Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study

INTRODUCTION

It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP.

MATERIALS AND METHODS

Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined.

RESULTS

Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001).

CONCLUSIONS

The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.

End of life care in the operating room for non-heart-beating donors: organization at the University Hospital of Liège

Non-heart-beating (NHB) organ donation has become an alternative source to increase organ supply for transplantation. A NHB donation program was implemented in our institution in 2002. As in many institutions the end of life care of the NHB donor (NHBD) is terminated in the operating room (OR) to reduce warm ischemia time. Herein we have described the organization of end of life care for these patients in our institution, including the problems addressed, the solution proposed, and the remaining issues. Emphasis is given to our protocol elaborated with the different contributors of the chain of the NHB donation program. This protocol specifies the information mandatory in the medical records, the end of life care procedure, the determination of death, and the issue of organ preservation measures before NHBD death. The persisting malaise associated with NHB donation reported by OR nurses is finally documented using an anonymous questionnaire.

Donor age as a risk factor in donation after circulatory death liver transplantation in a controlled withdrawal protocol programme

BACKGROUND

Results of donation after circulatory death (DCD) liver transplantation are impaired by graft loss, resulting mainly from non-anastomotic biliary stricture. Donor age is a risk factor in deceased donor liver transplantation, and particularly in DCD liver transplantation. At the authors' institute, age is not an absolute exclusion criterion for discarding DCD liver grafts, DCD donors receive comfort therapy before withdrawal, and cold ischaemia is minimized.

METHODS

All consecutive DCD liver transplantations performed from 2003 to 2012 were studied retrospectively. Three age groups were compared in terms of donor and recipient demographics, procurement and transplantation conditions, peak laboratory values during the first post-transplant 72 h, and results at 1 and 3 years.

RESULTS

A total of 70 DCD liver transplants were performed, including 32 liver grafts from donors aged 55 years or less, 20 aged 56-69 years, and 18 aged 70 years or more. The overall graft survival rate at 1 month, 1 and 3 years was 99, 91 and 72 per cent respectively, with no graft lost secondary to non-anastomotic stricture. No difference other than age was noted between the three groups for donor or recipient characteristics, or procurement conditions. No primary non-function occurred, but one patient needed retransplantation for artery thrombosis. Biliary complications were similar in the three groups. Graft and patient survival rates were no different at 1 and 3 years between the three groups (P = 0.605).

CONCLUSION

Results for DCD liver transplantation from younger and older donors were similar. Donor age above 50 years should not be a contraindication to DCD liver transplantation if other donor risk factors (such as warm and cold ischaemia time) are minimized.

[Proven and expected benefits of intravenous lidocaine administered during the perioperative period]

Local anesthetics which inhibit sodium channels are used for neural blockade during infiltration and locoregional anesthesia. Furthermore lidocaine given intravenously acts on other cellular systems and produces multiple properties, some of which are beneficial during the perioperative period. Indeed, intravenous lidocaine is analgesic, antihyperalgesic, antiinflammatory, and improves the recovery of bowel function after abdominal surgery. As a consequence, lidocaine has been added to postoperative analgesic strategies. This article reviews clinically relevant properties of intravenous lidocaine. Its future perspectives for the prevention of chronicisation of postoperative pain, facilitation of postoperative fast track programs, and prevention of tumoral recurrence are also discussed.

Contribution of donors after cardiac death to the deceased donor pool: 2002 to 2009 University of Liege experience

OBJECTIVE

In this study, we have evaluated the organ procurement and transplantation activity from donors after cardiac death (DCD) at our institution over an 8-year period. Our aim was to determine whether this program influenced transplantation programs, or donation after brain death (DBD) activity.

METHODS

We prospectively collected our procurement and transplantation statistics in a database for retrospective review.

RESULTS

We observed an increasing trend in potential and actual DCD number. The mean conversion rate turning potential into effective donors was 58.1%. DCD accounted for 16.6% of the deceased donor (DD) pool over 8 years. The mean age for effective DCD donors was 53.9 years (range, 3-79). Among the effective donors, 63.3% (n = 31) came from the transplant center and 36.7% (n = 18) were referred from collaborative hospitals. All donors were Maastricht III category. The number of kidney and liver transplants using DCD sources tended to increase. DCD kidney transplants represented 10.8% of the DD kidney pool and DCD liver transplants made up 13.9% of the DD liver pool over 8 years. The DBD program activity increased in the same time period. In 2009, 17 DCD and 33 DBD procurements were performed in a region with a little >1 million inhabitants.

