Safe laparoscopic access in pediatric patients

The most serious complications of laparoscopy are attributable to gaining access to the peritoneal cavity. This has traditionally been performed with a closed technique utilizing the Verres needle and subsequently with a 5 to 10 mm trocar. The risks of blind peritoneal access are magnified in pediatric patients due to the smaller abdominal cavity and the closer proximity of the great vessels. Open techniques have been devised for adults but often require a larger incision with an undesirable cosmetic result in pediatric patients. We describe a safe, open technique for laparoscopic access to the pediatric peritoneal cavity.     

Liver resection of noncolorectal secondaries

In this study, we evaluate retrospectively five years experience with the Swann Neck Missouri DC catheters. Sixty three catheters are placed in 51 patients. The total observation period is 695.6 months and the average time is 13.6 months per patient. The last 21 catheters are coiled type. Infectious complications remain the most worrisome problem in peritoneal dialysis. Exit site infections are seen in 24%, tunnel infections in 8%, peritonitis in 38% and abdominal hernias in 16% of the patients. The results in our series (peritonitis every 29.0 patient-months) are in accordance with data from the literature. The combination of a good surgical technique and an efficient postoperative attendance have reduced this frequency. In the situation of a tunnel infection, surgical removal remains the treatment of choice. To prevent an exit site infection, the entry port must be well nursed and protected. A coexisting abdominal hernia can be repaired during the implantation procedure. Fourty six peritoneal dialysis catheters have been removed. Transplantation and death are the main reasons (59%).     

Acute erosions of the gastric mucosa in burned rats: effect of sucralfate

Endometriosis remains a significant cause of pain and ill health for women and is a significant factor in reducing quality of life for women. The ability of desquamated endometrium to attach and implant within the peritoneal cavity is dependent upon its ability to establish and maintain an adequate blood supply. New vascularization is therefore a key part in the progression of endometriosis. Increased angiogenic activity is present in the peritoneal cavity of patients who suffer from the disease and more recently the potent angiogenic growth factor VEGF has been shown to be increased in the peritoneal fluid in patients with this disease. Whilst the desquamated endometrium itself under the influence of hypoxia further to retrograde menstruation is a likely rich source of VEGF, activated peritoneal fluid macrophages and infiltrating macrophages are also a rich source of this angiogenic growth factor. Surprisingly, steroidal regulation of macrophage expression of VEGF also appears to be a feature of this disease.     

Case report: pneumomediastinum and pneumothorax complicating colonoscopy

Colonic perforation is potentially the most serious complication of colonoscopy. Both the clinical manifestation and rapidity of onset of symptoms can vary depending on whether the perforation occurs directly into the peritoneal cavity or into the retroperitoneal space. Colonic perforation is often associated with abdominal pain, although more uncommon presentations have been documented. A case report of a unilateral pneumothorax and pneumomediastinum complicating colonoscopy is described, which responded well to conservative measures without recourse to surgical intervention, antibiotic therapy or parenteral alimentation.     

v-src activation of the collagenase-1 (matrix metalloproteinase-1) promoter through PEA3 and STAT: requirement of extracellular signal-regulated kinases and inhibition by retinoic acid receptors

The evaluation of ultrafiltration failure is embarked upon when a patient has persistent problems with symptoms and signs of fluid overload. Fluid overload is a common problem in peritoneal dialysis (PD) patients and the risk of its occurrence increases with time on dialysis. Although often attributed to changes in peritoneal membrane function (membrane failure), there are a number of potential, and frequently more common factors that can contribute to the failure of adequate fluid removal in patients on PD. Many of the causes of ultrafiltration failure may be apparent after an initial informal evaluation. However, if after this the etiology remains unexplained, a systematic approach to the differential diagnosis of this problem can be utilized with the use of the peritoneal equilibration test. Once a diagnosis is confirmed, a logical therapeutic plan can be formulated.     

