Haemolysin from Mycobacterium avium complex isolates from AIDS patients

OBJECTIVES: 856 cases of hypospadias, operated over a period of 7 years, using various methods of one-stage repair, are reviewed in order to assess their functional and cosmetic results and their rate of complications. PATIENTS AND METHODS: 856 boys with an average age of 3.5 years were classified according to the classification proposed by Duckett (anterior, middle and posterior hypospadias). Magpi, Mathieu's (flip-flap technique) and pedicled flaps tubularized or as onlay were utilized, depending upon the severity of the anomaly. RESULTS: Satisfactory functional and cosmetic results without complications were obtained in 736 cases (85.9%). We had early complications with 72 cases consisting of 64 fistulas (7. 5%) and 8 cases of breakdown (0.93%), and 48 cases of delayed complications consisting of 26 meatal retractions (3.1%) and 22 cases of meatal stenosis (2.5%).     

Substitution urethroplasties with free graft buccal mucosa

OBJECTIVE: To present our experience with free graft buccal mucosa substitution urethroplasties. METHODS: Between June, 1992 and December, 1997, we performed 18 urethroplasties with buccal mucosa in 17 patients (double urethroplasty in the same stage in one): 8 for the repair of urethral strictures, 9 for the repair of hypospadias cripples and one for epispadias repair, in an exstrophic boy. Only 3 patients had not undergone previous reconstructive operations. The mean age was 26.2 years (range 10-69). In 8 cases we harvested the graft from the inner cheek and in another 8 cases from the inner lower lip; in two cases we combined mucosa from the cheek and from the lip. In 14 patients we managed to preserve the urethral roof and the buccal mucosa was grafted as an onlay patch; 4 patients underwent full circumference tube replacement. The median follow-up of the series was 17.8 months, ranging from 1 month to 5.5 years. RESULTS: In 15 out of 18 repairs (83.3%) the final outcome was satisfactory, while in three cases the graft failed and reoperation was necessary. In 10 of the 15 successful urethroplasties the end result was excellent: first intention healing no complications or sequelae; in the other 5, although the end result was good, fistulae requiring surgery for closure developed in 2 and meatal stenosis requiring autodilations in three patients. The best results were obtained in strictures of the bulbar urethra secondary to trauma with 100% success rate. In hypospadias the success rate was 77.7%. Onlay patch grafts never failed, with 10 out of 14 excellent results. Three out of 4 tubed grafts failed. CONCLUSIONS: At short and medium term, the free grafts of buccal mucosa yield results comparable to those of other epitheliums in use for urethral repair, thus increasing the choice of techniques at our disposal for one-stage repairs. We consider that it is best suited for long strictures of the bulbar urethra.     

One-stage hypospadias repair with stent or suprapubic diversion: which is better?

PURPOSE: The authors report on 105 consecutive patients who underwent one-stage hypospadias repair based on use of suprapubic diversion or transurethral drainage with stenting. METHODS: The surgical procedures included 52 metal-based flap urethroplasty (Mathieu) for coronal, subcoronal, and distal shaft hypospadias; 32 transverse island pedicle graft (Duckett) for mid and proximal shaft hypospadias; 21 transverse island pedicle (Duckett) plus rolled midline tube (Thierchs) for penoscrotal and scrotal hypospadias. To accomplish urinary drainage, suprapubic diversion (cystofix) was used in 28 of 52 Mathieu operations, in 17 of 32 Duckett operations, and in 11 of 21 transverse island pedicle graft plus rolled midline tube operations. In the rest of the cases, transurethral drainage with stenting was used. RESULTS: All children had excellent cosmetic and functional outcomes. But the rates of complications such as fistula and meatal stenosis were significantly different between the groups in which suprapubic tube or urethral stent was used. In 56 of the 105 patients in whom suprapubic diversion was used, four (7.14%) had fistulas and three (5.35%) had meatal stenosis, in contrast to a fistula rate of 14.28% and meatal stenosis rate of 12.24% in patients that urethral stent is used for urinary drainage. CONCLUSION: The authors believe that the use of suprapubic diversion is advantageous for the outcome of one-stage hypospadias repair in relation to fistula occurrence and meatal stenosis.     

