[BCG vaccine immunotherapy after radical operations for lung cancer]. An investigation of immune reactivity to BCG vaccination was performed in 48 patients with lung cancer according to the Mantoux test. It was found that high immune reaction was noted in the group with 5-year survival and course without recurrences, the reaction growing after revaccinations. In patients with 2-year survival the reaction to vaccination was negative or weakly pronounced. A conclusion is made that the immune therapy facilitates improvement of long-term results of surgical treatment of patients with lung cancer.


[A comparative evaluation of the results of traditional and laser stomach resection]. Comparative evaluation of immediate and long-term results of gastric resection was made in 89 patients operated upon by a traditional method and in 69 patients after laser operations. It was found that laser scalpel used in gastric resection gives reliable hemostasis, reduces the intraoperative blood loss and the time of creation of gastroenteric anastomosis. At the same time 2 times greater amount of inflammatory complications of the anastomosis was noted. The cause of the development of anastomosis after laser resection of the stomach is discussed.


[Liver resection in closed injuries].

[Liver resection in closed injuries]. The authors have observed 129 patients with closed injuries of the liver. Resection is thought by the authors to be indicated to patients with vast wounds when there are areas with disturbed blood circulation, in patients with abruptions and crush of portions of the liver. Operations on most patients were performed as atypical resections with transparenchymatous ligation of the vessels and bile ducts. Lethality did not depend on the resection volume but was in direct correlation with the character of associated injuries. After resection of the liver 13 patients of 31 died. Of 98 patients who had ruptures of the liver and were subjected to other operations 47 patients died.


[The physiotherapeutic correction of secondary immunodeficiency in the preoperative period in patients with rheumatic heart defects]. Directed correction of immunity by physiotherapeutic methods was used at the period of preoperative preparing 45 patients who needed the operation for rheumatic valvular disease of the heart. The number of purulent complications during the postoperative period in the group of patients subjected to direct correction of the immune status was found to be less than in the control group.


[A point-scale assessment of the pathological changes in acute complicated cholecystitis]. The use of a present-day method of statistical investigation allowed to present the variety of pathological changes in acute cholecystitis in a parametric form, i.e. as a scale of scores. The scale allows determination of comparative severity of one or another changes characteristic of acute cholecystitis in the concrete patient. The correlation analysis as well as scores assessment show a substantial importance of the functional ability of detoxicating mechanisms for the characteristic of the degree of pathological changes.


[An improvement in the technic for operations in iatrogenic injuries and cicatricial strictures of the hepatic duct and choledochus]. The authors have an experience with operations on 78 patients with scarry strictures and iatrogenic injuries of the hepatocholedochus who had transhepatic drainage of the hepaticodigestive anastomosis after Pradery--Smith and Seipol--Kurianu. The authors have developed a special method of operations. For each step there are special instruments facilitating performance of operations, reducing traumatism and minimizing the amount of postoperative complications.


[The possibility of predicting the hypotensive effect of the surgical treatment of nephrogenic hypertension]. An acute captopril test with a repeated dynamic renoscintigraphy was made in 27 patients with unilateral diseases of the kidneys complicated by nephrogenic hypertension. The above pharmacotest allows the hypotensive effect of operation to be prognosed by the dynamics of the average arterial pressure, plasma renin and blood aldosterone activity as well as by the dynamics of the rate of glomerular filtration and efficient renal plasma flow in the contralateral kidney.


[Injuries to the musculus quadriceps femoris]. The work gives an analysis of results of operative treatment of 63 patients with different injuries of the musculus quadriceps femoris. Problems of diagnostics, surgical strategy and operative technique are discussed depending on the character of injuries (open and closed), their localization and ways of rehabilitation of the patients in the postoperative period.


[CO2 and YAG lasers in the surgery of traumatic lesions of the liver, spleen and kidney]. CO2 and YAG [correction of AIG] lasers were used in 86 patients with traumas of the liver, spleen, kidney. Methods of laser coagulation and indications for its use were developed and allowed to considerably reduce lethality in the surgery of closed injuries of the liver, to preserve the spleen in 46% of the patients, and to carry out treatment of kidney wounds with high quality. Laser coagulation is an effective method to arrest the parenchymal hemorrhage which results in substantially higher quality of the operations performed.


[The regional contractile function of the normal right ventricle and in congenital heart defects]. The authors have developed a method for studying the regional contractile function of the right ventricle (RV) performed by cineangiocardiogram in two projections. It allowed an analysis of the regional contractile function of the RV to be performed in patients with hypervolemic exercise of RV and hyperkinetic load to RV, and to compare them with normal conditions. It was established that the regional contractile function of the input and output parts are not equivalent and that there are reliable differences in changes of contractility of the output part of the RV in patients with stenosis of the pulmonary artery as compared with normal state.


[Difficulties in diagnosing a hernia of the esophageal hiatus in children]. Difficulties and errors in diagnosing the disease are described on the basis of an analysis of 79 observations of different kinds of hiatal hernias. A scheme of examinations of the children is recommended.


[Mesenteric lymphangiomas of the small intestine in children]. The authors have made an analysis of 15 cases with lymphangiomas of the small intestine mesentery in children aged from 3 days up to 12 years. Attention is called to problems in diagnosing this pathology. The optimum variant of examination is presented which allow the correct diagnosis to be made. All the children were operated upon. The method was chosen depending on localization of the cyst and on the patient's age. Good results of treatment were obtained.


[Endoscopic sclerotherapy in the combined treatment of portal hypertension in children]. The authors have performed 28 sessions of endoscopic sclerotherapy of dilated esophagus veins in children. The 70% ethyl alcohol was used. Six sessions were carried out in patients with gastroesophageal hemorrhage. In 22 patients the sclerotherapy was carried on according to plan. The fiber gastroscope with a standard injector was used. A conclusion is made of expediency of using endoscopic sclerotherapy in complex treatment of portal hypertension in children.


[Optimization of the therapeutic procedure in subcutaneous injuries to the Achilles tendon]. Curative tactics in operative treatment of not fresh and longstanding injuries of the Achilles tendon with biocompatible artificial materials are discussed. Expediency of performing surgical interventions under conditions of conductive anesthesia is noted when using a Z-shaped access. An original operative technique is described. In 16 patients with subcutaneous ruptures of the Achilles tendon who were treated by the proposed curative method the supporting ability of the foot was recovered within 2-3 months after operation.


[The treatment of trans- and epicondylar fractures of the humerus in children with a compression-distraction-derotation apparatus]. An analysis of results of treatment of 87 children enabled the authors to recommend using a compression-distraction-derotation apparatus. Good results were noted in 63 patients, satisfactory ones in 23 patients. Unsatisfactory result was noted in 1 patient.


[Intravenous laser irradiation of the blood in severe forms of chronic venous insufficiency]. Based on an analysis of results of treatment of 86 patients the authors have shown that the intravenous laser irradiation of blood results in hypocoagulation, lower hematocrit index. In 52 patients good results of treatment were obtained, in 26 patients results were satisfactory. No complications were noted.


[The efficacy of the ultraviolet irradiation of the blood in the combined treatment of erysipelatous inflammation]. An experience with treatment of 1527 patients with different forms of erysipelas is analyzed. Under study were clinical data, nonspecific resistance parameters, peripheral and central hemodynamics and viscosity of blood. Ultraviolet irradiation of blood is an effective method of pathogenetical treatment of erysipelas which results in rapid arrest of local and general symptoms of the disease. The number of complications and recurrences was reduced.


[The role of immunological studies in the diagnosis of bacterial endocarditis in patients with congenital heart defects]. An examination of 54 patients with congenital heart disease has established an increased production of immunoglobulins, M class in particular, enhanced formation of circulating immune complexes, insufficient phagocytic activity of neutrophils, decreased content of T-lymphocytes. Patients with bacterial endocarditis were found to have more pronounced changes in immune reactivity. Reliable differences were found when comparing indices of nitroblue tetrazolium test in patients with an infectious process and without it.


[The role of ultrasonic dopplerography of the renal arteries in the combined examination and treatment of patients with vasorenal hypertension]. The ultrasonic dopplerography of renal arteries (USDG) was used in 218 patients with arterial hypertension, 28 them having considerably decreased linear circulation rate. The findings of USDG of the renal arteries are highly informative (93.9i%), being inferior only to the informative value of contrast roentgenoangiography.


[The basic indices of cellular immunity in surgery for rheumatic heart defects]. Distinct changes of basic indicators of cellular immunity were diagnosed in 157 patients with rheumatic heart disease which needed surgical correction. A classification of disturbances of cellular immunity is proposed. A definite correlation between the degree of cellular immunity disturbances and basic clinical parameters of the rheumatic heart disease was followed as well as the influence of the immunological changes on the prognosis of operation results and the outcome of the disease.


[Repeated operations after reconstructive interventions on the aortofemoral segment]. At the department of vascular surgery of the Novgorod regional hospital 455 reconstructive operations for atherosclerotic occlusions in the aorto-femoral segment were performed at the period from 1984 to 1991. Specific complications requiring reconstructive reoperations took place in 92 patients (20.2%), 21 patients (4.6%) having earlier specific complications and 71 patients (15.6%)--late ones. Causes of the appearance of the specific complications are analyzed, the methods of treatment of such patients are recommended. Lethality after reoperations for late complications made up 9.8%, amputation of the extremity was performed in 14.1% of the patients. The positive result of the reoperations with a regress of ischemia and the preserved function of the extremity was noted in 76.1% of the patients.


[The immediate and late results of Billroth-I gastric resection with the application of the single-row suture]. An experience with gastric resections in 942 patients with ulcer disease of the duodenum is presented. Billroth-I resection was used in 760 patients (81%). The posterior wall of the gastroduodenal anastomosis was formed with the help of a one-row blanket catgut suture in 118 of these patients. Complications at the postoperative period were noted in 10 patients (8.5%). No lethal outcomes followed. Good long-term results in patients with Billroth-I resection of the stomach with a one-row suture of the posterior wall of the gastroduodenal anastomosis were noted in 98.6% of the cases.


