Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults

OBJECTIVE: To investigate the feasibility, safety and results of laparoscopic transperitoneal adrenalectomies performed with the patient supine, in patients affected by secreting and silent adrenal lesions. METHODS: Exclusion criteria were suspected adrenal primary malignancies. Fifty patients (33 women and 17 men; mean age 49.6 years, range 19-75 years) underwent 51 laparoscopic adrenalectomies (one bilateral). After complete endocrinological evaluation, computed tomography or magnetic resonance imaging, or a combination thereof, 14 non-secreting adenomas, 13 aldosterone-producing adenomas, 13 cortisol-producing adenomas, eight phaeochromocytomas (one bilateral), one androgen-secreting adenoma, and two metastases were considered eligible for adrenalectomy. In five patients, associated procedures were performed during surgery. RESULTS: The lesions ranged in size from 1.5 to 10 cm. There were no intraoperative complications and no blood transfusions were required. The postoperative course was uneventful and painless in all patients. Mean postoperative hospital stay was 2.5 days. In all hypertensive patients, significant improvement or cure of hypertension was observed at follow-up (mean 18 months). In patients with secreting adenomas, normalization of hormone concentrations was obtained after removal of the tumour. In six patients with incidentaloma, the exaggerated 17-hydroxyprogesterone response to ACTH disappeared after surgery. CONCLUSIONS: Secreting and non-secreting adrenal lesions were treated safely by laparoscopy. Relatively small incidentalomas and subclinical hormonally active tumours can be removed by laparoscopy. Early diagnosis enhances prevention and treatment.     

Laparoscopic adrenalectomy

Between June and September 1993, laparoscopic adrenalectomy was indicated in five patients (three women, two men; aged 25-50 years). Three had a phaeochromocytoma, two had an adenoma (Conn's syndrome). Four of the five tumours were localized to the right adrenal gland, one to the left. Tumour diameter ranged from 3 to 5 cm. The laparoscopic procedure was successful in four of the patients (three right, one left). In the fifth case the operations had to be completed by conventional surgery, because of non-controllable haemorrhage. Duration of operation ranged between 165 and 360 min for right adrenalectomy and was 135 min for the left one. Rapid convalescence, lower dose of pain-killing drug required, short hospital stay and good cosmetic results characterized the postoperative course after the laparoscopic procedure. This technique thus opens up new perspectives for adrenal surgery.     

Multicentric experience of the Belgian Group for Endoscopic Surgery (BGES) with endoscopic adrenalectomy

BACKGROUND: Adrenalectomy is not a frequent operation. Therefore the newly developed laparoscopic approach is sporadically performed by surgeons dealing with endocrine disorders. METHODS: Some 54 videoendoscopic adrenalectomies performed on 52 patients by five surgical teams between October 1993 and December 1996 were prospectively evaluated. RESULTS: Indications for endoscopic adrenalectomy were pheochromocytoma (n = 17), primary hyperaldosteronism (n = 15), Cushing's adenoma or disease (n = 7), nonsecreting adenoma (n = 7), single metastasis from adenocarcinoma (n = 2), adenoma with dehydroepiandrostenedione (DHEAS) hypersecretion (n = 3), and ACTH-secreting metastases from a thymoma (n = 1). Of the 54 adrenalectomies performed, 31 were of the left gland, 19 of the right and two bilateral. Laparoscopic adrenalectomy was successful in 50 patients (96%). Median tumor size was 4 cm (range 1.5-12), median operation duration was 80 min (range 59-360), and median postoperative stay was 4 days (range 2-13). One patient required blood transfusion. CONCLUSIONS: Endoscopic adrenalectomy can safely be performed-even sporadically-by surgeons well versed in adrenalectomy techniques for endocrine disorders and trained in endoscopic surgery.     

Can adrenal incidentalomas be safely observed?

