[Couinard's technics of liver resection]

Six cases of major liver resections (five right lobectomies and one left lobectomy) are reported. In all these cases the technique described by Couinaud (of suprahilar intrahepatic ligation of the portal pedicle) was used. Although the technique could be simple and rapid, it may produce severe accidents, especially in patients with biliary anomalies. Five of the six cases had an uneventful postoperative course, while in the sixth case, obstructive jaundice developed postoperatively. The case was solved through reoperation and a Roux-en-Y anastomosis. The main conclusion is that the Couinaud technique could be used, because of its advantages (speed, less blood loss) but special precautions are necessary when biliovascular anomalies of the liver are present.

[Scheduled reinterventions in the treatment of acute peritonitis]

This is a clinical series of 83 cases, admitted in the Surgical Department of Fundeni Hospital between 1988-1996 of severe acute peritonitis in which scheduled reoperations (at least one planned reoperation at 24-48 hours after the first operation) were performed. The main criteria for scheduled reoperations were; unresolved source of contamination, acute peritonitis older than 48 hours and the presence of multiple system organ failures. 63 cases (76%) were postoperative peritonitis. 203 planned reoperations were performed (minimum: 1, maximum: 10, mean: 2,4 reoperations per patient). In 12 cases (14,4%) a laparotomy "on demand" was necessary after the scheduled reoperations were stopped. The source of peritonitis was resolved in 61 cases (73,5%) and unresolved in 22 cases (26,5%). In 9 cases (10%) specific complications of the method (hemorrhages, fistulas) were encountered. The global mortality was 65,06%, with 55,73% mortality when the source of peritonitis was resolved and 90,9% mortality when the source was not resolved.

CONCLUSION

scheduled reoperations have to be reserved for the most severe cases of acute peritonitis in which the mortality after the "classical" methods of treatment is extremely high.

[Total vascular exclusion in liver surgery]

II cases of major hepatic resections under total vascular isolation (TVA) are presented: 4 women and 7 men, age between 17 and 70 years (mean 39.6 years). In another 2 cases the method was abandoned because the patients did not tolerate the vena cava clamping. The main indication for TVA were large tumors located near the suprahepatic veins opening into the vena cava. The diagnosis in the 11 cases was: hepatocellular carcinoma--3 cases, cholangiocarcinoma--1 case, colo-rectal metastasis--1 case, hemangioma--3 cases, hamartoma--2 cases, diffuse suppuration of the right lobe--1 case. The warm ischemia time was between 25 and 50 min (mean: 36.8 min). There were no intraoperative complications. The mean quantity of transfused blood was 450 ml. Postoperatively two patients bled and were reoperated. Both subsequently developed liver failure and died and in both cases microscopy found histologic lesions of chronic hepatitis. The mortality was then 18.1%. Six patients (54.5%) developed postoperative complications. Worth noting are 2 cases of transient liver failure, both in patients with cancer. The ICU stay was between 2 and 14 days (mean 7.1) and the whole postoperative hospitalization was between 11 and 46 days (mean: 16).

[Mechanical digestive system suturing devices]

Between 1994 (December)-1996 (May) 150 patients have been operated on using one or many stapling devices. The staplers disposable to us were the "Linear Cutter" or GIA (Gastrointestinal Anastomosis), "Linear Stapler" (TA) and "Intraluminal Circular Stapler" or EEA (end-to-end anastomosis) types, produced by ETHICON (Johnson and Johnson Ltd. Company). The principles operations performed were various digestive resections, intervisceralis anastomosis and interventions of reconstructions (in oesophagus surgery, ileal pouch etc.). The advantages of staplers applications are: a) the reduction of the time of operation, of the anesthesia, of the blood loss; b) a soft manipulation of the tissues; c) a smaller inflammatory reaction and the prevention of intraoperative septic contamination and d) a better and faster take back of the functionality of the anastomosis. There were only 4 intraoperative haemorrhages easy controllable. Postoperative complications: a) 3 haemorrhages medically treated; b) immediate leakage 1 patient after colorectoanastomosis, treated by Hartman colostomy; precocious, 7 patients and after 4-6 month, 2 patients. Corrective iterative interventions were necessary only in 5 patients. The operative mortality-1 patient, the cause of death being a bronhopneumonia after a radical oesophagectomy with oesophagoplasty (oesophageal cancer). There was not postoperative mortality depending of stapling application. We don't observed late postoperative complications like stenosis of various anastomosis, quoted in the literature, because the time of following of our 150 patients is too short (maximum 18 months). The conclusions are that the stapling devices are a real surgical progress with the conditions of a correct indication and adequate tactics and operative technique. The economical effort is justified and entirely compensated by the major benefits obtained for the patients.