[Aneurysms of the thoracic aorta detected in patients with aortic coarctation before surgery and in the late period afterwards]. At the period from 1964 to 1989 operations were performed on 454 patients with coarctation of the aorta. Long-term results were analyzed in 300 patients operated upon. The cause of the formation of false aneurysms in the area of an anastomosis at later terms after operation was in most cases the partial prosthetic detachment due to cutting or resorption of sutures, inflammatory destruction in the area of anastomosis. All the patients subjected to operation for aorta coarctation, alloprosthesing in particular, need the dynamic follow-up and examination.


[Subtotal Billroth-I gastric resection in cancer. The technic and the immediate results]. An analysis of literature data and results of operations on 150 patients with gastric cancer enabled the authors to make a conclusion that subtotal Billroth-I resection of the stomach with correct indications is more preferable as compared with the Billroth-II method. A contraindication for it is considered to be not technical problems of putting gastroduodenal anastomosis but spread of the tumor to the pylorus and duodenum. Based on an examination of preparations of the lymph nodes taken during extended lymphadenectomy performed in 34 patients the authors made a conclusion of its necessity in patients with not large primary tumors as well.


[Echography-guided percutaneous cholangiography in the diagnosis of the causes of mechanical jaundice]. Under analysis were results of percutaneous cholangiography under the ultrasonic control in 69 patients with jaundice. The investigation in question allowed the cause of the jaundice to be found in 66 of 69 cases. In 3 patients the examination proved to be not informative since only the gallbladder was filled with the contrast. The detection limit of the method was 95.6%. A complication in the form of bile discharge at the site of liver puncture was observed in 2 patients.


[The diagnosis of lymphedema of the lower extremities and an assessment of the surgical results using computed tomography]. Under study were potentialities of computed tomography (CT) in diagnostics and differential diagnostics of lymphedema of lower extremities by comparing findings of CT in 40 patients (11 men and 29 women) with the I-IV degree lymphedemas. It was shown that data of CT were thought to be an objective basis for the estimation of spreading the injury and efficiency of the operative procedures.


[The contraindications, indications and conditions for completing choledochotomy with a precision suture of the choledochus]. Based on literature and personal data (146 choledochotomies) the authors have developed a scheme of contraindications, indications and conditions for using the precision suture of the choledochus in patients with benign lesions of bile ducts. For this method of completing choledochotomy to be realized, the indications should be correlated with the complex of conditions. To most important conditions the authors refer the possibility to use the precision technique as well as the delicate highly informative diagnostic and curative endocholedochal manipulations. The choice of the variant of the precision suture of the choledochus is influenced by a group of conditions responsible for the state of the hepatocholedochus. Based on the proposed scheme the precision suture was used in 62 patients. No complications resulting from using this method of completing choledochotomy were noted.


[Wound infection].

[Wound infection]. A present-day view on the problem of wound infection is analyzed with special reference to recent data. Active surgical approach in combination with many-component antibacterial and correcting treatment still remains important in prevention and treatment of wound infection.


[Gunshot wounds of the chest].

[Gunshot wounds of the chest]. A generalized experience with treatment of more than 1000 patients with wounds of the chest is presented. Bullet wounds prevailed. Methods of treatment of penetrating wounds of the chest are described.


[The sequelae and late results of surgical treatment in wounds of the heart and pericardium]. An examination of 109 patients after surgical treatment of wounds of the heart and pericardium were performed at late terms after treatment. It was found that good results had 53.2% of the patients, 12.8% of the patients had limited working capacity, 4.6% of the patients became invalids. Satisfactory and bad outcomes resulted from the development of consequences of the trauma and operation. Terms of the recovery of working capacity depended on the severity of the trauma, timeliness of treatment of complications, state of the functional reserves and adequate regimen of motor activity.


[The surgical procedure in gunshot wounds of the liver]. An experience with treatment of 133 patients with gunshot wounds of the liver has shown that the optimum method of completing the surgical treatment of the gunshot wound of the liver is tamponade of it with the omentum on the pedicle and drainage of the subhepatic space, for extensive injuries of the liver the external decompression of bile ducts is necessary. Reinfusion of blood is safe in patients with injuries of the liver and is considered to be the most effective method to fill up the blood loss. The use of radionuclide methods and rheohepatography can give a sufficiently objective picture of the functional state of the liver in dynamics of the wound process. Long-term results of treatment of gunshot wounds of the liver are not considered to be satisfactory.


[The late results of treating kidney ruptures]. Under analysis are long-term results of the conservative treatment of 36 patients with ruptures of the kidney. It was found that sufficient information of primary structural injuries of the organ can be obtained with the help of such diagnostic methods as angiography, computed tomography added to traditional methods of examination which allows to make the treatment individualized for each patient. Conservative methods of treatment can be used in patients with superficial and deep ruptures and inconsiderable injuries of parenchyma. For deep ruptures with extensive injuries of the parenchyma early and organ-preserving, if possible, operations must be performed.


[The diagnosis and treatment of kidney ruptures]. An experience with diagnostics and treatment of 21 patients with injuries of the kidney is presented. Possible ways to determine the kind and localization of the rupture of the kidney with the help of computed tomography are described.


[The plastic repair of defects in the long tubular bones using vascularized bone autografts]. Free vascularized osseous autoplasty is an effective method of treatment of defects of long tubular bones and false joints. The microsurgical auto-osseous transplants are the source of osteogenesis in the recipient area since they are not objected to resorption and rearrangement and preserving its primary structure.


Congenital pulmonary alveolar proteinosis: failure of treatment with extracorporeal life support. Pulmonary alveolar proteinosis, a rare disease in neonates, is characterized by the accumulation of insoluble amorphous material within the alveoli. We describe two pairs of siblings with pulmonary alveolar proteinosis in two otherwise unaffected families. All four patients were term neonates in whom severe pulmonary failure developed within hours after birth; three had mature lung profiles. Radiographic lung markings were characterized by an early granular pattern followed by lung opacification. All patients were treated with extracorporeal life support for periods of 212 to 381 hours, but none survived. Life spans ranged from 16 to 190 days. We speculate that pulmonary alveolar proteinosis in neonates results from a genetic defect in surfactant processing that may not be amenable to conventional or unconventional therapies, including extracorporeal life support.


Toxoplasma colitis in the acquired immunodeficiency syndrome. In patients with acquired immunodeficiency syndrome (AIDS), toxoplasmosis almost exclusively involves the central nervous system (CNS), and extra-CNS organ infection is rare. We report a case of Toxoplasma gondii colitis in a patient with AIDS characterized by the following: 1) onset of diarrhea was simultaneous with disseminated toxoplasmosis; 2) T. gondii was found in colonic biopsies, whereas other infectious causes of diarrhea had been ruled out; 3) diarrhea was cured by anti-Toxoplasma therapy.


[The surgical treatment of closed injuries and strictures of the urethra]. Under analysis were results of operative treatment of 291 patients aged from 7 to 76 years with traumas and strictures of the urethra at the period from 1970 to 1990. Totally 325 operations have been performed. The primary suture of the urethra was successfully used in 8 of 36 patients with trauma of the urethra. Tunneling of the urethra for its strictures which was widely used in the clinic up to 1980 gave 46.2% of recurrences during the first 3 months after operation. It required the surgical methods to be changed. During the recent 11 years 161 operative interventions have been performed: 103 (64.0%) resections of the urethra, 45 (28.0%) internal optical urethrotomies and transurethral resections (TUR) of scarry tissues, 7 (4.3%) epidermoplasties of the urethra and 6 (3.7%) tunnelings of the urethra. The amount of recurrences dropped up to 13.7%. The primary suture of the urethra is necessary for penetrating ruptures of the urethra if the patient's state allowed. Resection of the urethra must be the operation of choice in patients with strictures and obliteration of the urethra. The endoscopic methods of treatment (urethrotomy and TUR) are indicated for short strictures and scarry deformity of the posterior urethra after operations on the prostate. The epidermoplasty is expedient for lengthy strictures.


Clinical presentation and outcome of listeriosis in patients with and without immunosuppressive therapy. Seventy-four cases of systemic listeriosis occurring from 1971 to 1989 in the greater Helsinki area in Finland are reviewed with a special interest in the effect of preceding immunosuppressive therapy on the clinical presentation. Of these patients, 66% had an underlying disease, most commonly malignancy, diabetes mellitus, or renal transplantation, and 43% had received immunosuppressive therapy within 1 week before onset of listeriosis. Bacteremia and central nervous system infections (both in 43% of cases) were the most common clinical entities. The percentage of patients with meningitis was not greater among immunosuppressed patients (13/32, 41%) than among patients with underlying diseases not treated with immunosuppressive agents (9/16, 56%) or among previously healthy nonpregnant hosts (7/11, 64%). Immunosuppressed patients did not die more frequently than did those with underlying diseases not treated with immunosuppressive therapy (case fatality rate, 29% vs. 38%, respectively). However, all previously healthy non-neonatal patients survived, whereas 32% (15/47) of those with any kind of underlying disease succumbed.


A population-based study of microinvasive disease of the cervix--a colposcopic and cytologic analysis. A study of 61 cases of microinvasion of the cervix occurring in our population between 1980 and 1989 is reported. The mean age of the women was 39 years, compared with 30 years for cervical intraepithelial grade 3 (CIN III) and 47 years for frank invasion, respectively. Colposcopic suspicion of microinvasion was present in 31 cases, giving a sensitivity of colposcopic diagnosis of 50% and a specificity of 91%. In 21 cases (34%) there was no suspicion either cytologically or colposcopically of microinvasion. Colposcopy predicted microinvasion more accurately with increasing depth of invasion. In 28 women there had been previous smears within 10 years available for review. The time interval between the first abnormal smear and the histological diagnosis ranged from 1 month to 9.8 years (mean, 4 years).


Joubert syndrome: a review.

Joubert syndrome: a review. We review 72 previously reported and 29 new patients with the possible diagnosis of Joubert syndrome. We define diagnostic criteria for this syndrome and present the data available in 94 patients that fulfill our criteria. We present the data regarding the clinical, neuroradiological, and ophthalmological manifestations and the prognosis of these 94 patients. We propose a classification of the patients with this diagnosis in 2 groups: those with retinal dystrophy and those without. Retinal dystrophy runs true in families and was never absent when renal cysts were reported.


