Drugs recently associated with lupus syndromes

To assess the long-term outcome in patients with acute cholecystitis treated initially by percutaneous cholecystostomy, the authors reviewed the medical and radiology records of all such patients treated at their hospital from January 1990 to September 1993. Of the 50 patients, 29 had calculous and 21 had acalculous cholecystitis. In the group with calculous cholecystitis, 1 of the patients required no further treatment, 3 subsequently underwent percutaneous stone removal, 14 underwent elective cholecystectomy, 6 underwent emergency cholecystectomy and 5 died of the underlying condition shortly after cholecystostomy. In the group with acalculous cholecystitis, 12 of the patients needed no further treatment after a mean follow-up period of 12 months; 8 of these underwent follow-up ultrasound examination, which revealed gallbladder calculi in only 1 patient. Four patients underwent elective cholecystectomy, 1 underwent emergency cholecystectomy, and 4 died of the underlying condition shortly after cholecystostomy. Over the long term, 23 (79%) of the 29 patients with calculous cholecystitis underwent surgery or removal of calculi. In the other group surgery was required in only 5 (24%) of the 21 patients. The authors conclude that percutaneous cholecystostomy is a useful temporizing measure, which allows patients with calculous cholecystitis to undergo elective cholecystectomy. In most cases of acalculous cholecystitis the procedure is curative, obviating the need for cholecystectomy.     

Acute inoperable cholecystitis treated by endoscopic naso-vesicular drainage. Study of 15 patients

OBJECTIVES: Cystic duct cannulation during endoscopic retrograde cholangiography is now possible, due to advances in endoscopic equipment and methodology. The aim of this study was to assess the role of endoscopic transpapillary cholecystostomy in inoperable patients with acute cholecystitis. METHODS: Between October 1993 and February 1996, cystic duct cannulation was performed in 15 patients with acute cholecystitis (9 men and 6 women; mean age 74.8 years. Acute calculous cholecystitis was associated with cholangitis in 4 cases, with pancreatitis in 2 cases, and with perforation of the gallbladder in 1 case. RESULTS: Cystic duct cannulation was successful in 13 patients (86.6%), and resulted in remission of cholecystitis by nasovesicular drainage associated with antibiotherapy in all cases. No morbidity and mortality due to this method was observed at one month. No recurrence was observed after a mean follow-up of 8 months (range: 6 weeks-14 months). CONCLUSION: This study suggests that endoscopic nasovesicular drainage is a good alternative treatment to percutaneous cholecystostomy in inoperable patients.     

Percutaneous cholecystostomy for suspected acute cholecystitis in the hospitalized patient

PURPOSE: The authors evaluated the outcome of 49 hospitalized patients with sepsis and possible acute cholecystitis in whom emergency percutaneous cholecystostomy was attempted on 50 occasions. PATIENTS AND METHODS: All cholecystostomy procedures were performed with ultrasound (US) guidance by using either the trocar (n = 35) or the Seldinger (n = 15) technique. Forty of the 50 cholecystostomies (80%) were attempted at the patients' bedside, and 49 of the 50 catheters (98%) were placed successfully. RESULTS: Twenty-five of these patients eventually died of other causes (51%), but there was clinical improvement in 31 of the 49 patients (63%) based on a 72-hour decrease of temperature to less than 37.3 degrees C, normalization of white blood cell count, and/or resolution of abdominal pain. US findings were correlated with clinical response. Clinical improvement occurred most frequently after cholecystostomy in patients with either a distended gallbladder (74%), pericholecystic fluid (80%), or gallstones (92%). Forty-three of the 49 patients underwent cholecystostomy alone (88%), and six required further procedures (12%). There were six complications (12%) including catheter dislodgment (n = 3), hematoma (n = 1), and severe pain (n = 2). No deaths were directly attributed to percutaneous cholecystostomy. CONCLUSION: Percutaneous cholecystostomy performed in septic hospitalized patients is a low-risk procedure that may be helpful in the treatment of some patients with suspected acute cholecystitis.     

