The prevalence and severity of cancer pain: a study of newly-diagnosed cancer patients in Taiwan

In current clinical practice the "double-stapling technique" is the standard for reanastomosis following minimally invasive sigmoid resection. In the present study, we compared the TESA technique (transient endoluminally stented anastomosis) with conventional stapled anastomosis and evaluated the effect of remnant foreign material on follow-up examination with endosonography. Laparoscopic sigmoid resection was performed in 12 pigs (mean weight 63+/-5.9 kg). Animals were randomly divided into two groups: In Group A, reanastomosis was performed following a standard technique using a 29-mm circular stapler. In Group B, the TESA technique using a resorbable radiopaque stent of polyglycolic acid was applied. The anastomosis was examined by plain x-ray on days 1, 7, and 14, and by contrast enema on day 42, respectively. Endosonography, macroscopic inspection, and histological evaluation of the anastomosis were performed on day 42. All anastomoses in group A were patent. In one animal in Group B stent displacement with subsequent leak of the anastomosis was observed. Circumferential length of the anastomosis on day 42 did not differ between the groups (Group A: 8.00+/-0.45 cm vs. Group B: 7.8+/-2.0 cm, p = 0.82). The duration of the operation was 130+/-27 minutes in Group A and 100+/-18 minutes in Group B (p = 0.06). Weight gain was equal: Group A: 24+/-9.6 kg vs. Group B: 24+/-5.0 kg, p = 0.74. Endosonography on day 42 postoperatively in the area of the anastomosis in group A was impaired due to metallic staples. TESA is a competitive method for reanastomosis following laparoscopic sigmoid resection. In contrast to the conventional technique, the anastomosis is free of foreign material 1 month after the operation, which facilitates follow-up examinations with endosonography as well as other imaging diagnostics.     

Ultrastructure of the glial cells after spinal cord compression in rabbits

Sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by gastrointestinal debris after choledochoduodenostomy, resulting in cholangitis or, less commonly pancreatitis. Obstruction of the biliary tree by gastrointestinal contents after Roux-en-Y choledochojejunostomy or hepaticojejunostomy has not been described in the English-language literature. This report details the diagnostic and operative management of the first patient with sump syndrome after hepaticojejunostomy. The presumed pathophysiology was reflux of vegetable matter up the efferent limb, resulting in hepatic duct obstruction and cholangitis. The patient ultimately required complex choledochoscopic drainage of the intrahepatic biliary tree and revision of the previous Roux-en-Y hepaticojejunostomy.     

Reversibility of hepatic mitochondrial damage in rats with long-term cholestasis

BACKGROUND/AIMS: Long-term bile duct ligation in rats is associated with secondary biliary cirrhosis and metabolic alterations, e.g. mitochondrial dysfunction. We performed the current studies to characterize the reversibility of hepatic mitochondrial dysfunction after reversing biliary obstruction by Roux-en-Y anastomosis. METHODS: Rats were studied after 4 weeks of bile duct ligation, and after 5 or 14 days of reanastomosis. Control rats were pair-fed to treated rats and all rats were studied after starvation for 24 h. Mitochondria were isolated by differential centrifugation and enzyme activities determined by spectrophotometric methods. RESULTS: In comparison to controls, plasma beta-hydroxybutyrate concentrations were decreased in bile duct ligated rats (200+/-70 vs. 790+/-200 micromol/l) and remained decreased after relief of biliary obstruction. In contrast, plasma free fatty acids were not different between controls and treated rats. Oxidative metabolism of L-glutamate, succinate and duroquinol was decreased in liver mitochondria from bile duct ligated rats. After relief of biliary obstruction, the metabolism of L-glutamate and duroquinol normalized quickly, whereas succinate metabolism remained impaired. Similar results were obtained for the mitochondrial oxidases in disrupted mitochondria. The activities of complex I, II, III and V of the respiratory chain were reduced in bile duct ligated rats. After relief of biliary obstruction, complex I and III normalized quickly, whereas complex II and V remained impaired. Oxidative metabolism of long-chain fatty acids by isolated liver mitochondria was decreased in bile duct ligated rats and did not recover after relief of biliary obstruction. CONCLUSIONS: Long-term cholestasis in the rat is associated with a decrease in specific functions of liver mitochondria which recover only partially after Roux-en-Y anastomosis. The persistence of decreased mitochondrial fatty acid metabolism cannot be explained by impaired activity of the respiratory chain, but is more likely due to alterations in mitochondrial beta-oxidation.     

