bluuebunny/crossref_metadata_2025 huggingface dataset:
Postoperative Elevated Serum Levels of Intact Parathyroid Hormone after Surgery for Parathyroid Adenoma: Sign of Bone Remineralization and Decreased Calcium Absorption
Authors: Westerdahl Johan , Valdemarsson Stig , Lindblom Pia , Bergenfelz Anders
Published: August 2002

Increased levels of intact parathyroid hormone (PTH) have been documented after surgery for primary hyperparathyroidism (pHPT) despite normocalcemia. The pathogenesis remains to be elucidated. Seventeen consecutive patients operated on for solitary parathyroid adenoma were investigated before and at 8 weeks and 1 year after surgery with serum levels of intact PTH, biochemical variables known to reflect PTH activity, and bone mineral content (BMC). In addition, an oral calcium loading test was performed 8 weeks after the operation. All patients had low or normal serum calcium levels during follow‐up. Eight weeks after operation six patients (35%) had an increased serum PTH level. These patients (group I) preoperatively had higher serum levels of PTH and alkaline phosphatase than patients with normal PTH levels (group II). They also had lower BMC and larger parathyroid adenomas. They did not differ in renal function. At 8 weeks after operation group I showed higher mean serum levels of osteocalcin and propeptide of type I procollagen but lower urinary calcium excretion. In contrast to patients in group II, they also showed a lower calciuric response and a trend to a lower calcemic response during the oral calcium load. The two groups showed similar parathyroid sensitivity for calcium. Patients in group I demonstrated a significant increase in BMC the first year after the operation. Increased serum PTH 8 weeks after surgery for sporadic parathyroid adenoma was not due to persistent pHPT or impaired renal function. Instead, the results imply there is diminished calcium absorption and increased bone turnover with cortical bone remineralization.
Lung Volume Reduction Surgery for Chronic Obstructive Pulmonary Disease: Where Do We Stand?
Authors: McKenna Robert J. , Gelb Arthur , Brenner Matt
Published: August 2002

Lung volume reduction surgery (LVRS) is a promising new treatment for selected patients with moderate to severe symptoms of emphysema. Medical management, including pulmonary rehabilitation, has been shown to reduce oxygen requirements during exercise and probably to reduce hospitalization for patients with severe emphysema, but it does not improve pulmonary function. By improving the elastic recoil of the lung, LVRS is the first treatment to demonstrate substantial improvement in pulmonary function and quality of life for selected patients with emphysema. The most important selection factor for LVRS is the presence of a heterogeneous pattern of emphysema. Because it is found in only 20% of patients with emphysema, only a small number of patients are candidates for the procedure. Published reports indicate that the optimal operative technique appears to be a bilateral staple operation during a single anesthetic. This procedure offers a 68% chance of oxygen independence, 85% chance of prednisone independence, and 60% to 70% improvement in pulmonary function for patients with an upper lobe distribution of emphysema. The long‐term benefits of the procedure are currently unknown, so several randomized, prospective studies are now comparing LVRS with maximal medical management.
Value of Bronchoscopic Pneumonia Diagnosis: Prospective Study
Authors: Prokop A. , Gawenda M. , Krüger I. , Pichlmaier H.
Published: August 2002

In a prospective clinical study we examined whether bronchoscopically controlled suctioning is preferable to the blind suctioning of mucus aspirates for bacterial identification of intensive care unit patients with pneumonia. Forty patients with clinical and radiologic signs of pneumonia underwent both bronchoscopically controlled and blind endotracheal lavage. Bronchoscopically controlled suctioning did not demonstrate greater sensitivity for identifying organisms than the results obtained from blind suctioning (58 organism were bronchoscopically identified, compared to 57 organisms identified by blind suctioning; p= 0.32, NS). Arterial and mixed venous partial oxygen pressure and shunt also showed no significant differences 15 minutes before and after examination, nor did the blood pressure or pulse. The use of four of the bronchoscopes resulted in preinterventional contamination withPseudomonas. Bronchoscopically controlled lavage shows no advantages over blind endotracheal lavage for diagnosing pneumonia. Blind suctioning with single‐use sterile catheters can be done more quickly and inexpensively with fewer personnel and a lower complication rate.
Clinical Significance of DNA Ploidy Pattern in Stage III Gastric Cancer
Authors: Sakusabe Masaru , Kodama Masashi , Sato Yasuhiko , Kikuchi Toshiki , Koyama Kenji
Published: August 2002

Nuclear DNA contents from stage III gastric cancers of 216 patients undergoing curative resection from 1972 to 1987 were measured by flow cytometry using paraffin‐embedded materials. To determine the clinical significance of the DNA ploidy pattern, the correlation between it and conventional clinicopathologic findings was studied and a prognostic factor for gastric cancer was investigated by both univariate and multivariate analysis. Survivals were compared for diploidy and aneuploidy patterns in subclasses of stage III gastric cancer as well. The grade of each clinicopathologic factor showed no differences between diploidy and aneuploidy patients. The multivariate analysis revealed that the pvalue and Hazard ratio of the DNA ploidy patterns were 0.001 and 2.099, respectively. Consequently, it was a valuable independent prognostic factor that could be used in addition to lymph node metastasis and depth of invasion. For the most advanced subclass of stage III gastric cancer the 5‐year survival rate of patients with a diploid tumor was significantly higher than that for those with aneuploid tumor. No difference was observed for the other subclasses. These results indicate that the DNA ploidy pattern is a valuable independent prognostic factor for gastric cancer, and that it is more useful for evaluating the prognosis of patients with more advanced lesions undergoing “curative resection.”
Inhibition of Unstimulated Exocrine Pancreatic Secretion by Peptide YY in the Rat
Authors: Robinson Diane C. , Rudnicki Marek , Tito Joseph M. , Gold Michael S.
Published: August 2002