CONCLUSION

The establishment of a DCD program in our institution enlarged the donor pool and did not compromise the development of the DBD program. In our experience, DCD are a valuable source for abdominal organ transplantation.

Effect of an intravenous infusion of lidocaine on cisatracurium-induced neuromuscular block duration: a randomized-controlled trial

BACKGROUND

Intravenous lidocaine can be used intraoperatively for its analgesic and antihyperalgesic properties but local anaesthetics may also prolong the duration of action of neuromuscular blocking agents. We hypothesized that intravenous lidocaine would prolong the time to recovery of neuromuscular function after cisatracurium.

METHODS

Forty-two patients were enrolled in this randomized, double-blind, placebo-controlled study. Before induction, patients were administered either a 1.5 mg/kg bolus of intravenous lidocaine followed by a 2 mg/kg/h infusion or an equal volume of saline. Anaesthesia was induced and maintained using propofol and remifentanil infusions. After loss of consciousness, a 0.15 mg/kg bolus of cisatracurium was administered. No additional cisatracurium injection was allowed. Neuromuscular function was assessed every 20 s using kinemyography. The primary endpoint was the time to spontaneous recovery of a train-of-four (TOF) ratio ≥ 0.9.

RESULTS

The time to spontaneous recovery of a TOF ratio ≥ 0.9 was 94 ± 15 min in the control group and 98 ± 16 min in the lidocaine group (P=0.27).

CONCLUSIONS

No significant prolongation of spontaneous recovery of a TOF ratio ≥ 0.9 after cisatracurium was found in patients receiving intravenous lidocaine.

[Combined carpometacarpal dislocations, hand lesions and fractures of the two bones of the forearm: a report of two cases]

The authors report two cases of complete dorsal carpometacarpal dislocations associated with lesions of the hand and the two bones of forearm. These dislocations are rare, and their clinical and radiological diagnosis is difficult. These cases are original through the association of carpometacarpal dislocation with lesions of the two bones of forearm. They demonstrate the need to stress the importance of a complete evaluation of the patient. Treatment must be immediate and begin with the osteosynthesis of the proximal lesions to avoid any irreducibility. These elements will determine the functional outcome.

Effects of oral preoperative carbohydrate on early postoperative outcome after thyroidectomy

BACKGROUND

Preoperative carbohydrate (CHO) reduces perioperative insulin resistance and improves preoperative patient comfort. We tested the hypotheses that preoperative CHO reduces the risk of postoperative nausea and vomiting (PONV) and improves early postoperative patient comfort.

METHODS

Two hundred women scheduled for thyroidectomy were randomly allocated to drink 50 g CHO in 400 ml of water or 0.5 g aspartam in 100 ml of water 2 h before surgery. The incidence and the severity of PONV, pain scores, and analgesic consumption were recorded postoperatively. Intensity of thirst, hunger, anxiety, fatigue were recorded on 100-mm visual analog scales just before the induction of anesthesia, 2, 6, and 24 h postoperatively.

RESULTS

The incidence and severity of PONV were similar in both groups. Patients from the CHO group reported significantly less thirst (P = 0.007), hunger (P = 0.04), and fatigue (P = 0.01) than patients from the control group. Postoperative pain scores did not differ significantly between both groups (P = 0.34). However patients from the CHO group requested less acetaminophen during the first 24 postoperative h: 3 g vs. 2 g (median, P = 0.002).

CONCLUSIONS

Oral carbohydrate before thyroidectomy improves pre- and postoperative patient comfort, as well as postoperative analgesia, but has no effect on the PONV.

Postoperative respiratory problems in morbidly obese patients

Morbid obesity results in a restrictive pulmonary syndrome including decreased functional residual capacity. General anaesthesia further decreases functional residual capacity, and consequently alters gas exchanges more profoundly in morbidly obese patients than in nonobese patients. Moreover, these changes persist longer during the postoperative period, rendering obese subjects vulnerable to postoperative respiratory complications. In this review, we present postoperative measures improving respiratory function of these patients. Whether these measures affect outcome remains however unknown. Patients suffering from obstructive sleep apnoea syndrome deserve special considerations that are briefly described. Finally, the algorithm of the postoperative respiratory management of morbid obese patients used in our institution is provided.