Stent placement compared with balloon angioplasty for obstructed coronary bypass grafts. Saphenous Vein De Novo Trial Investigators

BACKGROUND: Treatment of stenosis in saphenous-vein grafts after coronary-artery bypass surgery is a difficult challenge. The purpose of this study was to compare the effects of stent placement with those of balloon angioplasty on clinical and angiographic outcomes in patients with obstructive disease of saphenous-vein grafts. METHODS: A total of 220 patients with new lesions in aortocoronary-venous bypass grafts were randomly assigned to placement of Palmaz-Schatz stents or standard balloon angioplasty. Coronary angiography was performed during the index procedure and six months later. RESULTS: As compared with the patients assigned to angioplasty, those assigned to stenting had a higher rate of procedural efficacy, defined as a reduction in stenosis to less than 50 percent of the vessel diameter without a major cardiac complication (92 percent vs. 69 percent, P<0.001), but they had more frequent hemorrhagic complications (17 percent vs. 5 percent, P<0.01). Patients in the stent group had a larger mean (+/-SD) increase in luminal diameter immediately after the procedure (1.92+/-0.30 mm, as compared with 1.21+/-0.37 mm in the angioplasty group; P<0.001) and a greater mean net gain in luminal diameter at six months (0.85+/-0.96 vs. 0.54+/-0.91 mm, P=0.002). Restenosis occurred in 37 percent of the patients in the stent group and in 46 percent of the patients in the angioplasty group (P=0.24). The outcome in terms of freedom from death, myocardial infarction, repeated bypass surgery, or revascularization of the target lesion was significantly better in the stent group (73 percent vs. 58 percent, P = 0.03). CONCLUSIONS: As compared with balloon angioplasty, stenting of selected venous bypass-graft lesions resulted in superior procedural outcomes, a larger gain in luminal diameter, and a reduction in major cardiac events. However, there was no significant benefit in the rate of angiographic restenosis, which was the primary end point of the study.     

Recurrence and death in non-small cell lung carcinomas: a prognostic model using pathological parameters, microvessel count, and gene protein products

Optimized stent expansion by high-pressure inflations of oversized balloons has initially been derived from experience obtained with the Palmaz-Schatz stent, whereas there is little experience with this strategy in the Wallstent. By using this approach with quantitative coronary angiographic guidance, 20 Wallstents and 20 Palmaz-Schatz stents were implanted in 34 patients and consecutively examined by conventional two-dimensional (2D) intracoronary ultrasound (ICUS) and three-dimensional (3D) ICUS on the basis of the application of a pattern recognition algorithm. Ultrasound criteria of adequate stent expansion were defined as a complete apposition of the stent to the vessel wall, a stent symmetry index (SSI = minimum/maximum lumen diameter) > or = O.7, and a stent-reference lumen area ratio (SRR = Minimum intrastent lumen area/Average of proximal and distal reference lumen area) > or = O.8. In all cases a smooth angiographic lumen and a negative diameter stenosis, on the basis of a distal reference, was achieved. For the Wallstents ICUS showed a higher SSI (2D, 0.95 +/- 0.04 vs 0.85 +/- 0.09; p < 0.001; 3D, 0.90 +/- 0.09 vs 0.82 +/- 0.11, p < 0.05) and a lower SRR (2D, 0.66 +/- 0.12 vs 0.81 +/- 0.13, p < 0.005; 3D, 0.63 +/- 0.14 vs 0.74 +/- 0.15, p < 0.05) than for the Palmaz-Schatz stents. Ninety percent of failure in meeting these criteria resulted from a low SRR. The incidence of incomplete stent apposition (one in both stents) or SSI <0.7 was low and generally associated with an SRR <0.8. The Wallstents met the ICUS criteria less often (2D, 2(1O%) vs 10(50%), p < 0.01; 3D, 3(15%) vs 9(45%), p < 0.05), were significantly longer (35.1 +/- 7.7 mm and 14.3 +/- 3.3 mm, p < 0.0001), and generally demonstrated a larger vessel tapering, measured as proximal minus distal ICUS reference lumen area (1.33 +/- 2.91 mm2 vs 0.44 +/- 1.97 mm(2), not significant). Wallstents meeting the ICUS criteria, however, showed less vessel tapering (0.18 +/- 1.64 mm(2)). Thus optimized stent expansion was followed by excellent angiographic results for both Palmaz-Schatz and Wallstent. Although angiographic results and visual assessment of the ICUS examination suggested a good outcome, few Wallstents met the ICUS criteria in contrast to the Palmaz-Schatz stents. The low value of the SRR in the Wallstents is likely to be caused by vessel tapering, suggesting that this criterion may be unsuitable in assessing the adequacy of the expansion of relatively long stents such as the Wallstent.     

