Muscle flaps and musculocutaneous flaps in the repair of urinary fistulas

Techniques for including muscle flaps and musculocutaneous flaps in the repair of difficult vesicocutaneous, urethrocutaneous, and vesicovaginal fistulas are described. These methods have been uniformly successful in 10 consecutive patients. The incorporation of such healthy, well-vascularized tissue into the standard techniques of urologic repair can be a major factor in the successful management of these problems.     

Deep vein thrombosis after thoracotomy

In a prospective study of 183 patients undergoing lateral thoracotomy the 125 I fibrinogen uptake test and perioperative heparin prophylaxis for deep-vein thrombosis were investigated. There was an incidence of deep vein thrombosis in 51% in untreated control patients. The heparin prophylaxis effectively reduced the incidence of deep venous thrombosis to 28% (P less than 0.005) without increasing postoperative blood loss. Unilateral thrombosis was found to be significantly more frequent in the leg opposite the side of the thoracotomy (P less than 0.005). The 125I fibrinogen test is essential in assessing methods of prophylaxis but is not recommended as a routine.     

Successful treatment of postoperative right ventricular heart failure with the HIA-Medos-assist system in a 2-year-old girl

Communicating hydrocephalus can be handled either by the ventriculoperitoneal or, occasionally, the ventriculoatrial shunt. The lumboperitoneal shunt is another option. It does not require a transcranial approach; therefore, it is safer for the patient. We describe a technique that can be performed easily by a skilled laparoscopic surgeon through an anterior approach transabdominally. The lumboperitoneal (LP) shunt is placed laparoscopically under direct videoscopic vision, with the catheter inserted transabdominally through the L3 disc space into the thecal sac. In our patient, the lumboperitoneal shunt was placed at the L3 disc space for communicating hydrocephalus. There were no intraoperative or postoperative complications. The LP shunt can be easily placed by a skilled laparoscopic surgeon. The incidence of infection and complications is lower, and the patency rate is higher. This should be the initial choice for communicating hydrocephalus.     

Corneal epithelial recovery following photorefractive keratectomy

AIMS: To further understand the morphological and functional recovery of corneal epithelium following excimer laser photorefractive keratectomy (PRK). METHODS: The right eyes (group 1) of 15 male, New Zealand white rabbits weighing 2-3 kg underwent PRK. The left eye of each rabbit (group 2) underwent simple mechanical de-epithelialisation and were examined as treated controls. Both eyes of another eight rabbits (group 3) served as untreated controls. All eyes underwent a corneal epithelial permeability study by fluorophotometry at 2, 4, and 8 weeks after surgery. Five animals in groups 1 and 2 were sacrificed at 9, 10, and 12 weeks after surgery. The animals in group 3 were sacrificed at the end of the 12 week experimental period. Both eyes of each sacrificed animal were enucleated immediately and processed for both haematoxylin and eosin stain and electron microscopic study. The electron micrograph was magnified to 14,000x and the extent of hemidesmosome formation was quantified and analysed. RESULTS: The corneal epithelial barrier to sodium fluorescein was subnormal and returned to a normal barrier state 4 weeks after PRK in group 1 whereas it was normal in group 2 throughout the examination period. The extent of hemidesmosome formation was abundant yet subnormal in both groups 1 and 2 up to 12 weeks, when compared with that in group 3. CONCLUSION: The corneal epithelium regained its functional barrier 4 weeks after PRK in rabbits while the extent of hemidesmosome formation was still subnormal 12 weeks after mechanical de-epithelialisation, with or without PRK.     

Focal hyperexpression of hemeoxygenase-1 protein and messenger RNA in rat brain caused by cellular stress following subarachnoid injections of lysed blood