[Recent advances in liver surgery and transplantation]

Over the last 20 years, significant improvements in hepatic surgery and transplantation have allowed better results. Better patients selection, new preoperative modalities aiming at modifying the volume of the liver or the tumour, new surgical techniques, and better postoperative management are the keys to improved outcome. These progresses are reviewed in this article. In hepatic surgery, the latest surgical improvements are the possibility of laparoscopic hepatic resection and of radiofrequency ablation. Modern neoadjuvant chemotherapy may in some cases allow a reduction of large liver colorectal metastases and render them resectable. Improved radiological techniques allow better planning of the surgical resections, reduction of the risks by calculation of the residual liver mass, and induction of liver hypertrophy by preoperative portal embolisation. In liver transplantation, the most significant changes were the use of living related liver donors and of non-heart beating donors to overcome the cadaveric organ donor shortage.

Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy

BACKGROUND

Intravenous infusion of lidocaine decreases postoperative pain and speeds the return of bowel function. The authors therefore tested the hypothesis that perioperative lidocaine infusion facilitates acute rehabilitation protocol in patients undergoing laparoscopic colectomy.

METHODS

Forty patients scheduled to undergo laparoscopic colectomy were randomly allocated to receive intravenous lidocaine (bolus injection of 1.5 mg/kg lidocaine at induction of anesthesia, then a continuous infusion of 2 mg.kg.h intraoperatively and 1.33 mg.kg.h for 24 h postoperatively) or an equal volume of saline. All patients received similar intensive postoperative rehabilitation. Postoperative pain scores, opioid consumption, and fatigue scores were measured. Times to first flatus, defecation, and hospital discharge were recorded. Postoperative endocrine (cortisol and catecholamines) and metabolic (leukocytes, C-reactive protein, and glucose) responses were measured for 48 h. Data (presented as median [25-75% interquartile range], lidocaine vs. saline groups) were analyzed using Mann-Whitney tests. P<0.05 was considered statistically significant.

RESULTS

Patient demographics were similar in the two groups. Times to first flatus (17 [11-24] vs. 28 [25-33] h; P<0.001), defecation (28 [24-37] vs. 51 [41-70] h; P=0.001), and hospital discharge (2 [2-3] vs. 3 [3-4] days; P=0.001) were significantly shorter in patients who received lidocaine. Lidocaine significantly reduced opioid consumption (8 [5-18] vs. 22 [14-36] mg; P=0.005) and postoperative pain and fatigue scores. In contrast, endocrine and metabolic responses were similar in the two groups.

CONCLUSIONS

Intravenous lidocaine improves postoperative analgesia, fatigue, and bowel function after laparoscopic colectomy. These benefits are associated with a significant reduction in hospital stay.

Can I improve postoperative outcome after abdominal surgery?

Most of the textbooks of anesthesia do not devote any chapter to anesthesia for abdominal surgery. Whereas the choice of anesthetics has minimal impact on postoperative outcome of the patient scheduled for these procedures global perioperative anesthetic management however affects postoperative recovery, convalescence, or even morbidity. This presentation highlights practical measures susceptible of reducing postoperative complications and of shortening patient convalescence.

[Tinea capitis in department of dermatology and venerology in the University hospital of Donka at Conakry, Guinea]

The authors report the results of a study carried out on tinea capitis, in the Department of Dermatology and Venerology at the University Hospital of Donka in Conakry, during one year In this department, the tinea capitis represents 3.2% of the consultations and remains the second mycosis. Out of 414 consulted children, a male predominance of 75% was noted especially regarding the Trichophytic tinea. School children aged of 6-14 years old are the most affected by the disease. The trichophytic tinea is widely spread with 65.5% more than the microsporic 17% and inflammatory tinea 16.5%. The mixed tinea is exceptional and no case of favus has been found. The Trichophyton violaceum is the most dermatophyte to be found 56.70% whereas a survey carried out in 1959 showed the predominance of T. soudanense and M. audouini. The Microsporum canis and an association of M. canis and T. violaceum are also to be found.

Right lobe living related liver transplantation in adults without venous drainage of the paramedian sector

INTRODUCTION

There is some controversy on the necessity of venous reconstruction of the right paramedian sector (segments V and VIII) during right lobe living related liver transplantation. In this report we describe the evolution of posttransplant graft function in five consecutive right lobe recipients without specific drainage of the right paramedian sector.

MATERIAL AND METHODS

The technique of common right hepatectomy for right lobe graft harvesting and transplantation did not include the middle hepatic vein in the graft. The mean total ischemic time was 51 minutes (ranges: 35 to 64 minutes). The mean graft to recipient weight ratio was 1.35% +/- 0.15%. No patient developed small-for-size syndrome.

