Surgery for acquired cholesteatoma in children: long-term results and recurrence of cholesteatoma

The aim of the study was to evaluate the long-term results after surgery for acquired cholesteatoma in children and to contribute to the search for predictors of recurrence. During a 15-year period, 114 children underwent surgery. The patients were re-evaluated with a median observation time of 5.8 years. At the last re-evaluation 85 per cent of the ears were dry with an intact drum. Recurrence of cholesteatoma developed in 27 ears. The cumulated total recurrence rate was 24 per cent using the incidence rate calculation, applying Kaplan-Meier survival analysis the corresponding recurrence was 33 per cent. Recurrent disease occurred significantly more frequently in children younger than eight years, with a negative pre-operative Valsalva, with ossicular resorption and with large cholesteatomas. In conclusion, young children with poor Eustachian tube function and a large cholesteatoma with erosion of the ossicular chain, are at special risk of recurrence and should be observed for several years after surgery.     

2q21-qter trisomy in hepatoblastoma

Cytogenetic findings and fluorescens in situ hybridization results of a hepatoblastoma of a boy of two and half years of age are presented. Cytogenetic analysis and fluorescens in situ hybridization technique were performed using tumor tissue obtained by biopsy. The direct culture was harvested after 16 hour colcemid treatment. The results of G-banding were as follows: 47,XY,add(4) (q26),-9,+20. There were considerable variation in the degree of condensation and hence in the number of visible G-bands both between metaphases and between homologous chromosomes in the same metaphases. Fluorescens in situ hybridisation were carried out by whole chromosome painting probes: 2,3,4, and 20. The karyotype of the malignant cells was adjusted accordingly: 47,XY,der(4)(q35),dir ins(9;2)(p22;q?21q?25),+20. The results confirm the most common primary chromosome abnormalities in hepatoblastoma are the following: trisomy 2, trisomy 20 and 4q structural rearrangement. Fluorescens in situ hybridization confirms the importance of trisomy 2q21-qter in hepatoblastoma. Authors recommend the use of fluorescens in situ hybridization to correct any tumor karyotype with difficult or ambiguous chromosome morphology.     

Successful right trisegmentectomy for ruptured hepatoblastoma with preoperative transcatheter arterial embolization

This is the first report of the successful use of percutaneous transcatheter arterial embolization (TAE) in controlling hemorrhage from ruptured hepatoblastoma, allowing early major hepatic resection to be performed safely in a young infant. A 6-month-old girl presented with a huge abdominal mass and was found to have a hepatoblastoma that measured 15 x 10 x 12 cm and arose from the right lobe of her liver on computed tomography (CT) scan examination. The tumor spontaneously ruptured, and she went into shock. TAE with gelfoam cube particles successfully arrested the tumor bleeding and allowed stabilization of her blood pressure with blood transfusion. Right trisegmentectomy was performed 12 hours later. The postoperative course was uneventful. With three courses of cisplatin, vincristine, and 5-fluorouracil after the hepatectomy, the serum alpha-fetoprotein level returned to normal, and the patient has remained well 4 months postoperation.     

DNA analysis in hepatoblastoma by flow and image cytometry

BACKGROUND: In several types of tumors, including hepatocellular carcinoma, prognosis could be correlated with DNA ploidy. Few studies have been performed on hepatoblastoma with contradictory results. METHODS: Twenty-nine cases of nonpretreated hepatoblastoma were studied with flow cytometry and image cytometry for DNA index and proliferation index using paraffin-embedded tissue. RESULTS: Twenty-three (79.9%) tumors were diploid, and 6 (20.7%) were aneuploid (hyperdiploid). Patients with diploid tumors were younger than those with aneuploid tumors. With regard to stage, diploid tumors were almost equally distributed among stages (tumor, lymph node metastases, distant metastases), whereas aneuploid tumors tended to occur in higher stages (tumor, lymph node metastases, distant metastases). Diploid tumors had clearly a better prognosis than aneuploid tumors, although the difference was not statistically significant (flow cytometry, P = 0.06; image cytometry, P = 0.16). A more favorable prognosis was also noted for hepatoblastomas with low-proliferation index (< or = 7%), but the difference from tumors with high-proliferation index (> 7%) again was not statistically significant (P = 0.16). CONCLUSIONS: Although no statistically significant differences in prognosis between hepatoblastomas with diploid and aneuploid DNA content, respectively, were found, there is a clear tendency that diploid hepatoblastomas behave more favorably. The same is true for hepatoblastomas with low-proliferation index.     