Need-for-treatment criteria for involuntary civil commitment: impact in practice. There has been considerable discussion in the literature on the differences between criteria for involuntary commitment that are based on dangerousness and criteria based on need for treatment. A number of states have adopted clinical criteria, and other state legislatures are actively considering them. Some libertarians argue that dangerousness is constitutionally required if a person is to undergo the loss of liberty involved in commitment. Citing widely publicized data from the state of Washington, they predict that a return to clinical criteria would result in a deluge of inappropriate commitments. Some clinicians counter that use of clinical criteria would result in selection of a much more appropriate clinical population and point to research indicating that strict observation of the need-for-treatment provisions of the APA model commitment statute would actually decrease the number of commitments. The author examines state hospital admission and census data from eight states that added need-for-treatment criteria to their commitment codes between 1975 and 1990 and argues that the data indicate that there is little reason to believe that such changes would result in the deluge of admissions predicted by the critics.


Sinus histiocytosis with massive lymphoadenopathy (Rosai-Dorfman disease). Clinico-pathological analysis of a paediatric case. Histochemical and immunohistochemical studies performed in only a few cases of sinus histiocytosis with massive lymphoadenopathy (SHML) indicated that SHML cells belong to the macrophage--histiocyte system, though their exact origin is still uncertain. We analyzed the morphological, antigenic and enzymatic characteristics of the histiocyte-like cells in one paediatric case of SHML (also named Rosai-Dorfman disease). The SHML cells expressed the S-100 protein, lectins concanavalin A, peanut agglutinin and monocyte-macrophage related antigens CD 11c, CD 14, CD 33, CD 68 and LN 5. Reactivity with other anti-macrophage antibodies (MAC387, lysozyme, alpha-1 anti-chymotrypsin) was variable. The CD1a antigen was present only in scattered cells, whereas HLA-DR and the HLA-DR associated invariant chain were absent. Cytochemistry demonstrated an intense activity of acid phosphatase and non specific esterase of SHML cells. A large amount of medium sized mononuclear cells were located in the sinuses and intersinusoidal tissue. Our findings suggest that SHML cells have intermediate features between phagocytes and Langerhans cells/interdigitating reticulum cells. The heterogeneity of marker expression on SHML cells might be related to the local content of factors (e.g., cytokines), capable of modulating the phenotype of monocyted and derived cells.


Palindromic rheumatism: part of or apart from the spectrum of rheumatoid arthritis. Palindromic rheumatism (PR), originally described in 1944, is characterized by recurrent episodes of mostly oligoarticular arthritis with peri- and para-articular tissue inflammation, leaving no residual clinical and radiographic changes. It appears that palindromic syndrome is a heterogeneous entity, encompassing other inflammatory conditions at early stages of their evolution, and whose relationship with rheumatoid arthritis (RA) is evident but still unclear. Evolution of up to 50% of these cases into otherwise typical RA, commonly accompanied by the conversion to rheumatoid factor seropositivity, the frequent occurrence of nodules, the reported response to RA treatment, and the observation of familial aggregation of the two conditions suggest that PR is part of the spectrum, or a stage in the evolution of RA. However, justification for the distinct existence of PR comes from reports that identify well-defined and recognizable clinical manifestations such as descriptions of the acute attacks, the frequent peri-articular manifestations, the absence of bone and cartilage destruction even after extended periods of time, and the generally good long-term prognosis. Immunogenetic studies with HLA-DR phenotyping and the absence of female preponderance tend to add additional support for the separate identity of PR.


Antiphospholipid antibodies cross-reacting with erythrocyte membranes. A case report. We describe a patient with primary antiphospholipid syndrome (PAPS) and haemolytic anemia with cryoagglutinins, in whom antibodies eluted from red blood cells (RBC) displayed anti-cardiolipin (CL) binding activity. This activity was confined to the IgG isotype and was directed to the negatively-charged phospholipids only. In addition, the patient's IgG fraction displayed a higher binding to RBC in comparison to normal control IgG and this reactivity was inhibited after absorption of the anti-CL activity with CL-micelles. These findings further sustain the association between antiphospholipid antibodies (APA) and Coombs' positivity with or without haemolytic anemia and suggest that APA could be at least in part responsible for anti-RBC activity.


Pseudomelanosis duodeni and the controversial pigment--a clinical study of 4 cases. Despite the common practice of upper gastrointestinal endoscopy, the unique phenomenon of punctate black pigmentation of the duodenal mucosa, now known as pseudomelanosis duodeni, still remains a rare entity. Four patients with normal renal function at presentation were found to have this pigment on endoscopy. One developed renal failure subsequently but the pigmentation persisted and this observation has not been reported before. Histochemical and ultrastructural studies were made. It is postulated that the pigment is heterogenous and represents a form of stored iron. Anti-hypertensive drugs may have a role in the causation of the pigmentation formation.


Ectodermal dysplasias associated with clefting: significance of scalp dermatitis. Several clinical syndromes are characterized by ectodermal dysplasia (ED) in association with clefting of the lip and/or palate. The three most commonly recognized entities are (1) the EEC syndrome (ectodermal dysplasia, ectrodactyly, cleft lip/palate); (2) the Rapp-Hodgkin syndrome with ectodermal dysplasia, cleft lip/palate, and mid facial hypoplasia; and (3) the Hay-Wells or AEC syndrome (ankyloblepharon, ectodermal defects, cleft lip/palate). The clinical characteristics of these entities as well as several less common syndromes are reviewed and summarized. The presence of scalp dermatitis in patients with the AEC syndrome and less often the Rapp-Hodgkin syndrome is emphasized.


Junctura anatomy.

Junctura anatomy. Detailed dissection of 240 cadaver hands was undertaken, with particular attention to the connections between the extensor tendons. Three types of junctura were clearly identified: fascia, ligament, and tendon. Each hand had three juncturae. The most frequent presentation was for the three juncturae to be fascia-ligament-tendon, from radial to ulnar. A few aberrations of extensor tendon anatomy were also discovered, which might affect their use in tendon transfers.


Experience with 205 procedures of transcatheter closure of ductus arteriosus in 182 patients, with special reference to residual shunts and long-term follow-up. Between December 1987 and September 1991, 205 nonsurgical procedures for closure of patent ductus arteriosus were attempted in 182 infants, children, and young adults with use of the Rashkind double-disc ductal occluding device. The patients' ages ranged from 8 months to 26 years (median 5 years) with 18 aged less than 2 years. Their weights ranged from 7.4 to 55 kg (median 16 kg); in patients aged less than 2 years the mean weight was 10.2 +/- 1.5 kg, and in those aged more than 2 years mean weight was 19.5 +/- 9.6 kg. Successful occluder device implantation was achieved in 174 patients (96%) at the initial attempt. Device embolization to a pulmonary artery occurred in six patients; two of these devices were retrieved by grabber catheter and four at operation, all without adverse sequelae; there were two other technical failures. Follow-up studies included two-dimensional Doppler echocardiography with color flow mapping. The 6-week follow-up study revealed a small residual shunt in 27% (46/169) of patients. At the 6-month follow-up study, 22% (37/167) of the patients had a small residual shunt; this prevalence was 17% (24/145) in ducts with a narrowest diameter of less than 6 mm, and 59% (13/22) in ducts greater than 6 mm. Immediately after implantation of the occluder device and throughout the follow-up period, the mean narrowest ductal diameter of ducts with residual shunts was significantly larger than that of ducts in which total occlusion was achieved (range of p < 0.01 to 0.001). The use of the 17 mm occluder device, however, was significantly associated with an increased prevalence of residual shunt only immediately after implantation (p < 0.01). Implantation of a second occluder device was attempted in 21 patients with residual patent ductus together with a continuous murmur at the 6-month follow-up; embolization of one device to a pulmonary artery occurred immediately but it was retrieved by grabber catheter and another device was successfully implanted 1 month later. All 21 patients were seen for 6-month follow-up study, when only one (5%) had a small residual shunt that was subsequently successfully closed by the insertion of a third occluder device. Thus, after successful implantation of one or more occluder devices, complete closure of the ductus was achieved in 90% of all patients seen to date for their 6-month follow-up study. One patient had limited hemolysis. The maximum follow-up period is 50 months. These results confirm the efficacy, with low morbidity and no mortality, of the use of the Rashkind occluder device for nonsurgical closure of patent ductus arteriosus, especially in those with smaller diameters.


Raised plasma endothelin during acute migraine attack. Endothelins are the most potent vasoconstrictor peptides known. Plasma endothelin (ET-1) concentrations were measured in eight migraine patients (mean age 44.5 years), two during an acute migraine attack with aura and six during an attack without aura. The mean ET-1 values were elevated in all migraine patients above the range of normal subjects, and were 10.6 (range 6.0-16.0) pg/ml in migraine patients and 3.8 (range 0.7-5.8) pg/ml in controls. We hypothesize that ET-1 may constrict cerebral vessels during the initial stage of the migraine attack.


Production and characterization of monoclonal antibodies to human Pneumocystis carinii for the diagnosis of P. carinii pneumonia. Monoclonal antibodies against human Pneumocystis carinii were produced by fusion of myeloma cells (X63-AG8.653) with splenocytes from Biozzi mice that had been immunized against P. carinii cysts isolated from infected human lung. The aim of this study was to evaluate the usefulness of these monoclonal antibodies for the diagnosis of P. carinii pneumonia by indirect immunofluorescence in comparison with a modified silver stain method and commercial kits. One hundred fifty-seven specimens from 87 patients, infected or non-infected with human immunodeficiency virus, were examined for the presence of P. carinii. Specimens were either induced sputum samples or bronchoalveolar lavage fluids. Indirect immunofluorescence was performed with six stable clones obtained by limiting dilution. Four of the monoclonal antibodies were IgG1 isotypes, one was an IgG3 and one was an IgM. Their isoelectric points varied from 6.5 to 8.3. Tests were also performed with silver methenamine staining and with two commercially available monoclonal antibodies (Monofluo kit from Diagnostics Pasteur and MAb from Dako). The 6 antibodies all recognized P. carinii cysts in indirect immunofluorescence. No cross reactivity was observed with yeast or host cells. P. carinii antigens could not be identified with western immunoblotting suggesting that the monoclonal antibodies recognized native antigens. This result was confirmed by dot blot analysis. Spots were observed with native but not with denatured antigens. Inhibition studies showed that these 6 antibodies recognized the same or overlapping sites. The sensitivities of detection of P. carinii in sputum were 87% by silver stain and from 93.5 to 96.7% by immunofluorescence. The sensitivities of detection in bronchoalveolar lavage were 67.3% by silver stain and from 75.7% to 76.8% by immunofluorescence. Immunofluorescence was more sensitive than silver staining and the best results were obtained with E5-8 and A8-13 monoclonal antibodies and with Monofluo kit.