RESULTS

All patients showed a rise in transaminases with a maximum at postoperative day 2 (mean aspartate aminotransferase: 1067 +/- 432 IU/mL). Liver function improved rapidly, with coagulation normalized at postoperative day 5. Bilirubin decreased progressively to normalize in three patients at postoperative day 14. Ultrasonography and computed tomography demonstrated that the paramedian sector of the right liver was congested, a state that was temporary with normalization of the liver tests and congestion disappeared at follow-up. No complication was linked to congestion.

DISCUSSION

This series showed that in right lobe liver transplantation with a relatively large-size graft, reconstruction of the hepatic veins of the paramedian sector may not be necessary despite the induction of some degree of venous congestion. In smaller grafts, this congestion might be avoided by reconstruction of the large veins draining segments V and VIII.

Avoiding blood products during liver transplantation

Liver transplantation is a major surgical procedure usually requiring large amount of blood products (red cells, platelets, fresh-frozen plasma). We developed a multidisciplinary transfusion-free protocol for liver transplantation in Jehovah's witnesses who refuse the use of blood products but accept organ transplantation. Between September 1998 and November 2004, 9 of 29 Jehovah's witnesses evaluated for liver transplantation were transplanted after medical preparation. None of these patients received any blood product during the surgical procedure. This experience may be beneficial for the entire liver transplantation population, as excessive transfusion has been linked to increased morbidity and mortality in liver transplantation.

Acute rehabilitation program after laparoscopic colectomy using intravenous lidocaine

BACKGROUND

The concept of postoperative acute rehabilitation was introduced to accelerate postoperative recovery and improve outcome. We investigated whether intravenous lidocaine infusion, which decreases postoperative pain and speeds the return of bowel function, can be used instead of epidural analgesia in an acute rehabilitation protocol for patients undergoing laparoscopic colectomy.

METHODS

Twenty eight consecutive patients scheduled for laparoscopic colectomy were prospectively included in this case series study. Segmental colectomy was performed only for benign pathology. Intraoperative opioid use was restricted. After a bolus injection of lidocaine 1.5 mg x kg(-1), an infusion (2 mg x kg(-1) x h(-1), i.v.) was started before pneumoperitoneum. Balanced analgesia was used to reduce postoperative opioid consumption. Patients were allowed to drink 6 h postoperatively. The day after surgery, patients were allowed to eat a normal breakfast. Enforced mobilisation and ambulation were required from the patients. Our goal was to discharge patients within 3 days after surgery. Postoperative pain was measured. Time to first flatus, defecation, and hospital discharge were recorded.

RESULTS

Mean postoperative pain at rest and mobilisation remained below 30 mm on a 100 mm visual analogue scale. Time to first flatus, defecation, and hospital discharge were 29 +/- 13 h, 38 +/- 13 h, and 3.0 +/- 1.0 days, respectively.

CONCLUSION

Acute rehabilitation after laparoscopic colectomy using i.v. lidocaine gives similar outcomes to those reported using epidural analgesia.

Living related liver transplantation in adults: first year experience at the University of Liège

Living related liver transplantation (LRLT) in adult recipients has been recently developed to overcome the organ donor shortage, but LRLT leaves the healthy donors at risk of serious post-operative complications, or even death. The aim of this paper is to report the prospective evaluation of the initial experience of adult LRLT at the University of Liège. From March 2002 till March 2003, in a consecutive series of 35 adult liver transplantations, five recipients (mean age: 51 years) underwent LRLT, including one retransplantation. Indications for transplantation were autoimmune hepatitis, hepatitis B virus related cirrhosis with hepatocarcinoma (two cases), hepatitis C virus related cirrhosis with hepatocarcinoma, and ischemic intrahepatic bile duct necrosis 10 years after primary liver transplantation. Mean age of the donors was 34 years (range: 21-53 years). All donation cases were intra familial at first degree. The right lobe was used as a graft in four cases and the left lobe in one case. All right lobe donors developed transient hyperbilirubinemia and hypocoagulation for 4 to 6 days. No severe complication (transfusion, bile duct fistula, reintervention, rehospitalization) nor significant long-term sequelae were observed in the donors. In the recipients, graft function was immediate, and there was no small-for-size syndrome. One recipient developed biliary fistula treated by reoperation. One recipient died from invasive aspergillosis 11 days after the procedure. The four other recipients were alive without recurrence of the disease at follow-up. This report confirmed that LRLT may be a valuable alternative to cadaveric liver transplantation in the era of organ donor shortage. However, even if there was no severe complication for the donors in our preliminary experience, LRLT puts healthy living donors at risk of significant morbidity and even death.

