Helium and carbon dioxide pneumoperitoneum in patients with pheochromocytoma undergoing laparoscopic adrenalectomy

This retrospective study evaluates long-term growth of children with congenital heart disease (CHD) and looks for possible relationships between postsurgical catch-up growth and both severity of preoperative growth failure and operation age. Growth data of 123 children with isolated CHD were available. Mean z-scores and 95% confidence intervals for weight, height and weight-for-height were plotted for age-periods as well as for pre- and postoperative periods. Growth of children with a large VSD or a Tetralogy of Fallot was most abnormal and improved but did not normalize after operation. Catch-up growth for length was strongly correlated with severity of the preoperative growth failure (r = 0.92, p < 0.05) but not with operation age (r = 0.20, NS). We conclude that surgical correction results in catch-up growth for most individuals. Catch-up growth is positively correlated with the severity of the initial growth disturbance and not with age at the moment of surgical correction.     

Effects of carbon dioxide pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy on body weight and tumor growth

BACKGROUND: The oncologic consequences of intraperitoneal carbon dioxide (CO2) insufflation during the laparoscopic resection of cancer are under debate. The effect of other insufflating gases or gasless laparoscopy on cancer requires study. OBJECTIVE: To study body weight and tumor growth in rats after CO2 pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy. METHODS: On day 1, an 8-mg bolus of ROS-1 tumor was placed under the renal capsule of both kidneys in rats. In experiment A, rats had either CO2 insufflation (n=10) or a gasless laparoscopic bowel resection (n=10) on day 3 and were humanely killed after 7 days. In experiment B, rats had either a laparoscopic bowel resection with CO2 insufflation (n=11) or insufflation with air (n=11) on day 3 and were killed after 7 days. In both experiments, postoperative weight loss and tumor growth were measured, and the differences were tested with an analysis of covariance. RESULTS: Renal subcapsular tumor growth in the group having gasless laparoscopy was less than that in the group having CO2 pneumoperitoneum (P=.04). Postoperative weight loss in these groups showed no differences (P=.55). No differences in tumor growth or weight loss were found between rats having insufflation with CO2 and those having insufflation with air (P=.61 and P=.68, respectively). CONCLUSIONS: The restoration of body weight after a laparoscopic surgical procedure was similar with CO2, air, or gasless laparoscopy. Gasless laparoscopy was associated with less renal subcapsular tumor growth than was insufflation with CO2. Therefore, the application of gasless techniques in laparoscopic oncologic surgical treatment demands further study.     

Blood gas changes during laparoscopic cholecystectomy--comparative study of N2O pneumoperitoneum and CO2 pneumoperitoneum

During laparoscopic cholecystectomy by alternative insufflation of nitrous oxide and carbon dioxide, the changes of blood gas tensions were measured and analyzed in 12 patients. During N2O insufflation, PaO2 decreased by about 25 mmHg and PaCO2 was unaltered compared with the values before pneumoperitoneum. While during CO2 insufflation, PaO2 decreased by about 13 mmHg and PaCO2 increased by about 6 mmHg. We considered that decrease in PaO2 during N2O insufflation was associated with not only uneven ventilation/blood flow ratios but also with the reduction in the alveolar O2 tension caused by the diffusion of N2O absorbed from the peritoneum. PaCO2 increases during CO2 insufflation because CO2 is absorbed from the peritoneum, and is not excreted entirely through the lungs.     

The right laparoscopic adrenalectomy of an incidentaloma

The authors report a case of incidental lesion of right adrenal gland in a 56-years-old patient, followed for a liver disfunction. The lesion, with cystic and hemorrhagic histological characters, was treated with laparoscopic resection. The following case report covers the diagnostic procedures, laparoscopic technique, showing the advantages, and postoperative course in surrenal lesion without local infiltration.     