The dartos flap as an adjunct in preventing urethrocutaneous fistulas in repeat hypospadias surgery

PURPOSE: Vascularized flaps for repeat hypospadias repair are often limited. We report our experience with the dartos flap in children undergoing secondary hypospadias and complex urethral repair. MATERIALS AND METHODS: The dartos flap is fibroadipose tissue between the scrotal skin and tunica vaginalis layers with its vascular pedicle based at the penoscrotal angle. The flap reaches the distal penile shaft without tension. Eight patients 1 to 17 years old (mean age 6) underwent urethral surgery and an interposed dartos flap procedure in 1994 to 1995. RESULTS: Of 6 patients cosmesis was excellent in 84%, erections were straight in 100%, and urinary streams were of good quality and without fistula in 100% after repeat hypospadias surgery. Following staged repair for anterior urethral valves a urethrocutaneous fistula developed in 1 patient and following urethral duplication repair results were excellent in 1. Mean followup was 1 year. CONCLUSIONS: The dartos flap is easy to mobilize and it provides excellent coverage for repeat proximal hypospadias surgery, since the dartos remains undisturbed. We endorse its use for complex urethral surgery and believe that the extra layer of closure helps to prevent urethrocutaneous fistulas.     

One-stage anterior urethroplasty

PURPOSE: A deficient urethral segment was replaced with penile skin during a 1-stage procedure in patients with a long, tight urethral stricture, multiple attempts at hypospadias repair or severe hypospadias and circumcision. MATERIALS AND METHODS: In 29 patients a pedicled circumferential strip of distal penile skin was used to construct a neourethral floor. The roof was formed by regeneration of the epithelium from the edges of the floor over Buck's fascia. In our series the urethra was reconstructed because of an anterior urethral stricture in 11 patients, multiple failed hypospadias repairs in 6 and severe hypospadias with circumcision in 12. RESULTS: A neourethra of sufficient caliber and length was constructed with minimal postoperative complications in all patients. There were 2 cases of urethrocutaneous fistula at the subcoronal region, 1 meatal stenosis, 1 persistent chordee and 1 small distal penile skin patch slough that required only prolonged dressings. Mean followup was 19 months. CONCLUSIONS: Our urethroplasty technique can be used to correct various types of anterior urethral stricture or hypospadias associated with insufficient penile or preputial skin.     

Immunohistochemical identification of prostate-specific antigen in a parameatal urethral cyst of the glans penis

PURPOSE: We conducted a retrospective study of patients with strictures after hypospadias repair to identify factors contributing to the development of strictures and to attempt to define an optimal strategy for management. MATERIALS AND METHODS: Patients with the diagnosis of hypospadias who had undergone direct vision internal urethrotomy, urethral dilation or urethroplasty were identified. The original location of the meatus, type of initial repair, subsequent procedures and outcome of the interventions were recorded. RESULTS: A total of 38 patients were identified. Of the 29 patients who were initially treated with direct vision internal urethrotomy or urethral dilation 23 (79%) ultimately required open urethroplasty and did well. Of the 8 patients treated with initial urethroplasty 7 had successful outcomes. Overall success, defined as asymptomatic voiding without fistula or residual stricture, was 78% at a mean followup of 6.3 years. CONCLUSIONS: Stricture disease continues to be a significant complication of hypospadias reconstruction. Initial therapy should be urethral dilation but it should be recognized that the majority of these patients will ultimately require open urethroplasty.     