Conservative treatment of copperhead snakebites without antivenin

Polyvalent antivenin remains the most recommended treatment of crotalid envenomation, including copperhead snakebites. Because of the significant morbidity associated with antivenin therapy, some have proposed conservative therapy for less serious envenomations. Few if any studies have separated the treatment of the less serious copperhead bite from the more serious bite of a rattlesnake or a water moccasin. Fifty-five patients, including 12 children, with copperhead bites were treated over a 12-year period. All 55 patients were successfully treated conservatively without antivenin. Conservative treatment resulted in no deaths, limb loss, or residual disability. The mean hospital stay was 2.15 days compared with 3.9 days in patients with systemic symptoms. These data support a conservative approach to most copperhead envenomations and suggest that the treatment for copperhead bites should be segregated from the more serious rattlesnake and water moccasin snakebites.     

Endocrine apparatus of the epithelium of the appendicular mucosa (the appendix-- an endocrine gland, functioning in the embryonal period?

Based on the concept on gastroenteropancreatic system, endocrinocytes of which are diffusely scattered throughout the digestive tract epithelium and are found in pancreatic islets, an analysis of endocrine apparatus of epithelium in human appendicular mucosa was performed at different stages of ontogenesis. The response of appendicular endocrinocytes to clinical pathology of both this organ and the entire organism was studied. On the base of the analysis of the appendix function from morphological view, the authors proposed a hypothesis postulating it to be an organ equal to an actively functioning endocrine gland and its unique role on early stages of embryogenesis.     

Prognostic importance of alkaline phosphatase activity in serum from dogs with appendicular osteosarcoma: 75 cases (1990-1996)

OBJECTIVE: To determine whether alkaline phosphatase activity in dogs with appendicular osteosarcoma can be used as a prognostic indicator. DESIGN: Retrospective study. ANIMALS: 75 dogs with appendicular osteosarcoma. PROCEDURE: Serum total alkaline phosphatase (TALP) and bone-specific alkaline phosphatase (BALP) activities were determined from archival serum samples obtained at various times during treatment of appendicular osteosarcoma and follow-up evaluations. Associations among activities of TALP and BALP and survival and disease-free intervals, percentage of bone length involved with tumor, histologic subtype, and method of surgical treatment were evaluated. RESULTS: High activities of TALP and BALP before surgery were significantly associated with shorter survival and disease-free intervals in dogs undergoing surgery (amputation or limb-sparing procedure) and adjuvant chemotherapy. Activity of BALP significantly decreased in 29 dogs for which postoperative samples were available. Failure of BALP activity to decrease after surgery was correlated with shorter survival and disease-free intervals. CLINICAL IMPLICATIONS: Activities of TALP and BALP in serum are important prognostic factors for appendicular osteosarcoma in dogs. Prognostic factors may help clinicians initiate more aggressive treatment for dogs that are at higher risk of death or relapse.     

Kidney transplantation in the child

The goal of treatment of end-stage renal failure in pediatric patients is a functioning transplant. Due to the serious shortage of cadaver kidneys, we have to consider living related donor transplantation (tpl) more frequently. Certain features are characteristic of pediatric patients before transplantation: underlying disease (over 2/3 are congenital or hereditary), the form of dialysis (automated peritoneal dialysis at home in young children) and the frequent need for tube feeding and treatment with growth hormone. Patients weighing 10 kg or more can be given an adult kidney. Young recipients are at risk for vascular thrombosis and hence the CVP should be kept high to allow good circulation, and continuous heparinization (10 units per kg and hour) is advocated. Minor rejection episodes may be overlooked in the presence of a large graft in a small child. Bladder dysfunction is a problem in many children with obstructive uropathy. Later on, viral infections (CMV, EBV) may pose serious problems since most children have not previously been exposed to them. Further problems are pyelonephritis in the graft and recurrence of the underlying disease. Long-term results are very satisfactory in terms of survival and quality of life including later social integration.     