Peptide YY is an ileocolonic peptide known to inhibit postprandial and cholecystokinin‐induced pancreatic exocrine secretion. It has also been shown to increase intestinal water and electrolyte absorption. These findings implicate PYY as being potentially useful for controlling watery diarrhea. Although its inhibitory effect on stimulated pancreatic secretion has been well established, PYY effects on interdigestive, unstimulated pancreatic secretion is not known. This study was designed to evaluate the effect of PYY on basal pancreatic exocrine secretion in a conscious rat. Male Sprague‐Dawley rats were prepared with catheters for internal biliary bypass, pancreatic juice collection, and intraduodenal reinfusion of pancreatic juice. Jugular and carotid catheters were inserted for drug infusions and blood sampling. After overnight recovery, fasting rats were infused over 6 hours with saline or PYY (400 or 800 pmol/kg/hr). Pancreatic juice was measured and sampled at 60‐minute intervals for volume and its protein and bicarbonate content. The remainder was reinfused into the duodenum. Before and after the experiment, pancreatic juice was automatically reinfused by a photocell‐controlled peristaltic pump system. Intraductal pancreatic secretion was not affected by PYY at a dose of 400 pmol/kg/hr. PYY at a dose of 800 pmol/kg/hr significantly reduced the volume of pancreatic secretion and its protein and bicarbonate content. Pancreatic secretory response normalized within 24 hours. In conclusion, unstimulated pancreatic exocrine secretion can be inhibited by exogenous PYY in the rat.
Sepsis, SIRS, and MODS: What’s in a Name?
Authors: Nathens Avery B. , Marshall John C.
Published: August 2002

Progress in the care of the critically ill patient with life‐threatening infection has been hampered by inconsistent, often confusing terminology. The clinical syndrome of sepsis—familiar to all yet definable by none—describes a highly heterogeneous group of disorders with different causes and differing prognoses. The imminent availability of mediator‐directed therapy has created a sense of urgency to develop better methods for delineating discrete clinical syndromes and to modulate the host response, which may bring both benefit and harm, depending on the clinical circumstances. The term systemic inflammatory response syndrome (SIRS) was introduced several years ago to describe the familiar clinical syndrome of sepsis, independent of its cause. SIRS can result from trauma, pancreatitis, drug reactions, autoimmune disease, and a host of other disorders; when it arises in response to infection, sepsis is said to be present. SIRS describes a dynamic process that has adaptive survival value for the host. The maladaptive consequence of this process in the critically ill patient is the development of progressive but potentially reversible remote organ dysfunction—the multiple organ dysfunction syndrome. The development of cogent conceptual frameworks for classification of the septic response in critically ill patients is more than a question of linguistic pedantry. Optimal therapy presupposes identification of an homogeneous patient population with a characteristic disease process and a predictable response to an intervention. Although progress has been made in identifying such groups of critically ill patients, the disappointing results of clinical trials of agents that so clearly demonstrate efficacy in animal models indicates that considerable work remains.
Peritoneal Carcinomatosis from Adenocarcinoma of the Colon
Authors: Sugarbaker Paul H. , Schellinx Monique E. T. , Chang David , Koslowe Patricia , von Meyerfeldt Maarten
Published: August 2002

Peritoneal carcinomatosis is a major cause of surgical treatment failure in patients with colorectal cancer. In the past patients with this condition have had a lethal outcome. In this study, 64 consecutive patients were treated by the cytoreductive approach, which involved surgery to maximally resect all cancer in the abdomen and pelvis, early postoperative intraperitoneal chemotherapy with 5‐fluorouracil (5‐FU) and mitomycin C, and three cycles of adjuvant intraperitoneal 5‐FU with systemic mitomycin C. The clinical features that may affect prognosis were assessed and critically analyzed statistically. Peritoneal implant size of < 5 cm present in the abdomen and pelvis at the time of exploration correlated with a good prognosis (p < 0.0001), as did complete cytoreduction with tumor removed to nodules < 2.5 mm (p < 0.0001). Involvement of only one or two of the five abdominopelvic regions, compared to three or more regions, was a significant determinant of prognosis (p < 0.0001). Finally, a mucinous histologic type correlated adversely with prognosis when compared to intestinal‐type adenocarcinomas (p < 0.001). These data suggest that patients with small‐volume peritoneal seeding from colon cancer should be treated with cytoreductive surgery and aggressive regional and systemic chemotherapy in an attempt to achieve long‐term disease‐free survival.
Tropical Pyomyositis
Authors: Ansaloni Luca
Published: August 2002

