Waning of SARS-CoV-2 Vaccine Effectiveness in COPD Patients: Lessons from the Delta Variant

Although the COVID-19 pandemic is profoundly changing, data on the effect of vaccination and duration of protection against infection and severe disease can still be advantageous, especially for patients with COPD, who are more vulnerable to respiratory infections. The Hungarian COVID-19 registry was retrospectively investigated for risk of infection and hospitalization by time since the last vaccination, and vaccine effectiveness (VE) was calculated in adults with COPD diagnosis and an exact-matched control group during the Delta variant of concern (VOC) wave in Hungary (September-December 2021). For the matching, sex, age, major co-morbidities, vaccination status, and prior infection data were obtained on 23 August 2021. The study population included 373,962 cases divided into COPD patients (age: 66.67 ± 12.66) and a 1:1 matched group (age: 66.73 ± 12.67). In both groups, the female/male ratio was 52.2:47.7, respectively. Among the unvaccinated, there was no difference between groups in risk for infection or hospitalization. Regarding vaccinated cases, in the COPD group, a slightly faster decline in effectiveness was noted for hospitalization prevention, although in both groups, the vaccine lost its significant effect between 215 and 240 days after the last dose of vaccination. Based on a time-stratified multivariate Cox analysis of the vaccinated cases, the hazard was constantly higher in the COPD group, with an HR of 1.09 (95%: 1.05-1.14) for infection and 1.87 (95% CI: 1.59-2.19) for hospitalization. In our study, COPD patients displayed lower vaccine effectiveness against SARS-CoV-2 infection and hospitalization but a similar waning trajectory, as vaccines lost their preventive effect after 215 days. These data emphasize revaccination measures in the COPD patient population.

CYP1A2 expression rather than genotype is associated with olanzapine concentration in psychiatric patients

Olanzapine is a commonly prescribed atypical antipsychotic agent for treatment of patients with schizophrenia and bipolar disorders. Previous in vitro studies using human liver microsomes identified CYP1A2 and CYP2D6 enzymes being responsible for CYP-mediated metabolism of olanzapine. The present work focused on the impact of CYP1A2 and CYP2D6 genetic polymorphisms as well as of CYP1A2 metabolizing capacity influenced by non-genetic factors (sex, age, smoking) on olanzapine blood concentration in patients with psychiatric disorders (N = 139). CYP2D6 genotype-based phenotype appeared to have negligible contribution to olanzapine metabolism, whereas a dominant role of CYP1A2 in olanzapine exposure was confirmed. However, CYP1A2 expression rather than CYP1A2 genetic variability was demonstrated to be associated with olanzapine concentration in patients. Significant contribution of - 163C > A (rs762551), the most common SNP (single nucleotide polymorphism) in CYP1A2 gene, to enhanced inducibility was confirmed by an increase in CYP1A2 mRNA expression in smokers carrying - 163A, and smoking was found to have appreciable impact on olanzapine concentration normalized by the dose/bodyweight. Furthermore, patients' olanzapine exposure was in strong association with CYP1A2 expression; therefore, assaying CYP1A2 mRNA level in leukocytes can be an appropriate tool for the estimation of patients' olanzapine metabolizing capacity and may be relevant in optimizing olanzapine dosage.

Potential Association of Cytochrome P450 Copy Number Alteration in Tumour with Chemotherapy Resistance in Lung Adenocarcinoma Patients

