed in 71 (95%) and resection with anastomosis in 4 (5%). Ileus resolution was usually not complete until the eighth postoperative day, and the mean time until the surviving children were afebrile was 10 days. Complications other than death occurred in 7 (9%) children, and there were 15 deaths (20% mortality). All deaths were attributed to overwhelming sepsis, and all but one of the deaths occurred during the first 72 postoperative hours. The only factor statistically significant as a predictor of mortality was the duration of abdominal pain. Improvement in perioperative management including intensive care nursing and more effective antibiotics, although expensive, could result in decreased mortality. A significant decrease in mortality can occur only when the prevention of typhoid fever becomes a higher priority than its treatment.
Excision Curettage and Allografting of Giant Cell Tumor
Authors: Shih Hsin‐Nung , Hsu Robert Wen‐Wei , Sim Franklin H.
Published: August 2002

Between 1987 and 1994 we followed 22 patients with giant cell tumors involving the long bones. Their average age was 31 years (range 17–50 years). Five patients had grade II tumors and the other 17 grade III lesions. The average volume of lesions after curettage was 231 ml (range 56–450 ml). All of the patients underwent a modified excisional curettage, and the cavity was filled with deep‐frozen allogeneic corticocancellous bone graft with supplementary fixation. Two patients developed postoperative complications including a superficial wound infection in one case and a traumatic tibial plateau fracture in one case. The overall outcome was good or excellent in 91% of the patients (i.e., 20/22 cases). There was no degenerative joint arthritis and, surprisingly, no instance of tumor recurrence. Allograft infection and fracture were not present. An allogeneic cortical strut with cancellous bone graft can be used safely and is effective for grafting cavitary lesions created after complete removal of the tumor.
Cytokine Patterns in Patients Who Undergo Hemofiltration for Treatment of Multiple Organ Failure
Authors: Koperna Thomas , Vogl Sonja E. , Pöschl Gerald P. , Hamilton Gerhard , Röder G. , Germann Peter
Published: August 2002

The excessive uncontrolled activation of inflammatory cells and mediators after trauma or major surgery plays a key role in the development of adult respiratory distress syndrome and multiple organ system failure (MOSF). In the past elevated cytokine levels were shown to influence the outcome of these patients adversely. There are diverging results regarding the removal of circulating cytokines by various methods of hemopurification for clinical improvement of MOSF. Seven patients after trauma or major surgery underwent continuous venovenous hemofiltration (CVVH) for the treatment of severe organ failure of the heart and lungs (Murray score 2.74) but not for renal or liver failure. The cytokine levels were measured at the beginning and 15, 60, 120, and 240 minutes after initiation of CVVH (measure points MP1–5). Clinical improvement during the treatment was monitored, and correlation with cytokine levels was evaluated. Arterially measured tumor necrosis factor α rose from 11.14 ng/ml to 17.86 ng/ml
(p < 0.05). Arterial interleukin‐6 (IL‐6) levels significantly decreased during CVVH from 1284.7 ng/ml to 557.9 ng/ml; IL‐8 levels simultaneously decreased from an initial peak of up to 154.4 ng/ml at MP3 to 97.3 ng/ml at MP5. The drop in serum IL‐6 and IL‐8 levels closely correlated with clinical improvement. After 2 hours of CVVH the hemodynamic situation improved significantly, as revealed by a decrease in catecholamine expenditure, an increase in arterial pressure, and a decrease in pulmonary artery pressure. Moreover, 2 hours after the initiation of CVVH the oxygenation index rose significantly and correlated well with the drop in shunt fraction. The Murray score significantly fell to 1.86. The removal of IL‐6 and IL‐8 by CVVH after initial stimulation correlates with clinical improvement, which was demonstrated by significantly improved oxygenation and hemodynamics from 2 hours after the initiation of CVVH onward. The elimination of cytokines and several mediators by CVVH may contribute to the cardiopulmonary improvement of critically ill patients. In comparison with the clinical control group (n= 7), which was comparable in terms of MOSF, no intervention led to a similar improvement in cardiorespiratory failure, and overall two of these patients died. Moreover, patients of the control group experienced a significant longer stay at in the intensive care unit.
Radiation Enterocolitis: Overview of the Past 15 Years
Authors: Shiraishi Masayuki , Hiroyasu Shungo , Ishimine Tomonari , Shimabuku Masamori , Kusano Toshiomi , Higashi Masahiro , Muto Yoshihiro
Published: August 2002

