bluuebunny/crossref_metadata_2025 huggingface dataset:
Generalised folds for nested datatypes
Authors: Bird Richard , Paterson Ross
Published: August 2002

Nested datatypes generalise regular datatypes in much the same way that context-free languages generalise regular ones. Although the categorical semantics of nested types turns out to be similar to the regular case, the fold functions are more limited because they can only describe natural transformations. Practical considerations therefore dictate the introduction of a generalised fold function in which this limitation can be overcome. In the paper we show how to construct generalised folds systematically for each nested datatype, and show that they possess a uniqueness property analogous to that of ordinary folds. As a consequence, generalised folds satisfy fusion properties similar to those developed for regular datatypes. Such properties form the core of an effective calculational theory of inductive datatypes.
Sentinel Node Concept in Gastric Carcinoma
Authors: Ichikura Takashi , Morita Daisaku , Uchida Takefumi , Okura Eiji , Majima Takashi , Ogawa Toshiya , Mochizuki Hidetaka
Published: August 2002

To assess the applicability of thesentinel node concept to gastric carcinoma. The location of metastaticlymph nodes was analyzed retrospectively in 119 patients with gastriccarcinoma in whom metastasis was limited to one or two nodes.Intraoperative lymphatic mapping was attempted in 62 patients usingindocyanine green injected endoscopically into the gastric submucosaadjacent to the tumor. Metastatic lymph nodes were distributed beyondthe perigastric area in 4% of patients with a single node involved.The positive node was located along the greater curvature in 21% ofthe patients with a tumor on the lesser curvature. Two patients had ametastatic node totally occupied by cancer tissue. In 16% of patientswith two nodes involved, a positive node was located on both the lesserand greater curvatures. Lymphatic mapping was successful in allsubjects. A larger number and wider distribution of green‐stained nodeswere observed in patients injected with 8 ml of indocyanine greensolution than in those injected with 4 ml. No metastasis was observedin any nodes in 47 (96%) of the 49 patients who had no metastasis ingreen nodes. In one patient showing metastasis in non‐green nodeswithout metastasis in green nodes, the positive nodes were totallyoccupied by cancer tissue. Our results showed the complexity oflymphatic streams within and from the stomach. Lymphatic mapping usingindocyanine green can be a tool for identifying sentinel nodes ingastric carcinoma although lymph nodes occupied by cancer tissue maynot be detected by this technique.
Surgical Management of Early Colorectal Cancer
Authors: Nivatvongs Santhat
Published: August 2002

An early colorectal carcinoma is TNM stage T1NxMx. Most early carcinomas of the colon and rectum can be treated by adequate local excision, such as colonoscopic polypectomy and per‐anal excision. If there are adverse risk factors, especially poorly differentiated carcinoma, lymphovascular invasion, or incomplete excision, a radical resection is indicated if there is no contraindication. In the case of a low rectal carcinoma, adjuvant chemoradiation should be considered. Recently a new classification has been developed: sm1 is invasion to the upper one‐third of the submucosa, sm2 is invasion to the middle one‐third, and sm3 is invasion to the lower one‐third. Lesions of sm1 and sm2 have a low risk of local recurrence and lymph node metastasis; local excision is adequate. The sm3 lesions and sm2 flat and depressed types have a high risk of local recurrence and lymph node metastasis; further treatment is indicated.
Thyroid Cancer in Children of Ukraine after the Chernobyl Accident
Authors: Rybakov Stanislav J. , Komissarenko Igor V. , Tronko Nicolay D. , Kvachenyuk Andrey N. , Bogdanova Tatyana I. , Kovalenko Andrey E. , Bolgov Michail Y.
Published: August 2002

The results of treatment of 330 children (< 14 years) and adolescents (15–18 years) with thyroid cancer who were operated on at the Institute of Endocrinology after the Chernobyl accident in 1986 were analyzed. The number of young patients increased after 1986 (1981–1985, 9 cases; 1986–1990, 37 cases; 1991–1995, 177 cases; 1996–1998, 116 cases). Most of these children and adolescents were younger than 8 years at the time of the accident (84.2%). More than half of the children (58.1%) lived in areas receiving the highest radiation exposure. These thyroid cancers developed after a short latent period, were more aggressive at presentation, and expressed regional (57.3%) or distant (14.5%) metastasis. Solid papillary cancers were present in 93.1%. Coexisting thyroid conditions were common (thyroid hyperplasia, 25.1%; nodular goiter, 18.8%; chronic thyroiditis, 10.2%). Most patients were treated by total thyroidectomy with intraoperative visualization of recurrent laryngeal nerves and parathyroid glands. When lymph node metastases were identified, a modified neck dissection was performed. Such operations were done in 277 (84.1%) patients. Postoperatively, the patients were treated with radioiodine and thyroid‐stimulating hormone suppressive therapy. Postoperative complications included recurrent nerve palsy in 12.3% and permanent hypoparathyroidism in 6%. Operations for local recurrence of cancer were performed in 2.8% cases and for regional metastasis in 4%. The general mortality was 1.8%. We anticipate that there will be more patients with thyroid cancer during the next few years. Therefore this high risk population for thyroid cancer must be carefully monitored and evaluated during the next several decades.
Importance of the Duodenal Passage and Pouch Volume after Total Gastrectomy and Reconstruction with the Ulm Pouch: Prospective Randomized Clinical Study
Authors: Schwarz Andreas , Büchler Markus , Usinger Kerstin , Rieger Harald , Glasbrenner Bernd , Friess Helmut , Kunz Reiner , Beger Hans Günther
Published: August 2002