Tropical pyomyositis (TP), a suppurative disease caused predominantly by Staphylococcus aureus, is responsible for 3% to 4% of surgical admissions in some hospitals in certain tropical countries. This study describes the clinical features of 35 patients with TP (20 males, 15 females; mean ± SD age 28.3 ± 14.1 years) admitted to our hospital during a 1‐year period and analyzes the causal association between ancylostomiasis, human immunodeficiency virus (HIV) infection, and TP. Concerning the supposed etiologic association between Ancylostoma duodenale infection and TP, among the 35 patients with TP the stool examination of 22 (62.8%) revealed the presence of eggs of A. duodenale. In a control group of 100 asymptomatic subjects the prevalence of ancylostomiasis was 55%. The Odds ratio between the two groups is 1.38 (exact 95% confidence limits = 0.59 < OR < 3.34). Furthermore, the pus from all TP abscesses (41 in 35 patients) was carefully collected and examined microscopically, but nematode larvae were not detected in any of the specimens. Hence these results do not support an association between ancylostomiasis and TP. With the aim of correlating TP with HIV infection, I carried out a case‐control comparison of HIV seroprevalence among the patients affected by TP and an age‐ and sex‐matched control group of healthy subjects. Eleven patients with TP were HIV antibody‐positive (seroprevalence 31.42%), as were two controls (seroprevalence 5.71%). The matched analysis produced a Mantel‐Haenszel matched Odds ratio of 5.50 and a maximum likelihood estimate of OR (MLE) of 5.50 (exact 95% confidence limits for MLE: 1.20 < OR < 51.07). Among the 11 patients HIV‐seropositive, 9 (81.8%) fulfilled the World Health Organization clinical case definition (CCD) for AIDS, compared with 1 of 24 (4.1%) HIV‐negative subjects. The chi‐square test for difference in fulfilling the CCD for AIDS between patients with TP seropositive and seronegative result was statistically significant (p < 0.0001). It is concluded that TP is a bacterial infection highly significantly associated with HIV infection and thus must be considered a strong sign of stage III–IV of HIV disease.
Endovascular Repair of Aortic Aneurysms, Arteriovenous Fistulas, and False Aneurysms
Authors: Parodi Juan C.
Published: August 2002

Between September 1990 and June 1995, 103 patients were treated with transluminal placed endovascular grafts: 87 had abdominal aortic aneurysms (AAA), two had iliac artery aneurysms (one in association with an AAA), 3 had thoracic aneurysms, and 12 had vascular injuries in various localization of the arterial tree. The AAAs were excluded from the blood flow with a device composed of a balloon‐expandable stent (modification of the Palmaz stent) attached to a Dacron graft designed to expand at both ends of the accompanying stent extension. An 18F sheath containing the stent–graft device was introduced through a small cut‐down in the common femoral arteries and advanced under fluoroscopic guidance. Color duplex, contrast‐enhanced computed tomography (CT) scanning and angiography were performed before the procedure and then every 6 months. (Arteriography was performed once during the follow‐up period and whenever other studies disclosed an abnormal finding.) A total of 87 patients (75 men, 12 women) harboring an AAA were treated: Forty‐five patients underwent an aortoaortic procedure (8 patients had only a proximal stent implanted, and 37 had proximal and distal stents). Forty‐two patients were treated by implanting an aortoiliac graft, completing the procedure with a femorofemoral bypass. The contralateral common iliac artery was occluded by means of an occluding stent. One type A dissecting aneurysm and two descending thoracic aneurysms were successfully treated by the endovascular technique. The longest follow‐up period was 60 months and the shortest 1 month. Initial success was obtained in 84% of the aortoaortic cases and in 75% of the aortoiliac procedures. Long‐term follow‐up (> 12 months) disclosed 78% success for the aortoaortic cases and 90% for the aortoiliac procedures. Late failures included distal aortic dilatation, distal leak into the aneurysmal cavity, and proximal leak into the aneurysm. All trauma cases were successful over the short and long terms. Trauma cases included false aneurysms (common carotid, subclavian, common femoral arteries) and arteriovenous fistulas (subclavian, aortocava, common iliac‐cava and superficial femoral artery and vein). We concluded that stent–graft combination devices appear to be an alternative for treating vascular trauma and aneurysms. Initial success for treating AAAs is almost 100%, and late success in aortoiliac cases is also high (90%) for aortoaortic reconstruction. However, late failures are frequent and require further evaluation in relation to a persistent increase in the diameter of the proximal neck and distal cuff.
Endovascular Repair of Aortoiliac Occlusive Disease
Authors: Marin Michael L. , Veith Frank J. , Sanchez Luis A. , Cynamon Jacob , Lyon Ross T. , Suggs William D. , Bakal Curtis W. , Parsons Richard E.
Published: August 2002

Occlusive disease of the aorta and iliac and femoral arteries may lead to limb‐threatening ischemia when multiple levels of disease are present. The combined treatment of severe aortoiliac and infrainguinal disease using standard techniques may be hazardous or contraindicated in patients with multiple, previous reconstructions or severe co‐morbid medical illnesses. This report summarizes the technical feasibility and early results of aortoiliac endovascular stented grafts (ESGs) in combination with conventional surgical reconstructions for the treatment of multilevel arterial occlusive disease. Forty‐two patients with multilevel aortoiliofemoral limb‐threatening occlusive disease had an ESG inserted to treat long‐segment, multilevel, occlusive disease. ESGs originated from either the aorta or the common iliac artery and were inserted into one of the femoral arteries. ESG lengths ranged from 16 to 30 cm (mean 21 cm). Conventional surgical bypasses were constructed, when necessary, from polytetrafluoroethylene (PTFE) or saphenous vein and were extended using standard techniques to the popliteal, tibial, or contralateral femoral arteries. Technical success of graft insertion was achieved in 39 of 42 attempted ESG procedures (93%). The 18‐month primary and secondary cumulative patency rates for ESGs were 89 ± 9 (SE) and 100%, respectively. Limb salvage was achieved in 94% of patients at 24 months. Four patients had minor postprocedure complications (10%), and there was one death. Endovascular aortoiliac grafts, often in combination with conventional surgical infrainguinal bypasses, are a technically feasible, potentially safe option for the treatment of limb‐threatening aortoiliofemoral occlusive disease and have demonstrated encouraging early patency. Long‐term follow‐up is necessary before widespread application of this technique is instituted.
Sacrococcygeal Chordoma: Review of 50 Consecutive Patients
Authors: Chandawarkar Rajiv Y.
Published: August 2002