From April 1980 to April 1995 a total of 54 patients (53 women, 1 man) were hospitalized in our department for the surgical treatment of radiation enterocolitis. Two surgical protocols were applied for these patients: intestinal decompression procedures alone (intestinal bypass, colostomy, or both;
n= 18) or an intestinal resection in addition to decompression (n= 36). The clinical factors contributing to survival after irradiation were retrospectively reviewed by a multiple variate proportional hazards model. As a result, patients treated with decompression procedures alone had an 11 times higher risk for death than those treated with the addition of intestinal resection. In the former group, 5 of 18 patients died of bleeding from the remaining intestine after operation. We concluded that surgical resection of the diseased intestine is a useful procedure for treating radiation enterocolitis to reduce intestinal bleeding from the irradiated intestine.
Hypocalcemia following Thyroid Surgery: Incidence and Prediction of Outcome
Authors: Pattou François , Combemale Frederic , Fabre Sylvain , Carnaille Bruno , Decoulx Marc , Wemeau Jean‐Louis , Racadot Alain , Proye Charles
Published: August 2002

Postoperative hypocalcemia is a common and most often transient event after extensive thyroid surgery. It may reveal iatrogenic injury to the parathyroid glands and permanent hypoparathyroidism. We prospectively evaluated the incidence of hypocalcemia and permanent hypoparathyroidism following total or subtotal thyroidectomy in 1071 consecutive patients operated during 1990–1991. We then determined in a cross‐sectional study which early clinical and biochemical characteristics of patients experiencing postoperative hypocalcemia correlated with the long‐term outcome. Postoperative calcemia under 2 mmol/l was observed in 58 patients (5.4%). In 40 patients hypocalcemia was considered severe (confirmed for more than 2 days, symptomatic or both). At 1 year after surgery five patients (0.5%) had persistent hypocalcemia. We found that patients carried a high risk for permanent hypoparathyroidism if fewer than three parathyroid glands were preserved in situ during surgery or the early serum parathyroid hormone level was ≤ 12 pg/ml, the delayed serum calcium levels ≤ 8 mg/dl, or the delayed serum phosphorus level ≥ 4 mg/dl under oral calcium therapy. When one or more of these criteria are present, long‐term follow‐up should be enforced to check for chronic hypocalcemia and to avoid its severe complications by appropriate supplement therapy.
Early Operative Intervention for Urologic Complications of Kidney‐Pancreas Transplantation
Authors: Kaplan Adam J. , Valente John F. , First M. Roy , Demmy Ann M. , Munda Rino
Published: August 2002

Bladder drainage of exocrine secretions during pancreas transplantation can be associated with significant complications. We present a proactive approach to these complications consisting of early cystoenteric conversion (CEC). Altogether 81 patients underwent pancreas transplant between March 1985 and May 1995; 26 (32%) required CEC. Complications presented as urine leaks, other complications, and refractory metabolic acidosis. There were 13 patients who presented with a urine leak: 12 with acute abdominal pain, and 1 asymptomatic. Serum amylase and creatinine rose a mean of 823 IU and 0.61 mg/dl, respectively. The interval to CEC ranged from 2 to 45 months. One patient died of fungal sepsis. Postoperative complications included duodenojejunal anastomotic bleed (n= 1), negative relaparotomy (n= 1), myocardial infarction (n= 1), graft pancreatitis (n= 1), and wound infection (n= 1). Twelve patients presented with other complications: three women with cystitis (n= 2) or hematuria (n= 1), and nine men with urethritis (n= 6), scrotal edema (n= 2), or dysuria (n= 1). The interval to conversion ranged from 1 to 108 months. There were no deaths. One patient required relaparotomy for anastomotic bleed. One patient was converted because of refractory metabolic acidosis. Admissions and inpatient days were significantly reduced. Overall mortality was 3.8%, morbidity 23.1%, and graft salvage rate 96.1%. Leak‐associated mortality was 7.7%, morbidity 38.5%, and graft salvage rate 92.3%. For other complications the mortality was 0, morbidity 7.7%, and graft salvage rate 100%. CEC is a safe, effective treatment for urologic complications of pancreas transplantation. Morbidity and mortality were acceptable; admissions and hospital days were decreased. Early CEC results in superior outcomes and improved quality of life. It is preferable to nondefinitive measures for management of urologic complications of pancreatic transplantation.
Other Laparoscopic Bariatric Procedures
Authors: Lönroth H. , Dalenbäck Jan
Published: August 2002

