Minilaparotomy approach to tumors of the right colon

OBJECTIVE

The study contained herein was undertaken to describe the minilaparotomy approach to tumors of the right colon.

METHOD

Clinical data were prospectively registered from 47 patients who were undergoing resection of the right colon via minilaparotomy.

RESULTS

Bowel function returned after two days and passage of stools after four days. Pain medication was necessary only during the first three postoperative days. Major complications were few, and no postoperative deaths occurred. Tumors 10 cm or smaller could be handled by minilaparotomy, and the technique allowed a relevant number of lymph nodes to be removed. No local recurrences were detected during the early postoperative period.

CONCLUSION

The minilaparotomy approach to tumors of the right colon seems to be an attractive alternative to conventional colon surgery.

Parathyroid function in long-term renal transplant patients: importance of pre-transplant PTH concentrations

Lack of resolution of hyperparathyroidism after long-term renal transplantation is common. The relative roles of the graft function attained and the degree of pre-transplant hyperparathyroidism have not been established. Intact parathyroid hormone (iPTH) and several clinical parameters were studied before and 68.6+/-26.8 months (range: 30-124) after renal transplantation in 62 patients (20 females/42 males) with good renal function (creatinine <2 mg/dl). iPTH decreased from 214+/-229 pre-transplantation to 116+/-70 pg/ml post-transplantation (P<0.01). However, only 22.6% of patients had PTH concentrations in the normal range, and values greater than twice the upper normal limit were not uncommon (27.4%). Of the many variables analysed, creatinine (r=0.43; P=0.001) and pre-transplant PTH (r=0.31; P=0.02) significantly correlated with post-transplant PTH. After selecting patients with serum creatinine <1.5 mg/dl (n=46), pre-transplant PTH emerged as the more important predictor of post-transplant PTH (r=0.58; P<0.0001). After controlling for creatinine, the partial correlation was r=0.53, P<0.0001. We concluded that spontaneous resolution of hyperparathyroidism after renal transplantation is uncommon. In addition, the magnitude of pre-transplant hyperparathyroidism and the renal function determine the long-term post-transplant parathyroid function.

[Minilaparotomy is a careful method in right colon tumor surgery]

In a series of 47 patients, right colon tumours were treated surgically with a minilaparotomy approach, entailing a skin incision of less than 10 centimetres. The procedure allows appropriate oncological management of the tumour, and is associated with a mild postoperative course and a rapid recovery and resumption of normal life. The short-term outcome in this series has been promising, and the minilaparotomy approach would thus appear to be an attractive alternative to traditional open surgery of the right colon.

Influence of vitamin D receptor genotype on bone mass changes after renal transplantation

Renal transplant patients immunosuppressed with cyclosporine A (CsA) exhibit both a significant bone loss and an increased rate of bone fractures. An association between common allelic variants of the the vitamin D receptor (VDR) gene and bone mineral density and turnover has been reported in adults. However, the genetic influence on the rate of bone loss after renal transplantation has not been explored. We prospectively determined the changes in spinal mineral density in 34 consecutive nondiabetic adults who received a cadaveric renal allograft. Serum biochemical markers of bone metabolism and the vertebral mineral density (VMD) assessed by quantitative computed tomography were determined at the time of transplantation and three and twelve months later. In fifteen patients the histomorphometric features of iliac bone were analyzed at baseline and twelve months after transplantation. VDR alleles were typed by a PCR assay based on a polymorphic BsmI restriction site. Patients with the so-called "favorable" bb genotype (N = 12) were compared with those with the Bb or BB genotype (N = 22). Baseline VMD was similar in patients with or without the favorable bb genotype. Three months after transplantation the mean (+/- SD) VMD decreased 14 +/- 13.3 percent in all patients (16.5 +/- 13.1% in patients homozygous for the b allele and 13.77 +/- 13.9% in those with Bb or BB genotypes). The rate of VMD loss at this time inversely correlated with pretransplant PTH levels (r = -0.40; P < 0.05). Between 3 and 12 months after transplantation, patients with the favorable bb genotype recovered more VMD than those with Bb or BB types and showed a significantly higher Z score at the end of the follow-up (-0.37 +/- 1.16 vs. -1.10 +/- 1.20, respectively; P < 0.05). The beneficial effect of bb genotype was independent of the prevailing PTH levels and was also observed in those patients with a baseline PTH level < 250 pg/ml (final Z score: bb, -0.42 +/- 1.3, N = 11; Bb/BB, -1.35 +/- 0.8, N = 11, P < 0.05). At the end of follow-up, the histomorphometric studies showed a higher bone formation rate adjusted for PTH levels in patients with the Bb or BB genotype than in those with the favorable bb genotype (0.29 +/- 0.06 vs. 0.21 +/- 0.08 micron3/micron2/day respectively; P < 0.05). In conclusion, high pretransplant PTH levels enhance the early trabecular bone loss after renal transplantation, and functionally different alleles of the vitamin D receptor gene may condition the bone turnover and the degree of recovery of the bone mass.