Detection of silent arteriosclerotic lesions by intra-arterial ultrasonography. The aim of this study was to detect arteriosclerotic changes in the arterial wall at a preclinical stage. That is at a moment when these arteriosclerotic lesions are still fully asymptomatic and when the usual non-invasive vascular investigation techniques do not show any abnormalities. Fifty-six patients with one or more critical stenoses of the coronary arteries, but with a completely normal peripheral vascular examination, were submitted to intravascular ultrasonography of the peripheral arterial system following coronary arteriography. Sonicath Ultrasound catheters were used and images were created with a Diasonics Imaging System. Although these 56 patients, after a profound noninvasive investigation, were classified as having perfectly normal peripheral arteries, we found severe arteriosclerotic wall abnormalities of the abdominal aorta and/or the iliac arterial system in 5% of the subjects. In addition, this exploration technique was used to evaluate the nature and the structure of the registered degenerative arteriosclerotic lesions. Intra-arterial ultrasonography obviously is a very sensitive investigation method which allows tracing arteriosclerotic changes of the arterial wall in a very early preclinical stage. The external ultrasound exploration techniques still have several important limitations, which, of course, do not hinder the intravascular application. The remaining disadvantage of the intra-arterial ultrasonography is however its invasive character.


Relationships among gas exchange, spirometry and symptoms in asthma. The severity of asthma is usually evaluated by clinical examination and spirometry. In a small study of asthmatics considerable ventilation/perfusion (VA/Q) inequality was found, however, despite essentially normal flow rates. These findings prompted the current study. We prospectively examined symptoms, spirometry and VA/Q inequality in 26 patients with chronic, symptomatic asthma once a week for 9 consecutive weeks. VA/Q measurements were made using a less invasive approach of the multiple inert gas elimination technique and symptoms were scored. Correlation coefficients between indices for VA/Q inequality (log SDQ), spirometry (FEV1.0/VC, MEF25) and symptom scores were only in the range 0.24-0.29. We conclude that even at the individual level, symptoms, spirometry and VA/Q inequality are so poorly correlated that one cannot evaluate any of these aspects of asthma without measuring each. The data support the notion that spirometric and gas exchange abnormalities in asthma are caused by different pathophysiologic events.


Parathyroid function and bone metabolism in children with beta thalassaemia major: effects of sex steroid treatment. Data on parathyroid function in patients with homozygous beta-thalassaemia are discordant. Moreover, there is no report on the effects of sexual steroid treatment on bone metabolism in these patients. Serum parathyroid hormone (PTH), calcitonin (CT) and osteocalcin (GLA protein) levels were measured in 121 patients. Thirty-three prepubertal subjects were treated for six months with sexual steroids. Primary hypoparathyroidism was present in 3.3% of the patients. Osteocalcin levels were found to be lower in thalassaemic subjects than in controls, whereas CT values were similar. No effects of sexual steroid administration on plasmatic levels of osteocalcin were observed.


Progressive cognitive disorders due to focal cortical atrophy. Aphasia is a common feature of dementia of the Alzheimer type (DAT) in association with behavioural change and other cognitive abnormalities. The clinical syndrome of primary progressive aphasia corresponds to the gradual onset and worsening of language dysfunction in patients who otherwise remained independent for many years in daily living activities, insight, judgement and behaviour. Characteristically, memory and other neuropsychological functions are relatively spared. Brain imaging studies indicate cortical atrophy of the left temporal region, and measures of regional cerebral metabolism show localized deficit in the corresponding region. Other progressive focal disorders due to degenerative cortical diseases have been also reported. In each case, localized atrophy and hypometabolism were observed, depending on the nature of the neuropsychological deficit. The underlying histology of focal cortical degeneration is heterogeneous, suggesting that these slowly progressive disorders represent either atypical variants of DAT or Pick's disease, or distinct neurological entities characterized by spongiform change and astrocytic gliosis.


Teicoplanin treatment of alkaline encrusted cystitis due to Corynebacterium group D2. Alkaline-encrusted cystitis (AEC) is a chronic inflammation of the bladder related to the gram-positive bacillus Corynebacterium Group D2. This germ is often resistant to many antibiotics and is particularly difficult to eradicate in the particular setting of AEC. The authors report two observations of AEC treated with the glycopeptid antibiotic teicoplanin, which led to permanent cure of AEC.


Changes of serum neopterin, beta 2-microglobulin and interferon-gamma in patients with chronic hepatitis C treated with interferon-alpha 2b. Treatment with interferon (IFN) reduces viral replication and normalizes aminotransferase levels in a significant percentage of patients with non-A, non-B hepatitis or hepatitis C. Soluble immune activation markers were evaluated in patients with hepatitis. Serum concentrations of soluble immune activation markers neopterin and beta 2-microglobulin (B2M) were compared to endogenous IFN-gamma levels in 17 patients with chronic hepatitis C before, during and after 9-months of treatment with IFN-alpha 2b. Before therapy some patients had increased concentrations of the studied variables. During therapy neopterin and B2M concentrations further increased whereas IFN-gamma decreased. IFN-gamma and neopterin levels were correlated before but not during therapy. The correlations between neopterin and B2M were significant throughout the study. The data indicate that IFN-gamma decreases during treatment and IFN-alpha 2b appears to enhance formation of neopterin and B2M.


Use of pleural fluid C-reactive protein in laboratory diagnosis of pleural effusions. C-reactive protein (CRP) which is synthetized by hepatocytes is an acute phase protein and its serum level increases within 6-9 hours after infection or tissue damage. We investigated its usefulness as a marker of bacterial infection in patients with pleural effusion. We studied the usefulness of pleural fluid C-reactive protein measurement in a population of 72 patients with pleural effusion, by means of an immunoturbidimetric method (Hitachi 717, Boheringer Mannheim). A comparison of serum and pleural effusion C-reactive protein levels in different subgroups of patients with effusion was made. According to preset diagnostic criteria, 19 patient effusions were classified as transudates and the mean (+/- 5 D) pleural fluid CRP [5.3 (+/- 7.8) mg per liter, p < 0.001] were significantly lower than those in the exudate effusions group. Among the 53 patients with exudate effusion, eight were caused by neoplastic disease and the pleural fluid CRP mean (29.3 +/- 16.1 mg per liter, p < 0.001) were significantly lower than those in exudates from parapneumonic effusions (122.7 +/- 48.0 mg per liter, p < 0.001) and than those in the exudates from patients with effusion associated with tuberculosis (67.8 +/- 32.1 mg per liter, p < 0.001). Moreover, all but two transudates had a C-reactive protein lower than 10 mg/L, whereas only two exudates with tuberculosis origin had a C-reactive protein value lower than 10 mg/L, instead all pleural-fluid C-reactive protein from exudates with pneumonia were greater than 10 mg/L. We had found a correlation between the pleural and serum C-reactive protein (r = 0.6884, p < 0.0001). And transudates tended to have lower ratios of pleural to serum CRP (0.26) than exudates (0.55), and malignant effusions had lower ratios (0.37) than pneumonic and tuberculous effusions (0.52, 0.58). Pleural fluid CRP > 10 mg per liter had good sensitivity (82%), specificity (87.5%) and predictive value of positivity (95.5%) in the diagnosis of exudate effusions and higher CRP-levels may prove to be a practical, accurate and rapid method for differentiating pneumonic effusions and effusions associated with tuberculosis from others. It can be considered that quantitative immunoturbidimetric assay of pleural-fluid C-reactive protein will be a useful diagnostic tool to differentiate pleural effusions with bacterial origin from others.


Clinical and laboratory evaluation of CA 19-9 in cirrhotic patients. CA 19-9 is a tumour marker mainly used in the evaluation of digestive system cancers. However, abnormal values can also be found in benign hepatobiliary diseases. The purpose of this study was to evaluate the behaviour of CA 19-9 in cirrhotic patients to try to find the factors associated with increased antigen levels which could have pathogenetic implications. Eighty-five cirrhotic patients underwent a thorough clinical and laboratory evaluation. CA 19-9 levels and a wide range of liver tests were recorded in each case and evaluated with non-parametric statistical analysis. Forty patients (47.1%) had increased levels of CA 19-9 without significant differences between the Child's classes. Several laboratory parameters, especially transaminases, showed a significant correlation with CA 19-9. Patients with increased serum aspartate aminotransferase (ASAT) had higher CA 19-9 levels than those with normal ASAT (p < 0.0001). Multivariate analysis showed that the only independent factors significantly associated to CA 19-9 were ASAT and serum alanine aminotransferase (ALAT). Cirrhotic liver disease must be excluded when an abnormal CA 19-9 serum level is found in a cancer patient before attributing it to the malignancy. Although several mechanisms can be involved, cytolysis and/or regeneration seems to play a role in the increase of CA 19-9 in these patients.


Early detection of diabetic patients at risk of developing degenerative complications using electric gustometry: a five-year follow-up study. Taste impairment has been reported during the course of diabetes. Although a degenerative mechanism has been suspected, the natural history of taste disorders in diabetes remains unknown. The purpose of this study was to describe the five-year evolution of electric gustometry in diabetic patients compared to healthy control subjects and with reference to degenerative complications of the disease. Electrogustometry was studied initially and after 5 years in 73 diabetic out patients and 25 control subjects. None of them had any known cause of taste impairment other than diabetes. Diabetic patients and control subjects did not differ for demographic data and confounding factors. After five years, the electrogustometric threshold (EGT) significantly increased (51 +/- 6 vs 95 +/- 11 microA; p < 0.001), whereas slight changes occurred in control subjects (23 +/- 4 vs 25 +/- 5 microA; NS). Frequency of electric hypogeusia (EGT > or = 100 microA) increased from 11 to 46% in diabetic patients (p < 0.001), but did not vary in control subjects (4%). EGT was not strongly associated with individual factors such as blood pressure, tobacco and alcohol consumption, but correlated with age (p < 0.001). In the diabetic group, higher EGT were observed in patients treated with insulin (p < 0.001). EGT and its changes were associated with degenerative complication (p < 0.001), but neither with metabolic control, nor with duration of diabetes. Using multivariate analyses, the strongest associations were found with peripheral neuropathy and microalbuminuria (28 to 45% of variance explained; p < 0.001). The predictive value of initial hypogeusia on neuropathy at follow-up was 88% for a positive test and 63% for a negative one. These results suggest that the taste nerves transduction function is impaired during the course of diabetes. This impairment is associated with an increased occurrence of degenerative complications, leading to suspect a similar pathophysiological mechanism. Electric gustometry could be an interesting test for early screening for diabetes complications.