Gallbladder puncture and drainage as therapy of acute cholecystitis

PATIENTS AND METHODS: An ultrasound-guided, percutaneous puncture (n = 30) and cholecystostomy (n = 10) was performed on 40 high-risk patients aged between 38 and 99 (mean age 78 years old) suffering from acute lithogenic cholecystitis or acalculous stress cholecystitis on account of general inoperability. Two catheter dislocations and in 3 cases a slight bile leakage were observed as complications. RESULTS: The puncture and drainage led to a dramatic alleviation of pain for all patients, the involution of a paralytic subileus and improvement of the general condition. Eighteen patients underwent a laparoscopic or open interval cholecystectomy in a stabilised condition. There was no recurrence of inflammation in 22 patients over a follow-up period of up to 5 years, so that one can assume a cicatrised healing of the acute choleycstitis. CONCLUSIONS: Ultrasound-guided, percutaneous puncture and cholecystostomy are effective, low-risk, and only slightly invasive procedures which can be employed for risk patients with acute cholecystitis as a life-saving, and in some cases definitive treatment. On account of pathogenic considerations, they should be included in the diagnostic and therapeutic concept at an early stage, particularly for acute, acalculous stress cholecystitis.     

Some substrates and inhibitors of cytosolic epoxide hydrolase induce sister-chromatid exchanges in mammalian cells, but do not induce gene mutations in Salmonella typhimurium and V79 cells

We describe a 66-year-old man who presented initially with acute cholecystitis. He was treated by cholecystostomy and biopsy of the gallbladder mucosa which revealed carcinoma of the gallbladder. Four weeks later a cholecystectomy was performed followed by resection of the common bile duct, common hepatic duct and segments IV and V of the liver and a hepaticojejunostomy. Sixteen months later an abdomino-perineal resection was performed for a moderately differentiated Dukes' stage C carcinoma of the rectum. He is alive and without evidence of recurrence seven years later. Few patients survive for this length of time following resection of either carcinoma of the gallbladder or rectum. This case report demonstrates the value of aggressive surgical treatment in patients with early carcinoma of the gallbladder.     

Comments on emergency treatment of biliary lithiasis in patients over 75 years of age. Apropos of 157 cases]

Surgery remains the ideal emergency treatment for biliary lithiasis in elderly subjects despite perioperative morbidity and mortality. Minimally invasive techniques appear promising but require assessment. The aim of this work was to determine the usefulness of these techniques and evaluate outcome in a series of 157 patients over 75 years of age who were hospitalized in an emergency setting of complicated biliary lithiasis from January 1990 to December 1996. There were 103 women and 54 men, mean age 82 years. The patients' general status was evaluated according to the ASA classification; 66% of the patients were ASA III, IV or V. Diagnoses at admission were acute cholecystitis (n = 71, 45%), angiocholitis (n = 50, 31%) subintrant hepatic colic (n = 17, 10.8%), pancreatitis (n = 10, 6%), isolated jaundice (n = 2), peritonitis (n = 2) and occlusion (n = 5). Within 24 hours of admission, 7 patients underwent emergency surgery, and the 150 others were given medical treatment. Among these 150 patients, cure was considered to have been achieved with medical treatment alone in 41 (subsequent surgery being required in only one 6 months later), semi-emergency was performed in 17, and a minimally invasive procedure was performed in the 92 others (echo-guided percutaneous cholecystostomy in 42, endoscopic sphincterotomy in 50) followed by a subsequent operation in 29. In the 103 patients (65.5%) in this series who did not undergo surgery, mortality was 3.8% and in the 54 patients (34.5%) who did, mortality was 15%, but this rate was only 6.9% when the open procedure followed a minimally invasive technique. Surgical treatment of complicated biliary disease remains the ideal therapy but indications should be carefully weighed in these elderly fragilized subjects. Under surgical observation, abstention from surgery or use of minimally invasive techniques can play an important role in the therapeutic strategy aimed at lowering perioperative mortality.     