The objective of this randomized study was to examine which reconstruction method and which pouch volume offer the best preconditions for a good quality of life and extensive physiologic regulation of gastrointestinal hormones after total gastrectomy. Up to now there is no general agreement with regard to the ideal reconstruction after total gastrectomy. The importance of the duodenal passage, the need for a pouch reconstruction, and the ideal pouch volume are matters of controversy. A total of 60 patients underwent the following reconstructions: Ulm pouch (pouch reconstruction with preservation of the duodenal passage), Hunt‐Lawrence‐Rodino pouch, or Roux‐en‐Y reconstruction without pouch. The clinical course, quality of life, and regulation of gastrointestinal hormones in correlation to reconstruction type and pouch volume were documented. Quality of life was assessed by means of a standardized specific questionnaire. Blood glucose, insulin, cholecystokinin, motilin, secretin, and pancreatic polypeptide were measured after stimulation by a standardized test meal. Six months after total gastrectomy those patients with an Ulm pouch were found to have a significantly better life quality (p< 0.01), higher body weight, and better physiologic regulation of gastrointestinal hormones; moreover, they developed (in contrast to all other reconstruction types) no pathologic glucose tolerance. Our conclusion is that all patients with a postoperative life expectancy of at least 6 months (i.e., tumor stages UICC I and II) should undergo pouch reconstruction with preservation of the duodenal passage.
Metastatic Endocrine Tumors: Medical Treatment, Surgical Resection, or Liver Transplantation
Authors: Dousset Bertrand , Saint‐Marc Olivier , Pitre Jol , Soubrane Olivier , Houssin Didier , Chapuis Yves
Published: August 2002

We reviewed our experience with 34 patients with metastatic endocrine tumors (METs) who were treated by different modalities. Eight patients were treated by chemotherapy or chemoembolization because of stable disease or surgical contraindications. Seventeen patients underwent curative or cytoreductive surgical resection. Nine patients received grafts based on the following criteria: no extrahepatic spread on imaging workup and nonresectable symptomatic metastatic disease. Of the eight medically treated patients, the five patients with initial stable clinical condition are alive 32 to 56 months after referral. Of the 17 patients treated by liver resection, 13 are alive 6 to 108 months after surgery, and 7 are disease‐free. After curative resection, the 5‐year actuarial survival and disease‐free survival rates were 62% and 52%, respectively. Of the nine grafted patients, three patients grafted for carcinoid tumor are alive at 15, 24, and 62 months, one of whom has a late recurrence. Our results indicate that therapeutic indications for METs should be based on age, clinical symptoms, histologic type, and tumor extension: Patients with stable MET may benefit from surgical restraint; liver resection in patients with aggressive MET may provide good long‐term palliation and possibly cure one‐third of the patients; liver transplantation should be restricted to young patients with nonresectable carcinoid MET but remains a high‐risk operation because of previous surgery and chemoembolization.
Jet‐cutting Supported by High Frequency Current: New Technique for Hepatic Surgery
Authors: Rau Horst G. , Buttler Eckart R. , Baretton Gustav , Schardey Hans M. , Schildberg Friedrich W.
Published: August 2002

To reduce blood loss incurred during liver resection, techniques that separate vessels from liver parenchyma, such as the CUSA or the jet‐cutter, are in clinical use. By conducting high frequency current through the jet beam using hypertonic NaCl cutting solution, we developed a new method enabling simultaneous coagulation during selective cutting. In this study we examined the effects of this method on liver resection in a rabbit model. With the three techniques—jet‐cutting, CUSA, and high frequency‐supported jet‐cutting (HF‐jet)—we performed liver resection of the ventral lobe in six animals per group. We compared velocity of resection, blood loss, tissue trauma, selectivity (number of isolated vessels per area), electrolytes, and vital signs. Histopathology was carried out with the resectate and after 7 days with the remaining liver. Velocity of resection procedure and selectivity were significantly reduced in the HF‐jet group. Histopathology showed coagulated vessels and a deeper zone of necrosis. Accordingly, the liver enzymes transiently showed distinctly higher values in the HF‐jet group. Electrolyte disturbances or differences of vital signs could not be detected. Transferring our results to patient care we expect that with major resections the hilus clamping time, blood loss, and number of blood transfusions can be reduced. In our opinion the additional application of high frequency through the jet beam is a helpful improvement of the jet‐cutter.
Ultrasound‐Guided Aspiration Biopsy for Detection of Nonpalpable Axillary Node Metastases in Breast Cancer Patients: New Diagnostic Method
Authors: Bonnema Jorien , van Geel Albert N. , van Ooijen Bart , Mali Sybrand P.M. , Tjiam Swanny L. , Henzen‐Logmans Sonja C. , Schmitz Paul I.M. , Wiggers Theo
Published: August 2002