Pulmonary tuberculosis in the elderly: diagnostic difficulties. Although numerous case reports and reviews have suggested that pulmonary tuberculosis presents atypically in the elderly, our findings argue for a basic similarity in the radiological pattern between younger and older patients, but a dissimilarity in the clinical presentation. Indeed elderly patients present with more non-specific complaints and have more negative tuberculin skin tests. The combination of these features and confounding (e.g. pseudo-tumoural) aspects of roentgenographic manifestations of pulmonary tuberculosis, even if the localization is apicoposterior, frequently result in more misdiagnosis in elderly patients. It may be suggested that non-specific complaints, even in the presence of normal chest X-ray or of minor lesions in the upper portion of the lung, should prompt careful examination. Tuberculosis should be considered more frequently in the differential diagnosis even when malignancy or other infections seem to be more likely.


Phagocytic dysfunctions: a proposal for classification. The classification presented here is designed to help clinicians make therapeutic and diagnostic decisions. It is based on the modern view of the phagocytosis process as events involving ligand-receptor interaction, transmission of signal through second messenger systems and activation of effector mechanisms leading to specific cell behaviour. According to the classification proposed here, phagocytic disorders can be divided into extracellular disorders which are caused by abnormalities affecting ligands and cellular disorders caused by a pathological disturbance affecting the phagocytic cell. These cellular disorders are subdivided into defects of membrane receptors, defects of enzymatic equipment and defects of subcellular structures. Laboratory investigations of phagocytic cells make it possible to classify inborn, acquired, permanent and transient disorders into these groups. Examples of disorders in each of these groups are presented.


Possible viral implication in the pathogenesis of Sjögren's syndrome. How then could the observed pathological changes in the exocrine glands of patients with pSS be related to the various in vitro and in vivo laboratory findings? To begin with, the fact of inappropriate HLA-D/DR expression in epithelial cells in the absence of any infiltrating T cells or residual IFN-gamma must argue for an exogenous agent such as a virus that modulates the gene expression of epithelial cells. Such inappropriate expression is probably accompanied by the expression of other molecules that promote adhesion of lymphocytes in the proximal endothelium and infiltration into the exocrine gland. The autoimmune response takes place in these very exocrine glands and probably is initiated by the presentation of antigen(s) to the CD4+ T cells by the HLA-D/DR+ epithelial cells. The HLA-D/DR association shown in patients with pSS probably has to do with the antigenic fragments of the autoantigens that these molecules can preferentially bind to. The activated CD4+ T cells can then deliver help to specific B lymphocytes leading them to autoantibody-secreting plasma cells. In addition the extent of polyclonal activation of B lymphocytes and their potential for cytokine secretion and proliferation in vitro, is consistent with the view of virally-induced activation of these cells. The cross-reactivity to retroviral antigens observed in the sera of pSS patients, and the retroviral sequences detected in the salivary glands argue for some type of a retroviral infection of pSS patients in the course of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)


Clinical relevance of herpes simplex virus in the throat of elderly with Salmonella enteritidis gastroenteritis. It is not known whether the presence of Herpes simplex virus in the throat of elderly patients with severe gastroenteritis and pulmonary implications is of clinical relevance. We cultured throat swabs and faeces of elderly patients with (n = 11) and without (n = 12) severe Salmonella gastroenteritis for viruses and bacteria to study the aetiology of respiratory complications. Complement fixation titers for anti-Herpes simplex antibodies in paired sera were also ascertained. Throat swabs of 6 out of 11 elderly patients with severe Salmonella enteritidis gastroenteritis were positive for Herpes simplex virus type 1. However, a four-fold increase of anti-Herpes simplex antibody titers in paired sera could not be demonstrated. None of the 12 throat swabs of elderly patients without gastro enteritis grew Herpes simplex virus. No other pathogens causing pulmonary complications could be demonstrated in throat swabs of the elderly patients. Herpes simplex virus present in the throat of the elderly patients was very probably not the agent responsible for the pulmonary complications and consequently treatment with acyclovir was not indicated. Weakness caused by severe gastroenteritis and the relative T-lymphocyte immunodeficiency state in the elderly probably enhanced the shedding of Herpes simplex virus in the throat of the elderly patients, without clinical relevance.


Evoked potentials: a safe brain-death confirmatory tool? The diagnosis of brain death (BD) relies primarily on prerequisites (clear knowledge of the cause of coma, all remedial procedures proven unsuccessful) and clinical arguments (areactive coma, loss of brainstem reflexes, apnea). Confirmatory tests should be applied whenever any misleading factor (CNS depressant drugs, hypothermia, metabolic disturbances) can interfere with the clinical diagnosis. This paper reviews the different available confirmatory methods (EEG, four-vessel angiography, radioisotopic techniques, intracranial Doppler, evoked potentials). Both the author's own experience and the data from the literature indicate that evoked potentials are actually a safe and rapid BD confirmatory tool that can be performed at the patient's bedside. It is suggested that they be used in association with the clinical examination for all BD-suspected patients, except for children younger than 6 months of age in whom the guidelines of the Task Force for Brain Death in children (1987) are still recommended.


Pseudoaneurysm of the cervical carotid artery with hypoglossal and glossopharyngeal nerve paralysis. We report a case of a pseudoaneurysm of the internal carotid artery with associated hypoglossal and glossopharyngeal nerve paralysis. Correlative findings with magnetic resonance imagery and arteriography are described.


Alcohol: an underscored risk factor for diabetes mellitus. To investigate the link between alcohol consumption and glycoregulation. Cross-sectional study during the annual occupational health check-up at the work site, concerning 7402 workers, excluding known diabetic persons and pregnant women. Alcohol consumption was recorded as the number of glasses of alcoholic beverage per day as stated by the subjects. A proxy for the glycoregulation was the level of capillary blood glucose measured with a reflectance meter (Reflolux) at the time of the visit. The association of alcohol consumption with impaired glycoregulation was assessed by multivariate analysis including potential confounders. Mean capillary blood glucose increased with increasing alcohol consumption, in both men and women. This association remained significant (p < 0.001) after adjustment for risk factors (multiple linear regression). Among 366 subjects with a fasting glycaemia or an oral glucose tolerance test, 26 were diabetic. Alcohol consumption was found independently associated by logistic regression with diabetes mellitus. Alcohol consumption might be a target for primary and secondary prevention of impaired glycoregulation and diabetes mellitus.


Massive haemorrhage from rupture of a pancreatic pseudocyst after pentamidine-associated pancreatitis. A 40 year-old man with the acquired immunodeficiency syndrome who was treated with intravenous pentamidine suffered a massive spontaneous haemorrhage caused by rupture of a pancreatic pseudocyst after pentamidine-induced pancreatitis. The patient previously presented symptomatic hypoglycaemia, severe nephrotoxicity and hyperkalaemia, while not receiving any other drug but pentamidine. This is the first case reported of such a complication of pentamidine induced pancreatitis, and one of the few cases reported of the latter adverse event.


Androgen treatment of middle-aged, obese men: effects on metabolism, muscle and adipose tissues. This pilot investigation was conducted to explore the relationship between androgens and glucose tolerance in obese men and to select an optimal mode for androgen treatment. For exploratory purposes, testosterone (T) or dihydrotestosterone (DHT) were given in different doses and preparations for different periods of time to obese, middle-aged men. The administration forms were selected in order to by-pass the liver. In the first two studies T was given as a single intramuscular injection of 250 or 500 mg and the results evaluated after 1 week. In two subsequent studies testosterone was administered in moderate doses either as oral T undecanoate or a T and DHT in preparations applied on the skin for transdermal absorption for 6 weeks and 3 months respectively. Before and after treatment the following examinations were performed: glucose tolerance tests with insulin determinations or euglycemic clamps at submaximal insulin levels. Anthropometric measurements including the waist/hip circumference ratio and estimations of body fat and lean body mass (from measurements of whole body potassium content) were performed. Plasma triglyceride and cholesterol concentrations, liver function tests and blood pressure were followed. Physical examination including the prostate was performed before and after study. Muscle function, glycogen synthase and morphology were examined in the 3-month study. Administration of T was followed by moderate increases of circulating T concentrations in all studies, except after injection of 500 mg, where large increases were seen. Follicle stimulating hormone and luteinizing hormone levels decreased consistently. Injection of 500 mg T resulted in a decreased glucose tolerance. In the other treatment groups, plasma insulin decreased or glucose disappearance rate increased in clamp measurements, suggesting improved insulin sensitivity. This was most pronounced in men with relative hypogonadism from the outset. In the study of 3 months duration, a decrease in the waist/hip ratio, without a change in body fat mass, was also seen. Plasma lipids, liver function tests and blood pressure did not change. Muscle strength, the fractional velocity of glycogen synthase as well as the percentage and diameter of type IIB fibres increased after T treatment. No adverse effects were seen. 17 -beta oestradiol concentrations were unaltered and DHT administration was less effective than T, suggesting that T rather than derivatives of this hormone was mainly responsible for the effects observed. The results suggest that T administration to middle-aged, obese man may have beneficial effects.


Non-Hodgkin's lymphoma associated with primary Sjögren's syndrome. To evaluate the prevalence, the incidence and clinical presentation of non-Hodgkin's lymphoma associated with primary Sjögren's syndrome. Sixty-two patients with primary Sjögren's syndrome were analyzed retrospectively in an open investigation. Of 62 patients with primary Sjögren's syndrome, 4 of them (6.4%) developed non-Hodgkin's lymphoma (6.9 cases per 1000 per year). All of them were women. Non-Hodgkin's lymphoma always developed after the onset of primary Sjögren's syndrome with a time interval ranging from 3 to 27 years. Pathological findings showed two diffused mixed small and large cell cleaved lymphomas and two diffused large cell cleaved lymphomas. Three cases had extra-nodular localizations. All of these 4 patients are still alive and in complete remission 2 to 8 years after the diagnosis of non-Hodgkin's lymphoma. This study confirms the association of non-Hodgkin's lymphoma in primary Sjögren's syndrome. These non-Hodgkin's lymphomas frequently had extra-nodal localizations. Good sensitivity to treatment, when necessary, provided good prognosis.