Needlescopic adrenalectomy--the initial series: comparison with conventional laparoscopic adrenalectomy

Functional group gradients were prepared on low-density polyethylene (PE) sheets. The surface density of grafted functional groups was gradually changed along the sample length by way of corona discharge treatment with gradually increasing power following graft copolymerization of acrylic acid (AA), sodium p-styrene sulfonate (NaSS), or N,N-dimethyl aminopropyl acrylamide (DMAPAA). AA and NaSS are negatively chargeable and DMAPAA is positively chargeable in phosphate-buffered saline or plasma solution at pH 7.3-7.4. The prepared functional group gradient surfaces were characterized by measurement of the water contact angle, by electron spectroscopy for chemical analysis, and by Fourier transform infrared spectroscopy in the attenuated total reflectance mode. All these measurements indicated that the functional groups were grafted onto the PE surfaces with gradually increasing density. The platelets adhered to the functional group gradient surfaces along the sample length were counted and observed by scanning electron microscopy. It was observed that the platelet adhesion to the gradient surfaces decreased gradually with the increasing surface density of functional groups. This may be related to the hydrophilicity of the surfaces. The DMAPAA-grafted surface showed a large amount of platelet adhesion, probably due to its positive charge character, while the AA-grafted surface, which is charged negatively, showed poor platelet adhesion. However, the NaSS-grafted surface, which is also charged negatively, showed a relatively large amount of platelet adhesion. This may be associated with the existence of an aromatic ring close to the ionizable group in NaSS. It seems that surface functional groups and their charge character, as well as wettability, play important roles for platelet adhesion.     

Physiologic stress responses to laparoscopic cholecystectomy. A comparison of the gasless and pneumoperitoneal procedures

BACKGROUND: Differences in the physiological stress response to pneumoperitoneal (PP) and gasless abdominal wall-lifting (AWL) procedures used for laparoscopic cholecystectomy have not been properly evaluated. METHODS: We compared leukocyte count, interleukin-6 (IL-6) levels, arterial blood gases, creatinine clearance, plasma renin activity, cardiothoracic ratio, and clinical outcome in 27 patients without systemic complications who underwent laparoscopic cholecystectomy, including 11 by AWL and 16 by PP. RESULTS: Transient leukocytosis and high IL-6 levels were observed at POD 1 (postoperative day) in both groups, but both values returned to baseline by POD 2. IL-6 levels correlated significantly with operation time (p < 0.01). Changes in blood gases, creatinine clearance, plasma renin activity, and cardiothoracic ratio were not different for the two groups. The clinical outcome was similar for both groups. CONCLUSIONS: Our results indicate that both PP and AWL are appropriate for patients without serious complications.     

Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy

After laparoscopic cholecystectomy, residual gas is inevitably retained in the peritoneal cavity. An active attempt is not always made to remove it. Using a double-blind prospective protocol in 40 healthy patients, we evaluated the effect of residual pneumoperitoneum on post-laparoscopic cholecystectomy pain intensity. On completion of surgery, prior to removal of the surgical instruments, the patients were randomly divided into two groups: in the active aspiration (AA) group an active attempt was made to remove as much gas as possible from the peritoneal cavity, while in the nonactive aspiration (NAA) group no such effort was made. Postoperative pain was assessed hourly over a 4-h period with a visual analog scale (VAS) and a patient-controlled analgesia (PCA) device. During the first postoperative hour, the NAA patients made significantly (P < 0.05) more demands (mean +/- SD) for morphine than those in the AA group (31.3 +/- 26.2 vs 15.3 +/- 15.7) and also received a borderline significantly (P = 0.056) larger dose (mean +/- SD) of PCA morphine (3.9 +/- 1.9 mg vs 2.7 +/- 1.3 mg). The VAS scores (mean +/- SD) over the 4-h study period were similar in both groups, being high during the first postoperative hour (AA = 5.1 +/- 2.1 vs NAA = 6.1 +/- 2.2) and then decreasing. We conclude that residual pneumoperitoneum is a contributing factor in the etiology of postoperative pain after laparoscopic cholecystectomy.     