Alterations in renal microcirculation during cardiopulmonary bypass

BACKGROUND: This study was designed to investigate renal microvascular changes during cardiopulmonary bypass. METHODS: Kidneys were harvested from each of four groups of 6 pigs. Group A were anesthetized and heparinized only. The remaining three groups underwent cardiopulmonary bypass at 28 degrees C, group B for 30 minutes and groups C and D for 120 minutes; group D had an additional 30 minutes of normothermic perfusion at the end of the experiment. Renal cortical blood flow was measured using radiolabeled microspheres. Microvascular morphology was defined by corrosion casting and scanning electron microscopy. RESULTS: In group A, renal vascular resistance was 61+/-5.1 mm Hg x mL(-1) x min(-1). This value decreased to 28+/-7.8 in group B and 25+/-4.0 in group C (p < 0.05), and increased in group D to 40+/-4.1 (p < 0.05 versus groups A, B, and C). Cortical thickness, as measured by microvascular casts in groups A, B, and C, was 33, 34, and 31 mm, respectively, with equal distribution of the resin to the superficial and deep cortex but was significantly reduced in group D to 22 mm (p < 0.05 versus groups A, B, and C), with failure of the resin to fill the superficial cortical layer. Diameters of glomeruli as seen on the casts were 111+/-10.38 microm in group A, 100+/-9.24 microm in group B, and 82+/-4.4 microm in group C (p < 0.05 group A versus group C). The glomeruli from group D were still significantly smaller than group A (93+/-10.35 microm, p < 0.05). Mean glomerular capillary diameters were 4.65+/-0.26 microm in group A, 3.9+/-0.16 microm in group B, 3.6+/-0.19 microm in group C, and 3.65+/-0.3 microm in group D (p < 0.05 group A versus groups B, C, and D). CONCLUSIONS: Hypothermic nonpulsatile cardiopulmonary bypass decreased renal vascular resistance, but the superficial and deep layers of the cortex were perfused equally. Glomeruli were reduced in size because of capillary narrowing. This was consistent with diversion of blood through bypass channels. With restoration of normothermia, underperfusion of the superficial cortex occurred, with potential for damage to these nephrons during the increased metabolic demands of rewarming.     

Intestinal epithelial cell regulation of macrophage and lymphocyte interleukin 10 expression

Patients with recurrent angina after coronary artery bypass graft surgery pose a problem. Stent implantation has been advocated in an effort to avoid repeat operation and to address the limitations of balloon angioplasty. Aim of the present study was to determine the in-hospital and long-term results of stent deployment in focal, de novo lesions of vein grafts. Thirty-five focal, de novo lesions of vein grafts in 31 patients were treated with stent deployment. Twenty-four patients (77%) had three vessels, 6 (20%) two vessels and 1 (3%) single vessel disease. Saphenous vein grafts aged 9.7 +/- 4.2 years (range 1-19 years). Twenty-two lesions (63%) were located within the body of the saphenous graft, 8 (23%) at the graft/coronary artery anastomosis and 5 (14%) at the aorta/graft anastomosis. The indications for stent deployment included: suboptimal result from balloon angioplasty (defined as > or = 50% post-angioplasty residual stenosis) in 29/35 lesions (83%); post-angioplasty coronary dissection with threatening occlusion in 4/35 (11%); abrupt closure in 2/35 (6%). Patients were screened for death, myocardial infarction, bypass surgery and repeat angioplasty during in-hospital stay and after a follow-up of 12 +/- 8 months. Even-free survival curve was constructed by the Kaplan-Meier method. Stent deployment was successful in all patients. One stent was deployed in 24/35 lesions (69%), half Palmaz-Schatz stent in 6/35 (17%) and 2 or more stents in 5/35 (14%). The balloon/vessel ratio resulted of 1.0 +/- 0.1 Minimal lumen diameter increased from 0.8 +/- 0.4 to 3.8 +/- 0.6 mm, with a mean gain of 1.8 +/- 0.6 mm (range 1.8-4.0 mm). During the in-hospital period 1 patient (3.2%) died and 1 (3.2%) had a non Q wave myocardial infarction. Therefore, the clinical success rate, was 94%. During the follow-up period, 2 patients died (6.9%), 2 (6.9%) developed a non Q wave myocardial infarction, 1 (3.4%) underwent bypass surgery and 3 (10.3%) underwent repeat angioplasty. The estimated 2-year event-free survival rate (free from myocardial infarction, repeat surgery and repeat angioplasty) was 62%. In conclusion, Palmaz-Schatz stent deployment in focal, de novo vein grafts presents a high rate of procedural success, a low rate of acute complications and good long-term results.     