Suicide and fatal antidepressant poisoning. To compare the fatal toxicities of antidepressant drugs in England, Scotland and Wales 1985-1989. Epidemiological retrospective study using Department of Health prescription data and mortality data from the Office of Population Censuses and Surveys, and the Registrar General for Scotland, for the years 1974-1989. The fatal toxicity index (FTI) of groups of drugs and individual drugs was compared with the FTI for all antidepressant drugs for the years 1985-1989. Of 3,604 single antidepressant deaths between 1975 and 1989, the majority (70.95%) were from amitriptyline or dothiepin. The mean FTI for all drugs for the years 1985-1989 was 35.6; the FTIs for dothiepin, amitriptyline, nortriptyline and tranylcypromine were significantly higher than the mean of all, while those for clomipramine, lofepramine, fluvoxamine, trimipramine, maprotiline, trazodone, mianserin, protriptyline, isocarboxazid and phenelzine were lower. The FTI for the older tricyclic drugs was higher at 43.03 (p < 0.001). The FTI for the monoamine oxidase inhibitors, of 27.03 (p = 0.045), and for all drugs introduced after 1973, of 5.32 (p < 0.001), were each significantly lower than the mean of all drugs. Overdose deaths from antidepressants have not decreased over the last 15 years. A trend away from prescribing drugs with a higher fatal toxicity index in favour of those with a lower index, would reduce the number of deaths from antidepressant poisoning.


Familial Behçet's disease.

Familial Behçet's disease. To highlight the frequency, clinical features and histocompatibility antigen types of the familial form of Behçet's disease. Twenty-seven cases with familial Behçet's disease in 12 families were evaluated according to clinical features, sites of involvement, HLA-A and HLA-B typing. A review of the literature is presented. The frequency of familial form of Behçet's disease was found to be 8.7% among 137 patients studied. Vascular involvement was 7.4% (2/27) in the familial group while it was 28.8% (36/125) in patients without the familial form of the disease (p < 0.01). HLA-B51(5) and HLA-A2 were positive in 68% and 75% in 16 familial cases studied, respectively. Familial Behçet's disease, which constitutes a small group of patients with Behçet's disease, may represent a clinically heterogeneous subtype of this entity. Although lower frequency of vascular complications was observed in this study, it is not possible to indicate the precise frequency of vascular and ocular complications of the familial form of Behçet's disease. The frequencies of HLA-A2 and HLA-B51(5) positivity are higher than the previously reported non-Behçet's controls from Turkey.


Prospective randomized controlled trial of sequential treatment with corticoids and alpha-interferon versus treatment with interferon alone in patients with chronic active hepatitis B. A randomized controlled trial was conducted to prospectively compare the efficacy of sequential treatment with corticoids and alpha-interferon versus treatment with interferon (IFN) alone in patients with chronic hepatitis B. Sixty patients with chronic active hepatitis B and positive serum HBV-DNA were randomized into two treatment groups (n = 20, respectively) and one control group (no treatment; n = 20). In one treatment group, patients received first an oral corticoid (2 weeks 40 mg/day and further 2 weeks 20 mg/die prednisolone); thereafter interferon-alpha (Intron A, Essex) was given as three subcutaneous injections of 2 million units per week for 3 months. In patients in whom therapy did not eliminate HBe-Ag and HBV-DNA two months after its end, a similar sequential treatment was given with the same corticoid dose but a higher IFN dose of 5 MU. In the other treatment group patients were given three subcutaneous injections of 5 MU IFN per week for 4 months. The sequential corticoid/IFN treatment at a dose of 3 x 2 MU IFN resulted in seroconversion of HBe-Ag in only 4 of 20 patients (20%). Of the remaining 16 patients 14 subjects received a repetitive corticoid/IFN therapy with the same corticoid dose but with a 3 x 5 MU dose of IFN. With the higher IFN dose, 6 of 14 patients had a seroconversion of HBe-Ag. Therapy with 3 x 5 MU IFN without prior corticoids resulted in a seroconversion in 8 of 20 patients (40%). Calculated for both doses, the sequential corticoid/IFN therapy eliminated HBe-Ag and HBV-DNA in 10/20 patients (50%); therapy with IFN alone was almost as effective (40% seroconversion) (p > 0.05 for comparison of seroconversion rates by chi 2-test). Seroconversion of HBe-Ag and elimination of HBV-DNA occurred in parallel and were associated with a decrease of serum transaminases and a regression of inflammatory activity on rebiopsy. In the control group there was no spontaneous seroconversion of HBs-Ag, HBe-Ag or HBV-DNA. The present results show that in many patients who failed to respond to a sequential therapy with corticoids and 2 MU IFN, the higher IFN dose of 5 MU effectively eliminated HBe-Ag and HBV-DNA. Sequential corticoid/IFN therapy and therapy with IFN alone eliminated HBe-Ag and HBV-DNA in a similar percentage of patients. Further statistical analysis showed that, in particular, patients with low transaminases benefit from prior corticoid treatment. In all groups, patients with low serum HBV-DNA and a short history of infection had the best treatment results.


Comparison of thyroglobulin and radioiodine scintigraphy during follow-up of patients with differentiated thyroid carcinoma. To compare serum thyroglobulin concentration and radioiodine scintigraphy during follow-up after thyroidectomy and radioiodine ablation for differentiated, non-medullary thyroid carcinoma. One hundred fifty-eight patients received radiation ablation after thyroidectomy every 3-4 months until no pathological radioiodine uptake was seen on the scintigraphy. Simultaneously performed postablation scintigraphy and serum thyroglobulin measurement were related to clinical characteristics and mutually compared using kappa statistics (observed agreement not accounted for by chance divided by possible agreement not accounted for by chance). After three ablation doses, serum thyroglobulin concentration had fallen to below detection limit (5 micrograms/L) in 71% of the patients and 70% of the patients had achieved negative scintigraphy after a median radioiodine dose of 3700 MBq I-131 and a median follow-up time of 5 months. The observed agreement between serum thyroglobulin and scintigraphy after the third ablation dose was 62%. The chance agreement was 50% giving a kappa value of only 24%. The size of the thyroid cancer at admission was larger in patients with a positive scintigraphy after first ablation compared with patients with a negative scintigraphy (p = 0.005) and was correlated to thyroglobulin concentration (p = 0.05). Among patients with thyroglobulin level > 5 micrograms/L after thyroidectomy and first ablation dose, there were more patients who at admission had palpable lymph nodes in the neck (p = 0.06) and microscopically verified neck metastasis (p = 0.03) compared with the group with thyroglobulin < 5 micrograms/L. These differences were not seen when comparing patients with positive and negative scintigraphies. The low agreement between the two markers for thyroid cancer emphasizes the value of complementary use of thyroglobulin and scintigraphy in the follow-up of thyroid cancer patients. Patients with large tumours and neck metastasis probably need higher radioiodine doses for complete ablation.


A clinical study of the pineal hormone melatonin in patients with growth hormone or prolactin secreting pituitary tumours. Despite the well documented influence of the pineal gland on pituitary function, the evaluation of pineal activity is not generally included in the clinical investigation of patients with pituitary tumours. The present study analyzed the circadian secretion of melatonin, the main pineal hormone, in patients with pituitary adenomas. The study included 36 patients with pituitary tumours (acromegaly: 11; prolactinoma: 25), by comparing the results with those seen in 42 healthy controls. Moreover, patients were endocrinologically investigated after oral administration of 10 mg of melatonin. Abnormally high serum levels of melatonin during the period of maximum light and abnormally low increases during the night were seen in 7/36 and 16/36 patients, respectively, without any relation to tumour histotype. Moreover, night serum mean levels of melatonin were significantly lower in patients than in controls. Finally, the exogenous administration of melatonin did not influence growth hormone and prolactin secretions in patients with acromegaly and prolactinomas, respectively. This study demonstrates the existence of an altered pineal function in patients with pituitary tumours. Further studies will be required to establish the pathogenetic and prognostic significance of pineal disorders in neoplastic disease of the pituitary gland.


Are CAT-scans necessary for preoperative localization of insulinomas? Do CAT-scans provide useful information in terms of preoperative localization of insulinomas after a biochemical diagnosis is established or may CAT-scan imaging be safely abandoned? CAT-scan results from 30 consecutive patients between 1980-1990 with established insulinomas were retrospectively evaluated with regard to actual tumour size (volume) and identification and localization as verified during surgery. In all patients, the tumours were easily detected by manual palpation during surgery, although the size of 67% of the tumours (n = 20) was less than 2.5 cm3. In only 7 patients (23%) the tumour had been correctly localized by computer tomography. Detected tumours were significantly larger than undetected tumours (median size 5.3 vs 1.3 cm3; p < 0.005). Despite the low sensitivity of computer tomography as documented in this study, all patients with an insulinoma were definitely cured after surgical intervention. Thus, CAT-scans are neither necessary nor helpful for preoperative localization of insulinomas.


Papillomaviruses in human disease: Part I. Pathogenesis and epidemiology of human papillomavirus infections. Papillomas of man and animals were shown to contain an infectious agent at the beginning of this century. Since then, various attempts were made to isolate the papilloma inducing agent. Electron microscopic studies later revealed that the agent is a virus, however all attempts to culture it with conventional virological techniques failed. It took until the development of molecular cloning techniques before a detailed study of this virus could start. Today it is clear that the papilloma-associated viral agent represents one of a very heterogeneous group of viruses, now referred to as papillomaviruses. They induce various neoplastic lesions of the skin and mucosal epithelia. Most interestingly, it emerged that particular types are associated with human cancers. Here, the virological and epidemiological aspects of human papillomaviruses will be reviewed. In a second article in the December issue of EJM the molecular biology and immunology of papillomavirus infections focusing on papillomavirus associated carcinogenesis will be discussed.