Induction of the hemeoxygenase-1 (ho-1) stress gene is of importance for rapid heme metabolism and protection against oxidative injury in vitro and in vivo. Although ho-1 expression is observed in glia following exposure to whole blood and oxyhemoglobin, expression is mild, and other stress genes are not induced simultaneously in this setting. Hemeoxygenase-1 can be induced by several other physiological stresses in addition to heme. In the brain, ho-1 induction has been observed in the penumbra following focal cerebral ischemia. Because lysed blood is a spasmogen, the authors studied focal hyperexpression of the ho-1 gene after injection of lysed blood, whole blood, or saline into the cisterna magna of adult rats. Immunocytochemical analysis of HO-1 was performed at 1, 2, 3, and 4 days after the injections. Because the 70-kD inducible heat shock protein (HSP70) is induced by cellular stress, alternate sections were immunostained for HSP70 to assess whether focal hyperexpression was a stress phenomenon. An oligonucleotide probe was also used for in situ hybridization to demonstrate that ho-1 messenger (m)RNA was present. Focal HO-1 immunostained areas were observed after lysed blood injection only and were located mainly in the basal cortex and cerebellar hemisphere, although focal hyperexpression was also found in many other regions. The intensity of staining and the number of regions were maximum at 1 day. Double-labeled immunofluorescence revealed that many HO-1-immunoreactive cells were microglia. The HSP70 immunostaining of adjacent sections from the same animals demonstrated focal regions of immunoreactivity whose topography corresponded exactly with the topography of the HO-1-immunostained areas. Conventional histology in regions of HO-1 hyperexpression was often normal. In situ hybridization using the same oligonucleotide demonstrated that ho-1 mRNA was induced in focal areas of forebrain and in large regions of cerebellum within 6 hours of injection. These results demonstrate that focal hyperexpression of the ho-1 stress gene occurs after lysed blood injection and appears to be an indicator of cellular stress and injury in regions in which infarction does not occur. These results also suggest that cellular injury that occurs after injection of lysed blood may go undetected using conventional histology. Although direct heme metabolism was not investigated, our results indicate that rapid metabolism of heme, both intracellular and extracellular, may prove to be beneficial after subarachnoid hemorrhage.     

Pancreatic cancer: treatment with neutron irradiation alone and with chemotherapy

PURPOSE: To evaluate neutron irradiation alone and with chemotherapy to treat inoperable pancreatic cancer. MATERIALS AND METHODS: Between 1977 and 1994, 173 patients (60 men, 113 women, aged 43-77 years [mean, 59 years]) with unresectable adenocarcinoma of the exocrine pancreas were treated, 106 with neutron irradiation alone and 67 with concomitant chemotherapy (fluorouracil [5-FU]). At follow-up, which was performed at 2-month intervals until death (range, 4-64 months), clinical status was recorded, noting the presence of overt metastasis and the onset of any major complications. Actuarial (Kaplan-Meier) survival tables were computed for both groups. RESULTS: For neutron irradiation alone and neutron irradiation plus chemotherapy, median survival times were 6 months and 9 months, respectively; actuarial survival rates at 3 years were 0 and 7%, respectively; major reactions (grade 3 or higher [scale of the Radiation Therapy Oncology Group and European Organization for Research and Treatment of Cancer]) occurred in 19 (18%) and 17 (25%) patients, respectively; and severe complications (grade 4) occurred in five (5%) and four (6%) patients, respectively. Most deaths were due to metastatic disease rather than to failure of local control. CONCLUSIONS: Neutron irradiation obliterated pancreatic adenocarcinoma at the primary site but has no effect on long-term survival. With more effective concomitant chemotherapy to prevent metastasis, local control of pancreatic cancer with neutron irradiation could lead to increased long-term survival.     

Evaluating ovarian reserve: follicle stimulating hormone and oestradiol variability during cycle days 2-5

A prospective measurement of follicle stimulating hormone (FSH) and oestradiol between cycle days 2 and 5 was conducted to investigate the intra- and inter-cycle variability in a healthy population of women with regular menstrual intervals. Daily serum samples were obtained from 44 women for a total of 66 cycles on cycle days 2, 3, 4 and 5. FSH concentrations were consistent on all cycle days measured. Oestradiol concentrations on cycle day 2 were not different from cycle day 3, but concentrations on cycle day 4 and cycle day 5 were statistically different from both cycle day 2 and cycle day 3 by analysis of variance (P < or = 0.05). Evaluation of functional ovarian reserved by cycle day 3 FSH measurement has become the standard in most assisted reproductive technology programmes. The recent change in FSH standardization coupled with the inflexibility of cycle day 3 testing has led to a re-evaluation of testing protocols. Cycle day 3 appears to have emerged as a dictum because most ovulation induction protocols are initiated on cycle day 3, 4 or 5. Flexibility of sampling day can be introduced as suggested by these results. The additional information ascertained from oestradiol testing as applied to evaluation of ovarian reserve warrants further investigation.