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting

Basket extraction after endoscopic sphincterotomy failed to clear the bile ducts immediately in 85 (30%) of 283 consecutive patients with common bile duct stones. Temporary biliary drainage was established by the insertion of a single 7 Fr double pigtail stent before further planned endoscopic attempts at stone removal. In 84 patients (21 male: 63 female, mean age 77 years) this measure relieved biliary obstruction, mean serum bilirubin falling from 101 to 18 umol/l by the time of the second endoscopic retrograde cholangiopancreatography. Six patients died from non-biliary causes with temporary stents in situ. Common bile duct stone extraction was achieved endoscopically in 50 of the remaining 79 patients after a mean of 4.3 months (range 1-12), 34 (68%) requiring only one further procedure. Three patients were referred for biliary surgery. Single stents were also effective for longterm biliary drainage in the remaining 26 elderly patients with unextractable stones. The main biliary complication of stenting was 13 episodes of cholangitis but all except one responded to medical treatment and early stent exchange. If common bile duct stones remain after endoscopic sphincterotomy, a single 7 Fr double pigtail stent is effective and safe for temporary biliary drainage before further endoscopic attempts at duct clearance and for longterm biliary drainage especially in the old and frail.     

Prophylactic iron supplementation after Roux-en-Y gastric bypass: a prospective, double-blind, randomized study

OBJECTIVE: To determine whether prophylactic oral iron supplements (320 mg twice daily) would protect women from iron deficiency and anemia after Roux-en-Y gastric bypass. DESIGN: Prospective, double-blind, randomized study in which 29 patients received oral iron and 27 patients received a placebo beginning 1 month after Roux-en-Y gastric bypass. SETTING: Tertiary care medical center. PATIENTS AND INTERVENTIONS: Complete blood cell count and serum levels of iron, total iron binding capacity, ferritin, vitamin B12, and folate were determined preoperatively and at 6-month intervals postoperatively in 56 menstruating women who had Roux-en-Y gastric bypass. MAIN OUTCOME MEASURE: Incidence of iron deficiency and other hematological abnormalities in each treatment group. RESULTS: Hemoglobin, hematocrit, and vitamin B12 levels were significantly decreased compared with preoperative values in both groups. Conversely, folate levels increased significantly over time in both groups. Oral iron consistently prevented development of iron deficiency in the iron group. Ferritin levels did not change significantly in the iron group. However, in placebo-treated patients, ferritin levels 2 years postoperatively were significantly decreased compared with preoperative levels. There was no difference in the incidence of anemia between the 2 groups. However, the incidence of microcytosis was substantially greater (P=.07) in placebo-treated than iron-treated patients. CONCLUSIONS: Prophylactic oral iron supplements successfully prevented iron deficiency in menstruating women after Roux-en-Y gastric bypass but did not consistently protect these women from developing anemia. On the basis of these results we now routinely recommend prophylactic iron supplements to menstruating women who have Roux-en-Y gastric bypass.     

Endoscopic palliation of malignant obstructive jaundice using resterilized accessories: an audit of success, complications, mortality and cost