Resistance to anticancer agents is a major obstacle to efficacious tumour therapy and responsible for high cancer-related mortality rates. Some resistance mechanisms are associated with pharmacokinetic variability in anticancer drug exposure due to genetic polymorphisms of drug-metabolizing cytochrome P450 (CYP) enzymes, whereas variations in tumoural metabolism as a consequence of CYP copy number alterations are assumed to contribute to the selection of resistant cells. A high-throughput quantitative polymerase chain reaction (qPCR)-based method was developed for detection of CYP copy number alterations in tumours, and a scoring system improved the identification of inappropriate reference genes that underwent deletion/multiplication in tumours. The copy numbers of both the target (CYP2C8, CYP3A4) and the reference genes (ALB, B2M, BCKDHA, F5, CD36, MPO, TBP, RPPH1) established in primary lung adenocarcinoma by the qPCR-based method were congruent with those determined by next-generation sequencing (for 10 genes, slope = 0.9498, r2 = 0.72). In treatment naïve adenocarcinoma samples, the copy number multiplication of paclitaxel-metabolizing CYP2C8 and/or CYP3A4 was more prevalent in non-responder patients with progressive disease/exit than in responders with complete remission. The high-throughput qPCR-based method can become an alternative approach to next-generation sequencing in routine clinical practice, and identification of altered CYP copy numbers may provide a promising biomarker for therapy-resistant tumours.

Prediction of gastroesophageal reflux episodes by smooth muscle electromyography: A translational study in rats and adolescents

Aims

Our aim was to measure the myoelectric modifications during gastric acid secretion along with the gastric pH in a rat model and to detect the gastrointestinal (GI) myoelectric changes in adolescents suffering from gastroesophageal reflux disease (GERD) along with the esophageal pH measurement.

Main methods

In anesthetized rats, gastric acid secretion was initiated with intragastric histamine (50 mg/kg), and gastric pH, GI myoelectric activity and mechanical GI contractions were measured with intragastric pH electrode, subcutaneously implanted smooth muscle electromyography (SMEMG) electrodes and organ implanted strain gauges, respectively. In the clinical study, esophageal pH and GI myoelectric activity were measured in adolescents suffering from GERD with intraesophageal pH electrode and SMEMG electrodes placed on the abdominal surface, respectively. The SMEMG records were analyzed by fast Fourier transformation (FFT) and power spectrum density maximum (PsDmax) values were calculated for the GI segments.

Key findings

In rats, histamine initiated an immediate increase in gastric PsDmax, which preceded the significant reduction in gastric pH by 75 min. The myoelectric change was independent of mechanical GI contractions. In adolescents, the GERD episodes were preceded by a significant increase in gastric PsDmax 45 min earlier. These changes were independent of motion or meals.

Significance

Increased gastric myoelectric activity during histamine stimulation or GERD might be linked to the enhanced activity of the gastric proton pump, indicating a link between gastric acid secretion and GERD episodes. It is supposed that SMEMG might be a tool for predicting forthcoming reflux episodes in GERD.

Association between CYP2B6 genetic variability and cyclophosphamide therapy in pediatric patients with neuroblastoma

Cyclophosphamide, an oxazaphosphorine prodrug is frequently used in treatment of neuroblastoma, which is one of the most prevalent solid organ malignancies in infants and young children. Cytochrome P450 2B6 (CYP2B6) is the major catalyst and CYP2C19 is the minor enzyme in bioactivation and inactivation pathways of cyclophosphamide. CYP-mediated metabolism may contribute to the variable pharmacokinetics of cyclophosphamide and its toxic byproducts leading to insufficient response to the therapy and development of clinically significant side effects. The aim of the study was to reveal the contribution of pharmacogenetic variability in CYP2B6 and CYP2C19 to the treatment efficacy and cyclophosphamide-induced side effects in pediatric neuroblastoma patients under cyclophosphamide therapy (N = 50). Cyclophosphamide-induced hematologic toxicities were pivotal in all patients, whereas only moderate hepatorenal toxicity was developed. The patients' CYP2B6 metabolizer phenotypes were associated with the occurrence of lymphopenia, thrombocytopenia, and monocytopenia as well as of liver injury, but not with kidney or urinary bladder (hemorrhagic cystitis) toxicities. Furthermore, the patients' age (< 1.5 years, P = 0.03) and female gender (P ≤ 0.02), but not CYP2B6 or CYP2C19 metabolizer phenotypes appeared as significant prognostic factors in treatment outcomes. Our results may contribute to a better understanding of the impact of CYP2B6 variability on cyclophosphamide-induced side effects.