Specific degradation of subendothelial matrix proteoglycans by brain-metastatic melanoma and brain endothelial cell heparanases

Although kidney transplantation is the preferred treatment method for patients with ESRD, most patients are placed on dialysis either while awaiting transplantation or as their only therapy. The question of which dialytic method provides the best patient survival remains unresolved. Survival analyses comparing hemodialysis and continuous ambulatory peritoneal dialysis/continuous cyclic peritoneal dialysis (CAPD/CCPD), a newer and less costly dialytic modality, have yielded conflicting results. Using data obtained from the Canadian Organ Replacement Register, we compared mortality rates between hemodialysis and CAPD/CCPD among 11,970 ESRD patients who initiated treatment between 1990 and 1994 and were followed-up for a maximum of 5 years. Factors controlled for include age, primary renal diagnosis, center size, and predialysis comorbid conditions. The mortality rate ratio (RR) for CAPD/CCPD relative to hemodialysis, as estimated by Poisson regression, was 0.73 (95% confidence interval: 0.68 to 0.78). No such relationship was found when an intent-to-treat Cox regression model was fit. Decreased covariable-adjusted mortality for CAPD/CCPD held within all subgroups defined by age and diabetes status, although the RRs increased with age and diabetes prevalence. The increased mortality on hemodialysis compared with CAPD/CCPD was concentrated in the first 2 years of follow-up. Although continuous peritoneal dialysis was associated with significantly lower mortality rates relative to hemodialysis after adjusting for known prognostic factors, the potential impact of unmeasured patient characteristics must be considered. Notwithstanding, we present evidence that CAPD/CCPD, a newer and less costly method of renal replacement therapy, is not associated with increased mortality rates relative to hemodialysis.     

Acute pancreatitis: diagnosis and therapy in general practice]

Acute pancreatitis is a frequently serious abdominal condition. The cause remains unknown. Biliary tract diseases as well as alcohol are the most important etiological factors. Diagnostic measures, of help in the emergency situation, differential diagnosis and therapeutic procedures, which can be initiated in general practice, are discussed.     

Nosocomial infections implying viruses and unconventional transmissible agents]

Nosocomial infections due to viruses are frequent, especially in pediatrics. They are usually benign, sometimes inapparent or associated with each other. However, they can be more serious in compromised people and become life threatening. In all cases, the hands of medical staff are the main route of viral transmission and this must be strictly prevented. Transmission by infected instruments remains an unresolved question. It happens most often with unconventional agents resistant to common procedures of disinfection and is presently the main concern of hospital wards.     

Hemolytic anemia associated with lead poisoning from shotgun pellets and the response to Succimer treatment

The recent development of mini-invasive surgery includes appendectomy. We report our results of 4 years experience in this type of approach. We have operated on 154 patients (61 men, 93 women), mean age 26.7 years, presenting with clinical signs of appendicitis. The operation was completely carried out by laparoscopy in 144 cases, including treatment of abscess in 13 and peritonitis in 8 cases. Operation was converted into laparotomy in 10 cases, 4 of which because of some difficulty in appendix dissection. No deaths were recorded. Eight (5.2%) post-operative complications occurred: 4 infections of the trocar hole, one of which the cause of readmission; 3 cases of pain and fever (in one a re-laparoscopy was performed because of suspicion of leakage of the appendicular stump); 1 residual hematoma requiring second laparoscopy. Mean duration of hospitalisation was 4.9 days (range 2-25 days): at present, mean hospitalisation is 2 and 6 days respectively in cases with and without peritonitis. In conclusion, laparoscopic appendectomy appears to be feasible in the majority of cases, with better results when the appendix is ectopic and/or in the presence of peritoneal reaction.     

Emergency postcoital contraception

Pancreatitis may be acute or chronic, mild or severe. Acute necrotizing pancreatitis remains the most serious form of acute pancreatitis and accounts for the majority of complications. Although there is an established nomenclature for pancreatitis and pancreatic fluid collections, such as pancreatic pseudocysts, it is not widely understood or recognized by gastroenterologists. Because the management options for the treatment of pancreatic fluid collections continues to evolve with an increased use of endoscopic therapy, gastroenterologists will be increasingly called on to treat patients with pancreatitis and its complications. This article addresses and summarizes pancreatic fluid collections and their management, with an emphasis on endoscopic drainage.     