Mseleni joint disease--a molecular genetic approach to defining the aetiology

Mseleni joint disease (MJD) is an unusual form of progressive and widespread degenerative osteoarthropathy that has been identified in several hundred people in the remote Mseleni region of northern Zululand. Affected individuals experience articular discomfort in childhood and may be seriously handicapped as adults, often requiring prosthetic hip joint replacement. Although the condition clusters in families, there is no evidence of Mendelian inheritance and assessment of affected kindreds has not shown any evidence of genomic imprinting. To date our molecular work-up has entailed the study of 47 affected individuals from MJD kindreds to investigate familial predisposition based on the inheritance of a subset of markers and/or genes on the human genome, particularly those associated with the cartilage matrix. In addition, we have collected blood specimens form 111 unaffected but unrelated individuals from the same population group in order to determine whether any relationship exists between genetic components of the human leucocyte antigen (HLA) system and the MJD phenotype. Our investigations show the following: (i) there is no association between MJD and the HLA system which has previously been associated with non-Mendelian genetic conditions; (ii) COL2A1, which has been implicated in some forms of spondylo-epiphyseal dysplasia, may be involved in at least a subset of MJD patients; and (iii) type VI collagen is overabundant in degenerated hip joint cartilage.

Hematologic disorders in trauma patients during parenteral alimentation with lipids

Total parenteral nutrition with lipids is a well-accepted modality of metabolic support in seriously ill trauma patients. Intolerance to lipid administration is unusual when dosage limits are not exceeded, and few hematologic disturbances have been recorded with modern fat emulsions. In the course of intravenous alimentation of six adults admitted for traumatic lesions, eosinophilia with or without leukocytopenia was noticed after periods of four days to five weeks. Principal clinical events and hematologic derangements were documented in this population. Sepsis was not always present in the patients by the time of the complication, and in those that did require antibiotics and other drugs, the prescription remained unchanged along the episode. Discontinuation of the nutritional regimen with lipids was followed by normalization of the hematologic profile, suggesting that an acute or sub-acute allergic reaction was responsible. The appearance of skin rash in two occasions reinforces this hypothesis, and the possibility of hemophagocytosis merits consideration in two of the cases who displayed reversible acute leukocytopenia. It is concluded that blood cell aberrations are possible during intravenous feeding with lipids in trauma subjects, but tend to respond to suppression of the lipid-containing nutritional prescription.

Transient false-positive hepatobiliary scan associated with ceftriaxone therapy

Drug related false-positive hepatobiliary imaging is uncommon. The authors present a case of a 54-year-old woman who was treated with intravenous ceftriaxone for bacterial meningitis. Symptoms of acute cholecystitis subsequently developed and a sonogram revealed a gallstone. A Tc-99m DISIDA hepatobiliary study was positive for cystic duct obstruction. After discontinuation of ceftriaxone, the patient's clinical condition improved and, 2 weeks later, a repeat hepatobiliary scan was normal. High doses of ceftriaxone and prolonged administration may lead to formation of pseudocholelithiasis and signs of acute cholecystitis. Although this condition is usually benign and reversible, discontinuation of the drug is warranted when symptoms of acute cholecystitis are accompanied by a positive hepatobiliary scan.