[Modern views of fever management - about the FeverFriendTM program]

INTRODUCTION

A wealth of physiological, pathophysiological and clinical evidence of the beneficial effects of childhood fever exists already. Nevertheless, the public perception of fever has become persistently negative. Sociological research attributes this to a number of factors: unjustified fear, help-seeking behaviour, complex behavioural patterns of symptom avoidance and comfort-seeking. One of the keys to this change in attitudes, in the light of recent research, is linked to changes in the awareness and understanding of health among health professionals and lay people. The role of the young generation using media is crucial.

OBJECTIVE

To establish a long-term research project to reduce the use of medication (antipyretics and antibiotics) and the number of medical consultations and to improve attitudes towards fever, using media-based e-health tools.

METHOD

An observational, adaptive, prospective cohort study was conducted. The intervention under study is a publicly available application and linked knowledge base. We collect self-reported data from caregivers. The application takes these into account and provides a decision-supporting condition classification based on a differential diagnosis algorithm.

RESULTS

1) The parameters, primary and secondary criteria to be captured in the application as well as the data collection and data processing methodology for the assessment were defined by 100% consensus of the expert partners in a Delphi process. 2) Based on the available national and international guidelines, the above parameters were used to create the condition assessment, decision aid algorithm, which can be a starting point for machine learning in the long term. 3) We evaluated baseline data on demographics, febrile events and antipyretic use from 01/11/2020 to 15/06/2022.

CONCLUSION

The FeverFriendTM project can contribute to reduce the burden of medicalisation and care burden on the existing healthcare system through evidence-based modern fever management in the care of children and adults with fever. The impact of the FeverFriendTM program on target behavioural change needs to be further investigated through data analysis. Orv Hetil. 2023; 164(5): 179-185.

Booster Vaccination Decreases 28-Day All-Cause Mortality of the Elderly Hospitalized Due to SARS-CoV-2 Delta Variant

(1) Background: SARS-CoV-2 infections are associated with an increased risk of hospital admissions especially in the elderly (age ≥ 65 years) and people with multiple comorbid conditions. (2) Methods: We investigated the effect of additional booster vaccinations following the primary vaccination series of mRNA, inactivated whole virus, or vector vaccines on infections with the SARS-CoV-2 delta variant in the total Hungarian elderly population. The infection, hospital admission, and 28-day all-cause mortality of elderly population was assessed. (3) Results: A total of 1,984,176 people fulfilled the criteria of elderly including 299,216 unvaccinated individuals, while 1,037,069 had completed primary vaccination and 587,150 had obtained an additional booster. The primary vaccination series reduced the risk of infection by 48.88%, the risk of hospital admission by 71.55%, and mortality by 79.87%. The booster vaccination had an additional benefit, as the risk of infection, hospital admission, and all-cause mortality were even lower (82.95%; 92.71%; and 94.24%, respectively). Vaccinated patients needing hospitalization suffered significantly more comorbid conditions, indicating a more vulnerable population. (4) Conclusions: Our data confirmed that the primary vaccination series and especially the booster vaccination significantly reduced the risk of the SARS-CoV-2 delta-variant-associated hospital admission and 28-day all-cause mortality in the elderly despite significantly more severe comorbid conditions.

CYP1A2 mRNA Expression Rather than Genetic Variants Indicate Hepatic CYP1A2 Activity