Cytogenetic abnormalities and clonal evolution in an adult hepatoblastoma

Hepatoblastomas usually occur in children < 3 years of age, and only occasional adult cases have been described. To date, 20 cytogenetically abnormal childhood hepatoblastomas have been reported. Karyotypic investigations have shown that most hepatoblastomas are diploid or hyperdiploid, often displaying trisomies for chromosomes 2 and 20. We have cytogenetically investigated an adult hepatoblastoma for which no previous karyotypic data exist. A hypertriploid stemline with multiple numerical and structural chromosomal aberrations, including +2 and +20, was found. In addition, the tumor displayed extensive clonal evolution with 11 subclones. Although the tumor thus displayed some chromosomal abnormalities commonly observed in childhood tumors, providing further support for the importance of these abnormalities in the development of hepatoblastoma, the level of genomic complexity seen in the present case has never been described in childhood hepatoblastomas and may suggest a different etiology or pathogenesis.     

Surgery for epidermolysis bullosa in children: value of the association of inhalation anesthesia and locoregional anesthesia

Due to the cutaneous and mucosal fragility associated with epidermolysis bullosa, this disease is a source of various practical problems for the anaesthesiologist concerning the surgical posture, the monitoring of vital functions, the airways control and the vascular access, as all these procedures may worsen, sometimes dramatically, the lesions in these young patients, still in a precarious health state. Basing on published studies and their own experience, the authors have used in these patients a combined locoregional and general anaesthesia. The latter was obtained with isoflurane, administered in the non intubated and spontaneously breathing patient through a closed surgical isolation container (Vi-Drape), including the patient's head and ventilated with a ventilator generating a PEEP for long procedures. The results obtained during 9 procedures in 3 children are reported and discussed. For several shorter procedures (for example wound dressing), intramuscular ketamine was used.     

Extramedullary hematopoiesis and intratumoral production of cytokines in childhood hepatoblastoma

Extramedullary hematopoiesis is a characteristic feature of hepatoblastoma (HB). We investigated 15 HB to characterize intratumoral hematopoietic foci and to find clues to the pathophysiology of their formation. By conventional histology and immunohistochemistry, we found erythroblasts in all and megakaryocytes in 10 of the HB, whereas granulocyte and monocyte precursor cells could not be identified in hematopoietic foci of any tumor. Only a minority of erythropoietic cells in these foci contained fetal Hb (HbF). We recently found that HB cells produce IL-1 beta and thus stimulate stromal cells to secrete IL-6. We therefore searched for other hematopoietic cytokines in HB. Supernatants of primary HB cultures were subjected to ELISA, bioassayed, and immunoblotted. We detected erythropoietin (EPO) in 11 of 15, stem cell factor (SCF) in 7 of 11, granulocyte colony-stimulating factor (G-CSF) in 4 of 15, granulocyte/macrophage colony-stimulating factor (GM-CSF) in 6 of 15, IL-3 in 1 of 12, leukemia inhibitory factor (LIF) in 1 of 9, and macrophage colony-stimulating factor (M-CSF) in 1 of 8 conditioned media. With immunoenzymatic labeling we localized EPO and SCF to the cytoplasm of epithelial HB cells, whereas stromal cells and cells of immature fibrous tissue of mixed HB expressed SCF, G-CSF, GM-CSF, LIF, and M-CSF. EPO and SCF could also be detected in extracts of epithelial HB cells. We conclude that, in HB, erythropoiesis and megakaryopoiesis but not the granulocyte-macrophage lineage is induced by fetal and embryonal tumor cells in cooperation with stromal cells by locally secreted cytokines.     

Unusual US and CT findings in hepatoblastoma: a case report

Hepatoblastoma is the most common primary hepatic tumor in young children and its radiological findings have been well described. We report ultrasound and computer tomography findings in a case of hepatoblastoma diffusely involving the entire liver and presenting as inhomogeneity and numerous cystic lesions in the hepatic parenchyma.     