Surgical treatment of pancreatic ascites and pancreatic pleural effusions

BACKGROUND/AIMS

Massive ascites and pleural effusions are uncommon but well-documented complications of chronic pancreatitis. The present study reviews the results of surgical management of pancreatic ascites and pleural effusions of pancreatic origin.

PATIENTS AND MATERIALS

From forty-nine patients with chronic pancreatitis presenting with ascites and/or pleural effusion of pancreatic origin, 31 were surgically treated.

RESULTS

Nineteen had ascites only, ten pleural effusions and two presented with both conditions. Diagnosis of the internal pancreatic fistula was based on the findings of high amylase levels and elevated albumin content of the peritoneal and pleural exudates. Failure of medical therapy was the indication of surgical treatment in all patients. Thirteen were submitted to internal pancreatic drainage, 17 to external drainage and one to distal pancreatic resection. Eight of 17 externally drained patients were reoperated for intraperitoneal abscesses (2), infected pseudocyst (1), pain recurrence (3) and pancreatic fistula (2); whereas reoperation occurred in only one of the 13 patients submitted to internal drainage (p < 0.05).

CONCLUSIONS

Internal pancreatic drainage was the ideal surgical treatment for patients with pancreatic ascites and/or pleural effusion that did not respond to medical treatment. When this was not feasible external drainage was successfully used as an alternative to pancreatic resection.

[Surgical treatment of hepatocarcinoma in cirrhosis]

In 1986, our institution published the first results of surgical resection of hepatocarcinoma in cirrhotic patients. The aim of this paper is to present long term results of this surgical management. From April 1978 to February 1992, 74 patients were operated on at the surgical clinic of University Medical Center of Rennes (35000) France. There were 60 hepatectomies and 14 transplantations. The mean age was 60.2 years +/- 9 years and the sex ratio: 70 males and 4 females. The etiology was alcoholic in 43 patients (58%), post hepatitis (B and C) in 22 patients (30%) and due to hemochromatosis in 9 patients (12%). According to the Child Pugh classification, 48 patients were Child A, 11 Child B and one Child C in the hepatectomy group and 9 patients Child A and 5 Child B in transplantation group. The operative mortality was 10% in hepatectomy group and 35.7% in liver transplantation group. Overall survival was 61.8% at 1 year, 47.1% at 2 years, 38.2% at 3 years and 20% at 5 years. 5 year survival is 21.4% after transplantation and 18.5% after resection. This difference is not significant. In conclusion, according to 5 years survival and to operative mortality the treatment of choice is hepatectomy in HCC in cirrhotic patients. However the best treatment is the prevention of cirrhosis.

Achondroplasia is defined by recurrent G380R mutations of FGFR3

Genomic DNA from 154 unrelated individuals with achondroplasia was evaluated for mutations in the fibroblast growth factor receptor 3 (FGFR3) transmembrane domain. All but one, an atypical case, were found to have a glycine-to-arginine substitution at codon 380. Of these, 150 had a G-to-A transition at nt 1138, and 3 had a G-to-C transversion at this same position. On the basis of estimates of the prevalence of achondroplasia, the mutation rate at the FGFR3 1138 guanosine nucleotide is two to three orders of magnitude higher than that previously reported for tranversions and transitions in CpG dinucleotides. To date, this represents the most mutable single nucleotide reported in the human genome. The homogeneity of mutations in achondroplasia is unprecedented for an autosomal dominant disorder and may explain the relative lack of heterogeneity in the achondroplasia phenotype.