Characteristics of non-participants and reasons for non-participation in a population survey in Kin-Hu, Kinmen

We analyzed the pattern of failure and clinicopathologic factors influencing the disease-free survival of 78 patients who died after macroscopic curative resection for pancreatic cancer. Local recurrence was a component of failure in 56 patients (71.8%) and hepatic recurrence in 48 (61.5%), both accounting for 97% of the total recurrence rate. About 95% of recurrences occurred by 24 months after operation. Median disease-free survival time was 8 months, and cumulative 1-, 3-, and 5-year actuarial disease-free survival rates were 66%, 7%, and 3%, respectively. Multivariate analysis showed that tumor grade (p = 0.04), microscopic radicality of resection (p = 0.04), lymph node status (p = 0.01), and size of the tumor (p = 0.005) were independent predictors of disease-free survival. Patterns of failure and disease-free survival were not statistically influenced by the type of surgical procedure performed. Median survival time from the detection of recurrence until death was 7 months for local recurrence versus 3 months for hepatic or local plus hepatic recurrence (p < 0.05). From our experience and the data collected from the literature, it appears that surgery alone is an inadequate treatment for cure in patients with pancreatic carcinoma. Effective adjuvant therapies are needed to improve locoregional control of pancreatic cancer after surgical resection.     

Intramedullary spinal cord ependymomas in children: treatment, results and follow-up

A retrospective review of 20 pediatric patients with intramedullary spinal cord ependymomas, all of whom underwent operative resection between 1985 and 1996, was undertaken to determine surgical results, long-term follow-up and tumor recurrence. Twelve children operated on in the same period with filum or cauda equina ependymomas were not included in this study. Nine children had had previous treatment before referral. Gross total resection was achieved in 14 patients and subtotal in 6. None of these had a post-operative radiation therapy. The median follow-up period was 67 months (range 25-177 months). All children were clinically evaluated before and after operation and at the last follow-up. The clinical grade at the last follow-up showed improvement in 8 patients (40%), was unchanged in 10 (50%) and deteriorated in 2 (10%). Three patients had a recurrence, 2 at the primary site (2 and 3 years after our surgery) and 1 at a distant site (3 years after). The actuarial 5- and 10-year survival rates were both 90%; 5- and 10-year progression-free survival rates were 93 and 70%, respectively. We conclude that a complete removal can be achieved in almost all cases of intramedullary spinal cord ependymomas in children, and that the long survival rates justify avoiding post-operative radiation therapy.     

Acute cholecystitis in the intensive care unit

The development of acute cholecystitis in the ICU is now a well-recognized complication of many acute illnesses that precipitate ICU admission and may also result as a complication of the subsequent treatment. The etiology of the disease remains obscure and, unlike acute cholecystitis outside the ICU setting, most cases are acalculous and not associated with gallstones. The disease may often go unrecognized due to the complexity of the patient's medical and surgical problems. Clinical examination is often unhelpful, as many patients are receiving mechanical ventilation and have decreased mental awareness. Biochemical markers are nonspecific and contribute to the delay in diagnosis and treatment. Early diagnosis is essential to avoid the high rates of associated morbidity and mortality. The diagnosis is usually made by radiologic tests, most often by sonographic examination of the gallbladder, which can be performed at the bedside. However, radiologic findings may also be nonspecific. The treatment involves gallbladder drainage by percutaneous cholecystostomy, which is usually curative in acalculous cholecystitis. Interval cholecystectomy is indicated for the remaining patients with gallstone-associated cholecystitis.     

Pathologic features and clinical outcome after anatomic radical prostatectomy by transcoccygeal approach