OBJECTIVE: To assess the success, complications and cost of endoscopic endoprosthesis placement for palliation of obstructive jaundice caused by malignancy. METHODS: Four hundred and two consecutive patients with obstructive jaundice due to nonresectable malignancy undergoing endoscopic stenting were studied. Commercial or home-made 7F or 10F endoprostheses were placed using minor modifications of the standard technique. The accessories were sterilized and reused. RESULTS: Endoprosthesis placement was successful in 291 patients (72.4%, 95% CI 67.7-76.7)-241 in one attempt, 49 in two attempts, and one in three attempts. Fifty nine patients (14.6%, 95% CI 11.4-18.6) had procedure-related complications, including cholangitis (30), pancreatitis (15), perforation (3) and bleeding (11). The incidence of cholangitis was significantly higher in bifurcation blocks than in other lesions (17.6% vs 4.7%, p = 0.0005). The success rate did not differ between distal and proximal lesions (68.1% vs 72.9%). The procedural cost per patient could be reduced from Rs 14,850 to Rs 6565 by reusing accessories after sterilization, and using home-made stents. CONCLUSIONS: Endoscopic endoprosthesis placement is a safe and effective method for palliation of malignant obstructive jaundice. Preparation of indigenous stents and reuse of accessories can reduce the cost of the procedure by over 50%.     

Physicians and surgeons during the French intervention and the Second Empire

Little is known about the frequency of adverse events in the year following stent placement in patients treated with aspirin and ticlopidine, without warfarin. We analyzed the first such 234 consecutive patients treated at our hospital between October 1994 and December 1995. Their mean age was 62+/-12 years; 40% had had a prior myocardial infarction, 22% had undergone coronary artery bypass surgery, and 65% had multivessel disease. The indication for stent placement was dissection or abrupt closure in 24% of patients and suboptimal balloon angioplasty results in 14%; placement was elective in 62% of patients. Three hundred forty-five coronary segments were treated in the 234 patients; 305 stents (1.3 stents/patient) were placed. Palmaz-Schatz coronary stents (75%), Gianturco-Roubin stents (21%), and Johnson & Johnson biliary stents (4%) were used. Mean nominal stent size was 3.4+/-0.4 mm. High-pressure inflations (> or = 14 atm, mean 17+/-2) were performed in all patients. The mean residual stenosis was 3+/-5% by visual estimate. Intravascular ultrasound was utilized to facilitate stent placement in 53% of patients. Mean follow-up was 1.6+/-0.5 years. There were no deaths, Q-wave myocardial infarctions, coronary artery bypass operations, or repeat angioplasty procedures required during the remainder of the hospitalization or in 30 days after stent placement; stent thrombosis did not occur. Kaplan-Meier analysis of adverse events in the 6 months following the procedure revealed a mortality rate of 0.9%; the rate of myocardial infarction (Q-wave or non-Q-wave) was 1.3%. Bypass surgery was performed in 0.9% and angioplasty for in-stent restenosis was performed in 9.5% of patients. Any 1 of these events occurred in 11.7% of patients in the 6 months after the procedure. The corresponding event rates at 1 year were 1.3%, 2.2%, 3.5%, and 12.2%, respectively; any 1 of these events occurred in 16.5% of patients. In patients receiving intracoronary stents of varying designs followed by high-pressure postdeployment inflations in whom an excellent visual angiographic result is achieved, antithrombotic therapy with aspirin and ticlopidine is associated with a very low frequency of adverse cardiovascular events in the 12 months following the procedure regardless of the indication for stent placement.     

Application of rectal stents for palliation of obstructing rectosigmoid cancer

BACKGROUND: The rationale of palliative endoscopic treatment is to avoid a colostomy in patients with advanced disease and limited life expectancy. This study was conducted to evaluate the role of endoscopic stent implantation for palliation of obstructing rectal cancer. METHODS: Overall, 19 patients (aged 47-87 years) with nonresectable or metastatic rectal cancer were treated by stent insertion after laser recanalization or dilation. Three types of stents, i.e., plastic tubes (n = 8), self-expanding mesh stents (n = 6), and endocoil stents (n = 5), were used to maintain luminal patency. RESULTS: Endoscopic stent implantation was successfully performed in all 19 patients. Long-term luminal patency and satisfactory bowel function were achieved in 16 of 19 patients (84%). After a median follow-up of 6 months, eight of the patients have died and eight are still alive without evidence of recurrent obstruction. Dislocation of the endoprosthesis occurred in two of eight plastic tubes and one of five mesh stents. Recurrent obstruction due to tumor ingrowth was only observed in patients treated with self-expanding mesh stents (n = 2). In spite of reinsertion and laser therapy a colostomy was required in three of 19 patients. There was no evidence of treatment failure in five patients who received endocoil stents. None of the patients experienced serious complications related to the endoscopic procedure. CONCLUSIONS: Endoscopic stent implantation seems to be a safe and efficient palliative approach to selected patients with obstructing rectal cancer. Currently, self-expanding coil stents are superior to other devices because of lower risk of dislocation and tumor ingrowth.     