Laparoscopic surgery is regarded as a major improvement reflected by a rapid recovery and low perioperative and postoperative morbidity. In obese patients the gains of this new technique may be affected by obesity‐related problems, such as impaired respiratory function, high intraabdominal pressure, thick abdominal wall, and liver steatosis. This review describes the development of laparoscopic vertical banded gastroplasty (VBG) and gastric bypass procedures; and it addresses questions such as feasibility, comparability to open procedures, procedure‐related problems, and recovery. The clinical outcome after laparoscopic VBG and gastric bypass is also updated. Up to May 1997 we have operated on 105 patients with laparoscopic VBG and another 26 completed laparoscopic gastric bypass procedures. The weight loss after both procedures are in accordance with the weight loss seen with open surgery. Procedure‐related complications are described in detail in this paper. It is concluded that laparoscopic bariatric surgery will remain an area of importance for clinical practice, research, and development.
Endoscopic Surgery: The History, the Pioneers
Authors: Litynski Grzegorz S.
Published: August 2002

The introduction of endoscopy into surgical practice is one of the biggest success stories in the history of medicine. Endoscopy has its roots in the nineteenth century and was initially developed by urologists and internists. During the 1960s and 1970s gynecologists took the lead in the development of endoscopic surgery while most of the surgical community continued to ignore the possibilities of the new technique. This was due in part to the introduction of ever more sophisticated drugs, the impressive results of intensive care medicine, and advances in anesthesia, which led to the development of more radical and extensive operations, or “major surgery.” The idea that large problems require large incisions so deeply dominated surgical thinking that there was little room to appreciate the advances of “key‐hole” surgery. Working against this current, some general surgeons took up the challenge. In 1976 the Surgical Study Group on Endoscopy and Ultrasound (CAES) was formed in Hamburg. Five years later, on the other side of the Atlantic, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) was called into being. In 1987 the first issue of the journal Surgical Endoscopy was published, and the following year the First World Congress on Surgical Endoscopy took place in Berlin. The sweeping success of the “laparoscopic revolution” (1989–1990) marked the end of traditional open surgery and encouraged surgeons to consider new perspectives. By the 1990s the breakthrough had been accomplished: endoscopy was incorporated into surgical thinking.
Value of Extended Resection and Intraoperative Radiotherapy for Resectable Pancreatic Cancer
Authors: Hiraoka Takehisa , Kanemitsu Keiichirou
Published: August 2002

Since 1984 intraoperative radiotherapy (IORT) combined with extended resection for pancreatic cancer has been performed in our clinic to prevent local recurrence. Following extended resection, a dose of 30 Gy of 9‐ to 12‐MeV electrons is administered to the operative field, including the paraaortic area from the diaphragm above to the inferior mesenteric artery below. The 5‐year survival rate was 15.3% in all 37 cases, 20.2% in patients who had macroscopic tumor clearance, and 16.9% in patients with stage IVa tumor according to the Japanese classification. In autopsies of 10 patients who underwent combined therapy, four had local recurrence enclosed by thick, firm connective tissue. There was no local control recurrence in two patients who underwent noncurative resection. Enhanced local control induced by the combined therapy, however, has only a limited impact on overall survival because of the systemic spread of disease, especially hepatic metastases. At present, as we have no effective treatment for hepatic metastases, it is important to perform an extended resection with IORT on carefully selected patients. The combined therapy may offer the best approach to control local recurrence when dealing with advanced, but not highly advanced, cancer as defined by the stage of tumor. Therefore a combination of IORT and extended resection can have an impact on the results of surgical treatment for pancreatic cancer when anticancer treatment of hepatic metastases is established.
Evidence‐based Surgical Practice: What Is It and Do We Need It?
Authors: Kreder Hans J.
Published: August 2002

The concept of evidence‐based clinical practice involves integrating personal experience with the best available scientific information when making decisions about the care of patients. The purpose of this article is to introduce surgeons to the philosophy of evidence‐based practice and to discuss some of the necessary skills required for clinical and research application. Some of the concerns about misuse of the concept are also addressed.
Penetrating Cardiac Trauma: Follow‐up Study Including Electrocardiography, Echocardiography, and Functional Test
Authors: Duque Hector A. , Florez Luz E. , Moreno Alejandro , Jurado Hector , Jaramillo Carlos J. , Restrepo Martha C.
Published: August 2002