Fifty consecutive patients with sacrococcygeal chordomas treated during 1941–1991 at the Tata Memorial Hospital in India were studied retrospectively. Pain was the commonest presenting symptom (82%). An average time lapse of 14 months between the onset of pain and definitive diagnosis emphasizes the importance of a high index of suspicion and prompt use of sophisticated imaging techniques leading to an early diagnosis. All patients underwent a partial sacrococcygectomy, through a sacral approach in 22 patients (44%) and an abdominosacral approach in 28 (56%). Postoperative complications included urinary incontinence (14%), rectal incontinence (6%), hemorrhage (4%), and rectal injury (2%). Radiotherapy offered significant pain relief to patients with widespread recurrence. A total of 38 patients were ambulatory, and 12 needed support. The average disease‐free survival was 63 months, and the overall survival was 7 years. Aggressive resection through a combined abdominosacral approach offers the best results. Because postrecurrence salvage rates are poor, the primary surgery must be complete and curative.
Surgery in Hemophilia A Patients with Factor VIII Inhibitor: 10‐Year Experience
Authors: Scharf Romuald , Kucharski Witold , Nowak Tomasz
Published: August 2002

Patients with hemophilia A and circulating anticoagulant (factor VIII inhibitor) present a difficult, even unsolvable problem, particularly if they require surgical treatment and the inhibitor titer is high. During the 1986–1995 period 29 surgical procedures on inhibitor hemophilia A patients were performed in our center. Each of the cases had an individual character, and all demanded special clinical treatment. Based on this experience we present the possibilities of hemostasis maintenance during the perioperative period with high doses of human or porcine factor VIII, aPCC, plasmapheresis, and extracorporeal antibody adsorption to protein A–Sepharose. In some patients hemostasis maintenance requires combined treatment. To induce immunotolerance in patients with inhibitor is the gold standard treatment because it is then possible to achieve proper hemostasis after factor VIII infusion. Various methods of immunotolerance induction have been discussed and compared with our experience with immunotolerance induction in 11 patients with small factor VIII doses (25 IU/kg twice a week) and the modified Malmö protocol in 15 patients.
Intraoperative Secretion of Intact Parathyroid Hormone and Amino‐Terminal Parathyroid Hormone Fragments from Normal Parathyroid Glands Associated with Solitary Parathyroid Adenoma
Authors: Bergenfelz Anders , Ahrén Bo
Published: August 2002

The nonadenomatous parathyroid glands associated with parathyroid adenoma in patients with primary hyperparathyroidism (pHPT) are assumed to exhibit suppressed secretion of parathyroid hormone (PTH). Because the function of these glands is of clinical importance for calcium homeostasis after surgery for pHPT, we studied the decrease of serum levels associated with intact PTH (i‐PTH) and amino‐terminal PTH (N‐PTH) after excision of a parathyroid adenoma. Blood samples were obtained from the cubital vein and the inferior thyroid vein in six patients with pHPT. The results show that the levels of both i‐PTH and N‐PTH decreased after removal of the parathyroid adenoma (p< 0.05 for both). Because the reduction was more pronounced for i‐PTH than for N‐PTH, the N/i ratio increased from 0.54 ± 0.33 to 3.76 ± 1.62 (p< 0.05). Furthermore, the levels of i‐PTH and N‐PTH were higher centrally than peripherally both before and after adenoma excision (p< 0.05). The results therefore suggest that the secretion of i‐PTH and N‐PTH in the remaining normal‐size parathyroid glands is not completely suppressed. Furthermore, in these parathyroid glands the secretion of amino‐terminal PTH fragments is relatively predominant when compared to the release of the intact PTH. The findings underscore the importance of the N‐terminal PTH fragment for maintaining calcium homeostasis during the early postoperative period after surgery for pHPT and may explain the rarity of prolonged hypocalcemia after parathyroidectomy.
Impact of Intraoperative Ultrasonography on Surgery for Cystic Lesions of the Pancreas
Authors: Kubota Keiichi , Noie Tamaki , Sano Keiji , Abe Hideki , Bandai Yasutsugu , Makuuchi Masatoshi
Published: August 2002

