External oblique intercostal (EOI) block for enhanced recovery after liver surgery: a case series

We report our clinical experience with the external oblique intercostal block in three consecutive adult patients who underwent liver surgery for resection of metastases. Enhanced recovery guidelines for liver surgery recommend intrathecal opioids and peripheral regional anaesthetic techniques in the context of multimodal analgesia to achieve adequate postoperative analgesia and early functional recovery. However, both laparoscopic and open approaches to liver surgery involve incisions in the upper abdomen, an anatomical area not well covered by previously described peripheral regional anaesthetic techniques. The external oblique intercostal block is a novel motor- and opioid-sparing technique which blocks both the anterior and lateral cutaneous branches of the thoracoabdominal nerves which innervate the upper abdominal quadrant. In all cases in this series, we performed the blocks in a short period of time and without complications. All patients remained pain- and opioid-free in the postoperative period and achieved enhanced recovery outcomes early. We found the external oblique intercostal block to be a simple, convenient, effective and opioid-sparing regional anaesthetic technique for postoperative analgesia after liver surgery. By minimising opioid use and by obviating the need for central neuraxial anaesthesia techniques in the postoperative period, this block could be incorporated into enhanced recovery protocols for hepatobiliary surgery.

Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study

PURPOSE

The purpose of the present study was a comparison of the systemic inflammatory response intensity through the estimation of C- reactive protein and albumin levels before and after open tension free inguinal hernia repair performed under different anesthetic alternatives.

PATIENTS AND METHODS

Totally, 125 inguinal hernia patients scheduled for unilateral primary open tension free inguinal repair unRomader local (50 patients), spinal (50 patients) and general anesthesia (25 patients) have been included in this prospective study.

RESULTS

The group of local anesthesia was associated with the higher postoperative serum levels of albumin compared to the group of general anesthesia (P 0.013). Local anesthesia was also associated with higher postoperative serum albumin levels compared to regional anesthesia but however the difference was not statistically significant (P 0.282). The group of local anesthesia was also associated with the lower postoperative levels of CRP compared to the regional (P 0.0094) and general anesthesia (P 0.0009) groups.

CONCLUSION

Local anesthesia proved superior to regional or general anesthesia for open tension free inguinal hernia repair in the given patient sample from the standpoint of the inflammatory and acute phase response.

Virtual ileostomy in elective colorectal surgery: a systematic review of the literature

BACKGROUND

Anastomotic leak (AL) following colorectal surgery can be a life-threatening complication. The use of a diverting stoma has been proposed, to prevent or reduce morbidity and mortality associated with AL. Stomas, however, have their own distinct complications. Thus, virtual ileostomy (VI) has been proposed as an alternative to diverting stoma. The aim of the present study was to further evaluate the role of VI through systematic review of existing literature.

METHODS

A systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane handbook for systematic reviews of interventions. The primary endpoint of our study was the estimation of the overall VI complication rate. Secondary endpoints included the identification of the VI-specific adverse outcomes, perioperative endpoints such as the length of hospital stay, transfusion and postoperative leak rates, description of the operative variations of VI reported VI operative variations and details regarding the primary operation and previous neoadjuvant therapy.

RESULTS

In total, 11 studies and 554 patients were included in this systematic review. Overall, 158 laparoscopic and 191 open procedures were performed. The AL and VI conversion rates were 11.9% and 10.46%, respectively. The total complication rate was estimated to be 13.9%, while VI-specific adverse events were recorded in 2.1% of all cases.

CONCLUSIONS

VI could be a safe and effective alternative to a diverting stoma. Although currently, VI is not widely used, it could have a widespread application in laparoscopic surgery. However, definitive trials are needed before firm recommendations on the use of VI can be made.

Pioneers of exfoliative cytology in the 19th century: the predecessors of George Papanicolaou

The purpose of our study was to summarize the knowledge on exfoliative cytology during the 19th century and to track down Papanicolaou's predecessors. A thorough study of texts, medical books and reports, together with a review of the available literature in PubMed, was undertaken. The study of cytological preparations as a diagnostic procedure can be traced back to the work of the famous French microscopist Alfred François Donné. However, the systematic study and the criteria for the diagnosis of malignant cells should be attributed to Johannes Müller. The increasing interest in the cytological examination of various fluids of the human body can be confirmed by a plethora of studies published during this period. By the end of the 19th century, the invention of new techniques in pathology, such as the introduction of cell block techniques, tissue sections and new staining methods which provided the opportunity to study surgical specimens in three dimensions, led to a decrease in the interest in exfoliative cytology, which was re-discovered by George Papanicolaou almost three decades later.