CYP1A2, one of the most abundant hepatic cytochrome P450 enzymes, is involved in metabolism of several drugs and carcinogenic compounds. Data on the significance of CYP1A2 genetic polymorphisms in enzyme activity are highly inconsistent; therefore, the impact of CYP1A2 genetic variants (−3860G>A, −2467delT, −739T>G, −163C>A, 2159G>A) on mRNA expression and phenacetin O-dealkylation selective for CYP1A2 was investigated in human liver tissues and in psychiatric patients belonging to Caucasian populations. CYP1A2*1F, considered to be associated with high CYP1A2 inducibility, is generally identified by the presence of −163C>A polymorphism; however, we demonstrated that −163C>A existed in several haplotypes (CYP1A2*1F, CYP1A2*1L, CYP1A2*1M, CYP1A2*1V, CYP1A2*1W), and consequently, CYP1A2*1F was a much rarer allelic variant (0.4%) than reported in Caucasian populations. Of note, −163C>A polymorphism was found to result in an increase of neither mRNA nor the activity of CYP1A2. Moreover, hepatic CYP1A2 activity was associated with hepatic or leukocyte mRNA expression rather than genetic polymorphisms of CYP1A2. Consideration of non-genetic phenoconverting factors (co-medication with CYP1A2-specific inhibitors/inducers, tobacco smoking and non-specific factors, including amoxicillin+clavulanic acid therapy or chronic alcohol consumption) did not much improve genotype−phenotype estimation. In conclusion, CYP1A2-genotyping is inappropriate for the prediction of CYP1A2 function; however, CYP1A2 mRNA expression in leukocytes can inform about patients’ CYP1A2-metabolizing capacity.

CYP2B6 allelic variants and non-genetic factors influence CYP2B6 enzyme function

Human CYP2B6 enzyme although constitutes relatively low proportion (1–4%) of hepatic cytochrome P450 content, it is the major catalyst of metabolism of several clinically important drugs (efavirenz, cyclophosphamide, bupropion, methadone). High interindividual variability in CYP2B6 function, contributing to impaired drug-response and/or adverse reactions, is partly elucidated by genetic polymorphisms, whereas non-genetic factors can significantly modify the CYP2B6 phenotype. The influence of genetic and phenoconverting non-genetic factors on CYP2B6-selective activity and CYP2B6 expression was investigated in liver tissues from Caucasian subjects (N = 119). Strong association was observed between hepatic S-mephenytoin N-demethylase activity and CYP2B6 mRNA expression (P < 0.0001). In less than one third of the tissue donors, the CYP2B6 phenotype characterized by S-mephenytoin N-demethylase activity and/or CYP2B6 expression was concordant with CYP2B6 genotype, whereas in more than 35% of the subjects, an altered CYP2B6 phenotype was attributed to phenoconverting non-genetic factors (to CYP2B6-specific inhibitors and inducers, non-specific amoxicillin + clavulanic acid treatment and chronic alcohol consumption, but not to the gender). Furthermore, CYP2B6 genotype–phenotype mismatch still existed in one third of tissue donors. In conclusion, identifying potential sources of CYP2B6 variability and considering both genetic variations and non-genetic factors is a pressing requirement for appropriate elucidation of CYP2B6 genotype–phenotype mismatch.

Impact of genetic and non-genetic factors on hepatic CYP2C9 expression and activity in Hungarian subjects

CYP2C9, one of the most abundant hepatic cytochrome P450 enzymes, is involved in metabolism of 15–20% of clinically important drugs (warfarin, sulfonylureas, phenytoin, non-steroid anti-inflammatory drugs). To avoid adverse events and/or impaired drug-response, CYP2C9 pharmacogenetic testing is recommended. The impact of CYP2C9 polymorphic alleles (CYP2C9*2, CYP2C9*3) and phenoconverting non-genetic factors on CYP2C9 function and expression was investigated in liver tissues from Caucasian subjects (N = 164). The presence of CYP2C9*3 allele was associated with CYP2C9 functional impairment, and CYP2C9*2 influenced tolbutamide 4′-hydroxylase activity only in subjects with two polymorphic alleles, whereas the contribution of CYP2C8*3 was not confirmed. In addition to CYP2C9 genetic polymorphisms, non-genetic factors (co-medication with CYP2C9-specific inhibitors/inducers and non-specific factors including amoxicillin + clavulanic acid therapy or chronic alcohol consumption) contributed to the prediction of hepatic CYP2C9 activity; however, a CYP2C9 genotype–phenotype mismatch still existed in 32.6% of the subjects. Substantial variability in CYP2C9 mRNA levels, irrespective of CYP2C9 genotype, was demonstrated; however, CYP2C9 induction and non-specific non-genetic factors potentially resulting in liver injury appeared to modify CYP2C9 expression. In conclusion, complex implementation of CYP2C9 genotype and non-genetic factors for the most accurate estimation of hepatic CYP2C9 activity may improve efficiency and safety of medication with CYP2C9 substrate drugs in clinical practice.