The impact of intraoperative ultrasonography (IUS) on surgery for cystic lesions of the pancreas (CLPs) has not been fully clarified. Twenty patients with CLPs, including 5 pseudocysts and 15 true cysts, were scanned intraoperatively to evaluate the utility and practicality of IUS for CLPs. In four of the five patients with pseudocysts and two with retention cysts, the operative procedures were performed under IUS guidance. In one with a pseudocyst, IUS showed that the cyst did not involve the pancreas, and subsequently cystectomy without pancreatic resection was necessary. In one of the two patients with mucin‐producing cystadenocarcinomas, IUS demonstrated a skip lesion in the duct of the pancreatic tail, which contributed to changing the operative procedure from pancreatoduodenectomy to total pancreatectomy; in the other, IUS showed that the lesion was localized in the body of the pancreas, and subsequently segmental pancreatectomy was carried out instead of scheduled pancreatoduodenectomy or distal pancreatectomy. Thus in these three patients the operative procedures were changed in light of the IUS findings. In the remaining 11, although IUS visualized CLPs clearly, it added no new information relevant to the operations. We conclude that IUS contributes to performing surgery for certain types of CLP, such as pseudocysts with severe inflammation, retention cysts with nonpalpable or invisible small cysts, mucin‐producing cystadenocarcinomas, and possibly other lesions.
Early Limb Salvage: Open Tibia Fractures of Ambroise Paré (1510–1590) and Percivall Pott (1714–1789)
Authors: Kocher Mininder S.
Published: August 2002

Ambroise Paré and Percivall Pott were preeminent clinicians, writers, and educators who advanced the cause of surgery through their independent thinking and insightful observations. In addition to their legacies and numerous enduring contributions, both men sustained open tibial fractures that were successfully managed during times when most often amputation was prescribed for such injuries. This article explores their lives and their fractures.
Natural course of acute pancreatitis
Authors: Beger H. G. , Rau B. , Mayer J. , Pralle U.
Published: August 2002

Acute pancreatitis comprises, in terms of clinical, pathologic, biochemical, and bacteriologic data, four entities. Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations; pancreatic pseudocyst and pancreatic abscess are late complications after necrotizing pancreatitis, developing after 3 to 5 weeks. Determinants of the natural course of acute pancreatitis are pancreatic parenchymal necrosis, extrapancreatic retroperitoneal fatty tissue necrosis, biologically active compounds in pancreatic ascites, and infection of necrosis. Early in the course of acute pancreatitis multiple organ failure is the consequence of various inflammatory mediators that are released from the inflammatory process and from activated leukocytes attracted by pancreatic injury. During the late course, starting the second week, local and systemic septic complications are dominant. Around 80% of deaths in acute pancreatitis are caused by septic complications. The infection of pancreatic necrosis occurs in 8% to 12% of acute pancreatitis and in 30% to 40% of patients with necrotizing pancreatitis. Bacteriologic analysis of intraoperative smears and aspirates reveals predominantly gram‐negative germs deriving from the intestine, most frequently Escherichia coli. It has been confirmed that after necrotizing pancreatitis a considerable large group of patients suffer long‐lasting exocrine and endocrine insufficiency.
Tailored Antireflux Surgery for Gastroesophageal Reflux Disease: Effectiveness and Risk of Postoperative Dysphagia
Authors: Wetscher Gerold J. , Glaser Karl , Wieschemeyer Thomas , Gadenstaetter Michael , Prommegger Rupert , Profanter Christoph
Published: August 2002

The Nissen fundoplication is not the proper antireflux procedure for patients with poor esophageal peristalsis as it does not strengthen impaired esophageal peristalsis. The aim of this study was to investigate if tailoring of antireflux surgery according to esophageal contractility is an effective treatment of gastroesophageal reflux disease (GERD) with a low incidence of postoperative dysphagia. The Toupet fundoplication was laparoscopically performed on 32 patients with poor esophageal peristalsis and the Nissen fundoplication on 17 patients with normal peristalsis. After a median follow‐up of 15 months, only 1 of the 49 patients (2.04%)
complained of heartburn. Acute esophagitis was found in none of them on endoscopy. Of 40 patients tested postoperatively, 2 (5%) underwent pathologic esophageal pH monitoring. Postoperative dysphagia was found in two patients (4.1%) compared with 25 (51%) preoperatively
(
p < 0.05). There was a significant reduction of dysphagia following the Toupet fundoplication. Both procedures increased the resting pressure of the lower esophageal sphincter (LES)
significantly, which was more pronounced following the Nissen fundoplication. Relaxation of the LES was significantly better following the Toupet than after the Nissen fundoplication. There was significant improvement of esophageal peristalsis following the Toupet fundoplication. Tailored antireflux surgery is an effective strategy for treatment of GERD. The incidence of postoperative dysphagia is low owing to improvement of impaired esophageal peristalsis following the Toupet fundoplication. It may be due to the fact that the Toupet fundoplication causes less esophageal outflow resistance than the Nissen fundoplication.
Fundoplication Avoiding Complications of the Nissen Procedure: Prospective Evaluation
Authors: Pélissier Edouard P. , Ottignon Yves , Deschamps Jean‐Paul , Carayon Pierre
Published: August 2002