Inlay-onlay flap urethroplasty for hypospadias and urethral stricture repair

PURPOSE: The absence of a segment of the urethral plate renders the onlay urethroplasty procedure impossible. The plate may be too short (in hypospadias), or scarred after previous repair or due to a dense urethral stricture. A modified approach with restoration of urethral plate continuity is proposed instead of the tubularized island flap associated with higher complication rates. MATERIAL AND METHODS: In 12 of 20 patients with a partially deficient urethral plate the inlay-onlay preputial island flap was used. The wider part of the flap is inlaid in place of the missing plate and anastomosed to the residual plate. Formation of the urethra is then completed with standard onlay overlapping of the flap. In another 8 patients the combined (partially tubularized in advance) tube-onlay flap was used. RESULTS: The inlay-onlay flap technique was used in 3 new hypospadias patients, in 4 with a scarred, hair-bearing plate after previous operations and in 5 with virtually no urethral plate because of a dense urethral stricture. No urethral complications were encountered. Of the 8 patients undergoing the combined tube-onlay repair 3 had complications, including meatal stenosis (2) and partial dehiscence (1). CONCLUSIONS: Inlay-onlay flap urethroplasty allows correction of complex cases of hypospadias or urethral stricture with a partially deficient urethral plate in 1 stage with a low complication rate.     

Urological complications in renal transplantation

The urological complications associated with 128 consecutive renal transplants performed in the Department of Urology of the University Hospital Heidelberg between February 1967 and January 1975 are described. Extravesical ureteroneocystostomy has shown to be the preferable method for urinary tract reconstruction, providing satisfactory results in our hands. The technique of ureteroneocystostomy at the dome of the bladder, performed since 1967 in our series, is described and its advantages discussed. There was an overall incidence of urological complications of 21.2%. Major urological complications occurred in 18 patients (14.1%), urinary fistulae in 11 patients (8.6%), ureteric obstruction in 4 patients (3.2%) and spontaneous parenchymal ruptures in 3 patients (2.3%). Only two grafts were lost, due to spontaneous parenchymal ruptures. The mortality directly due to major urological complications was 5.6%. Minor complications (hydrocele, epididymitis, urethral stricture, urinary calculi) were seen in 9 patients (7%). Lymphoceles were not encountered. The management and outcome of urological complications are described.     

Urethral advancement and glanuloplasty UAGP vs. MAGPI for distal hypospadias repair

Distal hypospadias is a commonly encountered anomaly. Since its innovation by Duckett the MAGPI procedure has become almost the standard operation for the correction of minor cases. Recently case selection has been advised to avoid possible complications and limitations. Between April 1986 and April 1995, 153 boys were treated for distal hypospadias. In 51 patients (coronal 31, subcoronal 20) a modified technique of urethral advancement and glanuloplasty (UAGP) has been used. The main indications of UAGP were the presence of glanular chordee (7), failed MAGPI (3), circumcised children with distal hypospadias (7), immobile fibrotic urethral meatus (5), and as an alternative to MAGPI (29). The overall complication rate was 4% compared to 3.8% with the MAGPI procedure which has been used in the treatment of 102 patients (glanular 50, coronal 47, and subcoronal 5). We feel this technique can be used effectively in patients with coronal and subcoronal hypospadias, particularly in the presence of distal chordee, fibrotic immobile urethral meatus or MAGPI limitations. Also UAGP could be a useful alternative to MAGPI where tension-free urethral advancement and glanular wrapping can be achieved.     

Effects of daunomycin implants on filtering surgery outcomes in rabbits

BACKGROUND: Results of long-term testosterone treatment of congenital hypoplasia of the penis are sparse; the aim of this work was to evaluate these results according to age at onset of treatment, the presence or absence of hypospadias, and its eventual adverse effect upon growth and bone maturation. PATIENTS AND METHODS: Sixty-six children with congenital hypoplasia of the penis, isolated (n = 31) or associated with a hypospadias (n = 35), were evaluated between 1 day and 16 years of age. The prevalence (40% of the cases) of the different malformations and/or syndromes associated with congenital hypoplasia and its severity were not different whether the penis was isolated or associated with hypospadias (male-pseudohermaphroditism). The effect of the testosterone heptylate (IM) was evaluated in 40 children treated before 10 years of age. RESULTS: The penis' increase in length was more important in the children with isolated micropenis (+2.1 +/- 0.8 SDS) than those with hypospadias (+1.3 +/- 1.2 SDS) but, in all cases, its increase was better when the treatment was started during the neonatal period, which corresponded to those with the most severe forms of micropenis. A mean regression of the penile volume of -0.7 +/- 0.8 SDS was noticed after the end of each stimulation. No long-term secondary effects related to treatment were seen on later growth and bone-maturation. CONCLUSION: Penile length at the last follow-up was not associated with total dose of testosterone but with its length at the first evaluation time (r = 0.52; P = 0.002).     