[Clinical case of the month. Autoimmune cirrhosis treated by liver transplantation using the right hepatic lobe from a living related donor]

The authors describe the case of a 17-year-old girl who suffered from end-stage liver failure due to chronic autoimmune hepatitis. Liver failure was complicated by severe portal hypertension, hypersplenism and refractory ascites. Liver transplantation was indicated. She was listed for cadaveric whole liver transplantation, but her infrequent blood group (B) increased waiting time. Her condition deteriorated to Child C liver failure and living related liver transplant was considered. Her father was compatible and proposed himself for donation. Right lobe procurement was decided in order to provide sufficient liver mass. No transfusion of red cells, platelets, or fresh frozen plasma was used either in the donor or the recipient. Both recipient and donor left the ward at postoperative day 14, without complication. They were both asymptomatic and with normal liver tests at one year follow-up. Living related liver transplantation using the right lobe may offer an alternative to liver transplant candidates in this period of organ donor shortage.

Spinal Mechanisms Contribute to Analgesia Produced by Epidural Sufentanil Combined with Bupivacaine for Postoperative Analgesia

When used alone, lipid-soluble epidural opioids are thought to produce analgesia supraspinally via systemic absorption. However, spinal opioids and local anesthetics have been shown to act synergistically at the spinal level in animal studies. We, therefore, tested the hypothesis that sufentanil requirements will be less when given epidurally than IV in patients simultaneously given epidural bupivacaine after major abdominal surgery. Forty patients were anesthetized with isoflurane and epidural bupivacaine for major abdominal surgery. After surgery, each was given a continuous epidural infusion of bupivacaine at a rate of 5 mg/h and sufentanil patient-controlled analgesia (PCA). In a randomized, double-blinded fashion, the sufentanil was given either epidurally or IV. PCA settings were the same in each group. For 60 hrs after surgery, the following variables were measured: pain scores at rest, during mobilization, and during coughing; extension of sensory block; side effects; and sufentanil consumption. Pain scores, extension of sensory block, and the incidence of side effects did not differ between the two groups. Consumption of sufentanil in the epidural group was half that of the IV group (48 h after surgery: 107 +/- 57 microg versus 207 +/- 100 microg for the epidural and IV groups, respectively; P < 0.05). We conclude that spinal mechanisms contribute to the analgesia produced by epidural sufentanil in combination with a local anesthetic.

IMPLICATIONS

When combined with epidural bupivacaine, the sufentanil requirement was 50% less when given epidurally than IV. Epidural sufentanil thus appears to have a spinal mechanism of action.

Transition between anesthesia and post-operative analgesia: relevance of intra-operative administration of analgesics

The rapid awakening without residual analgesic effect seen with the new "fast-in-fast-out" anesthetic agents forces us to anticipate post-operative pain management. More then ever, "balanced analgesia" appears the key for successful transition between anesthesia and post-operative analgesia. This review focuses on practical aspects seeking to answer the following questions: which analgesics should be used?; how should they be given?; at what stage of the anesthetic time should they be injected? In the absence of a loco-regional technique, analgesics must be given before the end of surgery to obtain a quiet awakening. The transition in this delicate period may be facilitated by the intra-operative use of various adjuvant therapies such as ketamine, lidocaine infusion, clonidine, and magnesium, that reduce the needs for opioid and/or post-operative pain severity. All non-opioid analgesics (propacetamol, NSAIDs, tramadol) must be given according to their pharmacokinetic characteristics, indications and contraindications to ensure the required analgesic effect is effective at the time of awakening. If tramadol is not used, an initial dose of a long-acting opioid should be given 20-30 minutes before the end of surgery. Insufficient analgesia must be corrected by titrating an opioid intravenously before allowing the patient to control his/her analgesia using a PCA pump.

Role of sarcolectin (SCL) and interferons in coordinated T cell clonal expansion

T cell multiplication is attributed to the growth factor interleukin-2 (IL-2), which is, however, only activated when a specific cell membrane-bound receptor can be expressed. We found in all human sera tested a lectin that we described and called sarcolectin (SCL). SCL is a molecularly cloned 55-kDa protein that stimulates DNA synthesis in all immunocompetent cells and inhibits the interferon (IFN)-dependent antiviral state. SCL is excreted in conditioned medium of T cell cultures grown under serum-free conditions, where it can be demonstrated regularly by Western blots. In such cultures, in addition to SCL and IL-2, IFN-gamma and IFN-alpha also can be found, likely as a feedback response to DNA stimulation. Considered together, the data suggest that coordinated clonal expansion of T cells is governed by SCL-IL-2, both which induce T cell proliferation and simultaneously activate IL-2 receptors. T cell replication is downregulated by the effect of feedback IFN-gamma and IFN-alpha. To initiate a new growth cycle, SCL is thought to block the residual IFN-dependent antiproliferative state.