Surgery for cholelithiasis in cirrhotic patients

Although biliary tract surgery for cholelithiasis is performed frequently, cirrhotic patients require special consideration. The prevalence of postoperative severe complications, such as hepatic failure and biliary peritonitis caused by insufficient fistula formation after removal of the T-tube, is higher than non-cirrhotic patients. We suggest that definitive surgery can be carried out safely, in Child's A and B cirrhotic patients, either electively or as an emergency. However, a more conservative approach is advisable in Child's C patients with acute conditions and definitive surgery is recommended as an elective procedure after liver function has improved. And for the treatment of choledocholithiasis in patients with severe cirrhosis, avoiding surgical intervention through the use of such techniques as endoscopic papillotomy is recommended whenever possible.     

Surgery for urinary incontinence

Burch colposuspension remains the most effective surgical procedure for stress urinary incontinence with a continence rate, which shows better longevity than other methods of treatment. Sling procedures have a comparable continence rate to colposuspension and there appears to be little reduction in continence over time. It is expected that the tension-free vaginal tape will eventually supersede the open Burch colposuspension as the preferred method of primary incontinence surgery principally because it is a minimal-access procedure and medium-term data suggest similar effectiveness to colposuspension. Initial reports on the trans-obturator tape, which minimises bladder and vascular trauma, are encouraging but longer term results remain uncertain. Although the injectable agents have a lower success rate than other procedures, they may still have a role when other procedures have failed due to their low morbidity. Anterior colporrhaphy and needle suspension procedures should no longer be offered as treatments for stress urinary incontinence.The surgical options for detrusor activity should be considered when pharmacological options have been exhausted. Appropriate patient selection is crucial when choosing which surgical option would be most suitable, especially as many of these procedures carry with them a significant risk of morbidity. Some surgical options are becoming less invasive and modern developments, such as intravesical botulinum toxin injection may in future become a first line treatment option for detrusor overactivity.     

Surgery for gynecologic cancer

Surgery is an integral part of staging procedures for ovarian, endometrial, and vulvar cancers, with a move toward surgicopathologic rather than clinical staging in cervical cancer. Morbidity can be reduced without compromising patient cure by individualizing surgery for patients with early vulvar cancer, and reproductive potential can be maintained in some women with early ovarian cancer. The place of prophylactic oophorectomy and primary and secondary surgery in ovarian cancer remain controversial and await prospective study. Recent developments in laparoscopic techniques have been applied to a number of problems in gynecologic cancer surgery, and the feasibility of laparoscopic lymphadenectomy and radical pelvic surgery has been demonstrated. Care must be taken, however, to ensure that the tenets of surgical oncology are not sacrificed in order to offer minimal-access surgery to women with gynecologic cancer.     

Surgery for lung metastases

Authors analyse the cases of lung metastasectomy collected during fourteen years in eleven thoracic surgical departments in Hungary. 668 operations were carried out on 620 patients. The primary tumor originated mainly from kidney, testis and colo-rectum. Most of the interventions were performed through median sternotomy. The tumors were removed by tissue sparing lung resections (wedge resection). The prognosis depends basically on tumor free interval, however the number and the size of the metastases and the histology of the primary tumor have also impact on it. When lung lesions appear in a cancer patient, thoracic surgeon should be consulted to consider operability. In certain cases metastasectomies can result in longer survival and better quality of life.     

Surgery for gynecologic malignancies

At room temperature (23 degrees C-25 degrees C), the induction of long-term potentiation (LTP) in area CA1 of slices from young male Sprague-Dawley rats was depressed by preincubation with the nitric oxide synthase inhibitors NG-nitro-L-arginine (L-NA, 100 microM) and NG-nitro-L-arginine methyl ester (L-NAME, 100 microM). The D isomers were ineffective under the same conditions. Hemoglobin (20 microM) reduced but did not completely block LTP. Neither L-NA (at concentrations up to 1 mM) nor hemoglobin (20 microM) had any significant effect on LTP in slices from adult rats at room temperature, or in young rats at 29 degrees C-30 degrees C. These results suggest that nitric oxide is unlikely to play a role in the induction of LTP under physiological conditions.     

Surgery for peptic strictures

Benign peptic stricture of the esophagus is a complex disorder which results from persistent gastroesophageal reflux. Its successful management depends on an accurate preoperative evaluation of the stricture and the patient. Surgical management of peptic strictures can be quite effective in relieving the symptoms and halting the pathologic gastroesophageal reflux that accompanies this disorder. This article reviews the general principles of evaluation and surgical treatment of benign peptic esophageal strictures.     

