Management of major obstetric hemorrhage prior to peripartum hysterectomy and outcomes across nine European countries

Introduction

Peripartum hysterectomy is applied as a surgical intervention of last resort for major obstetric hemorrhage. It is performed in an emergency setting except for women with a strong suspicion of placenta accreta spectrum (PAS), where it may be anticipated before cesarean section. The aim of this study was to compare management strategies in the case of obstetric hemorrhage leading to hysterectomy, between nine European countries participating in the International Network of Obstetric Survey Systems (INOSS), and to describe pooled maternal and neonatal outcomes following peripartum hysterectomy.

Material and methods

We merged data from nine nationwide or multi‐regional obstetric surveillance studies performed in Belgium, Denmark, Finland, France, Italy, the Netherlands, Slovakia, Sweden and the UK collected between 2004 and 2016. Hysterectomies performed from 22 gestational weeks up to 48 h postpartum due to obstetric hemorrhage were included. Stratifying women with and without PAS, procedures performed in the management of obstetric hemorrhage prior to hysterectomy between countries were counted and compared. Prevalence of maternal mortality, complications after hysterectomy and neonatal adverse events (stillbirth or neonatal mortality) were calculated.

Results

A total of 1302 women with peripartum hysterectomy were included. In women without PAS who had major obstetric hemorrhage leading to hysterectomy, uterotonics administration was lowest in Slovakia (48/73, 66%) and highest in Denmark (25/27, 93%), intrauterine balloon use was lowest in Slovakia (1/72, 1%) and highest in Denmark (11/27, 41%), and interventional radiology varied between 0/27 in Denmark and Slovakia to 11/59 (79%) in Belgium. In women with PAS, uterotonics administration was lowest in Finland (5/16, 31%) and highest in the UK (84/103, 82%), intrauterine balloon use varied between 0/14 in Belgium and Slovakia to 29/103 (28%) in the UK. Interventional radiology was lowest in Denmark (0/16) and highest in Finland (9/15, 60%). Maternal mortality occurred in 14/1226 (1%), the most common complications were hematologic (95/1202, 8%) and respiratory (81/1101, 7%). Adverse neonatal events were observed in 79/1259 (6%) births.

Conclusions

Management of obstetric hemorrhage in women who eventually underwent peripartum hysterectomy varied greatly between these nine European countries. This potentially life‐saving procedure is associated with substantial adverse maternal and neonatal outcome.

Epidemiological analysis of peripartum hysterectomy across nine European countries

INTRODUCTION

Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries.

MATERIAL AND METHODS

We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section.

RESULTS

A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (ρ = 0.67, P < .05).

CONCLUSIONS

Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy.

Analyses of severe acute maternal morbidity in Slovakia during years 2012-2016

AIM

Severe acute maternal morbidity (SAMM) is a state of the woman, when she nearly died, but survived. The aim of study was to find out the exact incidence of SAMM in Slovakia, establishment of functional surveillance system and improve quality of health care.

MATERIALS AND METHODS

The regular annual analyses of SAMM cases in Slovakia from January 1st 2012 to December 31st 2016. Observed SAMM included: peripartum haemorrhage, peripartum hysterectomy, uterine rupture, abnormally invasive placenta, HELLP syndrome, eclampsia, sepsis, transport to intensive care unit or anaesthesiology and non-fatal amniotic fluid embolism.

RESULTS

The response rate of questionnaires was 84.8 %. The overall confirmed incidence of SAMM was 6.35/1,000 births (95% CI 6.03-6.67). The most often causes of SAMM were: peripartum haemorrhage (2.1/1,000 births), transport to intensive care unit or anaesthesiology (1.46/1,000 births), peripartum hysterectomy (0.84/1,000 births) and HELLP syndrome (0.63/1,000 births). The average age of women with SAMM was 30.3 years (14-46) and average parity was 1.16 (0-15).

CONCLUSION

The incidence of SAMM and especially incidence of peripartum haemorrhage and peripartum hysterectomy in Slovakia is one of the highest in Europe. To decrease incidence and improve management and outcome of patients, regular audit of SAMM is needed (Tab. 3, Fig. 2, Ref. 30).