OBJECTIVES: A nonrandomized prospective study was conducted aimed at verifying the clinical outcome and pathologic features of a group of patients submitted to transcoccygeal radical prostatectomy. METHODS: Radical transcoccygeal prostatectomy was performed at our institution in 26 patients after laparoscopic (24 cases) or open surgical (2 cases) pelvic lymphadenectomy. Eighteen patients were selected because they were considered to be at risk for nodal metastases on the basis of preoperative staging (prostate-specific antigen level of 20 ng/mL or greater and/or Gleason score greater than 5); the remaining 8 manifested incidental prostate carcinoma. RESULTS: Intraoperative complications included rectal injury in 1 patient (3.8%) and massive blood loss in another. Transitory leakage at the site of the urethrovesical anastomosis and urethrorectal fistula occurred postoperatively in 2 patients. The rate of positive surgical margins was 26.9%. The mean follow-up time is 27 months (range 3 to 39 months). Total urinary continence was obtained in 21 patients (80.8%); 5 patients (19.2%) still require urinary pads. Four patients (15.4%) have experienced tumor recurrence evidenced only by increased serum prostate-specific antigen levels. Local tumor recurrence with positive biopsy of the urethrovesical junction was diagnosed in 3 patients (11.5%), and 1 (3.8%) experienced systemic tumor recurrence. CONCLUSIONS: Radical transcoccygeal prostatectomy is a safe procedure for the surgical treatment of prostate cancer, both from a clinical and a pathologic point of view. Operative complication as well as pathologic features and clinical outcome reported in this series of patients must be related to selection criteria used in most cases. The exact role of radical transcoccygeal prostatectomy in the clinical setting has yet to be defined. According to these preliminary results, radical transcoccygeal prostatectomy should be further investigated in the treatment of incidental carcinoma after transurethral resection of the prostate or suprapubic prostatectomy and could become an elective indication in such cases.     

Total mesenteric excision in the surgical treatment of rectal cancer: a prospective study

BACKGROUND: Total mesorectal excision has been advocated in conjunction with low anterior or abdominoperineal resection as the optimal surgical treatment for rectal cancer. It involves removal of the entire rectal mesentery as an intact unit and maximizes the likelihood of obtaining a negative circumferential margin. OBJECTIVES: To prospectively validate the efficacy of total mesorectal excision in obtaining locoregional control, to identify the perioperative factors influencing the selection of either a sphincter sparing or a sphincter ablating procedure, and to identify independent factors that may influence long-term prognosis in rectal cancers. SETTINGS: Tertiary referral center. PATIENTS: Seventy-three consecutive patients with rectal cancer located within 10 cm of the anal verge were treated from 1984 to 1997 by the senior author (F.M.). Sixty-five patients form the basis of our analysis after the exclusion of 7 patients who had their cancer removed transanally and 1 patient who had a permanent diverting stoma as the only procedure. RESULTS: Twenty-six patients underwent a sphincter ablating procedure; 39 underwent a sphincter sparing procedure. Operative mortality was 1.5%. Follow-up was complete in 64 patients (39+/-30 months; range, 3-126 months). Five-year actuarial survival rates were 88% for the 34 patients with stage I and II adenocarcinoma and 65% for the 22 patients with stage III adenocarcinoma. The local recurrence rate was 6.2% overall, but only 3.1% in the potentially curable group (stages I-III). When only patients who did not receive adjuvant chemoradiation therapy were considered (n=23), local recurrence rate was 8.3% overall and 0% in the potentially curable group. Tumor stage (P=.04) and vascular and/or lymphatic invasion (P=.002) were statistically significant in their association with survival. Circumferential lesions (P<.001), gross invasion of contiguous organs (P<.001) and distance from the anal verge of less than 5 cm (P=.01) were statistically significant in their association with the choice of a sphincter ablating procedure. CONCLUSIONS: This study confirms the efficacy of total mesorectal excision in minimizing locoregional recurrence rates and confirms the well-established prognostic value of stage and microinvasion. Moreover, it indicates that circumferential lesions, distance from anal verge, and gross invasion of contiguous organs are significant perioperative factors in the selection of the type of surgical procedure.     

Sliding conjunctival flap for the treatment of primary pterygium

BACKGROUND: The major problems after pterygium removal are recurrence and complications of the therapy. The authors investigated a simple surgical treatment without adjunctive therapy for primary pterygium. METHODS: Patients eligible to be included in the study were identified from a pterygium treatment log. They represent consecutive cases over a 6 1/2-year period, all of whom had been treated by one surgeon using a superior, sliding, conjunctival flap to cover the pterygium defect. An attempt was made to obtain follow-up of at least 1 year for each patient. RESULTS: Two hundred fifty-eight eyes in 236 patients were included in the study. Two hundred twenty-two eyes (86%) were able to be followed by either record review or re-examination. Seven pterygia (3.2%) recurred, all identified by record review, with no recurrences identified by re-examination. Recurrences were more likely after early postoperative flap retraction (5 of 7 recurrences) and recurrence occurred at a mean interval of 4.3 months (range, 1.5-11 months) after surgery. Symptomatically, the patients were comfortable, and the cosmetic result was good. CONCLUSION: This study indicates that this simple surgical procedure for the treatment of primary pterygium should be evaluated further by controlled clinical trials.     