This study was designed to evaluate the accuracy of ultrasonography alone and in combination with fine‐needle aspiration biopsy (FNAB) for detection of axillary metastases of nonpalpable lymph nodes in breast cancer patients. Ultrasonography was carried out in 150 axillas of 148 patients (mean age 57 years, range 30–80 years); and in 93 axillas lymph nodes were detected. Nodes were described according to their dimension and echo patterns and were compared with histopathologic results. FNAB was carried out in 81 axillas (122 nodes). The sensitivity of ultrasonography was highest (87%) when size (length >5 mm) was used as criterion for malignancy, but the specificity was rather low (56%). When nodes with a malignant pattern (echo‐poor or inhomogeneous) were visualized, specificity was 95%. Ultrasound‐guided FNAB had a sensitivity of 80% and a specificity of 100% and detected metastases in 63% of node‐positive patients. It is concluded that FNAB is an easy, reliable, inexpensive method for identifying patients with positive nodes. In the case of negative findings, other diagnostic procedures to exclude lymph node metastases, such as sentinel node mapping, could be performed.
Mortality after Esophagectomy: Risk Factor Analysis
Authors: Ferguson Mark K. , Martin Terri R. , Reeder Laurie B. , Olak Jemi
Published: August 2002

Esophageal resection is associated with a high incidence of operative mortality, suggesting the need for predictors of operative risk. A retrospective analysis was performed for esophagectomy patients using univariate and multivariate analyses; relative risks (RR) were calculated. Of the 269 patients, 35 (13%)
died. The optimal model for the preoperative prediction of risk of mortality was defined by age (
p= 0.001; RR =
2.6) and performance status (p= 0.04; RR = 1.9). Delimiting the data pool using a calculated risk of 0.2 accurately identified outcomes in 79% of patients and predicted 41% of deaths. The optimal model for the overall prediction of risk of mortality was defined by age (p= 0.001; RR = 3.9), intraoperative blood loss (p < 0.001; RR = 1.7), pulmonary complications (p= 0.002; RR = 6.6), and the need for inotropic support (p= 0.003; RR
= 10.2). The individual risk of mortality after esophagectomy can be predicted preoperatively with a model based on patient age and performance status. The findings underscore the importance of preoperative evaluation of cardiopulmonary function, meticulous operative technique, and aggressive respiratory care in the management of the esophagectomy patient.
Staging and Management of Colorectal Cancer
Authors: Northover John M.A.
Published: August 2002

The management of colorectal cancer becomes ever more complex. Rational decision‐making depends on knowledge of the apparent stage of the disease in the individual patient. Many decisions require input from the patient, who therefore must be party to all relevant information, including any that is predictive of the likely outcome of the disease and the effects of treatment. The process of staging once required only pathologic information gleaned from the surgical specimen. Later clinical information was often added to produce a more practically useful prediction of outcome; necessarily, the staging process, whether pathologic or clinicopathologic, could only be completed postoperatively. Today there is a momentum toward preempting this process through the use of scanning and other modalities, so “staging” information can be used when planning primary treatment, including neoadjuvant therapy and surgery. The ultimate staging system would comprise just two reliably predictive patient categories: those expected to survive and those destined to die. So far no system has approached that “ideal.” Given such a system, therapeutic and research efforts could be concentrated on reversing the outcome for those predicted to die.
Laparoscopic versus Open Surgery for Colorectal Cancer
Authors: Milsom Jeffrey W. , Kim Seon‐Hahn
Published: August 2002

There are three basic roles of laparoscopic surgery for patients with colorectal cancer. First, although infrequently needed prior to therapy, diagnostic or staging laparoscopy may be valuable in certain colorectal cancer patients. Second, the laparoscopic approach may offer several attractive features for the palliative management of patients with incurable colorectal cancer. Finally, although this issue is the most controversial, there are theoretic but unproved advantages of using laparoscopic techniques for curative colorectal cancer therapy. The concerted efforts of surgical oncologists and their colleagues must prove this theory in well constructed trials.
Potentially Multicentric Hepatocellular Carcinoma: Clinicopathologic Characteristics and Postoperative Prognosis
Authors: Yasui Motoshi , Harada Akio , Nonami Toshiaki , Takeuchi Yuuki , Taniguchi Kenji , Nakao Akimasa , Takagi Hiroshi
Published: August 2002

When multiple hepatic tumors are present, it is sometimes difficult to distinguish between metastatic and multicentric hepatocellular carcinoma (HCC). To identify the important clinicopathologic features of multicentric HCC, we evaluated the clinical characteristics of patients with multicentric HCC and examined the usefulness of surgical treatment in those patients. A total of 99 patients with multiple HCCs were classified into one of the following two groups according to whether their tumors were multicentric or metastatic: Group MO consisted of 18 patients with tumors thought to have developed synchronously from multicentric origins. Group IM consisted of 64 patients with intrahepatic metastases. In this study 18% of the patients with multiple HCCs were thought to have presented with multicentric tumors. This study revealed that synchronous multicentric HCCs often affected multiple segments of the liver and responded relatively well to partial hepatectomy of individual tumor‐affected areas. To appropriately treat potentially multicentric HCC, it is important to understand the histopathologic characteristics of multicentric HCC and diagnose during preoperative and intraoperative ultrasonography, so surgical treatment may be useful.
Xenoantigens and Xenoantibodies: Their Modification
Authors: Cooper David K.C. , Thall Aron D.
Published: August 2002