The management and genetic background of pityriasis rubra pilaris: a single-centre experience

BACKGROUND

Pityriasis rubra pilaris (PRP) is a rare chronic inflammatory dermatosis with multifactorial aetiology. It is known that particular caspase recruitment domain family member 14 (CARD14) gene mutations are associated with familial PRP and certain forms of psoriasis. Additionally, few data are available about the role of CARD14 gene variants in sporadic PRP. The clinical picture is variable for the different types of PRP, therefore choosing the adequate treatment is often difficult, furthermore there are no specific guidelines for therapy.

OBJECTIVE

Our aim was to survey the efficacy of the applied therapies and to screen the CARD14 gene variants in our PRP patients.

METHODS

In this retrospective study, patients diagnosed with PRP between 2006 and 2016 at our clinic were involved. Besides the follow-up study of the treatments, the genetic analysis of CARD14 gene was performed.

RESULTS

We analysed 19 patients, among whom 17 were diagnosed with type I, one with type III, and one with type V PRP. The majority of the patients were successfully treated with acitretin in combination with systemic corticosteroids, and the remaining patients were treated with other systemic therapies with diverse effects. The genetic screening of CARD14 gene revealed two previously described mutations (rs114688446, rs117918077) and six polymorphisms (rs28674001, rs2066964, rs34367357, rs11653893, rs11652075, rs2289541). Ten of 19 patients carried different CARD14 genetic variants either alone or in combination.

CONCLUSION

Based on our experience, we propose that acitretin and an initial combination of short-term systemic corticosteroid therapy could be a successful treatment option for PRP. Although we identified several CARD14 variants in almost half of our cases, we did not find a correlation between the therapeutic response and the genetic background. Our data support the previous observation that CARD14 genetic variants are not specific to PRP, although they may indicate chronic inflammation.

Active surveillance of incidence and risk factors of hemolysis, elevated liver enzymes and low platelets syndrome in Slovakia

OBJECTIVE

Hemolysis, Elevated Liver Enzymes, Low Platelets syndrome (HELLP syndrome) is one of the actively haunted maternal morbidity through Slovak Obstetric Survey System (SOSS), the organisation for surveillance of severe maternal morbidity and mortality in Slovakia.

METHODS

The questionaires were sent in 55 Obstetric Units in Slovakia. The analyzed and here presented data had been collected cases those happened in the period from 1.1.2012 till 31.12.2014. Controls were women from SR during observed years, who delivered without HELLP syndrome.

RESULTS

The return rate of questionnaires was 89.67 %, thus covering 146 972 deliveries during the study period in Slovakia. The exact incidence of HELLP syndrome was 0.63/1000 deliveries (CI 95 % 0.51-0.78). Risk factors were age > 30 (OR = 1.63), nuliparous (OR = 2.96), pregnancy after assisted reproduction technology (OR = 8.29) and multiple pregnancy OR = 9.19). The mean gestation age at delivery was 33.8th weeks. Vaginal delivery was by 10 (10.8 %) patients with HELLP syndrome and in the 83 (89.2 %) patients pregnancy was terminated with acute caesarean section. There were reported 45 050 cases (30.7 %) of the caesarean section in the control group throughout the study period.

CONCLUSION

The older age, nulliparity, multiple pregnancy and pregnancy after assisted reproduction techniques was identified as a significant risk factors of HELLP syndrome (Tab. 5, Fig. 1, Ref. 21).

[Idiopathic bilateral patellar tendon rupture]

In the absence of systemic disease, specific treatment or sport tendonitis, simultaneous bilateral patellar tendon rupture is rare. Often missed on the first glance, it represents a diagnostic difficulty that should not be overlooked at the initial medical visit. The loss of active extension of the lower limb and a radiographic patella alta, even in a bilateral context, should raise suspicion of this diagnosis. It is then necessary to search for predisposing causes and to evoke the differential, or frequently associated, diagnoses. The present report illustrates these diagnostic difficulties and summarizes some clinical considerations that might help to avoid neglecting these different elements at the first medical visit (positive diagnosis, associated lesions, favouring factors).

[Medical decision in a very elderly patient: a case report of application of the Leonetti law in emergency medicine]

Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in accordance with the spirit of the law.