Initial experiences and outcome of gasless laparoscopic pelvic lymph node excision combined with Schauta vaginal radical hysterectomy in stage IB cervix carcinoma

In 11 patients with a cervical cancer stage IB a gasless laparoscopic pelvic lymph node dissection in combination with a vaginal radical Schauta-Amreich-hysterectomy was performed. The technique of the gasless lymph node dissection with the Laparolift (ORIGIN Medsystems, Menlo Park) is described. Because of the advantages of this technique (ability to use conventional and endoscopic instruments, perform irrigation and suction, dot with sponge sticks, change instruments quickly, prepare and remove lymph nodes without influence on visibility) it was possible to obtain a radicality (45 lymph nodes-median value) according to oncological standards for an abdominal radical Wertheim hysterectomy. If the radicality is equivalent to a Wertheim hysterectomy the combination of the radical vaginal Schauta-Amreich-hysterectomy and the gasless laparoscopic pelvic lymph node dissection offers a real alternative to the abdominal Wertheim hysterectomy because of low postoperative morbidity and quick mobilisation.     

Sonographic detection of pneumoperitoneum: an experimental and clinical study

The sonographic appearance of intraperitoneal air collection has been studied in 46 patients. In 30 patients (group I), a pneumoperitoneum had been iatrogenically induced either during aspiration of ascitic fluid or during laparoscopy. Three normal volunteers (group II) had been subjected to graded intraperitoneal air injection to quantify the smallest amount of air detectable by ultrasound (US). In eight patients (group III) the sonographic demonstration of free intraperitoneal air led to a diagnosis of hollow visceral perforation; whereas in another five patients (group IV) the sonographic findings reinforced the clinical suspicion of a 'sealed off' perforation in the presence of negative roentgenograms. In all patients intraperitoneal air was seen as an echogenic line with a posterior reverberation or ring down artefact. In patients with free air, this was best seen in the perihepatic spaces with the patient in the supine, left lateral decubitus or prone position. As little as 5 mL of air could be consistently detected in all three volunteers (group II). Artefacts leading to a pseudopneumoperitoneum on US included; (i) the artefacts distal to an overlying rib; (ii) ring-down artefact from air in the adjacent lungs; and (iii) hepatodiaphragmatic interposition of colon. With proper sonographic technique and principles of interpretation these can be distinguished from true intraperitoneal air. Although sonography may be more informative than conventional radiology in patients with hollow visceral perforation, we did not find it more sensitive than conventional roentgenograms in detecting free intraperitoneal air. Sonography, however, is distinctly superior in patients with a sealed off perforation in whom conventional roentgenograms are frequently negative.     

Clinical correlation between the premortem study and autopsy

BACKGROUND: Lately, autopsies are performed less frequently in hospitals, despite their importance as a diagnostic tool. AIM: To study the concordance between clinical diagnosis and postmortem study in patients that died in a teaching hospital. MATERIAL AND METHODS: Autopsy findings in 57 patients (aged 16 to 85 years old, 28 female) that died at a University hospital were analyzed. Clinical diagnoses were compared with those of the postmortem examination and the degree of concordance between both diagnoses was calculated. RESULTS: Seven major omissions (12.3%), whose knowledge could have changed the clinical course of patients, were detected. These omissions occurred in patients with complex diseases or due to limitations of diagnostic procedures. Also, seven omissions, found in severely ill patients, whose knowledge would not change the patient's evolution, were also detected. CONCLUSIONS: Autopsy still is a valuable tool to assess the quality of care for patients that die during their hospitalization.     

A comparison between somatic symptoms with and without clear organic cause: results of an international study

BACKGROUND: The aim of this study was to determine differences between patients attending primary-care clinics with somatic symptoms for which no organic cause can be found, and those with a clear organic basis for their complaints. METHODS: Physical and psychiatric morbidity was measured in 5447 subjects presenting for primary care in 14 countries. Subjects were recruited using a two-stage design from 26,969 consecutive attenders and 25,916 (96.5%) subjects were successfully screened using the General Health Questionnaire (GHQ-12). The response rate for the second-stage assessment was 63% and consisted of the Composite International Diagnostic Instrument adapted for use in primary care (CIDI-PHC), the 28-item GHQ, the Groningen Social Disability Schedule (GSDS) and GP ratings to assess physical psychiatric and social status. Patients who reached the threshold for the number of somatic symptoms (five or more symptoms) were then divided into two groups on the basis of whether their somatic symptoms were medically explained or not. RESULTS: The presence of somatic symptoms, irrespective of aetiology, was associated with increased social and psychiatric morbidity. In the case of non-medically explained symptoms there was a clear linear relationship while with medically explained symptoms psychiatric morbidity rose sharply in the presence of more than 11 symptoms. Patients who had five or more non-medically explained symptoms were significantly younger, had greater psychiatric morbidity, were at greater risk of harmful use of alcohol and reported greater social disability than those with a medical explanation for their somatic symptoms. Patients who had an excess of somatic symptoms in both categories had especially high rates of social and psychiatric morbidity. CONCLUSIONS: These results show a strong association between somatic symptoms irrespective of aetiology and psychiatric morbidity across disparate cultures.     