Surgical treatment of the acute cholecystitis in the laparoscopic age. A comparative study: laparoscopy against laparatomy

OBJECTIVE: The aim of this study was to assess the complications and results of the laparoscopic opposite to open treatment of the acute cholecystitis. METHODS: A retrospective randomized study with two groups of 30 patients each one. The parameters tested were age, sex, risk factors, surgical time, hospital stay, cholecystitis type, and early or late complications. RESULTS: In the two groups there were no significant differences in age, sex, risk factors, type of cholecystitis and surgical time. The average of hospital stay was significantly longer for open cholecystectomy (9.5) than for laparoscopic technique (2.30) (p < 0.001). The complication rate was higher (7.30%) in open cholecystectomy. CONCLUSIONS: The laparoscopic cholecystectomy should be the standard procedure for the treatment of the acute cholecystitis.     

Molecular beacon sequence analysis for detecting drug resistance in Mycobacterium tuberculosis

Strictureplasty for treatment of symptomatic intestinal strictures secondary to Crohn's disease is being performed with increasing frequency. To determine the overall clinical results after strictureplasty for Crohn's disease, all patients undergoing this procedure were prospectively studied. Between 6/1/89 and 2/1/97, 57 Crohn's disease patients underwent 60 operations utilizing strictureplasties. A total of 109 strictureplasties were performed (90 Heineke-Mikulicz, 6 Finney, and 13 side-to-side isoperistaltic). The 30-day perioperative morbidity was 12%, with complications being less common for patients undergoing elective versus unscheduled operations (p < 0.002). Recurrence of Crohn's disease requiring operation was seen in seven patients after a mean follow-up of 38 months. The estimated cumulative recurrence rate after 2 years was 15 +/- 6% (+/- standard error) and 22 +/- 10% at 5 years. A recurrence developed at the site of the previous strictureplasty in only five cases. Strictureplasty is a safe, effective means of providing long-term surgical palliation to selected patients with Crohn's disease. Perioperative complication rates are comparable to those seen with standard surgical treatment, and recurrences are not excessive.     

Is psychological stress a risk factor for cerebrovascular disease?

OBJECTIVE: This prospective study was conducted to assess functional results obtained after pseudo-continent perineal colostomy using the Schmidt procedure. METHODS: Functional outcome was assessed in 40 patients who had undergone amputation of the rectum for cancer and pseudo-continent perineal colostomy reconstruction between 1989 and 1995 in our institution. The cancer pathology, operative procedure and post-operative care were noted. Morbidity, functional outcome and degree of patient satisfaction were recorded. Mean follow-up was 45 months (18-87) in 100% of the patients. RESULTS: There were no operative deaths. Twenty patients had post-operative complications and 2 patients required early conversion to definitive abdominal colostomy due to severe perineal complications. Function outcome showed normal continence in 4 patients, air incontinence in 23, occasional minimal leakage in 9 and incontinence requiring iliac colostomy in 2. Eighty-six percent of the patients were highly satisfied or satisfied with their continence capacity. DISCUSSION: Pseudo-continent perineal colostomy is a reliable technique which can be proposed as an alternative to left iliac colostomy after amputation of the rectum for cancer if a rigorous procedure is applied: careful patient selection, informed consent, rigorous surgical procedure, daily life-long irrigation of the colon.     