The penile disassembly technique in hypospadias repair

OBJECTIVE: To report experience and results with penile disassembly in hypospadias repair. PATIENTS AND METHODS: From November 1995 to May 1997 penile disassembly was used in 92 patients aged from 9 months to 32 years. The indications for operation were hypospadias with severe penile curvature (especially with curvature in the distal third of the corpora cavernosa), chordee without hypospadias, and small penis with hypospadias. The technique involves separating the penis into its component parts, i.e. the glans cap with neurovascular bundle dorsally, together with the undivided or divided urethra and urethral plate ventrally, and the corpora cavernosa. The manoeuvre allows any curvature to be corrected, especially when in the distal third of the corporal bodies, glans tilt to be rectified, and the penis to be enlarged, particularly elongated, which is a significant gain in small penises with hypospadias. RESULTS: The patients were followed for 3-20 months (mean 14); the penis was straightened in all cases, with no recurrence of curvature. In 37 patients (40%) penile disassembly combined with extensive urethral mobilization resolved the hypospadiac meatus with no need to form a neourethra; the penis was larger after surgery. Complications were related to urethroplasty and included four urethral stenoses, two fistulae and three diverticula. There was no injury to the neurovascular bundle and urethra; sensitivity and erection were preserved in all patients. CONCLUSION: The penile disassembly technique is most effective for hypospadias with severe curvature, especially for glans tilt and curvature located distally. Penile augmentation is possible using this technique.     

Performance-based exposure control limits for pharmaceutical active ingredients

Numerous hypospadias correction techniques were described in the literature. The technique varies according to the position of the meatus and the importance of the chordee. These new techniques and the care taken in the manipulation of the tissues tend to decrease complications like stenoses and fistulas, frequent in the long urethroplasty. The correction of hypospadias should conform to aesthetic and plastic surgery. More than 300 corrections were carried out in our service. Surgical technique varied in the long run. Currently, we choose as often as possible a correction in one time: release of the chordae and urethroplasty. Straightening of the penis is obtained on one hand by release of the cutaneous chordae and wide dissection of the hypoplastic urethral plate and one or more dorsal plications according to Nesbit are carried out if it proves necessary. In the distal, glandular and coronal forms, the correction is of type M.A.G.P.I. (meatal advancement, glanduloplasty). The complication rate is extremely low. The aesthetic and functional result is very satisfactory. In the proximal forms, Duckett technique is used only in the obligatory cases given the large number of complications. It is generally replaced by Onlay technique. The urethral plate is left in continuity and serves as support to the pedicled and vascularized flap. In the intermediate situations with a middle shaft hypospadias, Mathieu technique is again of application. The aesthetic and functional result of this type of surgery requires good knowledge and careful application of the technique adapted to each case.     

Use of 99mTc-mercaptoacetyltriglycine (MAG3)-biocytin hepatobiliary scintigraphy to study the protective effect of a synthetic enzyme inhibitor on acute hepatotoxicity in mice

OBJECTIVES: To explain the preoperative assessment of the hypospadias cripple and define the fundamental principles of correction of the failed hypospadias repair. METHODS: Through case presentation and literature review, the defects associated with the failed hypospadias repair including persistent chordee, urethral stricture, urethrocutaneous fistula, urethral diverticulum, meatal retraction and stenosis, failed glansplasty are elaborated. Decision-making points in selecting a method of repair are also provided. RESULTS: The principles of successful reoperative hypospadias surgery are discussed and listed. CONCLUSIONS: A thorough assessment of the defect and precise application of standard principles of hypospadias repair allows for successful correction of even complex hypospadias cripples.     

