Ocular and palpebral surgery: indications and limits

The alcohol dehydrogenases (ADH) and their genes (Adh) of Drosophila have been much studied by population and evolutionary biologists. I attempt to put some of these studies into a broad adaptionist perspective, suggesting the co-evolution of this enzyme with the fleshy fruits of angiosperms and fermenting yeasts. I suggest that these events occurred at about the K/T boundary (65 million years ago) and that the typical Drosophila (as exemplified by D. melanogaster) evolved from flies unable to use fermenting substrates as breeding sites. I also hint that the ADH enzymes of other flies (e.g., the tephritid fruit flies) may have evolved independently of those of Drosophila, but from a common ancestral gene.     

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.     

Laparoscopic cholecystectomy in cirrhotic patients: expanding indications

Cirrhosis, portal hypertension, and bleeding disorders are being considered as relative or absolute contraindications to laparoscopic cholecystectomy (LC). This report describes four cirrhotic patients with clinical portal hypertension in three and mild to severe bleeding tendency in all. Laparoscopic cholecystectomy was uniformly successful in these patients with no complications. If the surgeon exercises extreme caution in securing hemostasis and does not overlook some details concerning patient management, LC can be efficiently and safely performed in cirrhotic patients. Compared with open cholecystectomy, LC may be even more advantageous concerning the virtual elimination of incision-related complications. Our preliminary experience is encouraging and suggests more liberal use of LC in cirrhosis-portal hypertension-bleeding tendency disease complex.     

Venous infarction of the adrenal glands

An investigation of 78 cases of adrenal haemorrhage and necrosis disclosed that 32 were examples of adrenal venous infarction. In all these cases there was thrombosis of the main adrenal vein and in most there was also thrombosis of the capsular veins, a finding which has not been well established. In a number of cases with venous infarction there was clinical and pathological evidence that disseminated intravascular coagulation (DIC) had occurred, but it appears that it was not the direct cause of venous thrombosis. The majority of cases of venous infarction occur in patients with severe infection, frequently of the respiratory tract. Venous infarction was found in five cases with hypothermia an association which had rarely been described, and in three of these there was evidence of DIC. This is apparently the first occasion on which DIC has been demonstrated in cases of hypothermia in man. The cause of venous thrombosis in the adrenal glands is obscure in most cases of venous infarction, although in three it was due to involvement by metastatic carcinoma. It is suggested that the factors responsible for the initiation of thrombosis in the adrenal veins are catecholamines, thrombin, fibrin and endotoxin. Localisation of the thrombi to the adrenal vein is due to the unique anatomical structure of the vein which, under certain circumstances, results in the local stasis of blood.     

Bilateral non-Hodgkin's lymphoma of the adrenal glands with adrenal insufficiency

A 66-year-old female presented with anorexia, fatigue, skin pigmentation, weight loss and low grade fever. Imaging studies demonstrated bilateral bulky masses confined to the adrenal glands. Ultrasonography guided needle biopsy of the mass showed findings of diffuse large B-sell lymphoma. Low levels of serum cortisol, urinary 17-OHCS and 17-KS, a high level of ACTH and a non-reactive pattern on the rapid ACTH test led to a diagnosis of Addison's disease. Only a partial regression was achieved by the first chemotherapy. She died due to disease progression, while the next course of chemotherapy had been postponed because of interstitial pneumonitis due to methotrexate.     

Laparoscopic ovarian transposition for pelvic malignancies: indications and functional outcomes

OBJECTIVE: To assess the indications and effectiveness of laparoscopic ovarian transposition before pelvic irradiation for a gynecologic cancer. DESIGN: Prospective study. SETTING: A gynecologic oncology department in a French anti-cancer center. PATIENT(S): Twenty-four patients treated for pelvic cancer. INTERVENTION(S): Laparoscopic ovarian transposition to paracolic gutters. Uterine conservation in 18 patients. MAIN OUTCOME MEASURE(S): Clinical and laboratory follow-up tests of ovarian function. RESULT(S): Bilateral laparoscopic ovarian transposition was achieved in 22 patients (94%). Twelve patients were treated for clear cell adenocarcinoma of the cervix and/or upper vagina, 6 patients for invasive squamous cervical carcinoma, 3 patients for pelvic sarcoma, 1 patient for recurrent cervical cancer to the upper vagina, 1 patient for ependymoma of the cauda equina, and 1 patient for ovarian dysgerminoma. Ovarian preservation was achieved in 79%. Three pregnancies were obtained. CONCLUSION(S): Laparoscopic ovarian transposition is a safe and effective procedure for preserving ovarian function. Bilateral ovarian transposition should be performed. The main indications for laparoscopic ovarian transposition are a patient with a small invasive cervical carcinoma (<2 cm) in a patient <40 years of age who is treated by initial laparoscopically assisted vaginal radical hysterectomy and a patient with a clear cell adenocarcinoma of the cervix and upper vagina.     

Contrast-enhanced MR imaging of the kidneys and adrenal glands

Technical developments including motion artifact compensation and the use of paramagnetic contrast agents have substantially improved the performance of MR imaging of the kidneys and adrenal glands. MR imaging allows one to assess morphologic alterations of the kidneys as well as perfusion and functional derangements. MR imaging is the best noninvasive method for distinction of benign from malignant adrenal masses.     