Promyelocytic blast crisis of chronic myelogenous leukaemia with translocations (9;22) and (15;17)

The murine monoclonal antibody A7 (MAb A7) is reactive against most human gastric cancer cell lines. Using a nude mouse peritoneal dissemination model of human gastric cancer, we investigated targeted chemotherapy using a conjugate of neocarzinostatin (NCS) with MAb A7 (A7-NCS). After demonstrating cytotoxicity of the complex against the human gastric cancer cell line MKN45 in vitro, we intraperitoneally injected A7-NCS, NCS or saline into nude mice bearing peritoneally disseminated human gastric cancer. A7-NCS inhibited peritoneal dissemination significantly more effectively than NCS. MAb A7 may prove to be an effective carrier for antineoplastic drugs in patients with peritoneal dissemination of gastric cancer.     

Magnetic resonance imaging in cervical spinal cord compression

In patients with cervical spondylotic myelopathy MRI sometimes shows increased signal intensity zones on the T2-weighted images. It has been suggested that these findings carry prognostic significance. We studied 56 subjects with cervical spinal cord compression. Twelve patients showed an increased signal intensity (21.4%) and a prevalence of narrowing of the AP-diameter (62% vs 24%). Furthermore, in this group, there was evidence of a longer mean duration of the symptoms and, in most of the patients, of more serious clinical conditions. The importance of these predisposing factors remains, however, to be clarified since they are also present in some patients without the increased signal intensity.     

Malignant mixed mullerian tumor of the female peritoneum: treatment and outcome of three cases

Three cases of malignant mixed mullerian tumor of the peritoneum are presented. One patient had a complete clinical and pathologic response and remains disease-free 42 months following diagnosis. As with peritoneal carcinoma and ovarian sarcoma, aggressive surgical cytoreduction and postoperative chemotherapy appear indicated.     

Pericardioperitoneal window

A technique to create a pericardial window is discussed. By creating a communication between the pericardial and peritoneal cavities, adequate drainage is obtained without the need for external draining systems. The technique is simple, easy to learn, and without serious complications.     

Efficacy of an intraperitoneal antibiotic to reduce the incidence of infection in the trauma patient: a prospective, randomized study

BACKGROUND: Antibiotic therapy in patients with blunt trauma remains an area of investigation. This study was undertaken in trauma patients evaluated with diagnostic peritoneal lavage to determine the effect of an intraperitoneal antibiotic on the following factors: infectious complications, length of hospital stay, and mortality. METHODS: A prospective, randomized double-blinded study compared using either 500 mg of intraperitoneal kanamycin or a saline control in 69 adult trauma patients requiring diagnostic peritoneal lavage was conducted over a 24-month period. Advanced trauma life support indications for performing diagnostic peritoneal lavage were used. Patients were randomized to receive 50 mL of solution intraperitoneally through a lavage catheter and were evaluated for all septic complications, length of hospital stay, and outcome. RESULTS: Over a 24-month period, 40 patients received kanamycin, and 29 patients received a placebo. Of patients receiving kanamycin, 27.5 percent experienced infectious complications compared to 65.5 percent of the control patients (p = 0.001, chi-square analysis). The average length of stay in the intensive care unit was 4.18 days in the kanamycin group and 6.96 days in the control group (p = 0.04, chi-square analysis). The average length of stay was 12.32 days for patients receiving kanamycin and 17.36 days for the control group (p = 0.03, chi-square analysis). The mortality rate for each group was 13 percent. CONCLUSIONS: Intraperitoneal kanamycin given to trauma patients requiring diagnostic peritoneal lavage within the first three hours following injury reduces the incidence of infectious complications and shortens intensive care unit and hospital stay.     

Congenital hypothyroidism

Congenital hypothyroidism (CH) occurs in 1/3 500 newborn infants. Interest in newborn screening for CH has been widely demonstrated in most countries. It was introduced in France in the last 70's; by the measurement of serum TSH level from an eluate of whole blood collected on filter paper on 3 days of life. It allows earlier diagnosis and treatment preventing most of the serious sequelae of the disease such as postnatal neurological damage. Their neuropsychological evaluation has shown normal mental development in most cases. Although CH with eutopic gland (15% of the cases) has recently been recognized as associated with different molecular defect, the cause of thyroid agenesis (85% of the cases with athyreosis or ectopic gland) remains unknown. These latter forms are usually sporadic but familial cases are described.