Comparison of zona manipulated and zona intact blastocyst transfers: a prospective randomized trial

PURPOSE

In this prospective randomized study the effects of enzymatic treatment of zona pellucida of blastocysts on implantation and pregnancy rates were evaluated in a group of patients who had more than five embryos on day 3.

METHODS

Forty-six patients with a mean age of 29.8 +/- 4.5 years and mean duration of infertility of 6.72 +/- 0.63 years had blastocyst stage transfers, with a mean number of 2.9 +/- 0.1 embryos replaced per patient. Patients were randomly divided into two groups. The first group consisted of patients (n = 22) who had zona intact blastocyst stage transfers and the second group consisted of patients (n = 24) who had zona manipulated (enzymatic treatment) blastocyst stage transfers. Patient and cycle characteristics were similar in both groups. A commercial cell and serum-free sequential culture system was used for all embryos.

RESULTS

Overall blastocyst formation rate was 50.3%. Transfer could be done in all patients. The positive beta-human chorionic gonadotropin rate in the zona intact group was 50% (11/22) and in the zona-manipulated group was 70.8% (17/24). Clinical pregnancy, ongoing pregnancy, and implantation rates in zona intact and manipulated groups were 45.5%, 27.3%, and 19%, and 62.5%, 45.8%, and 24% respectively. Although implantation and pregnancy rates in the zona-manipulated group were higher, there were no statistically significant differences in terms of these variables between two groups. No triplet pregnancy was obtained in either group, and the twin pregnancy rate was 20% (2/10) in the zona intact group and 13.3% (2/15) in the zona-manipulated group.

CONCLUSIONS

With further improvements in the embryo culture systems it will become possible in the near future to achieve high implantation rates even with single blastocyst transfers. Enzymatic treatment of the zona pellucida seems that it does not alter the pregnancy and implantation rates, but further studies with larger group of patients are needed to clarify the real effect of this zona manipulation on pregnancy outcome.

Fertilization and development of a blastocyst-stage embryo after selective intracytoplasmic sperm injection of a mature oocyte from a binovular zona pellucida: a case report

PURPOSE

Our purpose is to describe the development of a blastocyst-stage embryo after the selective fertilization of a mature oocyte from a binovular zona pellucida by intracytoplasmic sperm injection (ICSI).

METHOD

A 34-year-old woman underwent intracytoplasmic sperm injection due to severe male-factor infertility. After oocyte retrieval, a binovular zona pellucida including one mature metaphase II oocyte and one immature oocyte at the germinal vesicle stage as well as nine metaphase II oocytes was injected with spermatozoa using a one-to-one approach.

RESULTS

The injected mature oocyte of the binovular zona pellucida showed fertilization as evidence by the presence of two pronuclei and cleaved to a four-cell embryo on the second day, while the uninjected oocyte showed signs of degeneration. On the third day, this embryo further cleaved to six blastomeres with slight fragmentation and it reached the blastocyst stage on the sixth day.

CONCLUSIONS

Selective fertilization of one oocyte from a binovular zona pellucida by ICSI may lead to the development of a morphologically normal blastocyst-stage embryo which can be used for embryo transfer in the presence of a limited number of embryos.

Sarcolectin (SCL): structure and expression of the recombinant molecule

Interferons (IFNs) are major cytokines, responsible for down-regulating cell growth and for promoting cell differentiation. The sarcolectin (SCL) protein presented here blocks in the cells the established IFN-dependent interphase and stimulates DNA synthesis, probably in co-ordination with more specific growth factors or hormones. The SCL-DNA structure is closely related to that of cytokeratine K2C7 intermediate filaments, but the SCL is a monomer, or sometimes a dimer, which is excreted into the serum, where it is frequently bound to albumin. Its specific biological functions are carried by the beta sheets, and can be found on the two terminal domains of the molecule, the lectinic properties being located mainly on the N-terminus. The recombinant SCL molecule possesses the same biological functions as the native one, since it inhibits the IFN-dependent antiviral state both in human and in mouse cell cultures. On the contrary, antibodies raised against amino acids 41-55 located on the N-terminal domain of SCL inhibit this antagonistic effect. We postulate that the IFN and SCL proteins, because of their opposite biological functions, are in balance and are part of a feedback system operating the regulation of normal growth. In pathological cases, SCL could play a role in the development of tumors, as we have found in juvenile osteosarcomas or in AIDS cases.