Long-term results of endoscopic treatment of biliary duct obstruction due to pancreatic disease

BACKGROUND/AIMS: Endoscopic stenting has become an established method of providing palliative treatment in cases of malignant biliary obstruction, as well as in benign biliary stenosis. Several problems associated with the types of stent used have not yet been resolved, and an ideal stent has yet to be designed. Observation of the clinical course for patients with biliary obstruction of various etiologies, and evaluation of the results with various treatment methods are the aims of this study. METHODOLOGY: In 1993 and 1994, biliary obstruction was treated endoscopically in 47 patients with a malignant pancreatic tumor and in 18 patients with chronic pancreatitis. The primary intervention was assessed retrospectively on the basis of the patients' records, and information concerning the clinical course was obtained by contacting the patients or their relatives or general practitioners. RESULTS: Primary endoscopic drainage was successful in all cases. Only one of the patients with pancreatic tumors is still alive; survival after stent placement averaged 6.2 months. Metal stents remained patent significantly longer than plastic stents and percutaneous transhepatic biliary drains (PTBDs)(8.2 versus 3.5 or 1.9 months; p < 0.001). In cases of chronic pancreatitis, three of the nine patients who received only endoscopic treatment, without stenting, were able to continue without stents in the longer term, whereas seven of the nine who underwent surgery had no further problems. CONCLUSIONS: Endoscopic drainage of biliary obstruction provides excellent short-term results. In long-term treatment for purely palliative purposes, metal stents remain patent for longer than plastic stents. In chronic pancreatitis, surgical treatment clearly seems to provide better long-term results than endoscopic therapy.     

Outcome of palliative biliary and gastric bypass surgery for pancreatic head carcinoma in 126 patients

BACKGROUND: Recent reports of decreased morbidity and mortality following palliative surgery for patients with irresectable pancreatic head carcinoma prompted a review of the results in 126 patients (median age 64 (range 39-90) years) who had undergone palliative biliary and gastric bypass surgery. METHODS: The indication for surgical palliation was the finding of an irresectable tumour at laparotomy (n = 44), failure of endoscopic treatment (n = 43), clinical symptoms of gastric outlet obstruction (n = 28) and miscellaneous (n = 11). Biliary and gastric bypass was performed in 118 patients, biliary bypass alone in six and gastrojejunostomy alone in two. The indication for gastrojejunostomy was symptoms in 28 patients (23 per cent) and prophylaxis in 92 patients (77 per cent). RESULTS: Postoperative local complications occurred in 17 per cent of patients, general complications in 10 per cent and delayed gastric emptying in 14 per cent of patients. The 30-day mortality rate was 1 per cent and overall hospital mortality rate 2 per cent. Median hospital stay was 17 (range 5-80) days. Median overall postoperative survival was 190 (range 14-830) days. Late obstructive gastrointestinal symptoms occurred in 14 patients (11 per cent) after a median of 141 (range 21-356) days. CONCLUSION: Roux-en-Y hepaticojejunostomy combined with gastrojejunostomy offers effective palliation for irresectable pancreatic head cancer and can be performed with low mortality and acceptable morbidity rates.     

Assessing outcomes, costs, and benefits of emerging technology for minimally invasive saphenous vein in situ distal arterial bypasses