The hyperacute rejection of pig organs by primates, including humans, results from antibody‐mediated complement activation. Protection from complement injury still leads to delayed rejection, which results from other mechanisms that may also be dependent on the presence of antibody. Anti‐pig antibodies are directed largely, if not entirely, against α‐galactose (αGal) epitopes on pig vascular endothelium. Prevention of antibody–antigen binding is being attempted by methods that (1) alter antigen expression on the donor organ or (2) deplete the potential recipient of anti‐αGal antibody. To date, most progress has been made in depleting antibody by extracorporeal immunoadsorption using immunoaffinity columns of synthetic αGal oligosaccharides. A pig organ transplanted into a recipient baboon depleted of antibody functions for several days—in contrast to minutes to hours in unmodified baboons. The return of antibody, however, results in rejection of the graft. Pharmacologic immunosuppressive agents are relatively ineffective for prolonged suppression of anti‐αGal production. Total‐body irradiation and splenectomy are proving more successful. Studies are continuing with the aim of achieving a state of B cell tolerance toward αGal epitopes.
Cancer Dissemination during Laparoscopic Surgery: Tubes, Gas, and Cells
Authors: Targarona Eduardo M. , Martínez Joaquín , Nadal Alfons , Balagué Carmen , Cardesa Antonio , Pascual Salvador , Trias Manuel
Published: August 2002

Port‐site metastasis has been an unexpected finding after laparoscopic surgery in gastrointestinal cancer patients. No clear explanation exists for this phenomenom. The aims of this study were to evaluate the dissemination pattern in an experimental model of hepatocarcinoma in the rat and summarize current knowledge about the risks and the results of experimental studies on cancer dissemination during laparoscopic surgery. NDA‐induced hepatocarcinoma was obtained in Sprague‐Dawley rats. Tumors were manipulated during laparoscopy (group 1, n= 11) or laparotomy (group 2, n= 12). A Medline review of all experimental studies about the risk of cancer dissemination during laparoscopic surgery was undertaken. Both models were associated with implants in parietal wounds [1/11 in group 1 (9%) vs. 1/12 in group 2 (8%), p= NS]. Analysis of the current literature confirms that laparoscopy is associated with abdominal cell mobilization, and cells can be recovered in trocars, filtered exhaust gas, and instruments. Postoperative immunosuppression, the biologic aggressiveness of the tumor, and the gas used for laparoscopy also influence tumoral growth. Port‐site metastases are secondary to multiple factors, including the technical skill of the surgeon, the biologic properties of the tumors, and local environmental aspects. Undoubtedly, laparoscopy can help disseminate aggressive tumors and should be reserved for diagnostic and staging procedures or for treatment of low‐grade malignant tumors. Therapeutic resection, especially of colon cancer, should be restricted to prospective and randomized trials until there are enough hard data to rule out the clinical importance of this potentially severe complication.
Endothelial Cells: Role in Infection and Inflammation
Authors: McGill Sandra N. , Ahmed Najma A. , Christou Nicolas V.
Published: August 2002

Infection and resulting sepsis continue to be important causes of morbidity and mortality in surgical patients. Although much has been learned about the pathogens and the leukocyte responses to these pathogens, we are only beginning to understand the role of the host in these pathologies. The endothelium is a dynamic participant in cellular and organ function rather than a static barrier as it was once believed. Emerging evidence implicates the endothelium as a central effector in the inflammatory response. Through the expression of surface proteins and secretion of soluble mediators, the endothelium controls vascular tone and permeability, regulates coagulation and thrombosis, and directs the passage of leukocytes into areas of inflammation. Derangements in these normal functions may contribute significantly to a maladaptive inflammatory response leading to systemic inflammation and multiple organ failure.
Prophylactic Inspiratory Muscle Training in Patients Undergoing Coronary Artery Bypass Graft
Authors: Weiner Paltiel , Zeidan Fawaz , Zamir Doron , Pelled Benny , Waizman Joseph , Beckerman Marinella , Weiner Margalit
Published: August 2002

Pulmonary complications after cardiac surgery are a leading cause of postoperative morbidity and mortality. Respiratory muscle weakness may contribute to the postoperative pulmonary abnormalities. We hypothesized that: (1) there is a decrease in inspiratory muscle strength (PImax at residual volume) and endurance (Pmpeak/PImax) following coronary artery bypass graft (CABG); (2) this weakness is associated with reduced pulmonary function tests (PFTs), impaired gas exchange, and a higher rate of pulmonary complications; and (3) prophylactic inspiratory muscle training (IMT) can prevent those changes. Eighty‐four candidates for CABG, with ages ranging from 33 to 82 years, were evaluated prior to operation and randomized into two groups: 42 patients underwent IMT using a threshold trainer for 30 min/day for 2 weeks, 1 month before operation (group A); 42 patients served as a control group and underwent sham training (group B). There was a significant decrease in respiratory muscle function, PFTs, and gas exchange in the control group following CABG, whereas these parameters remained similar to those before entering the study in the training group. The differences between the groups were statistically significant. In addition, 11 (26%) patients in the control group but only 2 (5%) in the training group needed postsurgical mechanical ventilation longer than 24 hours. CABGs have a significant deteriorating effect on inspiratory muscle function, PFTs, and arterial blood gases. The decrease in these parameters can be prevented by prophylactic inspiratory muscle training, which may also prevent postsurgical pulmonary complications.
Parathyroidectomy in the Elderly: Do the Benefits Outweigh the Risks?
Authors: Chen Herbert , Parkerson Sara , Udelsman Robert
Published: August 2002