Localization and structure of v-mos in transformed mouse fibroblasts reverted by long-term interferon treatment to nonmalignancy

We have reported previously that Moloney virus-transformed cells, when treated for over 200 passages in the presence of low concentrations of mouse interferon-alpha/beta, can be reverted to a stable nonmalignant status. The cells recover full contact inhibition and are unable to raise tumors when grafted in nude mice. In the present report, we show that whether reverted or malignant, these cells contain deleted v-mos oncogenes, which have lost 392 nucleotides. The truncated oncogenes contain a reduced and modified open reading frame but are able, however, to induce tumors when transfected in mouse 3T3 cells. As there is no difference either in the location or in the structure of this modified v-mos, whether yielded by reverted or malignant cells, we postulate that both cell lines derive from the same population and this modification does not play any role in the reversion process obtained through prolonged IFN-dependent selection. We suggest that reversion could be an epigenetic phenomenon, involving the constitutive synthesis of IFN-beta only in the reverted and not in the malignant cells. The continued persistence of such noncancerous cells could result at least partly from a balance involving the expression of v-mos, IFN-beta, and an IFN antagonist, sarcolectin. These reverted cells can undergo an unlimited number of passages, but they must be trypsinized before day 5 in confluent cultures. Thereafter, the cells stop dividing, cannot proliferate anymore, progressively show signs of apoptosis, and die.

Postoperative spirometry after laparoscopy for lower abdominal or upper abdominal surgical procedures

In this prospective study, we have compared women undergoing laparoscopic cholecystectomy, laparoscopic gynaecological surgery and laparoscopic minor gynaecological procedures (diagnostic, tubal, ligation) (n = 10 in each group) to determine if lower abdominal laparoscopy results in less postoperative pulmonary dysfunction than upper abdominal laparoscopy. Pulmonary testing was performed before operation, and 3 and 6 h after operation, on the first and second days after surgery. After operation, a significant reduction in forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate occurred after laparoscopic cholecystectomy at each time. There were no significant changes after minor gynaecologic laparoscopy, whereas laparoscopic gynaecological surgery resulted in minor pulmonary dysfunction on the day of surgery only. We conclude that postoperative pulmonary function was less impaired after gynaecological laparoscopy than after laparoscopic cholecystectomy. This study suggests that the site of surgery is an important determinant of lung dysfunction after laparoscopy.

[Epidemiologic and therapeutic features of urogenital fistulae in Guinea (Conakry)]

OBJECTIVE

The authors analyse the epidemiological and therapeutic aspects of 186 cases of urogenital fistulas and attempt to define a preventive approach to these lesions.

METHODS

From January 1986 to December 31, 1993, 186 patients were admitted to the urology department of Ignace Deen hospital for urogenital fistulas. Each patient was submitted to the following assessment: complete clinical examination, laboratory examination, endoscopic examination, radiological examination. A therapeutic classification was established on the basis of this assessment: Group 1: complex fistulas. Group 2: difficult fistulas. Group 3: simple fistulas.

RESULTS

Urogenital fistulas were predominantly observed in young primiparous women living in rural zones and the principal cause was a dystocic delivery: 179 cases (96.23%), while only 7 cases (3.7%) were due to gynaecological lesions. 246 primary and secondary repair operations were performed, corresponding to an average of 1.3 operations per patient. Cure was obtained in 131 patients (70.43%) including 37.63%) in Group 1, 8.61% in Group 2 and 21.19% in Group 3. In three cases of partial success, the fistulas were closed; two patients have persistent dysuria with reduced bladder capacity and one patient suffers from dyspareunia with impossibility of coital penetration. Finally, the 49 failures (26.34%) concerned 34 type 1 fistulas; 5 type 2 fistulas and 10 type 3 fistulas.

CONCLUSIONS

In the light of our eight-year experience, urogenital fistula still appears to be a real problem in Guinea, where it represents a public health problem for which surgical cure still raises technical difficulties. In the fight for eradication of urogenital fistula in developing countries, emphasis must be placed on prevention with a just and equitable distribution of health care personnel in rural zones which are often underprivileged: constant improvement of the road network to allow rapid transfer of cases of foetomaternal dystocia to a reference centre; improvement of health structures; urological and obstetric surveillance of any woman operated for urogenital fistula.

Epidural clonidine combined with bupivacaine for analgesia in labor. Effects on mother and neonate

BACKGROUND AND OBJECTIVES

A double-blind study was conducted to assess the efficacy and the safety of epidural clonidine combined with bupivacaine for analgesia during labor.