Clinical significance of personalized tacrolimus dosing by adjusting to donor CYP3A-status in liver transplant recipients

Donor's CYP3A-status (CYP3A5 genotype and CYP3A4 expression) can provide prognostic information regarding tacrolimus-metabolizing capacity of the liver graft and initial tacrolimus dosing for therapeutic blood concentrations in liver transplants. The present work prospectively investigated whether CYP3A-status guided tacrolimus therapy has any potential clinical benefit for recipients in the early postoperative period.

METHODS

The contribution of preliminary assaying of donor CYP3A-status to the optimization of initial tacrolimus therapy and to the reduction of adverse events (acute rejection, infection, nephrotoxicity) was investigated in 112 liver transplant recipients (CYPtest group) comparing to 101 control patients on tacrolimus concentration guided therapy.

RESULTS

The time for achieving therapeutic tacrolimus concentration was significantly reduced, confirming potential benefit of initial tacrolimus therapy adjusted to donor's CYP3A-status over classical clinical practice of tacrolimus concentration guided treatment (4 vs 8 days, P < 0.0001). Acute rejection episodes (3.6 vs 23.8%, P < 0.0001) and tacrolimus induced nephrotoxicity (8 vs 27%, P = 0.0004) were less frequent in CYPtest group than in control patients, whereas occurrence of infectious disease was not influenced by tacrolimus dosing strategy (3.6 vs 5.9% in CYPtest and control groups, P > 0.05). Acute rejection was often accompanied with tacrolimus blood concentrations lower than 10 ng mL^-1 (20/24 of control and 2/4 of CYPtest patients), while nephrotoxicity was associated with high tacrolimus concentrations (>20 ng mL^-1 ) in the first week after transplantation (13/27 of control and 2/9 of CYPtest patients).

CONCLUSION

CYP3A-status guided therapy significantly improved the risk of misdosing induced early adverse effects (acute rejection, nephrotoxicity).

Sexual activity of young men is not related to their anthropometric parameters

INTRODUCTION

Many articles have been written about the deterioration of male sexual function, mainly in relation to metabolic diseases and aging. With younger men, unless they have a complaint, sexual issues are rarely discussed during medical consultations. No articles could be found about anthropometric parameters as factors potentially influencing sexual performance.

AIM

The aim of this study was to find the anthropometric parameters with the closest correlation with sexual activity.

MAIN OUTCOME MEASURES

Main outcome measures included self-reported weekly intercourses, age, body weight and height, body mass index (BMI), and waist circumference.

METHODS

Data for 531 heterosexual men aged 20-54 years were collected in three andrological centers. Past and recent morbidity, medications, and some lifestyle elements were recorded; anthropometric parameters were measured; and andrological examination was performed. The average weekly number of intercourses was asked confidentially.

RESULTS

The mean weekly coital frequency (±SD) was 2.55 ± 1.08. The highest self-reported weekly coital frequency was recorded for men between the ages of 25 and 29 (3.02 ± 1.27). Coital frequency was higher among men with a height of less than 175 cm (2.69 ± 1.24), weight of less than 78 kg (2.74 ± 1.18), normal BMI (2.74 ± 1.16), normal waist circumference (2.69 ± 1.19), and no metabolic disease (2.57 ± 1.11). Logistic regression described an inverse, statistically significant association between age and coital frequency, with the following odds ratios for coital frequency (ORcf ): ORcf≥2  = 0.932, P < 0.001; ORcf≥2.5  = 0.935, P < 0.001; ORcf≥3  = 0.940, P < 0.001; ORcf≥3.5  = 0.965, P = 0.041. Among men who reported a coital frequency of more than 3.5 times a week, waist circumference (ORcf≥3.5  = 0.986, P = 0.066) showed borderline association with lower sexual activity, while lesser height (ORcf≥3.5  = 0.951, P = 0.005) was associated with higher activity.