BACKGROUND: Instrumentation for a minimally invasive angioscopic in situ peripheral arterial bypass (MIAB) with catheter-directed side-branch occlusion has recently been approved for use. Despite the attractiveness of this approach (2 short incisions), benefits such as lower morbidity and shorter hospitalizations remain undocumented. To justify wide acceptance, minimally invasive surgical techniques must match conventional procedures in durability and cost while enhancing patient comfort. Often such comparisons are difficult during the implementation phase of a new procedure. OBJECTIVE: To compare the outcomes of the MIAB procedures with a concurrent group of patients undergoing conventional in situ bypass procedures. DESIGN: Retrospective review. SETTING: University medical center. PATIENT: The first 20 consecutive MIAB procedures in 19 patients performed between August 1, 1995, and July 31, 1997, were compared with 19 contemporaneous consecutive conventional in situ bypass procedures performed at the same institution. MAIN OUTCOME MEASURES: Operative time, postoperative length of stay, hospital costs, complications, primary assisted and secondary patency, limb salvage, and survival. RESULTS: The patient groups were comparable with respect to age, sex, incidence of smoking, coronary artery disease, hypertension, diabetes, renal failure, cerebrovascular disease, indication, and distal anastomosis level. The median operative time was significantly greater for the MIAB group (6.6 hours vs 5.7 hours; P=.009), and intraoperative completion arteriography more frequently showed retained arteriovenous fistulas in the MIAB group (55% vs 21%; P=.05). The median postoperative length of stay and total cost were 6.5 days and $18,000 for the MIAB group and 8 days and $27,800 for the conventional group (P > or = .05). There were no significant differences in major complications (10% in the MIAB group vs 11% in the conventional group), wound complications (10% vs 11%, respectively), primary assisted patency at 1 year (68%+/-11% vs 78%+/-10%, respectively), secondary patency at 1 year (79%+/-10% vs 88%+/-8%, respectively), limb salvage at 1 year (85%+/-10% vs 94%+/-6%, respectively), or patient survival at 1 year (89%+/-8% vs 61%+/-13%, respectively). CONCLUSION: Patients undergoing the MIAB procedure avoided lengthy vein exposure incisions without sacrificing short-term results. There was a trend toward decreased hospital stay and cost, which may be further realized as the clinical experience broadens. Although longer follow-up and larger cohorts will always be required to define durability, immediate access to outcomes and costs on small numbers of patients facilitates the early assessment of emerging technology.     

K+ Channel density increases selectively in the endfoot of retinal glial cells during development of Rana catesbiana

BACKGROUND: We investigated the bile duct wall thickness measured on intraductal US in patients who had not undergone biliary drainage, with special attention to the influence of cancer at the distal bile duct, bile duct stones, obstructive jaundice, longitudinal cancer extension, and primary sclerosing cholangitis on wall thickness. METHODS: The study included 183 patients. Patients who had undergone previous biliary drainage were excluded. Intraductal US was performed by the transpapillary route with use of a thin-caliber ultrasonic probe (2.0 mm diameter, 20 MHz frequency). The bile duct wall thickness (width of the inside hypoechoic layer) was retrospectively measured on US images. RESULTS: Bile duct wall thicknesses of the common hepatic duct for the control group (n = 95), cancer at the distal bile duct group (n = 9), bile duct stone group (n = 56), and obstructive jaundice group (n = 17) were 0.6 +/- 0.3 mm (mean +/- SD), 0.8 +/- 0.5 mm, 0.8 +/- 0.6 mm, and 0.8 +/- 0. 5 mm, respectively. No significant differences (p > 0.05) were found between them. However, wall thickness for the cancer extension to the common hepatic duct group (n = 4, 2.0 +/- 0.4 mm) and sclerosing cholangitis group (n = 2, 2.5 +/- 0.4 mm) were significantly greater than in the other groups (p < 0.005). CONCLUSIONS: In patients who have not undergone previous biliary drainage, the bile duct wall thickness was not thicker in patients with obstructive jaundice. However, the duct wall was significantly thicker in patients with either longitudinal cancer extension or primary sclerosing cholangitis compared with that of other groups.     

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.     

Proliferative potential of recurrent intracranial meningiomas as evaluated by labelling indices of BUdR and Ki-67, and tumour doubling time

BACKGROUND: Saphenous vein harvested with a traditional longitudinal technique often results in leg wound complications. An alternative endoscopic harvest technique may decrease these complications. METHODS: One hundred twelve patients scheduled for elective coronary artery bypass grafting were prospectively randomized to have vein harvested using either an endoscopic (group A, n = 54) or traditional technique (group B, n = 58). Groups A and B, respectively, were similar with regard to length of vein harvested (41 +/- 8 cm versus 40 +/- 14 cm), bypasses done (4.1 +/- 1.1 versus 4.2 +/- 1.4), age, preoperative risk stratification, and risks for wound complication (diabetes, sex, obesity, preoperative anemia, hypoalbuminemia, and peripheral vascular disease). RESULTS: Leg wound complications were significantly (p < or = 0.02) reduced in group A (4% [2 of 51] versus 19% [11 of 58]). Univariate analysis identified traditional incision (p < or = 0.02) and diabetes (p < or = 0.05) as wound complication risk factors. Multiple logistic regression analysis identified only the traditional harvest technique as a risk factor for leg wound complications with no significant interaction between harvest technique and any preoperative risk factor (p < or = 0.03). Harvest rate (0.9 +/- 0.4 cm/min versus 1.2 +/- 0.5 cm/min) was slower for group A (p < or = 0.02) and conversion from endoscopic to a traditional harvest occurred in 5.6% (3 of 54) of patients. CONCLUSIONS: In a prospective, randomized trial, saphenous vein harvested endoscopically was associated with fewer wound complications than the traditional longitudinal method.     