METHODS

Two groups of pregnant healthy women were allocated randomly to receive either 10 mL 0.125% bupivacaine plain solution (group B, n = 10) or with 75 micrograms clonidine (group B + C, n = 12). Visual analog scale (VAS) scores were measured over 30 minutes after each epidural injection. Patients were monitored with an automated blood pressure device (Dinamap and a pulse oximeter), and fetal heart rate was measured with a cardiotocograph. Plasma clonidine concentrations were measured at birth in mothers and in the umbilical cord by radioimmunoassay.

RESULTS

Visual analog scale scores were significantly lower in patients who received clonidine. Patients required a second epidural injection after 55 +/- 9 minutes in group B and 127 +/- 11 minutes in group B + C (P < .05). Visual analog scale scores were also significantly lower in group B + C than in group B, after the second injection. Decreases in arterial blood pressure were comparable in the two groups, and no patient experienced arterial oxygen desaturation or bradycardia. Fetal heart rate was decreased in group B + C at the time of the second injection. The duration of labor after epidural administration was prolonged in group B + C patients compared to group B (282 +/- 43 minutes and 169 +/- 26 minutes, respectively, P < .05). Apgar scores at 1 and 5 minutes were similar in both groups. Plasma clonidine concentrations were, respectively, 0.31 +/- 0.16 ng/mL 60 minutes after the first injection and 0.62 +/- 0.13 ng/mL at birth in mothers while plasma umbilical cord concentrations were 0.56 +/- 0.12 ng/mL.

CONCLUSIONS

The study documents that clonidine improves epidural bupivacaine analgesia during labor and demonstrates transfer of the drug across the placenta. Therefore, a more extensive study is required to determine the incidence of possible side effects of clonidine in neonates.

[Mechanism of proliferation of cells transformed by the Moloney mouse sarcoma virus after stable reversion to a non-malignant state]

Prolonged interferon (IFN) treatment can convert Moloney sarcoma-transformed mouse Balb C fibroblasts to a stable non-malignant status. The cells recover a number of differentiated features, which are maintained even when IFN is permanently omitted from the tissue culture medium. We show here that reversion could be at least in part attributed to constitutive IFN beta synthesized only in the reverted cells. The continued replication of these cells, although unable to induce tumours in athymic mice, could be the result of the maintained expression of an IFN antagonist termed sarcolectin (SCL), a balance being struck between the effects of v-mos oncogene, interferon beta and SCLs. In agreement with Lampl et al. [11], we suggest that normal cell growth is discontinuous, consisting of sudden bursts followed by prolonged arrests which could be necessary to promote differentiation during the ensuing interphase.

[Forum: reconstruction of the traumatised thumb. Reconstruction of the amputated thumb by progressive lengthening of the 1st metacarpal using mini-fixator. Apropos of 2 clinical cases]

The authors report two cases of reconstruction of a mutilated thumb by progressive elongation of the first metacarpal without the need for bone grafts, using a minifixation elongation device, which is very easy to use. It allows distraction which can be performed by the patient himself and adjustment to the desired length, up to 40 mm.

The molecular cloning and sequence of the common marmoset interferon-gamma (MaIFN-gamma) gene

A DNA fragment covering marmoset interferon gamma (MaIFN-gamma) was cloned from the DNA of peripheral blood leucocytes, sequenced and compared to its human IFN-gamma counterpart. The two nucleotide sequences were found to be highly homologous (90.3%). The position of the exons are directly comparable with those of the human IFN-gamma gene and follows the pattern of structural conservation found elsewhere. The present work makes available recombinant MaIFN-gamma for animal experiments.

[Management of digital ischemia. 5 cases]

Ischaemic fingers, a rare, generally chronic disease, may sometimes be acute, requiring emergency surgical treatment. Five cases are reported: 3 acute and 2 chronic. The 3 cases of acute ischaemia occurred in the context of cardiac arrhythmias in 2 cases and an aneurysm of the ulnar artery in 1 case. Treatment consisted of 2 thrombectomies with microsurgical digital sympathectomy thrombectomies with microsurgical digital sympathectomy and resection of the aneurysm. Complete clinical and functional recovery was obtained in these three cases. The 2 cases of chronic ischaemia were due to diabetes and Buerger's disease. In both cases, medical treatment was followed by thoracic sympathectomy with secondary resection of necrotic tissue as required. In conclusion, the prognosis in the acute cases depends on the rapidity of correction of the arterial obstruction associated with digital sympathectomy. In the case of chronic ischaemia, the clinical course depends on the efficacy of medico-surgical treatment and the severity of the underlying disease.