Apoptosis and cell proliferation correlated with tumor grade in patients with lung adenocarcinoma

BACKGROUND

Apoptosis and cell proliferation in patients with adenocarcinoma of the lung have not been well described with relation to fine-needle aspiration biopsies (FNABs). To investigate the contribution of apoptosis to the growth of adenocarcinoma of the lung, both apoptosis and cell proliferation were analysed for correlation with the grade of the tumor.

PATIENTS AND METHODS

Fifty tumors from 50 patients with adenocarcinoma of the lung were studied. Twelve tumors were well-differentiated, 22 were moderately differentiated and 16 were poorly differentiated. The detection of DNA fragments in situ using the terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick-end labeling (TUNEL) assay was applied to investigate active cell death (apoptosis) and the MIB-1 antigen was used to investigate cell proliferation.

RESULTS

The TUNEL indices were 0.55±0.09, 0.90±0.33 and 3.1±0.99 in well-, moderately and poorly differentiated adenocarcinoma of the lung respectively. The MIB-1 antigen labeling indices were 7.1±0.12, 14.3±3.5 and 28.7±6.9, respectively, in the same order of tumor differentiation. The differences in both TUNEL and MIB-1 labeling indices were significant between well-, moderately and poorly differentiated adenocarcinoma of the lung and a positive correlation was found between the TUNEL indices and the MIB-1 indices.

CONCLUSION

Apoptosis (cell death) and cell proliferation increases as the grade of differentiation decreases in adenocarcinoma of the lung, suggesting a rapid turn over of the tumor cells in tumors with a lower grade of differentiation.

Hallmarks in 18th- and 19th-century epilepsy research

The purpose of this study was to reveal the major views of the early scientific period (18th and 19th centuries) on epilepsy as both a disease and a symptom. The shaping of thought about illness and medicine as a science, which began in the Renaissance and progressed into the Enlightenment, intensified during the 18th and 19th centuries. During this period of increasingly methodical investigation, researchers undertook a thorough study of epilepsy. Renowned doctors of this period from the Dutch and German medical schools, the "golden era" of French medicine, and British medicine, including, of course, John Hughlings Jackson, all left their mark in this era of epilepsy research. Epidemiological studies using large patient data sets were conducted for the first time, as was systematic research on the pathophysiological, pathological, neurological, and psychiatric aspects of the disease.

What's in a name? Evidence that Papanicolaou, not Babes, deserves credit for the Pap test

The purpose of our study is to elaborate on the ongoing controversy regarding the origination of the Pap test between the supporters of George Papanicolaou and Aurel Babes. We studied the original articles published by Aurel Babes and George Papanicolaou and conducted a comparative evaluation of both methods. Babes' method is radically different from Papanicolaou's method. Differences included the sampling method, the fixation and staining technique, and the interpretation of the results regarding cases of cervical cancer. We conclude that the establishment of the technique in clinical practice and the idea of its application as preventive control of cervical cancer belong solely to George Papanicolaou.

Cancer and Roman medicine

In this article we present the opinions of some eminent Roman physicians about cancer. We emphasize the points of view of Galen, famous Roman physician of Greek origin whose doctrines dominated medicine for more than 15 centuries. We then cite the opinions about cancer of some other outstanding physicians of that period like Celsus, Pliny, Leonidis of Alexandria, Aretaeus of Cappadocia, Soranus of Ephesus etc. We also quote some examples of cancer and we describe what those physicians thought of its pathogenesis, diagnosis and treatment.

Léon Athanase Gosselin (1815–1887) et ses recherches sur les maladies du testicule

Léon Athanase Gosselin fut un des plus grands chirurgiens français du xix e siècle. Il dirigea, successivement, plusieurs services universitaires de chirurgie et excella surtout en orthopédie, en anatomie, en physiologie et en urologie. Grâce à ses recherches poussées sur les maladies du testicule, du cordon spermatique et du scrotum, ainsi que sur leurs conséquences sur la fécondité et la puissance virile, Gosselin peut être considéré, à juste titre, comme un grand andrologue avant la lettre.

The history of x-ray therapy

The aim of this article is to present briefly the accidental genesis of x-ray therapy that during its first application provoked great expectations and euphoria, soon followed by difficulties and disappointments due to the abuse of radiation and to the inexperience of the first radiotherapists. Nowadays, the use of radiotherapy is restricted to certain types of cancer with excellent treatment results and with less adverse effects.

Oncologic conceptions of Ambroise Paré (1509-1590), father of surgery

Ambroise Paré, one of the leading surgeons of the 16th century, is acknowledged as the father of surgery. He exercised vast influence on several fields of medicine and surgery through his writings. This article presents and criticizes Paré's conceptions on oncology.

The great surgeon Eugène Doyen (1859-1916) and his disputable treatments of cancer

We present the case of Eugène Doyen, famous Professor of surgery and gifted practitioner, distinguished by his surgical techniques and inventions but hardly criticized for violating the medical morals by his experiments on cancer grafts and the development of an anticancer serum as noisy as ineffective.