CONCLUSION

In this study's age range, none of the examined anthropometric parameters was perfectly correlated with sexual activity. Obesity and metabolic diseases can cause all types of sexual function to deteriorate in older age, whereas their effects may not yet be prominent at younger ages (below 45 years). Health promotion for all ages should focus on prevention of obesity so as to improve quality of life and sexual health.

Impact on survival of surgery after concomitant chemoradiotherapy for locally advanced cancers of the esophagus

BACKGROUND

To evaluate the results of chemoradiotherapy with or without surgery in locally-advanced esophageal carcinomas (T3 and/or nodal involvement).

METHODS

One hundred twelve patients with locally-advanced carcinoma of the esophagus without histologically proven invasion of the tracheobronchial tree or distant visceral metastases were treated with concomitant chemoradiotherapy followed by re-evaluation; surgery was performed or chemoradiotherapy continued, based on tumor regression and the patient's general status. Chemoradiotherapy consisted of concomitant 5-fluorouracil (5FU)(1 g/m(2) day 1-3), cisplatinum (50 mg/m(2) day 1 and 2), and external beam irradiation up to a dose of 40 or 43.2 Gy. After a 4-week rest period, radical esophagectomy or a new cycle of chemoradiotherapy (up to a total dose of 65 Gy) was performed.

RESULTS

A complete clinical response was obtained in 25.7% of the patients and a partial response in 45.9%. Fifty patients underwent surgery, but only 38 patients had an esophagectomy. Post-esophagectomy mortality was 5.3%. A complete histologic response rate of 23.7% was obtained. Two- and 5-year survival rates were, respectively, 41.5% and 28.6% for the whole population. According to multivariate analysis, prognostic factors for survival were Karnofsky index, esophagectomy, and response to chemoradiotherapy. Five-year survival for patients who experienced a partial response to radiation and chemotherapy was 49.1% for those who had surgery and 23.5% for those treated without surgery (p = 0.003). There was no obvious benefit for the small number of patients treated surgically after complete response to radiation and chemotherapy. Toxicity, essentially hematologic, was moderate.

CONCLUSION

For locally-advanced esophageal carcinomas, esophagectomy, after concomitant chemoradiotherapy, could improve the survival rate, especially for patients who responded partially to the latter.

[Effectiveness and adverse effects of sildenafil in erectile dysfunction]

Sildenafil is a selective and by oral administration potent type-5 phosphodiesterase (PDE 5) inhibitor, which increases the erection by corpus cavernosum smooth muscle relaxation. In a non-placebo controlled study, 134 patients with erectile dysfunction were treated with oral sildenafil. The aim of the study was to estimate the efficacy and adverse effects of this treatment. 51 patients (38%) had psychogenic, and 83 (62%) organic origin of the erectile dysfunction. 73 of them have already had some treatment for this problem before. The effective dose was 50 mg for 84 patients (63%), 100 mg for 32 (24%) and 25 mg for 4 patients. The treatment was effective for 120 patients (90%). The most common adverse effect was flushing in 18 (13%) and headache in 9 (7%) cases, two patients had headache and flushing together. Nasal congestion and visual disturbances were complained by two patients. Two patients reported prolonged (max. 2h) erections. Cardiological investigation was performed for cardiovascular patients and for patients with risk factors. Exact criteria of the cardiological opinion of sildenafil treatment are reviewed. Cardial or other serious adverse effects were not observed. It was not necessary to stop the treatment because of the adverse effects. The authors found, that sildenafil is an effective and safe treatment for the erectile dysfunction.

[Polysomnography in the prevention of crib death]

The authors stress the importance of polysomnography--a new electrophysiologic method--in the prevention of SIDS (cot death). SIDS is the most important and frequent cause of infant mortality between 1 and 12 months of age in western countries (nowadays between 1-2/1000!). In Hungary the frequency is not so high. In the last few years the incidence declined after the "back to sleep" campaigns, but to reach further success, it is very important to seek the so called "risk" babies. The unique cause of cot death is not yet understood exactly, but some instability in respiration (mostly during the sleep) is one of the accepted principal basic factors. The mentioned new method helps in choosing the SIDS risk infants from the "normal" population, allows to examine their respiratory irregularity or even disorders during the sleep and gives possibility for the prevention of lethal apneas. The authors describe the details of the prevention in case of abnormal polysomnography in their other publications.