The purpose of this study was to evaluate the results of a fundoplication aimed to avoid complications of the Nissen procedure. The procedure combined a posterior hemifundoplication and a short circular fundoplication and their fixation to crura. A total of 67 consecutive patients were prospectively evaluated before and after surgery (median follow‐up 24 months). Typical and atypical signs of reflux were present in 96.9% and 28.1% of cases, respectively, before operation versus 12.5% and 6.3% after. Patients alleged dysphagia in 26.6% of cases before surgery and 20.3% after. After operation belching and vomiting were impossible in 6.3% and
29.7% of cases, respectively. The pH test did not demonstrate any pathologic acid esophageal exposure in 93.3% cases after surgery. The mean duration of acid esophageal exposure was 45.1 ± 21.8%
(10–100%) before operation versus 1.9 ± 4.9% (0–30%) after
(
p < 0.001). The mean lower esophageal sphincter pressure increased from 12.4 ± 6.1 cm H2O (0–28 cm H2O) before operation to 20.5 ± 7.3 cm H2O (11–50 cm H2O) after (p< 0.0001). The velocity of esophageal waves increased from 2.8 ±
1.1 cm/sec (1.2–5.5) before surgery to 3.1 ± 1.5 cm/sec
(1.4–7.7 cm/sec) after (p < 0.001). None of the Nissen complications were observed, and it was not necessary to reoperate any patient. In conclusion, this procedure is effective, improves esophageal motor activity, and prevents the occurrence of complications of the Nissen procedure. It does not, however, alleviate side effects.
Femoral Pseudoaneurysms in Drug Addicts
Authors: Ting Albert C.W. , Cheng Stephen W.K.
Published: August 2002

Femoral pseudoaneurysm is a serious complication in drug addicts who habitually inject via the groin. A total of 33 drug addicts presenting with 34 infected femoral pseudoaneurysms were treated in the Department of Surgery, the University of Hong Kong, Queen Mary Hospital from July 1993 to June 1996. There were 27 men and 6 women, with ages ranging from 23 to 76 years (mean 39.6 years). Positive intraoperative tissue cultures were seen in 29 (85%), with 17 being pure growth of methicillin‐sensitive Staphylococcus aureus (MSSA). Twenty‐four pseudoaneurysms involved the femoral bifurcation and were treated by triple ligation of the common femoral, superficial femoral, and profunda femoris arteries. Seven other limbs underwent ligation of the common femoral artery alone, and three had superficial femoral artery ligation. Nineteen limbs had the external iliac artery ligated in addition to the femoral ligation for better proximal control. The mean postoperative ankle–brachial index (ABI) was 0.43 and 0.52 in those with triple ligation and those with single‐vessel ligation, respectively. There was no hospital mortality, and all patients were discharged with a viable limb. The duration of follow‐up ranged from 2 to 36 months (mean 15.5 months). Four patients were asymptomatic, but the rest suffered some degree of intermittent claudication. No delayed limb loss was identified. We conclude that systemic antibiotics active against MSSA are the antibiotics of choice in drug addicts with infected femoral pseudoaneurysms. Ligation and excision of the pseudoaneurysm without revascularization is safe, with acceptable morbidity and a low limb loss rate.
Patterns of Intestinal Motility Recovery during the Early Stage following Abdominal Surgery: Clinical and Manometric Study
Authors: Shibata Yoshihisa , Toyoda Sumio , Nimura Yuji , Miyati Masahiko
Published: August 2002

The purpose of this study was to evaluate the pattern of recovery of intestinal motility using manometric and clinical assessment in the postoperative ileus following abdominal surgery. We reviewed the charts of 18 patients who underwent partial colectomy for colon cancer (group A, without vagotomy) and compared them to those of 15 patients who underwent gastrectomy with truncal vagotomy and reconstruction by the Billroth I technique (group B, with vagotomy). A three‐lumen catheter was inserted via the nose into the proximal jejunum for drainage of intestinal fluids and to record intestinal motility at laparotomy. The first appearance of a burst activity following a silent period and a migrating motor complex (MMC) was at 3.8 hours (mean) and 16.4 hours, respectively, in group A, and at 2.5 and 14.3 hours, respectively, in group B. The first audible bowel sounds and the time of feeling abdominal fullness and passage of flatus was at 34.8, 47.5, and 62.9 hours (group A), and at 43.0, 53.8, and 77.9 hours (group B), respectively. The peak volume of nasointestinal drainage was recorded at 16 to 24 hours in group A and 40 to 48 hours in group B (p < 0.05). As measured by manometric examination, an MMC reappeared within a few hours after surgery. Physiologic postoperative ileus was ended when MMCs extended throughout the gastrointestinal (GI) tract with forwarding GI fluids.
Intraperitoneal Dissemination Probably Caused by Needle Biopsy of Alveolar Echinococcosis of the Liver: Experimental Study
Authors: Yamashita Kenichiro , Furuya Koji , Namieno Tsutomu , Sato Naoki , Shimamura Tsuyoshi , Une Yoshie , Uchino Junichi
Published: August 2002

Alveolar echinococcosis of the liver (AEL) is a parasitosis with a potential for malignant tumor‐like behavior. The disease is diagnosed by a combination of serologic tests, diagnostic images, and the histology of needle biopsy specimens. It remains unresolved whether the biopsy induces subsequent troubles. We designed this study to investigate critical problems after needle biopsy of AEL lesions using an experimental model. Five samples were prepared from the resected lesions of AEL patients: (A) 10% suspension of trypsin digests of the minced lesion; (B) 10% suspension of mesh‐filtered sediment of the minced lesion; (C) 10% sediment suspension after washing the nonminced lesion; (D) supernatant after centrifuging intracystic fluid; (E) 10% sediment suspension after centrifuging intracystic fluid. A 1‐ml aliquot of each sample was injected intraperitoneally into jirds (gerbils) or cotton rats, respectively. The animals were sacrificed 12 weeks later, and intraperitoneal metacestodes were observed. All samples except D developed metacestodes, and their histologies were all lesions of typical alveolar echinococcosis. These results suggest that a needle biopsy may cause intraperitoneal dissemination or tracial implantation of the parasites along the track of the needle.
Absorption Kinetics of Rectal Formalin Instillation
Authors: Myers Jonathan A. , Mall Julian , Doolas Alexander , Jakate Shriram M. , Saclarides Theodore J.
Published: August 2002