The first leg transplant for the treatment of a cancer by Saints Cosmas and Damian

The most renowned of all medically inclined saints must have been St. Cosmas and St. Damian. They became the special patrons of surgery, due to their miraculous operations. On one occasion, they amputated a cancerous leg and replaced it with another, taken from a Moor who had just died. This dramatic cure was meat and drink for artists, and has been portrayed many times.

Uroscopy in Byzantium (330-1453 AD)

PURPOSE

The macroscopic examination of urine constituted a lasting diagnostic method from the time of Hippocrates and Galen until the Renaissance. The Byzantines, as the carriers of ancient Greek medical knowledge, adopted uroscopy.

MATERIALS AND METHODS

We reviewed the medical and historical bibliography as well as the original texts of Byzantine doctors.

RESULTS

The outcome was impressive since, at that time, uroscopy was considered a main tool of clinical diagnosis. The Byzantines influenced the Arabs and Western Europe, their scriptures were considered points of reference, and they were regarded as experts on the subject of uroscopy.

CONCLUSIONS

Byzantine doctors added new elements to the concept of uroscopy, which was based on ancient Greek knowledge. Throughout the centuries uroscopy was established as an irreplaceable diagnostic method which affected medical thinking as well as the perception of examination and cure since it practically isolated doctor and patient, especially in Western Europe.

The great oncologic surgery of the eminent Romanian anatomist and surgeon Thomas Jonnesco (1860-1929)

Thomas Jonnesco was an eminent Romanian surgeon and anatomist. Politician and patriot, he was founder of the modern Romanian experimental surgery and initiator of general rachianaesthesia. Among his scientific works we underline his contribution to the field of oncology since he established new original surgical methods for the treatment of cancer.

Methods of Lithotripsy in Ancient Greece and Byzantium

PURPOSE

In this article we present the medical methods of lithotripsy applied by ancient Greek and Byzantine physicians, and their influence on the development of surgery after that time.

MATERIALS AND METHODS

Study and analysis of the original texts of the Byzantine medical writers, written in Greek and containing the knowledge of the ancient Greek, Hellenistic and Roman periods, were performed.

RESULTS

The Byzantine method of lithotripsy was the result of the eternal knowledge of the spasmolytic, analgesic and lithotriptic effect of various herbs, together with ancient surgical techniques of stone removal from Hellenistic and Roman periods. No operation was attempted for the extraction of stones from kidneys. Rather the idea was to drop the stones to the bladder or into the urethra, or dilute them into smaller pieces with various herbs.

CONCLUSIONS

Ancient Greek and Byzantine physicians described conservative and surgical methods, derived from the texts of early surgeons, to which they added their own observations.

Paul Broca (1824-1880): founder of anthropology, pioneer of neurology and oncology

Paul Broca was an eminent surgeon, neurologist and anthropologist. He wrote many articles on brain anatomy, pathology of bones and joints, aneurysms, craniometry and physical anthropology, and he invented measuring instruments which are used even today. He described the condition of aphasia, called Broca's aphasia. Over a dozen anatomical features, including parts of the brain governing speech and smell, have made his name familiar to students. Thanks to his works on cancer and on tumors in general, he is considered as precursor of oncology.

John Hunter (1728-1793): founder of scientific surgery and precursor of oncology

In the following article we briefly present the life and scientific work of John Hunter, founder of the experimental surgery, who by means of his researches and writings in the field of Oncology, contributed enormously to the development of this discipline. In reference to this matter, we quote some examples indicative of his work on Oncology.

Cancer's conceptions of Marie François Xavier Bichat (1771-1802), founder of histology

The French doctor Bichat had a brief but outstanding career. Although the training of Bichat was exclusively that of a surgeon, his scientific interests embraced all of medicine, especially descriptive anatomy, histology, pathological anatomy and histopathology. His important contribution was to point out that organs were not homogeneous structures but were composed of different tissues.

[Immunological graft reactions after penetrating keratoplasty - A prospective randomized trial comparing corneal excimer laser and motor trephination]

BACKGROUND AND PURPOSE

Nonmechanical trephination has been established as an advantageous procedure in penetrating keratoplasty (PK) for avascular corneal diseases and has been performed successfully in more than 1000 eyes at our institution. The purpose of this study was to compare incidence, type and reversibility of immunological graft reactions after mechanical and nonmechanical trephination for PK.