Clinical efficacy of lactulose in cirrhotic patients with and without subclinical hepatic encephalopathy

Seventy-five cirrhotic patients with hyperammonemia in the past or at the time of the study were randomly divided into two groups (treated with lactulose or nontreated) in 14 hospitals in Japan. Thirty-six cirrhotic patients were diagnosed as having subclinical hepatic encephalopathy (SHE), and 39 were diagnosed as non-SHE. SHE was diagnosed when the results of all three of the quantitative psychometric tests used (number connection test, and symbol digit and block design tests of the Wechsler adult intelligence scale [revised]) were abnormal as compared with age-matched normal values. The mean number of abnormal psychometric test results and the prevalence of SHE were used for a quantitative evaluation of the efficacy of the lactulose treatment. Twenty-two of the SHE patients were treated with lactulose (45 mL/d) for 8 weeks, and the other 14 SHE patients did not receive lactulose. In the SHE patients administered lactulose, the results of the quantitative psychometric evaluation were significantly improved at 4 and 8 weeks after the beginning of the lactulose administration. The SHE had disappeared in 10 (50%) of the 20 treated patients at week 8, but it persisted in 11 (85%) of the untreated 13 patients. We concluded that lactulose treatment in cirrhotic patients with SHE is effective with respect to psychometric tests.     

Laparoscopic adrenalectomy in a patient with Cushing syndrome

We present a female child with phenotypical and clinical features of the axial mesodermal dysplasia complex. Typical manifestations of both the Goldenhar syndrome and the caudal regression syndrome are present in this complex. Only a few reports have described patients with this pattern of malformations localized in both the cranial and caudal regions. Our case represents a mild form of the complex and may contribute to a better delineation of this condition.     

The quality of friendships between children with and without learning problems

The nature and quality of preadolescent friendships between children with and without learning problems due to mental retardation or mild cognitive difficulties were investigated. Based on an assessment of the reciprocal relationship status of 373 children, including 54 with learning problems, 33 friend and 32 acquaintance dyads were identified. Of these dyads, half included a child with learning problems and half consisted of 2 children without learning problems. The dyads were observed performing a play task. Unlike friendships between children without disabilities, friendships between children with and without learning problems were marked by limited collaboration and shared decision-making, a low level of cooperative play and shared laughter, and an asymmetrical, hierarchical division of roles. The importance of advancing beyond the study of the social acceptance of children with learning problems to study the qualitative aspects of their friendships was discussed.     

Immunological differentiation between tickborne encephalitis with and without concomitant neuroborreliosis

Cerebrospinal fluid lymphocyte subsets in patients with tickborne encephalitis (TBE) and in patients with TBE with concomitant neuroborreliosis (double infection) were analysed by flow cytometry. In the TBE group, higher percentages of CD4+DR+ T cells (p = 0.02) and CD25+ T cells (p = 0.0002) were observed, while in the group with double infection, higher percentages of CD19+ cells (p = 0.007), CD8+DR- T cells (p = 0.04), and CD3+CD71 + T cells (p = 0.0002) were found. It was concluded that several differences in immune cell parameters are present between the two groups of patients. Three variables (CD19+ cells, CD3+CD25+ T cells, CD3+CD71+ T cells) were included in the logistic regression model for calculation of probability for double infection. Flow cytometric characterisation of lymphocyte subsets in CSF can further substantiate the diagnosis of concomitant neuroborreliosis in patients with TBE.