We currently recommend excision of adrenal incidentalomas > or = 4 cm in size and all hormonally active tumors. The optimal management and follow-up of smaller nonfunctioning tumors are controversial. The aim of this study was to determine the clinical outcome of a well defined population of patients with incidentalomas followed without operative intervention. The study group comprised 231 patients, identified from the records of abdominal or thoracic computed tomographic (CT) scans performed between 1985 and 1989. The primary outcome variable analyzed was survival. Follow-up was obtained by office records, telephone contact, or letter. There were 101 male and 130 female patients with a mean age at diagnosis of 64 years (range 5-86 years). Most adrenal tumors were unilateral (right 113; left 98); 20 were bilateral. Mean tumor size was 2 cm (range 1-6 cm). In nine (4%) patients the tumor was > or = 4 cm. Follow-up [mean 7 years; range 1 month (patient died) to 11.7 years] was complete in 224 (97%) patients. Ninety-one (39%) patients had one or more additional CT scans performed during the follow-up period, with only four patients demonstrating a > 1 cm increase in the size of the adrenal mass. Surgical excision of these four lesions identified benign pathology. Eighty-one (35%) patients died of conditions unrelated to adrenal pathology. No patient developed subsequent adrenal hyperfunction or adrenal malignancy. Within the context of our guidelines, conservative management of adrenal incidentalomas considered benign or nonfunctioning at diagnosis is appropriate. Additional information provided by repeat CT scanning appears to confer limited benefit. This study does not support laparoscopic removal of small, nonfunctional adrenal tumors, as has been suggested.     

Free, autologous, skin transplantation in the horse

Seven pieces of autologous skin were transplanted onto freshly created, full thickness skin defects on the limbs and back of a one-year-old, male, piebald, Shetland pony. The transplantations were completed in two operative sessions, the transplants on the left side were done in the first session and the right side in the second. The sizes of the transplants varied from 20 sq cm to 2 sq cm and their thicknesses from whole skin to very thin, split skin. Donor sites were both rumps and the right side of the neck. Six of the seven grafts and two thirds of the remaining graft, were accepted. Both whole thickness transplants grew hair, whereas no hair growth was detected at the 26th and 16th week following surgery on the split thickness transplants placed on the left and right sides respectively. The full thickness donor sites healed by granulation, contraction and epithelialisation. Healing at the split skin donor sites was rapid and uneventfull, epithelialisation being completed within one week and hair growth manifest by one month.     

Large radiolucent lesion of the maxilla

In this cross-sectional study we investigated the effect of compressive and tensile forces applied on the proximal femur during weight-bearing activities. Ninety-seven men (29.9 +/- 1.7 years) were divided into two groups: 69 exercisers who had practiced regular high-impact weight-bearing activities for at least 5 years and 28 controls who had been sedentary for at least 5 years. The maximum isometric hip abduction strength was measured. The bone mineral density (BMD) of the femoral neck and the greater trochanter was assessed using dual-energy X-ray absorptiometry (DXA). Controls were considered as the reference population to calculate the Z score. Mean BMD values of the femoral neck were 0.97 g/cm2 on both sides in the exercisers and 0.83 g/cm2 on the right side and 0.84 g/cm2 on the left side in the controls. Mean BMD values of the greater trochanter were 0.86 g/cm2 on the right side and 0.87 g/cm2 on the left side in the exercisers, 0.73 g/cm2 on the right side and 0.72 g/cm2 on the left side in the controls. The BMD was significantly higher in exercisers at both trochanteric and cervical sites (P = 0. 0001). Both left and right hip abduction strength was significantly greater in the exercisers than in the controls (P < 0.05) and was positively correlated to cervical and trochanteric BMD (P < 0.01). In the exerciser group, the trochanteric Z score was higher than the cervical Z score at both right (P = 0.06) and left (P = 0.002) sides. Therefore, the proximal femoral BMD was significantly greater in exercised subjects as compared with sedentary controls. The difference was observed at the level of both the femoral neck (where it is known anatomically that only compressive gravitational forces are exerted) and the greater trochanter (where it is known that tensile forces are exerted). This result suggests the participation of both compressive and tensile forces in the mechanisms by which exercise influences bone trophicity.     