Renal dysfunction associated with liver transplantation

It has been known for some time that a variety of liver diseases affect kidney function, but renal dysfunction associated with orthotopic liver transplantation has received scant attention. Although the mechanisms mediating these abnormalities are incompletely defined, advances in the understanding of renal pathophysiology after liver transplantation have made it possible to develop new treatment strategies. Aggressive and early intervention to diagnose and treat renal complications associated with liver transplantation should be the goal for transplant centres.

A multidisciplinary approach to hepatocellular carcinoma in patients with cirrhosis

BACKGROUND

A multidisciplinary approach has been developed to evaluate and treat patients with cirrhosis and hepatocellular carcinoma (HCC).

STUDY DESIGN

We evaluated 153 patients with cirrhosis and HCC. Fourteen patients with Child's A cirrhosis underwent resection. Transplantation was performed in 40 patients with HCC less than 5 cm (32 incidental, eight recognized preoperatively), in six patients with HCC 5 cm or greater not recognized preoperatively, and in 11 patients with recognized HCC 5 cm or greater; the latter 11 underwent transplantation in a multimodality protocol using pretransplant chemoembolization and intraoperative and postoperative chemotherapy.

RESULTS

Among the 14 patients who underwent resection, the three-year survival rate was 39 percent. Among the 40 patients with HCC less than 5 cm who underwent transplantation, no tumor recurrence was observed. Among the six with HCC 5 cm or greater unrecognized preoperatively, three had tumor recurrence. Among the 11 with HCC 5 cm or greater enrolled in the protocol, there were no deaths and one recurrence at a mean of 433 days follow-up. The four-year survival rate for all patients who underwent transplantation with HCC was 56 percent (66 percent excluding the six patients with unrecognized HCC 5 cm or larger).

CONCLUSIONS

Hepatocellular carcinoma less than 5 cm in patients with cirrhosis (Child's B or C) is an indication for hepatic transplantation. Hepatocellular carcinoma less than 5 cm in patients with cirrhosis (Child's A), although resectable, may in some cases be better treated by hepatic transplantation. Transplantation for HCC 5 cm or greater within a multimodality protocol has yielded excellent results at two years.

Decision analysis in the clinical and imaging diagnosis of acute cholecystitis

The importance of clinical, laboratory and imaging data in the diagnosis of acute cholecystitis (AC) was studied in 825 patients with right upper quadrant pain hospitalized in the Surgical Clinic of the Fundeni Hospital--Bucharest, between January 1, 1986 and June 30, 1988. A number of 21 parameters were analysed in each case. Of these 825 patients, 259 were considered after surgery as AC. These 259 cases were divided, after the microscopical examination of the surgically-obtained specimens, into two groups: 1) pathologically confirmed AC (137 cases) and 2) pathologically non-confirmed AC (122 cases). The importance of every parameter in establishing a histologically confirmed diagnosis of AC was determined by the diagnostic probability calculated according to Bayes'theorem. The hierarchy of the value of parameters in the diagnosis of AC was based on their capacity to distinguish between the cases histologically confirmed and those detected on surgery, but without microscopically demonstrated changes of AC. The same decision criterion was used in building the decision trees in the exploration of the cases of presumed AC. In the 825 cases with right upper quadrant pain, the main and most frequent cause was chronic calculous cholecystitis (31.8%), followed by AC pathologically confirmed (16.6%), AC non-confirmed (14.7%) and chronic acalculous cholecystitis (12.4%). The most useful parameters in distinguishing between pathologically confirmed AC and pathologically non-confirmed AC were: 1) sudden onset of pain; 2) mild resistance to abdominal palpation; 3) frank peritoneal irritation; 4) stone impacted in the gallbladder neck (ultrasonography); 5) fever; 6) palpable gallbladder; 7) lithiasis (ultrasonography); 8) gallbladder wall with double outline (ultrasonography). Ultrasonography supplied a diagnostic probability of 85% for the correct diagnosis of AC in cases without a clinical picture suggestive for AC. The decision tree analysis supported the same conclusion: only ultrasonography gives a good distinction between pathologically confirmed AC and pathologically non-confirmed AC.