Although the incidence of hyperparathyroidism (HPT) in the elderly exceeds 1.5%, limited resources and co‐morbidity inhibit referral for parathyroidectomy. To determine the risks and benefits of surgery, we examined the outcomes of elderly patients who underwent exploration for primary HPT. Data from 211 consecutive patients who underwent parathyroidectomy by one surgeon at the Johns Hopkins Hospital between August 1990 and May 1996 were recorded prospectively. Of these patients, 184 had primary HPT. Demographic and outcome data of elderly patients (> 70 years of age) (n= 36) were compared to those from younger patients (< 70 years of age) (n= 148). Preoperative symptoms of mental impairment, bone disease, and fatigue were more common in elderly patients (p < 0.05), and nephrolithiasis was more frequent in younger patients (p < 0.025). Elderly patients presented with more advanced disease, manifested by higher preoperative parathyroid hormone levels (301.9 ± 63.3 vs. 169.2 ± 14.3 pg/ml, p < 0.05). The cure rate (94.4%), morbidity (5.5%), and mortality (0%) in the elderly were indistinguishable from those of their younger cohorts (98%, 1.4%, and 0%, respectively). In conclusion, the more advanced disease seen in the elderly suggests that they are referred for surgery with a higher threshold than younger patients. Although several series of parathyroidectomy in elderly patients have reported high morbidity rates, significant mortality, and long length of stay (LOS), we found that parathyroidectomy in these patients can be performed with high cures, low morbidity, no mortality, short LOS, and high patient satisfaction. These data suggest that the benefits of surgery outweigh its risks and argue for a lower threshold for referral of elderly patients with primary HPT for surgical treatment.
Reoperative Surgery for Organic Hyperinsulinism: Indications and Operative Strategy
Authors: Simon Dietmar , Starke Achim , Goretzki Peter E. , Roeher Hans D.
Published: August 2002

Organic hyperinsulinism has a good chance of cure by operation, although patients with diffuse or multiple disease run a high risk of recurrence or persistence of disease. Surgical management and outcome in these patients are presented and discussed. Between 1986 and April 1997 a total of 62 patients were operated on for organic hyperinsulinism [solitary 48, multiple 3, multiple endocrine neoplasia type I (MEN‐I) 2, diffuse 4, malignant 5]. Persistence or recurrence occurred in 10 patients (16%). Among the six that persisted, four were malignant and two benign. All four of those that recurred were benign. Patients with benign disease presented with multiple tumors (n= 3), MEN‐I syndrome (n= 1), and diffuse/nodular hyperplasia (n= 2). The duration between diagnosis and reintervention ranged from 1 to 10 years. Preoperative diagnosis was able to localize tumors in three patients (computed tomography 1, angiography 2, calcium stimulation 1). Operative procedures were multiple enucleations in two patients with sporadic disease, subtotal resection plus enucleation in the case of MEN‐I syndrome, subtotal resection for diffuse hyperplasia, left resection for adenomatosis, and tumor extirpation after multiple previous operations. Long‐term clinical and biochemical cure was achieved in five of six patients (mean follow‐up 5 years). Octreotide therapy shows good symptomatic control in the patient with operative failure. Reintervention for organic hyperinsulinism is successful (80% cure) and requires preoperative imaging and individual surgical management.
l‐Arginine: Effect on Reperfusion Injury after Heart Transplantation
Authors: Szabó Gábor , Bährle Susanne , Bátkai Sándor , Stumpf Nicole , Dengler Thomas J. , Zimmermann Rainer , Vahl Christian F. , Hagl Siegfried
Published: August 2002

Global myocardial ischemia and reperfusion injury play a major role in early postoperative myocardial graft dysfunction. The aim of the present study was to investigate the effects of the nitric oxide (NO) precursor l‐arginine on myocardial and endothelial function after hypothermic ischemia and reperfusion in a heterotopic rat heart transplantation model. After 1 hour ischemic preservation, reperfusion was started after application of placebo (control, n= 12) or l‐arginine (l‐Arg 40 mg/kg, n= 12), a substrate of NO synthesis. Myocardial blood flow (MBF) was assessed by the hydrogen clearance method. An implanted balloon was used to obtain pressure–volume relations of the transplanted heart. Left ventricular developed pressure (LVDP), rate of pressure development (dP/dt), end‐diastolic pressure (LVEDP), isovolumic relaxation constant (TE), and MBF were measured after 60 minutes and 24 hours of reperfusion. Endothelium‐dependent vasodilatation in response to acetylcholine (ACh) and endothelium‐independent vasodilatation in response to sodium nitroprusside (SNP) were also determined. After 1 hour the MBF was significantly higher in the l‐Arg group (3.6 ± 0.6 vs. 1.9 ± 0.2 ml/min/g, p < 0.05). The l‐Arg group showed better recovery of systolic function and myocardial relaxation (LVDP 106 ± 6 vs. 70 ± 7 mmHg, p < 0.05; maximal dP/dt 5145 ± 498 vs. 3410 ± 257 mmHg/s, p < 0.05; TE 12.1 ± 0.9 vs. 16.1 ± 1.5 ms, p < 0.05, at an intraventricular volume of 80 μl). LVEDP was similar in the two groups. After 24 hours no difference was found between the groups for basal MBF, LVP, dP/dt, TE, LVEDP, or the response of MBF to SNP. However, ACh led to a significantly higher increase in MBF in the l‐Arg group (52 ± 8% vs. 29 ± 7%,p < 0.05). These results indicate that (1) NO donation improves myocardial and endothelial functional recovery during early reperfusion after heart transplantation; and (2) initial treatment with l‐Arg has a persisting beneficial effect against reperfusion‐induced graft coronary endothelial dysfunction during late reperfusion.
Assessing the Suitability of Gastric Carcinoma for Limited Resection: Endoscopic Prediction of Lymph Node Metastases
Authors: Namieno Tsutomu , Koito Kazumitsu , Higashi Tsunemi , Takahashi Masato , Yamashita Kenichiro , Kondo Yukifumi
Published: August 2002