Predictability of Gleason score and reduction time (tau) of prostatic volume after castration for the prognosis of prostatic cancer

BACKGROUND: After 3 years from the introduction of laparoscopic adrenalectomy in an endocrine surgery unit the results are retrospectively compared with those achieved by traditional techniques with the aim of comparing the respective advantages. METHODS: During this period 68 laparoscopic adrenalectomies have been performed. The main pre-, intra- e postoperative parameters of the adrenalectomies for benign neoplasm have been examined. Mean follow-up was 51 months (65.3 for open adrenalectomy and 18.8 for laparoscopic). RESULTS: Statistical studies were homogeneous between the two groups. The laparoscopic adrenalectomy--with the same effectiveness--thanks to less peritoneum and parietal stress, is followed by fewer postoperative complications, faster resumption of biological functions, earlier return to work and better cosmetic results. CONCLUSIONS: On the basis of our personal experience laparoscopic adrenalectomy is to be considered the treatment of choice in the majority of adrenal benign neoplasms.     

Oculo-facio-cardio-dental (OFCD) syndrome

OBJECTIVE: The aim of this study is to present an economic and convenient modification of the layout for laparoscopic cholecystectomy, utilizing a three-port technique. METHODS: The surgeon stands on the left side of the patient, while the assistant stands between the patient's legs. The scrub nurse stands on the right side of the patient facing the surgeon. The assistant also operates the camera. Only three ports are used. This technique was used in 119 consecutive patients over a 24-month period. Endoscopic retrograde chlolangiopancreotography (ERCP) was done preoperatively in patients suspected to have choledocholithiasis. RESULTS: Sixteen patients had ERCP done preoperatively and in 12 of them sphincterotomy and stone removal was carried out. Laparoscopic cholecystectomy was successfully completed in 115 patients. The mean operative time was 35 minutes. Four cases were converted (3.6%), one due to bile duct injury, two others due to extensive adhesions, and a fourth due to cholecystoduodenal fistula. The total morbidity rate was 4.2%. The mean hospital stay was 1.8 days. CONCLUSIONS: Laparoscopic cholecystectomy can be safely and conveniently done using only three ports in the modified position described. You need only one assistant, only one monitor and one less trocar. There is no prolongation of the operative time and the results are comparable to the classic four-trocar technique.     

Laparoscopic surgery of adrenal glands: indications and limits

Over the last four years it has been demonstrated that laparoscopy can be used successfully for adrenalectomy, providing certain advantages over conventional open surgery. The aim of this study was to determine the indications for laparoscopic approach in adrenal surgery. From June 1994 to June 1996 laparoscopic transabdominal flank approaches were proposed in patients with a unilateral 8 cm or less, non-malignant tumors of the adrenal gland. For tumors under 4 cm in diameter only secreting tumors were removed. Among 77 patients requiring ablation of the adrenal gland, 50 (65%) underwent a laparoscopic procedure: 29 Conn adenomas, 10 Cushing adenomas, 6 Pheochromocytomas, 4 incidentalomas. One patient had Cushing's disease and underwent bilateral resection. Mean tumor size was 26 mm (7-75 mm). Malignancy was demonstrated in 2 tumors: one cortisone secreting tumor and one leiomyosarcoma. Conversion was required in 4 cases (8%). Mean operative time for unilateral adrenalectomies was 147 minutes (50-300'). There were no deaths. Morbidity included: one hemorrhage via the trocar orifice requiring reoperation, one infarction of the spleen which regressed spontaneously, one parietal hematoma, and one case of phebitis of the lower limb. The endocrinopathy was successfully cured in all patients with secreting tumors. The 27 other patients underwent open adrenalectomy. Laparoscopic approach was not proposed due to suspected malignancy in 13 cases, previous surgery in 8 cases and multiple, bilateral and/or extra adrenal tumors in 6 cases. Laparoscopic approach to the adrenal gland is the procedure of choice in patients with Conn adenomas, Cushing adenomas and in most cases of pheochromocytomas. It is not indicated for malignant and large tumor (> 8 cm). Currently two-thirds of our patients requiring and adrenalectomy are operated laparoscopically.     