[Some aspects of the use of prostaglandin E1 in cases of erectile dysfunction]

The author reports about his first experience of the use of prostaglandin E1 (PGE1) for the treatment of the erectile dysfunction. Results and observations of the self injection treatment with PGE1 of 46 patients are reported. Main indications and some practical aspects of the use of PGE1 are discussed after 5 short case reports. Upon the international experience and his own first results the authors opinion is, that the PGE1 is especially useful for the self injection treatment of the erectile dysfunction because of its rare complication rate.

[Paracetamol poisoning in infancy--is paracetamol safe?]

A 5-month-old baby was observed. At the severely ill infant accidental misadministration of Paracetamol was verified. After surveying the literature the authors discussed the possible pathobiochemical ways and draw attention to the dangers of the misuse of antipyretics.

A ten-year experience with hepatic resection in 338 patients: evolutions in indications and of operative mortality

OBJECTIVE

To report changes in indications for, and operative mortality of, elective hepatic resection during the 10 year period 1980-1989.

DESIGN

Retrospective study.

SETTING

District hospital.

SUBJECTS

338 consecutive patients who underwent elective hepatic resection.

INTERVENTIONS

During the first five years (1980-1984) 99 resections were done, 10 through a right thoracoabdominal incision, and the hepatic pedicle was clamped in 6. During the period 1985-1989 239 resections were done, only 7 (3%) through a thoracoabdominal incision, and the hepatic pedicle was occluded in 197 (82%).

MAIN OUTCOME MEASURES

Changes in indications for operation and operative technique, and mortality.

RESULTS

Indications for resection in the first period were: benign lesions (n = 39), primary hepatic cancer (n = 30-15 had hepatocellular carcinoma associated with cirrhosis), and metastatic disease (n = 30). Six patients died, five from uncontrollable bleeding during operation. Indications during the second half were: benign lesions (n = 105, 44%), primary hepatic cancer (n = 87, 36%-62 (29%) had hepatocellular carcinoma associated with cirrhosis), and metastatic disease (n = 47, 20%). There was only 1 death during operation (air embolism), and 9 cirrhotic patients died during the postoperative period.

CONCLUSIONS

More hepatic resections are being done and the indications are changing, with more patients with cancer and benign tumours being operated on; increasing use of pedicle occlusion has resulted in a significant decrease in uncontrollable operative bleeding; and mortality is still related to the presence of associated cirrhosis.

[Indications for organ-conserving operations in cases of kidney tumors in the age of radical surgery]

The authors analyze the experiences of 29 operations of malign renal tumors, performed during the last 10 years conservating the organs. In 20 cases the conservation of the organ was indicated by necessity due to some diseases or the lack of the contralateral kidney, and in 9 cases due to the small extension of the tumor. The authors reveal their experiences on preoperative examinations; they discuss some questions of surgical techniques and describe their system of patient control. Based upon their experiences, in selected cases they consider indicated conservation of the organ, if the tumor can be extirpated ablastically.

Drainage after elective hepatic resection. A randomized trial

OBJECTIVE

This prospective randomized study determined the influence of closed-suction drainage on the incidence of postoperative complications after elective hepatic resection.

SUMMARY BACKGROUND DATA

Routine drainage is no longer advocated after several intra-abdominal surgical procedures.

METHODS

A series of 81 patients who underwent elective hepatic resection were randomly allocated to either a nondrainage group (n = 39) and a drainage group with closed-suction drainage (n = 42). Indications for resection were 42 benign lesions and 39 malignant tumors, including 19 with cirrhosis. Major hepatic resection was performed in 25 patients and minor resection, in 56. All patients underwent ultrasonography with puncture for bacteriologic cultures of all fluid collections within the first 5 postoperative days.