Formalin instillation has become an accepted treatment of radiation‐induced hemorrhagic cystitis and proctitis since the initial report by Brown in 1969 (Med. J. Aust. 1:23, 1969). Although its use is widespread, no studies have been performed to determine the safest volume or duration of formalin exposure. The purpose of our study was to determine the optimum technique for instillation and the safety margin regarding the maximum time that formalin can be in contact with the rectal mucosa without causing serum toxicity. In a pilot canine study, 4% neutral buffered formalin was instilled into the rectum in 30 ml aliquots for 60 seconds each after which each aliquot was withdrawn; a total volume of 400 ml was used. Our subsequent experiment involved rectal instillation of a single formalin bolus of 100 ml for 1 hour without removal during this time. Formalin metabolites were measured in the blood and urine to assess toxicity. Results indicate that with the latter technique serum formic acid reaches toxic levels within 15 minutes of instillation and may stay elevated for several hours. Metabolites in the urine similarly increase within 15 minutes, lagging only shortly behind the rise in serum levels. Performing formalin instillation in a series of 30 ml aliquots appears to be a safer treatment, as toxic serum levels were not reached and their slight rise above baseline returned to normal within 3 hours.
Influence of Enteral Nutrition‐induced Splanchnic Hyperemia on the Septic Origin of Splanchnic Ischemia
Authors: Kazamias Pantelis , Kotzampassi Katerina , Koufogiannis Dimitris , Eleftheriadis Efthimios
Published: August 2002

The purpose of this experimental study was to investigate whether enteral nutrition‐induced postprandial intestinal hyperemia has a beneficial effect on the splanchnic ischemia due to sepsis. Fourteen dogs, after exposure to Escherichia coli endotoxin via portal vein administration were grouped according to whether they were fed enterally via a jejunostomy or given a placebo. Systemic hemodynamics; portal vein, hepatic, and superior mesenteric artery blood flow; hepatic and intestinal microcirculation; hepatic tissue PO2; intestinal pHi; and hepatic energy charge were assessed before, during, and after endotoxin infusion as well as during and after enteral or placebo feeding. All splanchnic hemodynamic parameters revealed a statistically significant decline (p= 0.001) during the endotoxin shock period relative to the baseline. After enteral feeding all parameters exhibited a statistically significant increase (p= 0.001) relative to the placebo group. The results of this study led us to suggest that enteral nutrition reverses the lipopolysaccharide infusion‐induced splanchnic ischemia.
Diagnostic Value of Positron Emission Tomography for Detecting Breast Cancer
Authors: Noh Dong‐Young , Yun Ik‐Jin , Kim Jee‐Soo , Kang Han‐Sung , Lee Dong‐Soo , Chung June‐Key , Lee Myung Chul , Youn Yeo‐Kyu , Oh Seung Keun , Choe Kuk Jin
Published: August 2002

Positron emission tomography (PET) is an imaging method that employs radionuclide and tomography techniques. PET has high sensitivity for detecting breast cancer, both the primary tumor and axillary node metastasis. From June 1995 to November 1996 a total of 27 patients underwent breast operations based on PET results at Seoul National University Hospital. Whole‐body PET images were obtained beginning 60 minutes after injection of 370 MBq (10 mCi) 18F‐fluorodeoxyglucose. Regional scans were also obtained with transmission images. We compared the PET results with those from the physical examination and mammography. All cases were histologically confirmed. The diagnostic accuracy of PET was excellent for the primary tumor mass (97%) compared with that of the physical examination (78%) and mammography (67%). For axillary lymph node metastasis, PET had outstanding detection accuracy (96%) compared with the physical examination and mammography (74% and 60%, respectively). Whole‐body PET scans made it possible to see all of the metastatic lesions at a glance in cases of metastatic or recurrent breast cancer. There was a probable correlation between the standard uptake value (SUV) and the number of axillary lymph node metastases, but in this study statistical significance was not proved because of the small number of cases. PET also could detect breast cancer in paraffin‐augmented breasts. We concluded that PET is a highly sensitive, accurate diagnostic tool for breast cancer and that SUV, after more studies, could be used as an important prognostic factor.
Critical Assessment of the Head and Neck Clinical Skills of General Surgery Residents
Authors: Sloan David A. , Donnelly Michael B. , Schwartz Richard W. , Vásconez Henry C. , Plymale Margaret , Kenady Daniel E.
Published: August 2002

Head and neck surgery is an important part of general surgery. There is, however, little information about the quality of residents’ clinical skills in this important field. In an Objective Structured Clinical Examination (OSCE), residents encounter multiple patients with various clinical problems and are rated by faculty members using objective criteria. This study was undertaken to assess the head and neck surgery skills of a group of general surgical residents. Fifty‐one general surgery residents examined the same nine patients with head and neck disease. Faculty members graded each clinical interaction according to preset objective criteria. Both actual (e.g., thyroid nodule, oral cancer follow‐up examination) and simulated (e.g., dysphagia) patients were used in the OSCE. The reliability of the examination was assessed by coefficient α. The construct validity was determined by a two‐way analysis of variance with one repeated measure. The reliability was 0.75 for the clinical examination. Performance varied by level of training: Residents performed at a higher level than interns (p< 0.0001), but overall scores were poor (mean score 55%). Important deficits in skills were identified at all levels of training. It is concluded that more attention should be focused on specific outcome assessments of surgical training programs and on strategies for upgrading the clinical skills of surgical residents.
Abdominal Sonography Screening of Clinically Diagnosed or Suspected Appendicitis before Surgery
Authors: Chen Shyr‐Chyr , Chen Kai‐Mo , Wang Shih‐Ming , Chang King‐Jen
Published: August 2002