Anti-DNA antibodies and their relationships with anti-histone and anti-nucleosome specificities. Systemic lupus erythematosus (SLE) is the archetypic non-organ specific autoimmune disease in which polyclonal B-cell activation is reflected by the wide range of auto-antibody specificities. Among these, anti-ds DNA antibodies bear special significance since they are disease specific, tend to occur at high titers in an active clinical state and are considered to be pathogenic through immune complex formation. However, data accumulated in the last few years have led to a somewhat more complex view of anti-DNA autoantibodies and SLE pathogenesis. For instance, the definition of pathogenic subpopulations of anti-DNA antibodies is an important question which has been addressed in terms of isotypes, idiotypes and DNA sequences of antibodies. Also, some of the cross reactivities described with monoclonal anti-DNA antibodies appear to be due to the formation of immune complexes with DNA, histones or nucleosomes. In addition, anti-DNA-nucleosome immune complexes can react with the cell membrane. These findings indicate that not only DNA but also the nucleosome as a multimolecular complex or its non-DNA component, i.e. histone, may be viewed as relevant target autoantigens in SLE. This review will focus on experimental data supporting this new representation of this set of autoantibodies directed against DNA, histone and the nucleosome, and their possible intervention in SLE pathogenesis.


Bile duct injury in laparoscopic cholecystectomy. Bile duct injury is an unusual complication of laparoscopic cholecystectomy. Although the exact incidence is yet to be determined, it does appear to be more common than bile duct injury during open cholecystectomy. Previous publications have attempted to document the incidence of bile duct injuries and methods to prevent it. We reviewed our experience with 11 bile duct injuries from laparoscopic cholecystectomy. Such injuries were manifested by abdominal pain, low-grade fever, and hyperbilirubinemia or biliary fistula. These patients' injuries were treated by using drainage or reexploration and ligation of cystic duct and subcholecystic duct leaks and Roux-en-Y hepaticojejunostomy for common duct strictures and lacerations.


Hypercarbia during carbon dioxide gas insufflation for therapeutic laparoscopy: a note of caution. During the past decade, the number of laparoscopic procedures performed in the United States, primarily with cholecystectomy, has increased phenomenally. We recently had a patient who developed hypercarbia and cardiovascular compromise during laparoscopic cholecystectomy. The cardiovascular compromise was caused by mechanical factors directly related to increasing intra-abdominal pressures affecting ventilation and venous return as well as the absorption of carbon dioxide (CO2) into the circulation, leading to acidosis and further depression of the cardiopulmonary system. Cardiovascular compromise can be avoided with early recognition of increased end-tidal CO2 concentrations and by preventing intra-abdominal pressures from exceeding 16 mm Hg.


A history of endoscopic surgery.

A history of endoscopic surgery. Laparoscopic cholecystectomy has become the procedure of choice for the treatment of symptomatic gallbladder disease. This had led to a flurry of activity and a widespread interest in laparoscopic and thoracoscopic procedures. Both surgical endoscopy and gallbladder surgery had their beginnings in the 1800s. "Modern" surgical endoscopes were first developed in the early 1800s, and cholecystotomy was first performed in Indianapolis, Indiana by Dr. John S. Bobbs. A brief history of endoscopes, endoscopic surgery, and of the first gallbladder operation in the world follows.


Thoracoscopic vagectomy for recurrent peptic ulcer disease. Duodenal and marginal jejunal ulcers respond promptly to vagus section. When a prior gastric drainage procedure has been done, the approach of choice for these ulcers is vagectomy through the left chest. This report describes four patients who were subjected to thoracoscopic vagectomy and had prompt early benefit. A description of our technique is presented.


Laparoscopic nephrectomy: a review of 16 cases. Laparoscopic nephrectomy is a new procedure in which the entire kidney is removed via an endoscopic technique using a surgical sack entrapment method in combination with a recently developed high-speed 10-mm electrical tissue morcellator. Since June 25, 1990, this procedure has been successfully accomplished in 16 consecutive patients. The average operating room time was 5.6 h. Two patients received a blood transfusion (one and three units, respectively). The average hospital stay was 4.6 days, and convalescence was completed within an average of 12 days. We believe the methods developed for laparoscopic nephrectomy will allow surgeons in other disciplines to broaden their indications for laparoscopic surgery as the entrapment sack and morcellator can potentially be applied to the removal of many other solid intraabdominal and pelvic tissues.


Laparoscopy: basic technique, instrumentation, and complications. Laparoscopy has been an important diagnostic and therapeutic modality in gynecology for several decades. Recently, general surgeons and urologists have adopted laparoscopy to treat many disorders that formerly required an open laparotomy. Laparoscopic surgery requires additional instrumentation and skills as well as familiarity with a number of operative complications unique to laparoscopy. This overview discusses the basic equipment and instrumentation of laparoscopy and describes its possible associated complications.


Complications of laparoscopic cholecystectomy. Laparoscopic cholecystectomy has proven popular with both surgeons and patients. The rapid adoption of laparoscopic surgery has resulted in a number of new operative complications, including problems related to distension of the peritoneal cavity, a lack of depth perception afforded by the video image, and new instruments used with this technique. Few reports deal with complications associated with laparoscopic biliary tract surgery. This report discusses the problems that have occurred most frequently in my region as well as problems related to me in discussions with other experienced laparoscopic surgeons; it also presents methods of recognizing such injuries and preventing them.


Anatomical laparoscopic hernia repair of direct or indirect inguinal hernias using the transversalis fascia and iliopubic tract. Fourteen patients with symptomatic inguinal hernias underwent anatomic repair, which approximates the transversalis muscle and fascia to the iliopubic tract. Polyproprolene mesh was used to obliterate the canal space formerly occupied by the hernia sac. Nine patients were operated on for a direct inguinal hernia, four for an indirect hernia, and one recurrent direct hernia. Two patients required the laparoscopic approach to abandoned in favor of an open method. The remaining 12 patients underwent laparoscopic repair and were discharged within 23 h of the procedure.


Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. From October 1990 to December 1991, we performed 61 laparoscopic preperitoneal mesh repairs of inguinal hernias on 52 patients, including 22 direct, 38 indirect, and one femoral hernias. The laparoscopic technique employs the same principles as open preperitoneal mesh repair of replacing and reinforcing attenuated transversalis fascia. After entering the peritoneal cavity through the umbilicus, the preperitoneal space is entered by excising the hernia sac. The preperitoneal space is bluntly dissected and the transversalis fascia exposed. For a direct or recurrent hernia, the defect in the transversalis fascia is closed with a pursestring or running suture without tension. For an indirect hernia, the internal ring is tightened with an interrupted suture. Next a piece of mesh approximately 2.5 x 4.5 inches is trimmed to fit over the internal ring, the testicular vessels, and spermatic cord laterally, Hesselbach's triangle medially, and Cooper's ligament inferiorly, which covers potential sites for a new hernia or recurrence. The mesh (Prolene or Marlex) is then sutured with 3-0 vicryl to the transversalis fascia and transversus abdominis aponeurosis superior-medially, to the iliopubic tract or Cooper's ligament inferiorly, and to the transversalis fascia and transversus abdominis lateral to the internal inguinal ring. Upon completion of the tensionless repair, the peritoneum is reapproximated. Compared with the open procedure, laparoscopic repair reduces postoperative pain and shortens convalescence. No lifting restrictions are imposed on the patient. We have had three minor complications and no recurrences to date, but follow-up is too short to make firm conclusions.


Laparoscopic herniorrhaphy.

Laparoscopic herniorrhaphy. Laparoscopic preperitoneal prosthetic repair of inguinal and femoral hernias was done in 27 patients, including 18 indirect, nine direct, and two femoral hernias. In four patients bilateral hernias were repaired simultaneously. General anesthesia with endotracheal intubation was used in all patients. Three laparoscopic cannulas were inserted. The peritoneum overlying the internal inguinal ring and floor of Hesselbach's triangle was opened. If an indirect hernia sac was found, it was dissected off the cord structures. A polypropylene prosthesis was used to occlude any potential canal space and to reinforce the pelvic floor. No major operative complications or early recurrences (follow-up, 1-7 months) occurred. Patients were to return to full employment an average of 5 days after surgery (range, 3-7 days).


Laparoscopic lymphadenectomy.

Laparoscopic lymphadenectomy. Although first performed by gynecologists in the United States and Europe, laparoscopic pelvic lymphadenectomy has recently become a popular procedure among many urologists. Gynecologists in the United States, however, have been slow to adopt this procedure. Indications for this procedure include malignancies where accurate histologic staging is required to determine the appropriate management and where subsequent therapy does not necessarily include an open laparotomy.


Laparoscopic cholecystectomy: the St. Vincent experience. Laparoscopic cholecystectomy has rapidly become the procedure of choice for the management of patients with symptomatic gallbladder disease. Since December 1989, a total of 622 patients have undergone laparoscopic gallbladder surgery. The operative technique we employ requires the insertion of only three laparoscopic cannulas and uses monopolar electrocautery to dissect the gallbladder from the liver bed. Average operating room time was 90.5 min. Twenty-six (4.2%) of the 622 patients required conversion to open laparotomy. A total of 24 (3.8%) operative complications occurred, including one common bile duct injury. Eight patients required readmission to the hospital. Eighteen percent of patients were discharged on the same day as the operative procedure, and overall average hospital stay was 1.8 days (range, 0 to 59 days).


Laparoscopic cholecystectomy: the Methodist Hospital experience. This report relates our experience with laparoscopic cholecystectomy at Methodist Hospital of Indiana (Indianapolis). We began to develop a technique for this procedure in our animal laboratory in January 1988 and over the subsequent 18 months performed this procedure successfully in eight animals. Our first human cholecystectomy by the laparoscopic method was done on September 13, 1989. Since then more than 900 cholecystectomies have been completed under laparoscopic guidance at our institution. In this 1,000-bed hospital, 18 surgeons have been trained to perform laparoscopic biliary tract surgery on a regular basis. In addition, approximately 70 other surgeons from around the state have been trained in our program of "mini"-fellowships. This report reviews these 900 cases, presents some anecdotal information, and relates some of the unique features that we have developed.


Laparoscopic bowel injury.