Psychopathology as adaptive development along distinctive pathways

The vast majority of post-operative bile duct strictures occur following cholecystectomy, these injuries having been seen at an increased frequency since the introduction of laparoscopic cholecystectomy. Bile duct injuries usually present early in the post-operative period, obstructive jaundice or evidence of a bile leak being the most common mode of presentation. In patients presenting with a post-operative bile duct stricture months to years after surgery, cholangitis is the most common symptom. The 'gold standard' for the diagnosis of bile duct strictures is cholangiography. Percutaneous transhepatic cholangiography is generally more valuable than endoscopic retrograde cholangiography in that it defines the anatomy of the proximal biliary tree that is to be used in surgical reconstruction. The most commonly employed surgical procedure with the best overall results for the treatment of bile duct stricture is a Roux-en-Y hepaticojejunostomy. The results of the surgical repair of bile duct strictures are excellent, long-term success rates being in excess of 80% in most series. Recent data have suggested that, at intermediate follow-up of approximately 3 years, an excellent outcome can be obtained following repair of bile duct injuries after laparoscopic cholecystectomy. Percutaneous and endoscopic techniques for the dilatation of bile duct strictures can be useful adjuncts to the management of bile duct strictures if the anatomical situation and clinical scenario favour this approach. In selected patients, the results of both endoscopic and percutaneous dilatation are comparable to those of surgical reconstruction.     

Endoscopic transthoracic sympathectomy for idiopathic upper limb hyperhidrosis

A 5-year experience of 51 endoscopic transthoracic dorsal sympathectomies for idiopathic palmar hyperhidrosis in 26 patients is presented. Fifty-two percent complained of excessive sweating over their hands, 28% of axillary sweating and 20% over both areas, with a mean duration of 10 years. The second, third and fourth thoracic ganglia and their interconnecting fibres on the affected side were ablated using diathermy cautery. Over a mean follow up time of 26 months, this procedure was successful in curing or improving intractable sweating in 92%. However, axillary sweating was less well controlled than in the palms with 20% of patients describing residual wetness in the axilla. Compensatory sweating (75%) and gustatory sweating (48%) were the commonest side effects; despite this, most patients were satisfied with the functional and cosmetic outcome. Other complications included a temporary Horner's syndrome in one patient, a pneumothorax in the immediate post-operative period in another and a unilateral non-infective reactionary pleural effusion in a third. Two patients developed recurrence of palmar hyperhidrosis within 6 months of surgery. One has been successfully treated by re-operation on the affected side. All patients complained of mild to moderate interscapular chest pain which was easily controlled by non-steroidal anti-inflammatory agents, and resolved within 7-10 days post-operatively. The technique of endoscope transthoracic sympathectomy is effective, relatively simple to perform and usually requires only an overnight stay. It is recommended as the surgical treatment of choice for upper limb hyperhidrosis unresponsive to conservative measures.     

Surgical treatment of acute cholecystitis

A study of the results of surgical treatment of patients with acute cholecystitis showed that cholecystectomy is a safe procedure for the majority of patients during their initial hospitalization and avoids the risk of recurrent attacks and readmissions. Cholecystostomy has a limited place in the treatment of older patients with systemic disease and advanced local disease. Early aggressive management of acute cholecystitis will probably reduce complications of cholecystitis and reduce the need for cholecystostomy.     

Cholecystostomy

The role of cholecystostomy in the sugical treatment of gallstones has been considered. In a consecutive series of 558 patients who underwent surgery for gallstones, 30 (5-4 per cent) had cholecystostomy alone and a further 17 (3-1 per cent) cholecystostomy combined with exploration of the bile ducts. Cholecystostomy was done because cholecystectomy was technically very hazardous in 15 patients. In the remaining patients cholecystostomy was preferred to cholecystectomy because o f the poor general condition of the patient or the presence of pancreatitis. Of the 47 patients submitted to cholecystostomy, 2(4-2 per cent) died postoeratively and 4(8-4 percent) subsequently underwent cholecystectomy. Of 24 patients who were available for long term follow-up, only 1 patient had pain which was definitely considered to be due to gallstones, although 3 other patients also had abdominal pain, while 7 patients showed radiological evidience of gallstones. It is contended that cholecystostomy has a small but definite part to play in the immediate surgical treatment of gallstones and that the long term results of the operation are sufficiently good to justify its use in selected patients.