Ablation of irreversibly rejected renal allograft by embolization with absolute ethanol: a new clinical application

Surgical allograft nephrectomy has been the conventional therapy for removing failed kidney allografts when clinical manifestations of graft intolerance appear. However, removal of a transplanted kidney is an extensive surgical procedure. On the other hand, transcatheter vascular embolization (TVE) has proven useful in ablating organs and could be applied to renal transplant ablation. The aim of this study was to present the results of TVE for the treatment of graft intolerance syndrome (GIS) in failed allograft kidneys. Transcatheter vascular embolization was performed in 14 allograft recipients (33 +/- 13 years of age; 10 men and four women) affected by GIS after irreversible kidney allograft failure. Graft intolerance syndrome was diagnosed by fever (93%), hematuria (50%), graft pain (36%), flu-like symptoms (29%), and increased graft size (29%). Absolute ethanol (0.1 mL/kg body weight) was injected in the allograft artery, and in seven patients a stainless steel coil was left in the renal artery following ethanol injection. All patients showed clinical disappearance of the GIS. No major complication occurred, although a postembolization syndrome of pain, fever, hematuria, numbness, and paresthesia of the affected area appeared in 11 of the 14 patients. After 2 to 56 months of follow-up no late complications occurred, with the exception of a graft abscess formation in one patient after 6 months of embolization. Subsequent transplantectomy was uneventful. In conclusion, TVE is a safe and effective method for kidney graft ablation, and it may become an alternative treatment for GIS following irreversible rejection.

Magnetic resonance imaging in HTLV-I associated myelopathy

Magnetic resonance imaging of the brain and spinal cord were carried out for seventeen consecutive patients with HTLV-1 associated myelopathy (HAM). Eight patients had brain abnormalities and four had decreased thoracic spinal cord diameter. Brain lesions were mostly located in subcortical and periventricular areas. Our data suggest that diffuse central nervous system lesions are present in patients with HAM.

Production of cytokines around loosened cemented acetabular components. Analysis with immunohistochemical techniques and in situ hybridization

The chronic inflammatory response to wear particles from orthopaedic joint implants is believed to cause osteolysis and to contribute to prosthetic loosening. Previous in vitro experiments have demonstrated that particulate debris from joint implants causes cells in culture to release products that have been implicated in this pathological bone resorption. The purpose of the current study was to investigate the in vivo features of this complex process in patients who had had a total hip replacement. Membraneous tissue was obtained from the cement-bone interface of ten polyethylene acetabular components that had been revised for aseptic loosening in ten patients. The immunoperoxidase technique, which involves the use of specific antibodies for each cell type, showed that macrophages were the predominant cellular constituents but also that fibroblasts, many of which were not identified on plain histological study, were present and were actively producing collagen. T lymphocytes were present variably, but they generally composed less than 10 percent of the cells. Particulate debris (polyethylene, methylmethacrylate, and metal) was present in all membrane specimens but was intracellular only in macrophages and multinucleated giant cells. 35S-labeled nucleic-acid probes, complementary to human interleukin-1-beta and to platelet-derived growth-factor-2 messenger RNA (mRNA), were hybridized with serial tissue sections. Hybridization demonstrated interleukin-1-beta mRNA predominantly in macrophages, and not in fibroblasts or in T lymphocytes to any major extent. In contrast, immunolocalization demonstrated interleukin-1-beta protein on both macrophages and fibroblasts, suggesting that macrophages release interleukin-1-beta, which then binds to both fibroblasts and macrophages. Platelet-derived growth-factor transcripts were found in both macrophages and fibroblasts.

Endothelin in the urinary bladder. I. Synthesis of endothelin-1 by epithelia, muscle and fibroblasts suggests autocrine and paracrine cellular regulation

The synthesis and localization of endothelin-1 were studied in human and rabbit bladder. In addition, the effects of endothelin-1 on smooth muscle tone and cholinergic neurotransmission were investigated in rabbit bladder. Endothelin-like immunoreactivity was localized in the transitional epithelium, serosal mesothelium, and vascular endothelium; smooth muscle of the bladder (non-vascular) and that of blood vessels; and fibroblasts. With in situ hybridization, transcripts of endothelin messenger ribonucleic acid (mRNA) were localized with the same cellular distribution as endothelin-like immunoreactivity, in bladder tissue. Northern blot analysis of bladder RNA confirmed the expression of preproendothelin-1 mRNA. Rabbit bladder strips in organ chambers contracted when exposed to endothelin-1 and this response was partially attenuated by calcium channel blockers or by removal of extracellular calcium. Transmural electrical stimulation of rabbit bladder strips elicited contractions that were greatly reduced by atropine. The remaining atropine resistant component was blocked by alpha, beta-methylene ATP, which desensitizes purinergic receptors. Endothelin-1 caused a small but consistent attenuation of the atropine sensitive component of the neurogenic contraction, while it had no effect on the atropine resistant component. The localization of endothelin synthesis in epithelia, smooth muscle, and fibroblasts suggests that endothelin may act as an autocrine hormone in the regulation of the bladder wall structure and smooth muscle tone. In addition, endothelin-1 may regulate cholinergic neurotransmission by a paracrine mechanism.