Laparoscopic colo-rectal surgery

Laparoscopic colorectal surgery was less invasive for patients although it was difficult to perform complete resection of colon combined with regional lymph node. The skillful manner of the laparoscopic surgery was required for the surgical team. The laparoscopic equipments, in order to perform curative dissection of mesenterium and intermediate lymph node, such as Ultrasonic-aspiration surgical unit (USU) or Harmonic scalpel laparoscopic coagulation shears (LCS), were useful for safer dissection of D2 regional lymph node. Meticulous manner of grasping forceps and special dissectors was made sufficient lymph node dissection. The reconstruction of extracorporeal anastomotic technique by hand or valtrac (biofragmentable anastomosis ring) were safer manner for anastomosis after resection of the right side colon. Reconstruction by double stapling technique of linear stapler and circular stapler was admired for anastomosis for left side colonic and rectal surgery. We had safely performed locar resection in 3, partial resection with Do dissection in 2, with D1 dissection in 14, with D2 dissection in 21 and right and left hemicolectomy in 1 each.     

Laparoscopic adrenalectomy. An alternative to open surgery of minor adrenal tumors

In the period February 1994 to November 1995 11 laparoscopic adrenalectomies were performed at our institution (seven women, four men). A transperitoneal approach was used in both right- and left-sided operations. Results were collected retrospectively. Indications for surgery were: Conn's syndrome (four), Cushing's syndrome (two), phaecromocytoma (four), and incidentaloma (one). The operations took median 170 minutes (range 105-250 minutes). Median size of the tumour was 4 cm range 1(1/2)-5 cm). No significant peri- or postoperative complications were recorded. The patients were discharged from the surgical unit median two days after surgery. Laparoscopic operation emerges as an alternative to open operation when dealing with smaller adrenal tumours. Because of the small number of patients, these operations have to be restricted to a few centres where both internists, anaesthesiologists and surgeons with expertise in this field are found.     

Platelet transfusion practice: time for renewed consensus

BACKGROUND: Bilateral tubal pregnancies are rare and are usually confirmed simultaneously during the same operation. We report a case in which the right salpingectomy was performed seven weeks before the left salpingectomy. When the right salpingectomy was done, the left uterine tube appeared entirely normal. CASE: A 38-year-old woman underwent laparoscopic surgery for suspected right tubal pregnancy. A right tubal pregnancy was found to have partially aborted into the peritoneal cavity. The left uterine tube was carefully inspected and appeared normal. Histopathology of the right tube showed products of conception and chorionic tissue. Seven weeks after surgery, the woman presented in hemorrhagic shock necessitating emergency laparotomy and left salpingectomy. Histopathology of the left tube confirmed the presence of chronic tissue. The patient did not have coitus between the two salpingectomies. CONCLUSION: The explanation of the presentation is uncertain. However, this case underscores the importance of careful follow-up of patients after laparoscopic surgery for ectopic pregnancies.     