Laparoscopic bowel injury. Laparoscopy is not a new procedure, but instead represents a minimally invasive method of access to the peritoneal cavity, accomplishing the same procedures under laparoscopic guidance as performed through a large abdominal incision. The adoption of any new surgical procedure or technology is associated with new as well as previously recognized complications. Intestinal injuries associated with laparoscopic surgery can occur as a result of insufflation needle or trocar insertion, or they can occur during the operative dissection. Insufflation needle injuries are usually self-limiting and require no specific treatment. Injuries associated with trocar insertion or operative dissection should be identified and managed appropriately. As surgeons increase their experience with laparoscopic surgery, they should be able to manage many such injuries without needing to convert to open laparotomy. Direct suture repair under laparoscopic guidance and the use of innovative endoscopic stapling devices have been successfully used to manage such injuries.


Preliminary experience with laparoscopic-guided colectomy. Laparoscopic-assisted colonic resection was attempted in 18 patients: 12 patients had surgery for ascending colon lesions, three underwent attempted left-sided colectomies, and three patients had low anterior resection. Three early patients required conversion to open laparotomy when the pathologic lesion could not be identified under laparoscopic guidance. In patients undergoing laparoscopic surgery, postoperative pain was markedly reduced. Oral intake was begun between the first and third postoperative days, and average hospital stay was 4 days. No operative morbidity or mortality occurred in this small group of patients.


Common bile duct foreign body: an unusual case. A 59-year-old woman had symptomatic gallbladder stones. A laparoscopic cholecystectomy was performed using absorbable clips. Eleven weeks later, recent pain in the right upper quadrant and interscapular resulted in an ERCP. This examination demonstrated two Absolok Plus clips migrated in the biliary tract. We question the use of those clips and discuss the migration mechanism.


Managing gynecologic problems found at laparoscopy. Several gynecological problems are occasionally found at laparoscopy. These include pelvic endometriosis, pelvic adhesions, blocked fallopian tubes, tubal pregnancy, pelvic inflammatory disease, ovarian cysts, and uterine fibroids. Most can be handled endoscopically, with the laparoscope inserted through an umbilical incision, although an open laparotomy may sometimes be necessary.


Laparoscopic hysterectomy.

Laparoscopic hysterectomy. Approximately 600,000 hysterectomies are performed each year in the United States, more than 75% of which are removed via an open laparotomy. Most hysterectomies that currently require an abdominal approach may be performed with laparoscopic dissection of part or all of the abdominal portion, followed by vaginal removal of the specimen. Indications for laparoscopic-guided hysterectomy include endometriosis, extensive fibroid disease, adnexal masses, adhesions from prior surgery, or inflammatory disease. Laparoscopic hysterectomy may also be considered for stage I endometrial, ovarian, and cervical cancer.


Arthroscopic surgery.

Arthroscopic surgery. The first examination of a knee joint was in 1918 by the Japanese surgeon Takagi. Since this first attempt at joint space surgery, numerous advances have been made in arthroscopic design, video imaging, instrumentation, and the adoption of laser energy devices. As a result, diagnostic and therapeutic arthroscopy is currently performed in every major joint space in the body. Recently, clinical investigators have begun exploring the potential of endoscopic examination of small joint spaces, such as the temporomandibular joint. Also on the horizon are scopes and instruments to intervene therapeutically in the spinal canal.


Treatment of recurrent spontaneous pneumothorax. Thoracoscopy is a natural extension of laparoscopic techniques that have proved to be useful in the treatment of biliary tract disease and other general surgery problems. Similar to the experience with laparoscopic surgery, thoracoscopy also provides for early recovery and return of normal activity. The treatment of spontaneous pneumothorax under thoracoscopic guidance represents a major advance in thoracic surgery. Recently developed endoscopic stapler devices allow for both the excision and closure of ruptured blebs in a fashion identical to the traditional approach with open thoracotomy. Presented in this report are 17 consecutive cases of pneumothorax that were treated using a thoracoscopic approach. No postoperative complications were encountered and no recurrences have been identified. The surgical methods and techniques are outlined.


Experimental transperitoneal laparoscopic pyloroplasty. Interest in laparoscopic abdominal surgery continues to grow, which has persuaded a number of centers to pursue actively laparoscopic techniques that will allow surgeons to perform additional operative procedures in a less invasive manner. Peptic ulcer surgery, because of the morbidity associated with gastric surgery as well as the pain and discomfort associated with any major abdominal operation, has been largely replaced by pharmacologic therapy. As a result, patients are often advised to continue drug therapy indefinitely. This form of therapy, however, often only partially relieves the symptoms associated with peptic ulcer disease and leaves the patient at risk to develop life-threatening complications such as bleeding and perforation. Therefore, the rapid advances occurring in the field of laparoscopic surgery provide a fertile area for the development of simple, safe, and effective procedures to treat peptic ulcer disease in selected patients. A variety of different peptic ulcer operations have already been successfully performed under laparoscopic guidance. This report describes an experimental technique of transperitoneal stapled laparoscopic pyloroplasty using a modified end-to-end anastomotic stapling device (EEA Stapler; United States Surgical Corporation, Norwalk, CT, U.S.A.). The feasibility of this procedure was documented by detailed histologic evaluation of the pyloroplasty and revealed that the pyloric musculature had been excised, resulting in a true gastroduodenostomy. Pyloroplasty, coupled with either transabdominal or transthoracic vagotomy, could be a simple alternative to more extensive open abdominal surgery. This procedure represents one additional step in providing the practicing surgeon with the ability to perform a variety of different ulcer operations in a minimally invasive (laparoscopic) fashion.


Laparoscopic inguinal herniorrhaphy: the mushroom plug repair. Laparoscopic inguinal herniorrhaphy was performed on 76 patients with a total of 82 hernias. A modified Schultz repair was done using a mushroom-shaped mesh plug. The flat piece of this plug acts as a stopper to prevent migration of the plug into the inguinal canal or the subcutaneous tissue (in the direct hernia, primary or recurrent). Average operative time was 69 min (range 42-140 min). Short-term follow-up of 1 to 7 months showed no recurrence and good acceptance of the repair by patients.


The use of a Doppler probe for identifying the cystic artery during a laparoscopic cholecystectomy: a pilot study. A prototype Doppler probe was used laparoscopically to identify the cystic artery in 30 consecutive patients undergoing laparoscopic cholecystectomy. This pilot study revealed that the probe provided valuable assistance in identifying the artery in 33.3% of the patients. In 10% of the patients, the Doppler identified the artery when standard dissection techniques failed to do so. The probe was particularly helpful in patients with acute cholecystitis.


Laparoscopic segmental resection of the sigmoid and rectosigmoid colon for endometriosis. Patients with symptomatic endometriosis of the colon and distal small bowel usually present with crampy abdominal pain, pelvic and rectal pain, constipation, and dyspareunia. Superficial disease can be easily resected laparoscopically with scissors. Deeper lesions require full-thickness resection and closure of the bowel. Occasionally deep, large, or multiple lesions will require segmental resection for adequate control of the disease. Five patients with intestinal endometriosis underwent attempted laparoscopic segmental colon resection. Two patients required conversion to open laparotomy because of difficulty with the anastomosis. No operative complications or deaths occurred in this group. Those patients undergoing laparoscopic colectomy showed return of bowel function within 24 to 48 h and were discharged home on postoperative day 4.


Pulmonary changes after laparoscopic cholecystectomy. Laparoscopic cholecystectomy has become a widely used procedure. Upper abdominal surgery and particularly open cholecystectomy are known to be associated with marked declines in lung volume and a high risk of postoperative pulmonary complications. The pulmonary effects of laparoscopic cholecystectomy have not yet been studied. We prospectively evaluated 22 patients admitted for laparoscopic cholecystectomy for lung volume changes and development of postoperative pulmonary complications. The procedure was associated with a marked decline in forced vital capacity (FVC, 41.2 +/- 20.7%) and forced expiratory volume in one second (FEV1, 41.4 +/- 20.8%) in the immediate postoperative period. There was no significant difference in loss of lung function according to age (p = 0.18), sex (p = 0.33), or smoking history (p = 0.58). Despite the marked loss in lung function in the immediate postoperative period, no major pulmonary complications occurred. We conclude that laparoscopic cholecystectomy, although associated with early loss of lung function, is a safe and effective procedure with an incidence of postoperative pulmonary complications much less than with open cholecystectomy.


To drain or not to drain in laparoscopic cholecystectomy: rationale and technique. Routine drainage was adopted in laparoscopic cholecystectomy since we started to perform this operation, in November 1989. Its use was triggered by a fear of complications that might require an open operation. Between November 1989 and June 1991, 480 elective procedures were performed. Bile drainage was encountered in five patients and bleeding in three patients. None of the patients with bile drainage developed bile peritonitis or required reoperation; one patient with bleeding required reoperation. Complaint of shoulder pain was minimal (4.8%).


Simultaneous laparotomy and endoscopy for control of bleeding gastric ulcerations after liver transplantation without enterotomy. Treatment of gastric peptic ulcerations, which requires both medical and surgical coordination in its management, is a complex subject. Despite advances in the medical therapy of ulcers, medications have little impact on the course of bleeding peptic ulceration. Newer endoscopic techniques of injection with adrenaline or alcohol, heater probes, and vicaps electrodes have controlled bleeding in many patients. Still, a subset of patients remains who will require surgical interventions with gastrotomy and oversewing of the ulcer crater. We describe a new technique for management of the acute gastric ulcer bleeding that avoids gastrotomy and potential contamination in the post-transplant patient.


Laparoscopic cholecystectomy technique for removal of the gallbladder from the peritoneal cavity. A new laparoscopic cholecystectomy technique for removing the gallbladder from the peritoneal cavity through the umbilical incision is presented. This method is faster than the traditional technique and eliminates the necessity of transferring the camera from the umbilical port to a second port.


Percutaneous access to the common bile duct in laparoscopic cholecystectomy. A simple, direct way to access the common bile duct percutaneously is described. Alternate methods of common bile duct exploration via operative laparoscopy are described and contrasted to the proposed method with respect to ease, advantages, and limitations.


Laparoscopic para-aortic lymph node biopsy for diagnosis of a non-Hodgkin's lymphoma. We present a case report of a 76-year-old male with non-Hodgkin's lymphoma diagnosed by laparoscopic transperitoneal infrarenal para-aortic lymph node biopsy. This is the second report of the use of this technique in diagnosing a nonpelvic malignancy. The patient was discharged from the hospital in less than 24 h, during which complete histologic and immunochemical typing were performed. Laparoscopic biopsy offers significant advantages as an alternative to either fine-needle biopsy or open laparotomy.