A prospective study was carried out to analyze the evolution of patients who survived penetrating cardiac trauma. A total of 642 patients were evaluated. A 1‐year follow‐up, which included physical examinations, electrocardiography, echocardiography and stress tests, was completed in 192 patients. Data processing included calculation of average and percentage values. At follow‐up, 90% of patients were asymptomatic at 2 days after surgery, with normal cardiac monitoring; baseline and control ECGs showed myocardial infarction in 9.1% of patients. Baseline ECGs showed pericarditis as well in 27% of patients and repolarization changes in 35.2%. The latter became normal within 1 to 6 months after the trauma. All (100%) of the patients had a functional status I stress test, and 56% had a normal echocardiography. In conclusion, the epidemiologic behavior of penetrating cardiac trauma is identical to that of general trauma. ECG is useful during the postsurgery period for diagnosis of traumatic myocardial infarction. Likewise, the stress test is useful in patients with myocardial infarction and echocardiography in the presence of either myocardial infarction or any symptom suggesting anatomic or functional alterations of the heart.
Role of Wire‐guided Breast Biopsy for Diagnosis of Malignant Nonpalpable Mammographic Lesions
Authors: Lantsberg Leonid , Kirshtein Boris , Koretz Michael , Strano Selwyn
Published: August 2002

Biopsies of mammographically detected nonpalpable lesions have resulted in increased numbers of diagnosed early breast malignancies. From June 1992 to September 1996 a total of 433 consecutive patients underwent 438 biopsies. The mean age was 55.7 years (range 30–82 years); 150 patients were younger than 50 years. Mammographic findings were classified as microcalcifications (C), masses (M), masses with microcalcifications (MC), architectural distortions (A), and stellate lesions (S). In 30 women two needles were placed to localize a lesion in the ipsilateral side and in 5 on the contralateral side. There were 182 (41.6%) biopsies performed for M, 144 (32.9%) for C, 78 (17.8%) for A, 25 (5.7%) for MC, and 9 (2.1%) for S. The overall malignancy rate was 34% (149/438). Thirty‐four women (23%) who presented malignancy were younger than 50 years of age. From year to year, it increased from 27% during the first year to 51% during the fourth year. Altogether 100 (67%) patients had invasive carcinoma, 40 (27%) ductal carcinoma in situ (DCIS), 6 (4%) lobular carcinoma in situ, and 3 (2%) tubular carcinoma. Four patients had simultaneous bilateral palpable and nonpalpable carcinoma. Among the patients, 9 of 20 with previously operated breast carcinoma and 9 of 19 with other previous malignancies were found to have early breast carcinoma. The mammographic finding with high rates of malignancy were S 67%, MC 40%, M 34%, C 33%, and A 28%. A group of 11 of 110 (10%) patients had histologically proven axillary lymph node metastasis. Results from this large retrospective study of wire‐guided localization biopsies showed a relatively high rate of malignancy (34%) and DCIS (27%).
Gastric Acidity following Pancreaticogastrostomy with Pylorus‐preserving Pancreaticoduodenectomy
Authors: Shinchi Hiroyuki , Takao Sonshin , Maenohara Shigeho , Aikou Takashi
Published: August 2002

Pancreaticogastrostomy (PG) has been reintroduced and employed occasionally as a useful alternative to pancreaticojejunostomy (PJ) after Whipple resection or pylorus‐preserving pancreaticoduodenectomy (PPPD). Although the physiologic alteration in the stomach is important for the correlation between gastric and pancreatic functions, the actual intragastric pH profile after PG is still unclear. This study was conducted to investigate the physiologic changes in gastric pH and serum gastrin and secretin levels before and after PPPD reconstructed with PG (PPPD‐PG) in humans. Twenty‐four hour continuous intragastric pH and serum gastrin and secretin levels in the fasting state were examined in 25 patients who had undergone PPPD‐PG. No peptic ulcer was detected after the operation. After PG, serum gastrin and secretin levels were unchanged. Twenty‐four hour gastric pH monitoring revealed two distinct patterns during the nocturnal period before the operation: patients with acid‐type secretion (n= 11) exhibited a persistent acid pH, whereas those with alkaline‐type secretion (n= 14) had cyclic variations between an acid and an alkaline pH value. After PG, in both acid‐ and alkaline‐type patients, median pH and percentages of time that the gastric pH was less than 4 (% pH < 4) and more than 6 (% pH > 6) did not change, and circadian pH patterns also remained unchanged. These results suggest that PPPD‐PG has little influence on gastric acidity, and the neurohumoral relation between the stomach, duodenum, and pancreas is preserved after PG. Therefore, physiologically, PG can be recommended as a reconstructive procedure after PPPD.