Effect of hyaluron derivate gel in prevention of postsurgical peritoneal adhesions--an experimental study in pigs

BACKGROUND/AIMS

The aim of this study was to assess the efficacy of a hyaluronic acid derivate gel in reducing adhesions in pigs undergoing laparoscopic abdominal cavity surgery.

METHODOLOGY

20 domestic female pigs underwent laparoscopy in general anesthesia. 4 defined serosal defects have been made (hepatoduodenal ligament, parietal, anterior stomach wall and jejunal mesentery). The defects have been covered with 20 mL Hyalobarrier Gel in 10 randomly selected pigs. 2 weeks postoperatively the pigs got reoperated for evaluation of potential adhesions.

RESULTS

17 pigs remained for evaluation. 2 pigs died during introduction of anesthesia, one at the end of the operation. None of the pigs died due to a reaction to the gel. We found adhesions in 33% of the gel group (n=3 out of 9) and in 87.5% in the group without gel (7 out of 8): p < 0.05. Most of the adhesions have been found at the parietal defect (7 out of 17 at all).

CONCLUSIONS

The hyaluronic acid gel was highly efficacious and reduced the number and extent of adhesions throughout the abdomen following laparoscopic peritoneal surgery significantly.

Laparoscopic Azygoportal Disconnection Procedure with a Bipolar Feedback Controlled Sealing System in a Porcine Model1

BACKGROUND

To examine the feasibility of a new, minimally invasive procedure for the devascularization of the proximal stomach and distal esophagus to prevent recurrent variceal bleeding in portal hypertension in a new animal model.

MATERIAL AND METHODS

Portal hypertension was created by laparoscopic clip ligation of the portal vein on 20 pigs. After 2 weeks the azygoportal disconnection procedure was performed with the LigaSure-ATLAS instrument.

RESULTS

There were 16 pigs out of 20 that survived both operations. Two died during introduction of anesthesia, one because of a cardiac arrest (second operation). One pig died resulting from necrosis of the gastric and esophageal wall. Autopsy (2 weeks later) showed that there was a complete arterial devascularization. At autopsy, none of the remaining 16 pigs had esophageal varices or necrosis of the stomach or esophagus.

CONCLUSION

Laparoscopic azygoportal disconnection is a less invasive method for the prevention of rebleeding and seems to be safely performed with the LigaSure-ATLAS instrument.

Short- versus long-sequence MRI cholangiography for the preoperative imaging of the common bile duct in patients with cholecystolithiasis

BACKGROUND

This study aimed to compare an 18-s fast spin echo magnetic resonance image sequence (coronal thick-section two-dimensional breathhold) with a three-dimensional axial and coronal thin-section sequence and its secondary reconstruction, and to assess its value in the diagnosis of bile duct pathologies, particularly common bile duct stones (CBDS) before laparoscopic cholecystectomy.

METHODS

This study prospectively included 72 patients. Because of protocol violations, 14 of these patients had to be excluded. Thus, 58 patients (29 Man and 29 women with a mean age of 51 years) who had cholecystolithiasis or suspected choledocholithiasis were evaluated. Magnetic resonance cholangiopancreatography (MRCP) was performed for all patients with a fast sequence (18 s) and a long sequence (coronal oblique and axial respiratory triggered; 16 min). Two radiologists, blinded with respect to diagnosis, evaluated all the radiographic images. The MRCP results were confirmed for all the patients: 20 by endoscopic retrograde cholangiopancreatography, 46 by intraoperative cholangiography, and 2 by percutaneous transhepatic cholangiography.

RESULTS

According to the findings, 16 patients (28%) had CBDS, 6 patients (10%) had common bile duct stenosis, and 36 patients (62%) had a clear bile duct. With regard to CBDS, the short sequence had 100% specificity, 94% sensitivity, and an overall accuracy of 98%. Its negative predictive value was 98%, and its positive predictive value was 100%. The long sequence had a specificity of 100% and a sensitivity of 100%.

CONCLUSION

Because of its high sensitivity and specifity, MRCP has the potential to be the diagnostic method of choice for CBD evaluation. The short sequence is not suitable for the diagnosis of all CBD pathologies, but in cases of suspected CBDS, more than 80% of the patients could be diagnosed correctly, and the complete sequence could be dropped.