Surgery for unstable hips in cerebral palsy

A survey of canine heartworm (Dirofilaria immitis) infections among German shepherds in five areas of South Korea was performed from October 1994 to August 1995 using a microfilarial test (modified Knott's test) and an antigen test (DiroCHEK, Synbiotics, USA). The infection rate of 127 German shepherds (71 males and 56 females) was 10.2% (13/127) by the microfilarial test, but was 28.3% (36/127) by the antigen test, revealing that 24 of the 36 antigen-positive dogs were microfilaria negative in the peripheral blood. All dogs that were microfilaria-positive were also antigen positive. There of the microfilaria negative and antigen positive dogs contained 4.15 adult heartworms in the heart and pulmonary arteries upon necropsy. The infection rate among German shepherds was the highest in Hoengsong-gun (Kangwon-do, 84.4%), while those of Yechon gun (Kyongsangbuk-do) and Chungwon-gun (Chungchongbuk-do) areas were 20.0% and 14.3%, respectively. None of the dogs in the Kimhae-shi (Kyongsangnam-do) and Kwangju areas was heartworm positive. The infection rates of heartworm in dogs at the age of 1-3, 4-6, and 7-11 years were 6.2%, 21.4%, and 56.4%, respectively. Based on the fact that the antigen test is more accurate than the microfilarial test, this study strongly indicates that the prevalence rate of canine heartworm in Korea may be higher than previously reported (3.1 approximately 23.0%) which utilized microfilarial tests.     

Surgery for inflammatory bowel disease in Singapore

Inflammatory bowel disease is uncommon in Asians and reports of surgery in these populations are rare. Eighty-two patients with inflammatory bowel disease were seen in the Department of Colorectal Surgery over a five-year period (1989-1994). Twenty-three patients underwent surgery for their disease. There were 12 males and 11 females with 16 Chinese, 4 Indians and 3 Malays. Twelve had Crohn's disease and 11, ulcerative colitis. The majority of patients with Crohn's disease had emergency surgery for bleeding, perforation, abdominal masses and intestinal fistulae. Fifty percent of these had the diagnosis made intraoperatively or post-operatively. Surgery for ulcerative colitis was indicated because of multiple relapses, non-response to medical treatment, side effects of therapy or malignant change. The median age at surgery of patients with Crohn's disease and ulcerative colitis was 39 years (range 24-84) and 40 (range 18-60) respectively. The median follow-up was 22.4 months (range 9-50). The results of surgical therapy in these patients show that surgery when indicated can be done with minimum morbidity and mortality.     

Surgery for cervical myelopathy in geriatric patients

OBJECTIVE: The number of geriatric patients seeking surgical treatment for cervical myelopathy is steadily increasing. Although anecdotal experiences have been good, insufficient data exists in the spine literature concerning this particular group. We decided to review our experience to determine efficacy of surgical management and examine our morbidity with this select group. METHODS: We undertook a retrospective review of all surgical procedures for nontraumatic cervical myelopathy performed at Mt Sinai Medical Center and Jackson Memorial Medical Center between January 1 1987 and June 1 1992, in patients older than 70 years of age (33 men and 18 women). RESULTS: A total of 53 cervical surgical procedures were performed in 51 patients (nine expansile laminoplasties, 20 anterior cervical diskectomies and fusion and 24 decompressive posterior laminectomies). The average hospital stay was 7.7 +/- 3.4 days. Twenty-one (41%) patients required inpatient rehabilitation; the remaining 30 patients received outpatient rehabilitative therapy. The major morbidity rate was 3.9%, and the minor morbidity rate was 5.8%. Perioperative medical complications included cardiac arrhythmias, hypertensive episodes, atelectasis, confusion, urinary dysfunction and hyponatremia. All of these complications resolved except in one patient. The perioperative mortality rate was 2%. Office follow-up was performed for a mean of 11.1 +/- 2.5 months postoperatively. Comparison of preoperative and postoperative functional status was performed using Nurick's criteria as described in the literature. At follow-up, 60.8% of the patients had improvement in their myelopathic symptoms, especially in regard to gait; 33.3% were stabilized and 5.9% had worsened neurological function. CONCLUSION: This study demonstrates that corrective surgical procedures for significant nontraumatic cervical myelopathy in the geriatric population may be performed safely, that is, with acceptable risk of morbidity and reasonable expectation for clinical improvement.