Laparoscopic adrenalectomy. A new standard of care

OBJECTIVE: The authors review their experience with laparoscopic adrenalectomy in patients with benign adrenal neoplasms. Efficacy, safety, and cost effectiveness of the procedure are examined. BACKGROUND: Laparoscopic adrenalectomy is replacing open adrenalectomy in some medical centers as the standard surgical approach for uncomplicated tumors. However, laparoscopic adrenalectomy often is considered more difficult and more expensive than traditional "open" surgery. METHODS: Perioperative and postoperative records as well as hospital charges from the first 19 patients undergoing laparoscopic unilateral adrenalectomies at the authors' medical institutions were examined and compared with 19 patients who underwent open unilateral adrenalectomies. RESULTS: None of the 19 patients undergoing unilateral laparoscopic adrenalectomy required conversion to open adrenalectomy. Mean operative times as well as total hospital charges were similar in those patients undergoing either laparoscopic or open adrenalectomy. However, the morbidity and postoperative length of hospital stay were significantly less in those patients undergoing laparoscopic adrenalectomy. CONCLUSIONS: Laparoscopic adrenalectomy can be performed safety and with the benefits associated with minimally invasive surgery. In addition, the procedure is cost effective. These factors suggest that laparoscopic adrenalectomy should be the preferential surgical technique for benign adrenal disease.     

Laparoscopic hysterectomy in a case of male pseudohermaphroditism with persistent Müllerian duct derivatives

We describe laparoscopic diagnosis and treatment for a case of dysgenetic male pseudohermaphroditism with persistent Mullerian ducts. The patient, a 32 year old man, with a history of surgery for hypospadias and cryptorchidism during childhood, was referred because of anejaculation. He was of short stature, with male external genitalia composed of a small penis and hypoplastic testis (1 ml right, 6 ml left side). Plasma follicle stimulating hormone (FSH) was high (17 mUI/ml), testosterone low (1.9 ng/ml), and his karyotype was 46,XY. Pelvic ultrasound, nuclear magnetic resonance (NMR) and genitography disclosed a uterine-like structure with cavity communicating with the urethra. Laparoscopy and urethrocystoscopy confirmed the presence of a 4 cm uterus, which was removed endoscopically at the same time. A biopsy of the left gonad was also performed. The uterus contained endometrial tissue and was fibrotic. Histology of the left gonad showed spermatocytic arrest. We diagnosed dysgenetic male pseudohermaphroditism. Laparoscopy, in our opinion, is an optimal tool to diagnose and treat abnormal sexual conditions.     

Laparoscopic adrenalectomy: lessons learned from 100 consecutive procedures

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm. OBJECTIVE: The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders. SUMMARY BACKGROUND DATA: Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations. METHODS: One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection. RESULTS: Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess. CONCLUSION: Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.     

Contribution to the surgical treatment of haematoma and hygroma in adults (author's transl)

Among thirty cases of chronic subdural hematoma and hygroma in patients between 16 and 78 years of age, nine were found on the left side, ten on the right side and eleven were bilateral. The diagnosis was made in all cases by computer assisted tomography. Surgical treatment consisted in evacuating the subdural collection of fluid through two or three enlarged burr-holes, resection of the membranes were accessible through the burr-hole, irrigation of the subdural space and its subsequent drainage. The drain was left in postoperatively until the draining fluid became clear or the subdural space was dry. In one case there was a superficial intracerebral hematoma which obsorbed spontaneously. One patient with a subdural empyema required craniotomy. Only four out of ten patients who were comatose pre-operatively survived. Out of the 30 patients, 24 had a satisfactory postoperative outcome.     

Calcitriol mediated hypercalcaemia in a T cell rich B cell lymphoma

We report a "walking" catheter resulted in failed epidural anesthesia. An 85-year-old woman was scheduled for insertion of a nail in the left humerus. At 10 a.m. on the day of surgery, a Tuohy needle was inserted into the epidural space between the C6 and C7 vertebrae, and then we inserted an epidural catheter for 5 cm. Epidurography revealed that the catheter was inserted between C5 and C6, and the tip of the catheter was positioned windingly at C4. The contrast medium was found spread bilaterally from the C2 level to the Th2 level. The patient entered the operating room at 3 p.m. We infused 10 milliliters of 1% mepivacaine through the epidural catheter. Hypesthesia was obtained on the right side of her neck, from the C2 to the C5 level, after 10 minutes. Epidurography after surgery showed that the coiled catheter was placed straight into the right side of the epidural space; contrast medium infused through the catheter was found spread only to the right side from the C2 to the C4 level.     