PATIENTS AND METHODS

As part of a prospective randomized clinical trial 179 eyes of 76 females and 103 males were included, that had primary central PK without previous intraocular surgery between 10/1992 and 12/1997 for Fuchs' dystrophy (diameter 7.5 mm, n=73) or keratoconus (8.0 mm, n=106). The recipient and donor trephinations were performed from the epithelial side using either a motor trephine (Microkeratron, Geuder, n=91) or an 193-nm excimer laser (MEL60, Aesculap-Meditec, 1.5 x 1.5 mm spot mode, 16 - 24 mJ/pulse, repetition rate 25/s) along round metal masks with 8 "orientation teeth/notches" (n=88). As a routine, donor oversize was 0.1 mm. 128 patients (72 %) had PK only, 51 patients had simultaneous cataract extraction and PC-IOL implantation (triple procedure). Wound closure was achieved using a 16-bite double running diagonal suture by one surgeon (G.O.H.N.). In 53 % of procedures short-term-preserved donor tissue, in 47 % organ-cultured tissue was used. The mean patient/donor age was 51 +/- 17/57 +/- 19 years with nonmechanical trephination and 50 +/- 19/58 +/- 20 years with mechanical trephination. Incidence, type and reversibility of endothelial immunologic graft reactions were recorded continuously by clinical follow-up in an outpatient service with cornea specialization (after 6 weeks, then every 3 months until after suture removal, then every half year).

RESULTS

During a mean follow-up of 40 +/- 15 months, 7.3 % of eyes developed an immunological endothelial graft reaction. Acute diffuse (5.6 %) were more frequent than chronic focal reactions (1.7 %). Only 1.7 % of grafts became irreversibly cloudy. More than 80 % of all graft reactions occurred later than one year (on average 23 +/- 13 months) after PK. Neither incidence (p=0.82, Chi square test) nor cumulative 3-year-rate of immunological graft reactions (p=0.91, LogRank test) differed significantly comparing nonmechanical (6.8 % or 7.3 %) and mechanical (7.7 % or 5.6 %) trephination. In eyes with keratoconus (6.6 %, 16 +/- 8 months) graft reactions did not occur more frequently (p=0.68) but earlier (p=0.02) than in eyes with Fuchs' dystrophy (8.2 %, 31 +/- 11 months). Donor age, post-mortem-time and preservation period did not significantly affect the rate of graft reactions in our study setting.

CONCLUSIONS

Besides well-established optical advantages, nonmechanical trephination using the excimer laser seems to have no immunologic drawbacks in contrast to conventional mechanical trephination. Donor parameters appear to have no major impact on the incidence of graft reactions after non-high-risk PK. Rather, an adequate postoperative therapy with topical steroids, an informed patients' compliance, a consequent long-term follow-up in a clinical out-patient service with corneal specialization and a good education of and cooperation with the referring ophthalmologists are of utmost importance for the clear corneal graft in the long run.

Peoscopic diagnosis of flat condyloma and penile intraepithelial neoplasia. Clinical manifestation

Peoscopy was performed in order to assess penile lesions in the male sexual partners of 326 women with cervical intraepithelial neoplasia (CIN) or flat condyloma (FC). Each patient was submitted to a careful naked-eye inspection, peoscopy and biopsy of any suspicious lesion which was confirmed histologically and immunohistochemically. A brush cytologic examination of the distal portion of the urethra was also performed. The distribution of penile lesions was as follows: (1) 8 patients with herpes virus infection; (2) 37 patients with condyloma accuminata (CA); (3) 89 patients with FC; (4) 51 patients with FC and CA; (5) 18 patients with penile intraepithelial neoplasia grade 1 (PIN-I); (6) 2 patients with PIN-II; (7) 17 patients with PIN-III; (8) 92 patients with no penile lesions; (9) 7 patients with human papilloma virus infection of papillae coronae glandis, and (10) 5 patients with FC of the distal portion of the urethra. Naked-eye inspection revealed the presence of penile lesions in 39 of 233 patients (16.73%). Peoscopic examination revealed the presence of penile lesions in 233 of 326 patients (71.48%). In 135 of 155 patients the peoscopic findings were in accordance with the histologic diagnosis (87.09%). Immunohistochemical (by indirect peroxidase-antiperoxidase method) detection of virus antigens was positive in 16 of 34 patients (47.03%). It is concluded that peoscopy of the male sexual partners of women with CIN or FC should be performed to better assess the treatment used in the couple.

Peoscopic diagnosis of flat condyloma and penile intraepithelial neoplasia. IV. Urethral reservoir

The aim of the present study was to test the method of urethral cytologic sampling and to assess its results in the cytologic detection of human papillomavirus infection in the male partners of infected women. Cytologic evidence of abnormal epithelium was found in a total of 50 out of 167 cases (29.94%). It is interesting to note that 9 (5.38%) patients with cytological evidence of flat condylomas of the urethra did not have any other lesion. On the basis of the present study, we conclude that cytobrush urethral cytology should be routinely associated with peoscopy in studying the male partners of women affected by human papillomavirus infection, in an effort to diminish the reservoir of a virus strongly associated with cervical and penile neoplasia.