Closure of the cystic duct during laparoscopic cholecystectomy with a new feedback-controlled bipolar sealing system in case of biliary obstruction--an experimental study in pigs

BACKGROUND/AIMS

The excellent results of new devices like the new bipolar feedback-controlled sealing system (LigaSure) for closure of blood vessels encouraged surgeons to use these instruments for other structures like bile ducts. The aim of this study was to evaluate the feasibility of closure of cystic duct in case of biliary obstruction.

METHODOLOGY

Ten domestic pigs underwent laparoscopic cholecystectomy sealing the cystic duct with LigaSure. The common bile duct was closed with an endoclip to create a biliary hypertension. On the 12th postoperative day blood samples were taken for liver enzymes. At autopsy on day 15 the pigs were investigated for bile leaks or biliary peritonitis. The cystic duct was resected for histological examination.

RESULTS

Seven pigs survived, one pig died during introduction of anesthesia, one on the 1st and one on the 2nd postoperative day without any findings at the autopsy. One pig out of 7 had a bile leak; the other 6 were without any sign of leakage. Histologically 3 pigs had a regular coagulation zone at the cystic duct, 3 had a total necrosis, one a partial necrosis of the mucosa only.

CONCLUSIONS

Though there was only one insufficiency, the feedback-controlled bipolar vessel sealer cannot be recommended for biliary surgery with regard to the high rate of necrosis stated in our experiment.

Novel technique of laparoscopic azygoportal disconnection for treatment of esophageal varicosis: preliminary experience with five patients

BACKGROUND

Liver cirrhosis leads frequently to the development of ascites and a formation of varicose veins in the esophagus. The latter presents increased mortality risk. Recently, significant progress in laparoscopic technology enabled devascularization of the proximal stomach in a less invasive way. The results experienced by five patients are presented.

METHODS

Laparoscopic azygoportal disconnection was performed by means of novel technique (Danis procedure) in five men with esophagus varices bleeding (2nd to 11th events) and liver cirrhosis stage Child-Pugh B and C. This procedure was performed after all other methods had either failed to prevent recurrent bleeding or were refused by the patient. Five ports were positioned on the upper abdominal wall. The veins in the lesser omentum were divided by means of the LigaSure-Atlas device. The stomach coronary vein was visualized, and all the proximal branches toward the esophagus as well as the short gastric vessels were divided. The diaphragm hiatus was opened, and the distal esophagus was dissected. The paraesophageal venous collaterals also were divided, and the remaining varicose veins of the esophagus were interrupted by transmural stitching.

RESULTS

All the patients survived the minimally invasive procedure. Two of them died 9 and 16 months after surgery, respectively, because of liver insufficiency. No bleeding event from varicose veins in the esophagus occurred postoperatively.

CONCLUSION

Laparoscopic azygoportal disconnection is a less invasive method for prevention of rebleeding from varicose veins in the esophagus. Further studies are necessary to confirm these preliminary results.

Laparoscopic resection of an accessory spleen in a patient with chronic lower abdominal pain

During a diagnostic laparoscopy in a patient with chronic lower abdominal pain we found a pediculated accessory spleen (AS) near the left adnex. The pedicle was dissected by ultrascision, it was cut by an Endo GIA, and the AS was extracted. AS occurs in 25-40% of the population. They are always situated on the left side: hilum of the spleen, splenic artery, pancreas, splenocolic ligament, greater omentum, mesenterium, adnexal region, and scrotum. In most cases they are asymptomatic. In hematological disorders they can take over the function of the original spleen after splenectomy. Sometimes, AS can mimic tumors in other organs, such as pancreas, kidney, or liver. Likewise, there are descriptions of AS in the scrotum, the spermatic cord, the adnexes, the uterus, the stomach, the small intestine, or the heart. In rare cases they can cause pain because of cysts, abscesses, hemorrhage, or spontaneous rupture. In acute pedicle torsion an infarction can be caused presenting as acute abdomen, which is most often seen in young patients. In our case the pain was caused by pedicle torsions or mechanical irritation of the adnex. The cause of the changing localization of the pain was the long pedicle. In describing this case, we point out the advantage of diagnostic laparoscopy in patients with chronic lower abdominal pain.