One-stage versus two-stage Soave pull-through for Hirschsprung's disease in the first year of life

Several investigators have reported good results after a one-stage Soave procedure without a stoma for infants with Hirschsprung's disease. The authors reviewed their concurrent experience with the one- and two-stage approaches, comparing the two groups with respect to rate of complications and clinical outcome. Over a 3-year period, 36 infants with colonic Hirschsprung's disease presenting in the first year of life were treated with a Soave pull-through. Thirteen had a one-stage pull-through, and 23 had a two-stage procedure using an initial stoma. There was no difference with respect to median age at time of diagnosis, median follow-up period, length of aganglionosis, or male:female ratio between the groups. The incidences of major complications such as small bowel obstruction, segmental or acquired aganglionosis, anastomotic leak, and malabsorption were equal between the two groups. However, 13% of the two-stage patients required revision of the stoma. All major complications in the one-stage group were in those who weighed less than 4 kg at the time of surgery. Minor complications such as wound infection, perianal excoriation, and need for repeated dilatation were similar between the groups, but minor stoma-related complications (prolapse or retraction) occurred in 26% of the two-stage infants. When complications were stratified using a more sophisticated scale of severity, no significant difference was found between the groups. The overall complication rate was 1.5 events per patient in the one-stage group and 2.0 events per patient in the two-stage group. This small difference was related to the presence of a stoma in the two-stage group. Overall, 10 of 12 survivors in the one-stage group and 22 of 23 in the two-stage group were doing well, with normal bowel function noted on long-term follow-up (mean period, of 14 and 19 months, respectively). Both one- and two-stage approaches were associated with a significant complication rate, although long-term outcome was excellent in both groups. The higher complication rate in the two-stage group was attributable to the presence of a stoma. For small infants, it may be beneficial to delay the one-stage pull-through until weight exceeds 4 kg.     

In vitro activity of 9 antibiotics and 3 beta-lactamase inhibitors against 107 clinical isolates of Acinetobacter baumanii

Twenty eight of 227 patients undergoing restorative proctocolectomy for inflammatory bowel disease, familial adenomatous polyposis or functional disease were over the age of 50 years: ages 50 to 60 (n = 13), 60 to 70 (n = 10), and over 70 (n = 5). Major complications occurred in 5 patients over the age of 50 (18%) compared with 43 patients under the age of 50 (23%). Three patients above the age of 50 had their pouch excised (11%) compared with 23 under the age of 50 (12%). Functional outcome was assessed with a 12 point symptom score. This was similar in all age bands: under 50 years (mean = 2.2; sd +/- 2.2; n = 109), 50 to 60 years (mean = 2.5; sd +/- 2.5; n = 12), 60 to 70 years (mean = 2.8; sd +/- 2.3; n = 7) and over 70 years (mean = 4.0; sd +/- 3.7; n = 5): P > 0.05). When analysed for ulcerative colitis alone, no significant differences were seen between the two age groups. Restorative proctocolectomy in the elderly gives results which are comparable to the younger population.     

Renopancreatic transplant. Urologic complications

OBJECTIVE: Retrospective study of urological complications in our series of reno-pancreatic transplants. MATERIAL AND METHODS: Between February 1983 and May 1994 our group has conducted 93 RPT, 80 of which, mean age 36 +/- 6 years (24-54 years), are studied in this paper: 57 male and 23 female with an average time in dialysis of 20 +/- 15 months (0-84 months) and diabetes evolution of 21 +/- 5 years (11-37 years). RESULTS: Actuarial annual survival of patient, renal graft and pancreatic graft has been 85%, 79% and 74% respectively. Haematuria: 25% incidence, with graft pancreatitis etiology in 16 cases, rejection in 8 and urinary fistula in 6. Urinary infection: 85% incidence, symptomatic in 23 patients (29%) and asymptomatic in the remaining cases. Dysuria, urethritis and urethral stenosis: 14 patients, all male, most with both conditions associated. Reconversion of pancreatic exocrine secretion by intestinal route was performed in 7 patients. Urinary fistula: secondary to surgery in 9 cases and rejection in 4. Etiology of one case remained unknown. In 4 cases it was resolved with conservative treatment, and with surgical correction in 8. One patient required pancreatic transplantectomy and one patient died of AMI. CONCLUSIONS: Urological complication in RPT account for a significant morbidity, urinary fistula being the one with greater repercussion on the patient and pancreatic graft survival.     