Endotoxin temporarily impairs canine jejunal absorption of water, electrolytes, and glucose

OBJECTIVE: To evaluate the usefulness of a portable, computer-based, oscillometric, noninvasive blood pressure monitor for the automatic surveillance of postoperative infrainguinal bypasses. DESIGN: Prospective unblinded study. SETTING: Regional tertiary care Veterans Affairs medical center. PATIENTS: A total of 60 limbs were examined in 3 groups (n = 20 in each group): normal, asymptomatic volunteers; older patients with symptomatic peripheral vascular disease; and patients who had undergone infrainguinal bypass procedures. INTERVENTIONS: Noninvasive blood pressure monitor pressures, complete lower extremity arterial studies with Doppler ankle-brachial index (ABI), segmental pressures, and pulse volume recordings were performed in all groups. The patients who had undergone surgery also had hourly noninvasive blood pressure measurements taken. MAIN OUTCOME MEASURES: Ankle-brachial indices obtained with the noninvasive blood pressure monitor were compared with simultaneous manual Doppler ABIs and pulse volume recordings. RESULTS: There was a significant overall correlation between the Doppler-derived ABIs and automatic oscillometric values (r = 0.89, P < .001). Although there was a slight difference in absolute values (+/-SEM) (0.90 +/- 0.03 vs 0.84 +/- 0.03, respectively), an excellent correlation was found between the 2 methods in the clinically relevant range of ABI values between 0.60 and 1.10. The oscillometric method, however, overestimated the ABI when it was less than 0.60 by the Doppler method (0.61 +/- 0.02 vs 0.44 +/- 0.03, P < .001) and underestimated it when it was more than 1.10 (1.05 +/- 0.02 vs 1.16 +/- 0.01, P < .001). (All values given as +/-SEM.) Oscillometric overestimation correlated with depressed pulse volume recording waveforms (P < .001) or diminished pulse volume recording amplitudes of less than 10 mm (P < .001). CONCLUSION: The automatic oscillometric monitor provides a useful, accurate, objective, and quantitative method for postoperative bypass graft surveillance.     

Virilizing ovarian tumor of low malignant potential associated with antecedent tamoxifen use for breast cancer

OBJECTIVE: To assess the value and the associated morbidity of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic endoprosthesis insertion in the treatment of patients with Klatskin tumors. DESIGN: Retrospective study. SETTING: A tertiary referral center. PATIENTS: Fifty-five consecutive patients with Klatskin tumors diagnosed through typical cholangiographic and computed tomographic findings. INTERVENTION: Standard ERCP with endoscopic stenting technique was employed. Once the diagnosis of Klatskin tumor was confirmed on cholangiogram, endoscopic stenting was performed to bypass the stricture. Multiple stents were inserted if necessary to ensure adequate biliary drainage. MAIN OUTCOME MEASURES: The success rate of ERCP and endoscopic endoprosthesis insertion, successful drainage rate, early complications of endoscopic procedure, procedure-related mortality, and long-term outcome of endoprosthesis. RESULTS: Of the 55 patients, cholangiography was performed in 53 (96%). In the 49 patients in whom endoscopic stenting was attempted, the procedure was successful in 28 patients (57%) at the first attempt and 8 patients (16%) at the second attempt, resulting in a cumulative success rate of 73%. Only 20 of these patients had satisfactory biliary drainage, resulting in an overall successful drainage rate of 41%. Early complications, including acute cholangitis, acute pancreatitis, and postpapillotomy bleeding occurred in 14 patients (25%). Three patients (5%) died of procedure-related complications. The median patency of the first endoprosthesis inserted was 1 week (range, 0-8 wk). The 30-day mortality rate was 18%. CONCLUSIONS: In patients with Klatskin tumors, ERCP and endoscopic endoprosthesis insertion have a low successful drainage rate, are associated with high morbidity and procedure-related mortality, and have a limited effect on long-term palliation. Endoscopic retrograde cholangiopancreatography and endoscopic endoprosthesis insertion have a limited value in the management of patients with Klatskin tumors.