Laparoscopic Sugiura procedure for conditioning of the blood stream through TIPSS in cirrhotic patient. Initial experience

The Sugiura procedure or the proximal gastric devascularisation was formerly the method of choice for esophageal varicose treatment in some patients. The frequency of this operation decreased stenting after the introduction of the transjugular portosystemic shunt into clinical practice. However this method performed laparoscopically could be useful as a complementary procedure when the blood stream through the transjugular intrahepatic portosystemic stent shunt is low and an esophageal rebleeding occurs. A 40-year old patient with hepatic cirrhosis and Child stage "B" was admitted to our clinic due to recurrent esophageal varicose bleeding. He underwent a transjugular intrahepatic portosystemic stent shunt implantation 27 months before the admission and the transjugular intrahepatic portosystemic stent shunt became occluded 3 times since implantation and was repeatedly revised. After admission a color Doppler of the stent was performed. The blood stream was 15 cm/s. The laparoscopic Sugiura procedure was performed after conditioning of the general status of the patient. Five ports were introduced 5 cm above the umbilicus, under the xiphoid, the right and left hypochondrium as well as the left mesogastrium. The dilated veins between the gastric coronary vein and esophagus and the short gastric veins on the great curvature were interrupted by means of an ultrasonic scalpel. The hiatus esophagus was opened, the esophagus was prepared up to the first pulmonal vein and the dilated esophageal veins were occluded with stitch ligatures. The operation was completed with Toupet partial fundoplication. The patient was followed 6 months after the surgery. No rebleeding occurred in this time period. Immediately after surgery the blood flow increased up to 97 cm/s; at 3 and 6 months follow-up the intrahepatic shunt remained open with 82 and 80 cm/s blood flow respectively. Laparoscopic Sugiura procedure performed as a complementary surgery after transjugular intrahepatic portosystemic stent shunt implantation increased blood perfusion through the intrahepatal constructed shunt and prevented its occlusion. However this initial experience has to be confirmed with a larger number of patients.

Laparoscopic transgastric pancreatic pseudocystogastrostomy--first experience with extraluminal approach

BACKGROUND/AIMS

Transgastric cystogastrostomy (Jurasz procedure) became a standard procedure in the treatment of mature pancreatic pseudocysts contacting the stomach. The first experience with laparoscopically performed transgastric cystogastrostomy under performing anterior gastrostomy is discussed.

METHODOLOGY

Five ports were used. The anterior stomach wall was opened 2 cm in length. The communication channel with the pseudocyst was created by means of precise coagulation of the posterior stomach as well as the pseudocyst wall. The pseudocyst was evacuated and the stoma was completed by stapling with the EndoGIA lineal stapler 3 cm in length. The anterior stomach wall was also closed with EndoGIA stapler.

RESULTS

Excellent results could be achieved. The pseudocyst resoluted within 1 month after the operation, and the anastomosis healed completely. The patient was discharged on the 8th post-operative day. The follow-up for 1 year was free of complications.

CONCLUSIONS

Laparoscopic pseudocystogastrostomy appears to be a reliable method for treatment of large size mature pancreas pseudocysts because it is a minimally invasive procedure with standardized stapler-performed anastomosis. However, this initial experience has to be confirmed with a large number of patients.

The effect of contrast variation on task performance in video evaluation

BACKGROUND

Luminosity and brightness of the organs viewed on the screen are important for orientation during teleoperating. They can impair the precision of our orientation ability.

METHODS

The way in which organs scatter light during laparoscopic operation was detected and analyzed by means of reflection spectrophotometry with the Photoshop program package (ADOBE). The arithmetical skill was measured during different illumination conditions of the screen created randomly, using values of the liver, gallbladder, and omental fat.

RESULTS

Separate human tissues and organs could be divided on the basis of their luminosity into three basic groups: the luminous tissues such as fat, the stomach, and the bowel; medium-luminous organs such as diaphragm and gallbladder; and dark, mostly parenchymatous organs such as the liver and the spleen. The most luminous tissue illuminated the screen intensely. In experiments the hyperillumination impaired arithmetical skills of 15 volunteers. The errors appeared constantly and the time needed to count the generated points was significantly longer when 40% of intensively illuminated view was exceeded.