Complications and risks of living donor nephrectomy

BACKGROUND: Short- and long-term patient and graft survival rates are better for living donor (vs. cadaver) kidney transplant recipients. However, donor nephrectomy is associated with at least some morbidity and mortality. We have previously estimated the mortality of living donor nephrectomy to be 0.03%. In our present study, to determine associated perioperative morbidity, we reviewed donor nephrectomies performed at our institution from January 1, 1985, to December 31, 1995. METHODS: The records of 871 donors were complete and available for review. Of these donors, 380 (44%) were male and 491 (56%) were female. The mean age at the time of donation was 38 years (range: 17-74 years), and mean postoperative stay was 4.9 days (range: 2-14 days). RESULTS: We noted two (0.2%) major complications: femoral nerve compression with resulting weakness, and a retained sponge that required reexploration. We noted 86 minor complications in 69 (8%) donors: 22 (2.4%) suspected wound infections (only 1 wound was opened), 13 (1.5%) pneumothoraces (6 required intervention, 7 resolved spontaneously), 11 (1.3%) unexplained fevers, 8 (0.9%) instances of operative blood loss > or = 750 ml (not associated with other complications), 8 (0.9%) pneumonias (all of which resolved quickly with antibiotics alone), 5 (0.6%) wound hematomas or seromas (none were opened), 4 (0.5%) phlebitic intravenous sites, 3 (0.3%) urinary tract infections, 3 (0.3%) readmissions (2 for pain control and 1 for mild confusion that resolved with discontinuation of narcotics), 3 (0.3%) cases of atelectasis, 2 (0.2%) corneal abrasions, 1 (0.1%) subacute epididymitis, 1 (0.1%) Clostridium difficile colitis, 1 (0.1%) urethral trauma from catheter placement, and 1 (0.1%) enterotomy. At our institution, no donor died or required ventilation or intensive care. We noted no myocardial infarctions, deep wound infections, or reexplorations for bleeding. Analysis, by logistic regression, identified these significant risk factors for perioperative complications: male gender (vs. female, P<0.001), pleural entry (vs. no pleural entry, P<0.004), and weight > or = 100 kg (vs. < 100 kg, P<0.02). Similar analysis identified these significant risk factors for postoperative stay > 5 days: operative duration > or = 4 hr (vs. < 4 hr, P<0.001) and age > or = 50 years (vs. < 50 years, P<0.001). CONCLUSIONS: Living donor nephrectomy can be done with little major morbidity. The risks of nephrectomy must be balanced against the better outcome for recipients of living donor transplants.     

Mental prognosis of Apert syndrome

BACKGROUND: Mental retardation, considered as common in Apert syndrome could be in part due to associated brain abnormalities. POPULATION AND METHODS: Sixty patients (32 males, 28 females) were included in the study. Patient age at the last examination was over 3 years (mean 10 years, range 3-28 years) in 38 patients. IQ was assessed from psychometric tests adapted for age. Brain anatomy was studied by MRI. Age at operation and quality of familial environment were also evaluated. RESULTS: The IQ was over 70 in 12 patients (32%), over 90 in five (13%) and the mean IQ was 62 (10-114). Thirty percent of patients had abnormalities of the corpus callosum, 43% of the cerebral ventricles and 55% of the septum pellucidum. There was no anomaly in 28% of the patients. One or more operations were performed in 53 patients, before one year of age in 37. Ten children were institutionalized or in deleterious family situation. The main factor influencing the mental prognosis was the age at operation: the final IQ was over 70 in 50% of the children operated on before one year of age versus 8% in those operated on later (P = 0.01). Only the anomalies of the septum pellucidum seemed to play a role: 50% of the patients with normal septum had an IQ > 70 compared to 18% in those with septum anomalies (P < 0.04). The quality of the familial environment also influenced the mental development: 12.5% of the patients who were institutionalized or in difficult familial situation had an IQ > 70 compared to 39% of those who live in a normal family. CONCLUSIONS: Careful investigation including MRI is necessary for detecting associated brain abnormalities. The patients must be operated on early, if possible before the age of nine months. Attention has also to be paid to quality of the sociofamilial environment.     