Changes in the adrenal glands in menigococcemia

Post-mortem morphological, histochemical, and morphometric investigations of the adrenals in 46 deceased patients who suffered from meningococcemia with and without lesions of the meninges were carried out. The control group was composed of 7 practically healthy persons who had perished suddenly as a result of craniocerebral trauma. It was shown that the adrenals might often be seriously damaged in meningococcemia without clinical and morphological signs of meningitis. Hemodynamic disorders, in particular, involvement of the vessels of the microcirculatory bed, contributed considerably to the lesions of the adrenals. However, even in meningococcemia free from signs of meningitis, in a number of cases individual areas of the cortex retained a high functional activity. In meningococcemia combined with lesions of the meninges, despite considerable damage of the cortical layer, in the majority of cases there were evidences of the tense functioning of the adrenal cells.     

Ambulatory surgery. Laparoscopic surgery

Laparoscopic surgery procedures have increased over the past decade and newer uses are being investigated. The major reasons for increased use of laparoscopic procedures include decreased pain, smaller incisions, and decreased length of hospital stay. Although the cost of hospital stay is decreased, there are increased costs associated with longer surgery time, increased anesthesia time, and additional equipment. Other drawbacks to the procedure are miniaturized instruments, decreased field of vision, inability to palpate tissue and organs directly, and necessary hand-eye coordination.     

Pseudocysts of the adrenal glands in newborn infants

With diagnostic aims the author used direct laryngeal tomography in patients with median stenosis of the larynx. Tomography made it possible to define the width of the lumen of the sumplica area. Depending on the change of the subplica area the author varied the extent of surgical intervention. He used the extralaryngeal method of vocal plica laterification in all patients. With narrow subglottis he practiced complete mobilization of the elastic cone and its subsequent laterification; with wide subglottis he mobilized only the uper edge of the elastic cone. He succeeded in obtaining good functional results concerning respiration in all patients.     

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.     

Reoperative surgery for organic hyperinsulinism: indications and operative strategy

Organic hyperinsulinism has a good chance of cure by operation, although patients with diffuse or multiple disease run a high risk of recurrence or persistence of disease. Surgical management and outcome in these patients are presented and discussed. Between 1986 and April 1997 a total of 62 patients were operated on for organic hyperinsulinism [solitary 48, multiple 3, multiple endocrine neoplasia type I (MEN-I) 2, diffuse 4, malignant 5]. Persistence or recurrence occurred in 10 patients (16%). Among the six that persisted, four were malignant and two benign. All four of those that recurred were benign. Patients with benign disease presented with multiple tumors (n = 3), MEN-I syndrome (n = 1), and diffuse/nodular hyperplasia (n = 2). The duration between diagnosis and reintervention ranged from 1 to 10 years. Preoperative diagnosis was able to localize tumors in three patients (computed tomography 1, angiography 2, calcium stimulation 1). Operative procedures were multiple enucleations in two patients with sporadic disease, subtotal resection plus enucleation in the case of MEN-I syndrome, subtotal resection for diffuse hyperplasia, left resection for adenomatosis, and tumor extirpation after multiple previous operations. Long-term clinical and biochemical cure was achieved in five of six patients (mean follow-up 5 years). Octreotide therapy shows good symptomatic control in the patient with operative failure. Reintervention for organic hyperinsulinism is successful (80% cure) and requires preoperative imaging and individual surgical management.     

Laparoscopic antireflux surgery

Gastroesophageal reflux disease is very common, and there continues to be a need for gastroesophageal reflux surgery despite improved medical therapy. With the relatively new option of laparoscopic antireflux surgery, many more of these procedures are now being performed. In order to perform these well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.     

Laparoscopic colorectal surgery and cancer

Review article of the actual level of knowledge about laparoscopic colorectal surgery and laparoscopic-assisted procedures. At present time laparoscopy for the cure of colorectal neoplasia should only be performed within prospective randomized trials. In the meantime it is perfectly appropriate to perform laparoscopy for palliation of metastatic disease. Patients with benign colorectal neoplasms can achieve better outcome if treated by laparoscopy rather than laparotomy. Other areas in which laparoscopy may be useful include enterolysis and possibly, treatment of rectal prolapse. Laparoscopy can be appropriately applied for the treatment of terminal ileal Crohn's disease, sigmoid diverticulitis, reversal of Hartmann's pouches and the construction of stomas.     

Adrenalectomy for metastatic disease to the adrenal glands

A policy of supportive treatment is frequently adopted for patients with metastatic disease to the adrenal glands. This study reports an experience with adrenalectomy for adrenal metastasis. Between 1983 and 1993, adrenalectomy was performed in 52 patients for metastasis to the adrenal glands. Survival was calculated by the Kaplan-Meier method and compared with the log rank test. Primary tumour sites included kidney (n = 15), lung (n = 11), colon (n = 7), unknown (n = 5), stomach (n = 3), melanoma (n = 3) and other (n = 8). Adenocarcinoma (69 per cent) was the most common histological cell type. Thirty-two patients were asymptomatic on initial evaluation. Symptomatic adrenal pain relief was achieved in 11 of 13 patients. Overall survival rates were 73 per cent at 1 year and 40 per cent at 2 years. Patients with potentially curative resection had better survival than those who had a palliative procedure. Patients with adrenal metastases due to adenocarcinoma had improved survival compared with that in those with other histological cell types. Although long-term survival is generally poor, highly selected patients with adrenal metastasis (symptomatic disease or adenocarcinoma) may benefit from surgical resection.