CONCLUSIONS

A situation may occur wherein the imaging system lacks the capacity to transmit needed optical information. Intense brightness of the screen may suppress surgical skills during teleoperating. Critical limit was achieved in our experiment with 40% of the view illuminated by omentum fat. This limit can be important for robotic surgical systems such as automated robotic camera control.

Anterior luxtasphincteric stapled rectumresection

BACKGROUND/AIMS

Sphincter saving deep anterior rectumresection improved the live quality of the rectal cancer patients. With the technical progress the resection level could be moved significant distally. The initial experiences are referred with the use of the stapler with flexible shaft in six patients operated due to very deep rectal cancer.

METHODOLOGY

After the usual rectum mobilization the Proximate access AX55 mm (Ethicon) is positioned onto the stretched rectum. The flexible shaft has to be curved to the front and the jaw has to be angled parallel to the handle. The partially closed jaw of the stapler is then pushed towards the anus and then fired. The rectum is the resected. The operation is completed with EEA stapled anastomosis.

RESULTS

Excellent results in all six patients could be noticed 3-18 months after the procedure. No cancer recurrence occurred. Functional sphincter investigation was performed in two patients with result of physiologic sphincter function. Stolen frequency has been stabilised between 2-8 a day.

CONCLUSION

Improved transabdominal stapled method of rectum resection guarantees comfortable and oncologically safe resection of the distal rectum with maintenance of the sphincter function.

The "balanced" operation for life threatening complications of severe "non responding" form of gastroesophageal reflux disease. A case report

The fate of patients developing life-threatening complications of the Barret's non-responding ulcer during an acute treatment is lacking in the literature. Medical therapy with proton pump inhibitors (PPI) for severe forms of gastroesophageal reflux disease fails in 15-20%. Emergency operation is indicated in failed cases. We present an operation which restores anatomical and functional deviations causing reflux disease. Two patients required early surgery due to bleeding and penetration of Barret's ulcer during PPI therapy. Both patients had reflux disease, a Savary Miller stage of IV, and/or the M3; U1; S0; E3 and M3; U3; S0; E3 stage of "MUSE" assessment respectively. The modified "balanced operation" was performed consisting of a truncal vagotomy, hiatus hernia reposition, posterior crura repair, fundoplication and extramucosal pyloroplasty. Both patients had excellent outcomes after surgery. Visick I and II, or M3; U0; S0; E1 and M3; U0; S0; E0 respectively and remained well over the year without any medication. The modified "balanced" operation seems to be the method of choice for treatment of severe, "non responding" form of GERD when complications occur. Various pathophysiological factors such as hyperacidity, the cardia valve and gastric emptying are affected simultaneously. The rationale for the performance of all steps of the "balanced" operation is based on the fact that we do not know before the operation, which steps will be necessary to produce a good result.

Theoretical basis for camera control in teleoperating

BACKGROUND

The triangle paralaxis method for camera control in teleoperating is presented.

METHODS

For orientation in the 3D space of the corporic cavity there are three points necessary for the creation of the paralaxis triangle. This triangle is then imagined and compared with topography during surgery. The first and second points are created in one's mind at the locus of the entry of the instruments into the viewing field of the camera. The third apex of the triangle is the area of dissection-the point in which the instruments converge. The fourth point to be viewed determines the course of dissection. Triangle paralaxis may be applied in dissection with only one instrument as well as in the zooming technique, closely viewing a part of the dissecting instrument.

RESULTS

Using this technique a 7.78% rate of conversion and 2.15% rate of reoperation could be achieved in 334 evaluated laparoscopic cholecystectomies performed in a small public hospital.

CONCLUSIONS

Triangle paralaxis seems to be a simple method for ensuring an optimal camera view during laparoscopic surgery.