Some early gastric carcinomas are free of lymph node involvement; however, the pathosis of these carcinomas is neither well understood nor reflected in the choice of less extensive treatment. We investigated the relation of nodal involvement to pathologic findings of the resected specimens. We present promising standards for predicting the nodal status of early gastric carcinomas, contributing to the indication for limited surgery. The relation of lymph node metastasis to tumor size, infiltration depth, macroscopic appearance, and histologic type of early gastric carcinomas were investigated in 1470 patients with a single primary early gastric carcinoma. Of these carcinomas, 763 were limited to the mucosa (mucosal carcinoma) and 707 to the submucosa (submucosal carcinoma). The overall incidence of lymph node metastasis was 9.0%:2.1% in mucosal carcinomas and 16.5% in submucosal ones, with a significant (p < 0.001) difference of nodal involvement between the two. The macroscopically elevated or compound‐type carcinomas 10 mm or less in diameter were all node‐negative, whereas some depressed‐type carcinomas were node‐positive. The incidence of undifferentiated carcinomas increased with tumor diameter, irrespective of whether they were mucosal or submucosal carcinomas, and they were significantly more node‐positive than were differentiated carcinomas: p< 0.001 for mucosal carcinomas and p < 0.05 for submucosal ones. The carcinomas satisfying the following criteria are node‐negative and eligible for limited surgery: (1) mucosal carcinoma; (2) elevated lesion <10 mm in diameter; (3) differentiated adenocarcinoma; and (4) no ulcer or ulcer scar. The other carcinomas are potentially node‐positive and standard surgery is recommended.
Pattern of Recurrence after Resection for Intraductal Papillary Mucinous Tumors of the Pancreas
Authors: Sho Masayuki , Nakajima Yoshiyuki , Kanehiro Hiromichi , Hisanaga Michiyoshi , Nishio Kazushi , Nagao Mitsuo , Ikeda Naoya , Kanokogi Hideki , Yamada Takatsugu , Nakano Hiroshige
Published: August 2002

The objective of this study was to clarify the patterns of recurrence and prognosis after resection of intraductal papillary mucinous tumors (IPMTs). Fourteen patients with IPMT were reviewed histologically; intraductal papillary adenocarcinoma was present in 12 cases and intraductal papillary adenoma in 2. Six patients were alive with no evidence of disease. Two patients died from other causes. Six patients had recurrences. The median survival time was 46 months. In the six recurrent cases, the median postoperative disease‐free interval was 38 months. Four patients died of recurrence, and the median survival time after recurrence was 6 months. The major site of recurrence was the remnant pancreas. The other sites were the liver in two cases, peritoneum in two, and local in one. These results suggest the multicentric or metachronous oncogenesis of IPMT. Because of the low frequency of lymph node metastases, an operation to preserve pancreatic function may be recommended, especially for localized tumors such as the branch type. It is important to avoid an incomplete resection using intraoperative pancreatoscopy and ultrasonography. Long‐term follow‐up after surgery is necessary even for a curative resection. We should perform total pancreatectomy for recurrences without distant metastases.
Manometric Findings of the Upper Esophageal Sphincter in Esophageal Achalasia
Authors: Yoneyama Fumihiko , Miyachi Masahiko , Nimura Yuji
Published: August 2002

Pharyngeal and upper esophageal sphincter (UES) manometry was performed in 15 patients with esophageal achalasia and compared with that in 10 healthy controls. Neither the pharyngeal contraction pressure nor the UES resting pressure were significantly different between the two groups, although the UES residual pressure in patients with achalasia was significantly increased compared with that in controls. Pneumatic dilatation of the lower esophageal sphincter (LES) was performed in these patients. After successful LES dilatation, the increased UES residual pressure in patients with esophageal achalasia decreased significantly. Our results suggest that UES relaxation in patients with esophageal achalasia is incomplete compared with that in healthy adults. This UES abnormality is not a primary defect but a secondary phenomenon.
CO2 Pneumoperitoneum: What We Know and What We Need to Know
Authors: Holthausen Ulla H. , Nagelschmidt Manfred , Troidl Hans
Published: August 2002

The development of the laparoscopic technique in surgery was so overwhelming that scientific evaluation could not keep in step. While investigators were still discussing the effects of the pneumoperitoneum on the healthy organism, laparoscopy was already performed in patients with an acute abdomen due to trauma or disease. Therefore, there is an urgent need of further experimental and clinical studies with relevant endpoints to gain external evidence concerning the benefits of diagnostic or therapeutic laparoscopy for critically ill patients. In experiments with pigs we have shown that even in a healthy organism perfusion and energy metabolism of the small bowel is impaired by a pneumoperitoneum with carbon dioxide. Under the conditions of a systemic inflammatory response syndrome induced by infusion of endotoxin, the negative effects of the pneumoperitoneum were significantly amplified. Furthermore, we found that the increased intracranial pressure as caused by a head injury was further enhanced during a pneumoperitoneum but not by the alternative method of mechanical wall retraction. The current literature dealing with the effects of a pneumoperitoneum in critically ill patients is still controversial. Our data support the results of those authors who hold the opinion that creating a pneumoperitoneum in patients with acute abdominal problems means an additional serious burden that in single cases may lead to a disaster. As evidence is lacking, the current extension of laparoscopy into the field of intensive care medicine is still a human experiment that must be performed with high responsibility, extensive monitoring, and according to the rules of a clinical study.
Tumor Seeding following Laparoscopy: International Survey
Authors: Paolucci Vittorio , Schaeff Beate , Schneider Muammer , Gutt Carsten
Published: August 2002