Multicenter pathological study of chronic pancreatitis. Morphological regional variations and differences between chronic calcifying pancreatitis and obstructive pancreatitis

To examine previous work carried out at a single center, i.e., France, on the pathologic features of chronic pancreatitis and to examine geographic differences, 359 cases of chronic pancreatitis from five centers were studied pathologically and the results analyzed according to appropriate statistical methods. It was found that it was easy to separate chronic calcifying pancreatitis from obstructive pancreatitis occurring distal to obstruction to the pancreatic duct by pathological means. On the other hand, geographic differences between France, Italy, Brazil, and South Africa, although present, were not sufficient for identification of a specific profile for each of the countries studied, and it was found that the minor differences were probably dependent on environmental rather than racial factors.

Expanded role of the cerebrospinal fluid reservoir in neurooncology: indications, causes of revision, and complications

Advances in chemotherapy have increased the indications for insertion of cerebrospinal fluid (CSF) reservoirs in the treatment of both primary and secondary central nervous system neoplasia. There have been no recent evaluations of the current indications and complications of this procedure in a general neurooncology practice. We undertook a retrospective review of our total experience of 60 patients who were implanted with CSF reservoirs between November 1977 and October 1983. The mean age of those implanted was 38 years (range, 22 months to 79 years). The reasons for insertion were: drug instillation, 35 cases (58.3%); drug level monitoring, 15 cases (25.0%); intermittent tumor cyst drainage, 6 cases (15.0%); and syrinx drainage, 1 case (1.6%). Drug level monitoring was most often done in conjunction with specific experimental chemotherapy protocols. There were no complications after primary insertion, but 9 of 60 reservoirs (15%) required revision for technical failure. Revision was much more likely to occur in the presence of an intracranial mass lesion (7 of 34, or 20.5%). The revision rate in cases of meningeal carcinomatosis was only 7.6% (2 of 26). Patients requiring revision included 5 with glioblastoma, 2 with metastatic tumors, and 2 with meningeal carcinomatosis. Four of the 9 patients requiring revisions developed complications (44%). There were three infections with positive CSF cultures and one subdural hematoma. Infected patients included those with multiple craniotomies, prior cranial irradiation, or some form of chemotherapy. We conclude that primary insertion of a CSF reservoir in a patient with neoplastic involvement of the central nervous system is extremely safe, that technical failure tends to occur in the presence of mass lesions, and that the complication rate of repeated insertion is quite high.

Acute pancreatitis and hyperamylasemia in renal homograft recipients

In a series of 301 renal homograft recipients, 17 (5.6%) had acute pancreatitis at some time after transplantation. Eleven of these patients died, for a mortality of 64.7%. In each instance, pancreatitis was a major factor in a complex chain of lethal events to which immunosuppression invariably contributed. An additional 43 patients (14.3%) developed asymptomatic hyperamylasemia after transplantation and, undoubtedly, some of these recipients also had pancreatitis. The factors causing pancreatitis in the renal transplantation patient include uremia, hyperparathyroidism, pancreatic injury by drugs, infections resulting from chronic immunosuppression, gallstones, and operative trauma to the pancreas. In cases of preexisting pancreatitis, transplantation is not necessarily precluded, but efforts should be made to find a specific cause of the pancreatitis and take corrective measures, such as biliary tract surgery or parathyroidectomy if indicated, in advance of transplantation.