In vitro and in vivo viability assessment of unpurified pancreatic islet tissue

The viability of porcine collagenase-prepared islet preparations (n = 16) was classified by 31P-NMR spectroscopy, staining by neutral red and trypan blue, and in vitro insulin secretion following glucose challenge. Vital islets exhibited a phosphate diester/phosphate monoester (PDE/PME) ratio of 0.5-0.9, a staining score of 18-30 and an insulin secretion responding well to glucose challenge. Damaged islets performed at a PDE/PME of 0.2-0.49 and a staining score of 9-17 and necrotic islets had 0.0-0.49 and a staining score of 9-17 and necrotic islets had 0.0-0.19 and 0-8, respectively. The islets of the latter two groups did not adequately respond to glucose. The in vivo function following autotransplantation of these islets into the spleen was investigated in five recipients of more than 3000/kg vital islets of which 4 expressed daily normoglycemia (< 200 mg%), normalized intravenous glucose tolerance (K = -2.21), and a prolonged survival (mean +/- SD) of 167 +/- 12 days compared to five recipients of > 3000/kg damaged islets (K = -0.814) (P = 0.0017) and a survival of 86 +/- 21 days (P = 0.0096). It is suggested that 31P-NMR spectroscopy is a valuable and practical method to predict islet graft viability prior to transplantation in order to assure good graft function in the recipient.

[The pig--an experimental model for transplantation of isolated islets pancreatic islets]

The authors present results of autotransplantation of the islets of Langerhans of the pancreas in pigs and miniature pigs ("Troll"). Diabetes was induced by total pancreatomy. From the removed pancreas the islets of Langerhans were separated by the method of intraductal perfusion with collagenase and implanted into the spleen or liver via the portal vein. The mortality on operation in pigs was 33%, in miniature pigs 20%. In domestic pigs normal blood sugar levels were achieved in 25% after implantation of the islets of Langerhans into the liver (in 2 of 8 animals) and in 50% after implantation into the spleen (in 4 of 8 animals). In miniature pigs autotransplantation of the islets of Langerhans was equally successful when transplanted into the liver or the spleen -50%. The 50% success of autotransplantations justifies the use of pigs as a model for further investigations of allo- or xenotransplantations of the islets of Langerhans.

[Extracorporeal lithotripsy--a new possibility in the treatment of gallstones?]

In the submitted review the author presents the results of treatment of cholelithiasis by extracorporeal lithotripsy by shock waves. Provided there is strict selection of patients with 1-3 cholesterol concrements in the gallbladder, treatment is successful in 70-90%. Complications occur in cca one third of the patients, the mortality rate is zero. The author gives criteria for indication which are met by cca 15-20% patients with cholelithiasis. In the discussion the author analyzes possibilities of urgent and preventive lithotripsy of gallstones, the number of relapses and biological effectiveness of shock sound waves, problems of competence and the economic effect of treatment.

31P NMR spectroscopy for in vitro viability testing of porcine pancreatic islets

The quality of pancreatic islets prepared by an intraductal pancreas collagenase perfusion technique was tested using three independent methods: 31P NMR spectroscopy, an insulin secretion test, and a staining method. The viability of pancreatic islet tissue was evaluated using the ratio of phosphate diester to phosphate monoester (PDE/PME) as a new criterion obtained by 31P NMR spectroscopy. According to this criterion, three types of tissue fragments could be characterized: vital (PDE/PME 0.5-0.9), damaged (PDE/PME less than 0.2), and necrotic (no PDE, no PME). The findings in the three different groups could be correlated to three trends of insulin secretion of the preparations following glucose challenge: good response to the glucose challenge, continuous decrease of insulin production, and no insulin secretion. We feel that 31P NMR spectroscopy offers a rapid and suitable method for classifying the viability of isolated pancreatic islets.

[In vitro and in vivo studies of isolation, transplantation and function of Langerhans islets in the swine]

Limits and possibilities of the transplantation of islets of Langerhans in pigs were studied. 6 x 10(4) to 3 x 10(6) islets and insulin producing fragments per pancreas were obtained by intraductal collagenase digestion of the pancreatic gland following total pancreatectomy. Islets grafted into the spleen or liver rendered normoglycemia to the pancreatectomized animals as demonstrated by normal fasting blood sugars and normal intravenous glucose tolerance tests as compared to not operated animals permitting a survival time of up to one year. Apancreatic controls died of ketoacidosis and diabetic coma 10 to 12 days posttransplant. The number of isolated and transplanted islets correlated well to the normoglycemic state of the animal. Beyond that the in vitro challenge of the islets with glucose and resulting insulin secretion was a very important indicator for the functional status and integrity of the islets after transplantation. Thus the pig appears to be a suitable model for the preclinical studying of islet transplantation especially since immunologic, physiologic and anatomic features of the pig are similar to those in the human regarding pancreas and nutrition.