The aim of the study was to determine if tumor seeding during laparoscopic surgery for cancer is a rare event or a typical complication of this procedure. Laparoscopic staging and treatment of intraabdominal tumors is increasing in gastroenterology, gynecology, and general surgery. A total of 1052 questionnaires were mailed to surgical department chairmen, members of the German Society of Surgery, Swiss Association for Laparoscopic and Thoracoscopic Surgery, and Austrian Society of Minimal Invasive Surgery asking them to list their department's experience with tumor seeding after laparoscopy for nonapparent or known malignancy. There were 607 (57.7%) surgeons who reported a total of 117,840 laparoscopic cholecystectomies, 409 incidental gallbladder carcinomas, and 412 laparoscopies on patients with colorectal carcinoma. Altogether 109 patients who developed tumor recurrence in connection with laparoscopic surgery have been reported. Port‐site recurrence was identified in 70 of 409 patients (17.1%) with a median of 180 days following laparoscopic cholecystectomy for nonapparent gallbladder carcinoma. In 8 cases (11.5%) a protective plastic bag had been used for gallbladder retrieval. Six patients without port‐site metastases were found to have a diffuse peritoneal carcinomatosis a median of 120 days after cholecystectomy. Of 412 laparoscopies for colorectal cancer, 19 cases (4.6%) of tumor seeding have been reported, 16 of which (3.9%) had documented port‐site and scar recurrences a median of 196 days after laparoscopy. The tumor specimen was intact, and a plastic bag was used for extraction in seven cases. In 14 patients trocar‐site metastases have been reported a median of 70 days after laparoscopy for different nonapparent or known malignancies. The probability of developing abdominal wall metastasis is higher after laparoscopy for cancer than after open surgery. An intact surgical specimen and the use of a plastic retrieval bag do not exclude the risk of port‐site recurrences. These facts and the early appearance of peritoneal carcinosis in a few cases of intraabdominal malignancies seem to confirm a specific laparoscopic risk for intraperitoneal tumor cell seeding and implantation.
New Simple Technique for Hepatic Parenchymal Resection Using a Cavitron Ultrasonic Surgical Aspirator® and Bipolar Cautery Equipped with a Channel for Water Dripping
Authors: Yamamoto Yuzo , Ikai Iwao , Kume Makoto , Sakai Yoshiharu , Yamauchi Akira , Shinohara Hisashi , Morimoto Taisuke , Shimahara Yasuyuki , Yamamoto Masayuki , Yamaoka Yoshio
Published: August 2002

We have developed a new technique to resect hepatic parenchyma without inflow occlusion by using the Cavitron Ultrasonic Surgical Aspirator (CUSA®) and bipolar cautery with a saline irrigation system. The significance of this method in hepatectomy was analyzed in comparison with historical control of hepatectomy using Pringle's maneuver. An ordinary bipolar cautery was remodeled with an infusion line to bring saline droplets down the inner surface of one arm of the tweezers through an opening about 1.5 cm proximal to its tip. The optimal flow rate of saline was approximately one drop per second. The power of bipolar cautery was adjusted to 50 watts. When the tweezer blades were approximated to 1 or 2 mm, saline droplets were directed to the tip of tweezers and could be immediately evaporated. After sonicating parenchymal cells, the tissue of small branches of Glisson's tree or small tributaries of the hepatic vein were coagulated by bipolar cautery. The coagulated cords were then easily cut by scissors. The impact of this technique on ordinary liver resections was evaluated by analyzing the postoperative clinical course in relation to the hepatic functional reserve necessary for major hepatectomy, duration of hepatectomy, and intraoperative blood loss. Hepatic resection without vascular occlusion using this technique could decrease the morbidity in patients who have less hepatic functional reserve. It could also decrease intraoperative blood loss. This new technique effectively decreased the surgical load of the remnant liver during parenchymal resection by avoiding ischemic stress. Consequently it extends the safety limits of major hepatectomy.
Oral Urografin in Postoperative Small Bowel Obstruction
Authors: Chen Shyr‐Chyr , Chang King‐Jen , Lee Po‐Huang , Wang Shih‐Ming , Chen Kai‐Mo , Lin Fang‐Yue
Published: August 2002