We conducted a prospective study to evaluate the value of abdominal sonography in the diagnosis of acute appendicitis and determine the need for abdominal sonography before operation. Altogether 191 patients with clinically diagnosed or suspected appendicitis underwent an abdominal sonography examination performed by a staff surgeon before operation. The sonographic findings are classified into three categories: appendicitis, other diseases, or normal screening. A total of 158 patients (82.7%) with positive findings of appendicitis proceeded to surgery; 18 patients (9.4%) were found to have other diseases, and they were treated for their conditions; and 15 patients (7.9%) with normal screening were discharged from the hospital and were reevaluated 2 weeks later. Only one patient had a false‐negative finding. Of the 158 patients undergoing operation, 143 (90.5%) were proved to have appendicitis by the pathologic reports. A total of 32 negative appendectomies (16.8%) were prevented after sonographic examination. Abdominal sonography for detecting acute appendicitis had a sensitivity of 99.3%, a specificity of 68.1%, an accuracy of 91.6%, a positive predictive value of 90.5%, and a negative predictive value of 97.0%. The value of meticulous history‐taking, physical examination, and laboratory tests cannot be overemphasized. Our experience suggests that patients with clinically diagnosed or suspected acute appendicitis should routinely undergo abdominal sonography examination, performed by an experienced surgeon, to further decrease the negative appendectomy rates.
Fibrin Glue Sandwich Prevents Pancreatic Fistula following Distal Pancreatectomy
Authors: Ohwada Susumu , Ogawa Tetsushi , Tanahashi Yoshifumi , Nakamura Seiji , Takeyoshi Izumi , Ohya Toshihiro , Ikeya Toshiroh , Kawashima Kenji , Kawashima Yoshiyuki , Morishita Yasuo
Published: August 2002

Pancreatic fistula is a major form of morbidity following pancreatic resection. We conducted a nonrandomized clinical trial comparing the sealing and sandwich techniques of spraying fibrin glue to prevent pancreatic fistula following distal pancreatectomy. The pancreas was transected with a scalpel to identify and suture the main pancreatic duct and its small branches. In the sealing group, fibrin glue was sprayed over the closed pancreatic stump and sutures. Alternatively, in the sandwich group fibrin glue was sprayed so as to cover and join the cut surface of the pancreatic remnant, which was then held closed with sutures. Altogether 111 patients were included in the study (90 with gastric cancer, 10 with esophageal cancer, and 11 with pancreatic cancer). Patients were nonrandomly assigned to the sandwich or the sealing group. Morbidity was 21.8% for the patients in the sandwich group versus 33.9% in the sealing group. Pancreatic fistulas occurred in 9.0% of the sandwich group versus 26.8% of the sealing group. The incidence of fistula was thus significantly lower in the sandwich group. The incidence of fistula was also significantly lower in the sandwich group for gastric malignancy patients undergoing extended radical lymphadenectomy down to the paraaortic lymph nodes combined with left adrenalectomy. Of the patients with gastric malignancy, pancreatic fistulas occurred in 9.3% of the sandwich group versus 25.5% of the sealing group. The fibrin glue sandwich technique is simple and reliable and should be valuable for complementing other prophylactic methods of preventing pancreatic fistula.
Prospective Surgical Outcome Study of Relief of Symptoms following Surgery in Patients with Primary Hyperparathyroidism
Authors: Pasieka Janice L. , Parsons Louise L.
Published: August 2002

Many of the symptoms experienced by patients with primary hyperparathyroidism (HPT) develop insidiously and have often been misinterpreted as normal aging. The purpose of this study was to quantify HPT patients’ preoperative symptoms prospectively and study the impact of successful surgical intervention on these symptoms. Altogether 63 consecutive patients with primary HPT and 54 comparison patients with nontoxic thyroid disease were prospectively enrolled in the study. An outcome questionnaire documenting symptoms with a visual analog scale (VAS) was used. The questionnaire was filled out preoperatively and at 7 to 10 days and 3 and 12 months postoperatively. At 1 year the questionnaire also included a general health assessment and quality of life index. Demographic data and follow‐up blood work was obtained. Descriptive statistics, parametric comparisons (t‐tests, ANOVA), and nonparametric comparisons (Mann‐Whitney U‐test) were calculated. The HPT group demonstrated a significant decrease in reported symptoms between the preoperatively assessment and 7 to 10 days after operation (p < 0.001). There were no further statistically significant decreases in the HPT group's symptoms at 3 and 12 months, but there was a trend for these symptoms to decrease over time. HPT patients perceived a 60% increase in their general health at 1 year; the comparison group perceived no increase. There was no significant change in the symptoms reported by the comparison group between each of the study intervals. Surgical intervention on HPT patients significantly reduces preoperative symptoms, and this reduction is most marked within the first 10 days after surgery.