The significance of prenatally identified isolated clubfoot: is amniocentesis indicated?

OBJECTIVE: Our purpose was to determine the significance of finding an isolated clubfoot on a prenatal sonogram. STUDY DESIGN: All fetuses found to have an isolated congenital clubfoot over a 9-year period were retrospectively identified. Fetuses with associated anomalies were excluded. Review of medical records for obstetric and neonatal outcome and pathologic and cytogenic results were tabulated. RESULTS: Eighty-seven fetuses were identified from our database as having isolated clubfoot on prenatal ultrasonography, with complete follow-up available for 68 fetuses. Sixty of the 68 fetuses were confirmed as having clubfoot after delivery (false-positive rate = 11.8%). The male/female ratio was 2:1. Four fetuses (5.9%) had abnormal karyotypes: 47,XXY, 47,XXX, trisomy 18, and trisomy 21. Nine fetuses had hip or other limb abnormalities noted after birth. Other anomalies not detected until delivery included a unilateral undescended testis, ventriculoseptal defects (n = 2), hypospadias (n = 2), early renal dysplasia, mild posterior urethral valves, and a two-vessel cord. Five of the 68 patients (including those with aneuploidy) had pregnancy terminations. Eleven patients were delivered preterm. CONCLUSION: Karyotypic evaluation is recommended when isolated clubfoot is identified on prenatal sonogram because other subtle associated malformations may not be detected ultrasonographically in the early second trimester.     

Characterization of two Chinese hamster ovary cell lines expressing the COOH-terminal domains of sterol regulatory element-binding protein (SREBP)-1

BACKGROUND: To assess surgical outcome after oesophagectomy, we reviewed operative techniques and postoperative course among 90 patients who underwent oesophageal resection for malignancies from January 1989 to December 1995. METHODS: There were 73 males and 17 females; mean age was 64.2 years. Indications were squamous cell carcinoma in 49 patients and adenocarcinoma in 41. Preoperatively 7 patients had chemotherapy and 18 benefited from radiochemotherapy. There were 56 total thoracic oesophagectomies, with anastomosis in the neck in 34 patients and at the thoracic inlet in 22. In 34 cases operation was limited to distal oesophageal resections. Digestive continuity was restored with the stomach in 62 patients, with the colon in 24, and with a jejunal loop in 4. A feeding jejunostomy was constructed in 48 patients with a gastric transplant. RESULTS: Mortality was 10% (9 patients), decreasing from 18.5% (before 1993) to 3.8% (since 1993). One patient died in the colonic graft group and 8 in the gastric pull-up group. Postoperative complications occurred in 9 patients after colonic interposition and in 23 after gastric pull-up; they consisted in pulmonary infection or insufficiency in 26 patients, cerebrovascular accident in one, renal insufficiency in 2, recurrent nerve palsy in 4, and anastomotic leakage in 6. Transhiatal approach was not associated with a decreased incidence of postoperative deaths or complications. Eighteen patients (72%) developed postoperative pulmonary complications after preoperative chemotherapy. CONCLUSION: Oesophagectomy can be performed with low mortality. A colonic graft is not associated with an increased incidence of perioperative deaths or complications and is the substitute of choice when there is any question regarding gastric vascularization, or in young patients with long life expectancy. Preoperative neoadjuvant treatment significantly increases postoperative pulmonary complications.