The aim of our study was to determine whether Urografin has the potential to offer surgeons a way of differentiating complete from partial small bowel obstruction and whether partial small bowel obstruction can be treated nonoperatively. Altogether 116 patients who had postoperative small bowel obstructions without any toxic signs underwent Urografin studies. Urografin (40 ml) mixed with 40 ml of distilled water was administrated either orally or via nasogastric tube to each patient. Serial plain abdominal radiographs were taken 2, 4, and 8 hours later. A total of 74 patients (63.8%) whose contrast medium reached the colon within the first 8 hours were considered to have partial obstruction and were successfully treated with intravenous hydration and nasogastric decompression. The remaining 42 patients (36.2%) in whom the contrast medium failed to reach the colon within the first 8 hours were regarded as having complete obstruction, and 34 of those patients (81.0%) underwent surgery; 8 (19.0%) received conservative treatment. Adhesion bands with complete bowel obstruction were observed in all 34 patients (100.0%) during laparotomy. Regardless of the presence of an air‐fluid level on a plain abdominal radiograph or abdominal pain, a liquid diet followed by a soft diet could be given to those patients whose Urografin emptied into the colon. All the patients with partial bowel obstruction were treated successfully with nonoperative methods. The presence of Urografin in the colon within 8 hours of ingestion as an indicator for nonoperative treatment had a sensitivity of 90.2%, a specificity of 100%, and an accuracy of 93.1%. Urografin, a safe and reliable water‐soluble contrast medium, can be used to differentiate partial intestinal obstruction from complete intestinal obstruction. Early oral intake was found to be a major advantage of Urografin use in this study, and the potential of Urografin use to shorten the period of conservative treatment for postoperative small bowel obstruction needs further investigation.
Prognostic Factors in Patients with Locally Advanced Rectal Adenocarcinoma Treated with Preoperative Radiotherapy and Surgery
Authors: Luna‐Pérez Pedro , Trejo‐Valdivia Belém , Labastida Sonia , García‐Alvarado Santiago , Rodríguez Dario F. , Delgado Serafín
Published: August 2002

Preoperative radiation therapy (PRT) prior to potential curative resection for rectal adenocarcinoma is not widely accepted. This report evaluates the prognostic factors affecting local recurrence and 5‐year survival. This is a retrospective study of 214 patients with primary rectal adenocarcinoma treated from January 1986 to December 1994. A PRT dosage of 45 Gy in 20 fractions was administered to patients with clinically tethered or fixed tumors, and 4 to 8 weeks later surgery was performed (group I). Patients with clinically mobile tumors were treated by surgery alone (group II). There were 130 men and 84 women. The median age was 58 years (range 19–85 years). There were 111 patients in group I: 7 patients had no microscopic residual tumor, 80 had Dukes' A and B, and 24 had Dukes' C. There were 103 patients in group II: 70 patients were classified as Dukes' A and B and 33 as Dukes' C. The mean follow‐up of the entire cohort was 62 months (range 2–132 months). Local recurrence was seen in 17% of patients in group I and 35% in group II (p= 0.002). Distant recurrence in patients with metastatic lymph nodes was seen in 79% of group I and in 34% of group II (p= 0.001). The favorable prognostic factors for local control were the administration of PRT and well differentiated cancer. The favorable prognostic factors for survival were age < 50 years and the absence of lymph node metastasis. The administration of PRT diminishes the risk of local recurrence. The presence of metastatic lymph nodes in the postirradiated specimen is an ominous prognostic factor for survival. Therefore such patients should be considered for adjuvant chemotherapy.
Proximal Gastric Vagotomy: Does It Have a Place in the Future Management of Peptic Ulcer?
Authors: Johnson Alan G.
Published: August 2002

Proximal gastric vagotomy (PGV) is a modification of truncal vagotomy, which was introduced by Dragstedt for the treatment of duodenal ulcer (DU) in 1943. It is a technically demanding operation; but when performed by an experienced surgeon, it is safe and gives a cure rate for DU of more than 90%, with minimal side effects. The operation permanently alters the natural history of the disease and may be used for gastric ulcer (GU), with ulcer excision; but it is not as effective. Further adaptations, such as posterior truncal vagotomy with anterior seromyotomy, were introduced to simplify and shorten the operation, but they did not receive wide acceptance. Recently, with the identification of Helicobacter, it was found that DU can also be cured by eliminating the infection. PGV is therefore used electively in patients with persistent DU that is not Helicobacter‐positive or in the few in whom Helicobacter cannot be eliminated. In patients with bleeding or perforated DUs, PGV may be used in conjunction with underrunning the vessel or patching the perforation. However, few surgeons doing emergency peptic ulcer surgery have experience with PGV, so simple suture followed by medical treatment is the safest option. Because elective PGV is now a rare procedure, patients should be referred to a center with special expertise. If Helicobacter becomes resistant to antibiotics in the future, surgery may be needed regularly again, but the technical nuances would have to be relearned.
Risk of Stomach Cancer in Patients with Peptic Ulcer Disease
Authors: Hansson Lars‐Erik
Published: August 2002

The relation between peptic ulcer and stomach cancer has long been disputed, but there is accumulating evidence that gastric ulcer disease is positively associated and duodenal ulcerations negatively associated with the risk of developing stomach cancer. As Helicobacter pylori infection is associated with both types of ulceration and stomach cancer, the varying outcomes of the infection indicate that factors other than the infection must be of importance. At present, there is no convincing evidence that pharmacologic inhibition of acid secretion for treatment of peptic ulcer increases the risk of stomach cancer. However, some recent studies indicate that prolonged treatment with proton pump inhibitors may accelerate the development of atrophic gastritis, a risk factor for stomach cancer, in individuals infected with H. pylori. It has repeatedly been shown that there is an at least twofold increased risk of stomach cancer 15 years after gastric resection for peptic ulcer disease, and that the risk increases with the passage of time. Whether vagotomy has the same risk‐increasing effect is still unclear.