Somatostatin-like immunoreactivity in the cerebrospinal fluid of aged patients with Parkinson's disease. The effect of dopatherapy

Cerebrospinal fluid (CSF) somatostatin concentrations were measured in 35 aged patients with Parkinson's disease (mean age, 79.5 years) and 11 control subjects (mean age, 82.3 years). In patients with Parkinson's disease the levels of somatostatin-like immunoreactivity were lower than in controls (P less than .02); these values were lowest in the untreated group. Somatostatin-like immunoreactivity levels in the CSF tended to increase with treatment but not significantly (P = .11). Somatostatin values were not correlated to age, sex, or duration of the disease. Somatostatin concentrations tended to be lower in more severely affected patients with higher scores on the Hoehn and Yahr (P = .13) and Webster staging scales (P = .13) and lower scores on Mini-Mental State (P = .10), but without statistical significance for these correlations.

[The indications for subtotal and total colectomy]

Subtotal and total colectomy was the choice therapeutic solution for multiple colonic cancer, diffuse rectocolonic polyposis, multiple colonic polyposis, ulcerohaemorrhagic rectocolitis, and for two rare diseases; megacolon with extensive atrophy of lymph nodes, and acute ischaemia of the colon. A total of 35 cases are reported. Ileorectal anastomosis was the method used for this type of intervention. The opportunity of rectal conservation is discussed, in cases of rectocolonic polyposis and ulcerative haemorrhagic rectocolitis. The difficulty of making an optimal choice in complicated forms of ulcerohaemorrhagic rectocolitis is exemplified with the aid of clinical observations.

The causal diagnosis of obstructive jaundice. A Bayesian approach

To compare the contribution of clinical, laboratory and imaging data for the diagnostic accuracy in establishing the cause of obstructive jaundice, the records of 333 patients operated on for a presumed obstruction of the biliary ducts were analysed. The final diagnoses, after surgery, were divided into six groups: stones of the gallbladder and biliary tract, pancreatic cancer, biliary tract neoplasms, ampullary carcinoma, postoperative stenosis of the bile ducts, intrahepatic cholestasis (biliary cirrhosis, chronic cholangitis) and other causes of jaundice (liver tumours, cysts, extended cancer of the upper abdomen). Twenty-three parameters (9 clinical symptoms and signs, 10 biochemical alterations and 4 imaging methods) were examined. Not every case had all the investigations performed but the number of each group of data was large enough to allow a statistically significant conclusion. The contribution of each of the 23 parameters in increasing the probability of correct diagnosis was determined using a computer program based on Bayes' theorem. This analysis showed that for patients which presented suggestive clinical signs and symptoms for stones of the gallbladder and biliary tract and for pancreatic cancer, the diagnosis can be predicted with a probability of 90% only on the basis of clinical findings. The probability of a correct preoperative diagnosis was increased to 99% by imaging methods. On the contrary, for patients with a less clear diagnostic probability (with ampullary carcinoma, intrahepatic cholestasis and other causes) only ultrasonography and computed tomography could increase the probability of correct diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical attitude in cancer of the ovary]

The authors start from the observation that some of the clinical forms of ovarian cancers determine hospitalization and resolution of the cases in surgical departments. They have also based their study on their personal experience acquired over a period of 20 years, during which they have operated on 180 patients. They noted that the best surgical attitude was not adopted in all of the cases and make an analysis of various methods applied, such as the radical ones, the conservative procedures, and those aimed at a reduction of the tumoral mass. The value of associated therapies is presented, consisting in surgery, chemotherapy and irradiation.

The development of a glucose clamp

A reliable control system was developed for clamping (i.e., holding at a steady level) the concentration of blood glucose in the hyperglycemic region of a normal nonanesthetized dog. The system is based upon, and hence largely validates, a mathematical model of the canine glucoregulatory mechanism which was assembled from the results of experiments in which radioisotopes were used. The operation of the clamp, however, does not require the use of radioisotopes. The glucose clamp is a tool which may be applicable clinically in the measurement of glucose turnover and in the laboratory in the study of the effects of glucose turnover of variable insulin with constant glucose levels.

[Uremigenic cholangitis]

The treatment is presented, applied in a case of severe angiocholitis complicated by acute renal failure, known in the literature under the name of uremigenic angiocholitis. After three emergency hospitalizations, two interventions consisting in surgical drainage, de-shocking procedures, treatment of the hepato-renal failure and applications of wide-range antibiotics for the treatment of infection the angiocholitic phenomena disappeared and the hepato-renal failure is on the way to recovery. At this moment of the evolution the patient developed atrial fibrillation that was improved by Narcotan anesthesia. The efficiency is remarked of the treatment with large amounts of Furosemid in the anuric period, as a means to avoid extra-renal depuration.