Preserved musical abilities following right temporal lobectomy

It has been widely accepted that the right temporal lobe plays a major role in the processing of music. One of the main lines of evidence was derived from Milner's study, published in 1962, which reported that right temporal lobectomy led to a decline in patient scores on four of the six subtests (Tonal Memory, Timbre, Loudness, and Time subtests) of the Seashore Measures of Musical Talents. That finding had led some surgeons and patients to hesitate in choosing right temporal lobectomy as a treatment for intractable epilepsy. The authors examined performance on the Seashore Measures before and after operations in 20 patients with right temporal lobectomy and nine patients with left temporal lobectomy. No disturbances in the Seashore Measures were detected after temporal lobectomy on either side. The extent of these temporal lobectomies was smaller than that of the temporal lobectomies in Milner's study, as measured along the sylvian fissure (1.5-4 cm; mean 2.7 cm, standard deviation (SD) 0.92 cm) and the base of the temporal lobe (3.5-5.5 cm; mean 4.7 cm, SD 0.63 cm). These findings indicate that the region resected on right temporal lobectomy in the present study is not essential for basic musical processing.     

Doppler sonographic assessment of functional response of the right and left portal venous branches to a meal

PURPOSE: The aim of our study was to quantitate by Doppler sonography the blood flow in the right and left portal vein branches before and after a standard meal. We also assessed the functional response of the right and left lobes of the liver. METHODS: Portal blood flow was measured by Doppler sonography in the left and right portal vein branches and main portal trunk in 20 healthy volunteers in both fasting and postprandial states. The ratio between portal blood flow and liver volume (determined by MRI) was the portal flow index (PFI). RESULTS: Before the meal, a statistically significant difference in portal blood flow volume was observed between the right and left portal branches (p < 0.01). The right PFI (0.83 ml/minute/cm3) and left PFI (1.1 ml/minute/cm3) were also significantly different (p < 0.01). The increase in portal venous blood flow after a meal was found to be greater in the left portal branch (128%) than in the right portal branch (78%). The postprandial PFI also differed significantly (right, 1.54 ml/minute/cm3; left, 2.5 ml/minute/cm3). CONCLUSIONS: These findings suggest that the left lobe of the liver has a better postprandial compliance than the right lobe has.     

Internal carotid artery occlusion related to seat belt shoulder strap: report of two cases

Two cases of traumatic internal carotid artery occlusion probably related to the seat belt shoulder strap are reported. Case 1. A 20-year-old woman was driving and was struck on the right front side of her car by another car. There were neither bruises, abrasions on her neck, nor weakness in her extremities. About 4 hours later, she developed left hemiplegia, and CT scan taken on the following day revealed low density areas in the capsulostriatal area on the right. The right carotid angiography revealed occlusion of the internal carotid artery about 3 cm distal to the bifurcation. Case 2. A 43-year-old man was driving and was struck on the front of his car by a hard iron railing. He sustained a sternum fracture, but there was no disturbance of consciousness or paresis of the extremities. His neck was unremarkable externally. About 50 days later, he developed left hemiplegia. CT scan and MRI revealed a massive infarction in the distribution of the right middle cerebral artery territories. The carotid angiography revealed occlusion of the right internal carotid artery about 3 cm distal to the bifurcation. In each cases, the driver was wearing a three-point shoulder seatbelt when the car was struck on the front or on the right front. Previous experimental studies have revealed in these situations the neck is flexed right anteriorly, and then quickly overextended left posteriorly. The overextension of the neck probably injured the intima of the internal carotid artery ipsilateral to the shoulder fixed in the seatbelt, resulting in the subsequent occlusion by a thrombus.