RESULTS

One patient died in each group. Ultrasonography found a significantly higher rate of subphrenic collections in the drainage group compared with the nondrainage group (respectively, 36% vs. 15%, p < 0.05). These collections were more frequently infected in the drainage group (n = 6) than in the nondrainage group (n = 2). After major liver resection, the rate of intra-abdominal postoperative complications (i.e., subphrenic fluid collections, hematomas, and bilomas) was similar between the two groups.

CONCLUSIONS

Minor liver resection is safer without drainage. Major liver resection can be performed with or without abdominal drainage.

Factors predictive of liver histopathological appearance in chronic alcoholic pancreatitis with common bile duct stenosis and increased serum alkaline phosphatase

In the course of alcoholic chronic pancreatitis, increased serum alkaline phosphatase level is usually caused by common bile duct stenosis but may also be due to alcoholic liver disease. The aims of this prospective study were to investigate whether clinical, biochemical and radiological factors could predict liver histopathological appearance. The study comprised 48 patients with chronic alcoholic pancreatitis, common bile duct stenosis and increased serum alkaline phosphatase levels; clinical, biochemical, radiological and histological data were recorded in all cases. Liver biopsy examination (surgical [n = 45] or intercostal [n = 3]) showed (a) biliary obstructive liver abnormalities (n = 33), which were severe in 20 cases (biliary fibrosis in 15, secondary biliary cirrhosis in 3, secondary sclerosing cholangitis in 2) and moderate in 13 cases; (b) alcoholic liver disease in 9; and (c) normal liver in 6. Clinical, biochemical and radiological data were not statistically different between patients with biliary obstructive liver disease and those with alcoholic liver disease. Forty-five patients underwent surgery; two patients with alcoholic hepatitis died after surgery, at the beginning of this study. We conclude that in chronic alcoholic pancreatitis with common bile duct stenosis and increased serum alkaline phosphatase levels, clinical, biochemical and radiological data cannot be used to predict the type of liver lesions. Therefore liver biopsy is warranted to identify (a) alcoholic hepatitis, which increases operative risk; and (b) biliary obstructive liver disease, frequent and often severe, in which surgical biliary decompression should be considered.

[Dysfunction of penile erection]

Nearly 250 men with erectile dysfunction examined during the past 3 years period. Beside the examination technique development the author emphasizes on the importance of the medical history and the psychological exploration. The examinations are indicated after the analysis of the history and after the positive result of the noninvasive examination the invasive one is only indicated. Intracavernous injection of the vasoactive drugs remains important part of the diagnosis, but the combination with the Doppler examination gives more information about the origin of the dysfunction.

Indications for Performing Organ Conserving Operations in Renal Tumour Cases in the Age of Radical Surgery

The authors analyse 29 operations of malignant renal tumours performed during the last 10 years, where the organs were preserved. In 20 cases conservation of the organ was indicated by necessity due to disease or lack of the contralateral kidney, and in 9 cases due to a small extension of the tumour. The authors report their experience in preoperative examinations; they discuss some surgical techniques and describe their system of patient control. Based upon their experience, conservation of the organ is indicated in those cases where radical surgical removal is possible.

What is the place of antrectomy with Roux-en-Y in the treatment of reflux disease? Experience with 83 total duodenal diversions

Antrectomy with Roux-en-Y gastrojejunostomy was performed in 83 patients with "complicated" forms of peptic esophagitis. The esophagitis was considered complicated either because of the severity of the lesions (stricture, brachyesophagus, or endobrachyesophagus) or because of postoperative conditions after one or more previous operations (Heller's myotomy, esophagogastric resections, or hiatal hernia repair). A standard procedure was performed in 56 patients while technical adjustments were required for 27 patients who had previously undergone surgery. Two patients died from pulmonary embolism. Early postoperative complications occurred in 11% of patients. Healing of esophagitis was observed for all the patients treated with the standard procedures. Six partial regressions and 1 complete regression of Barrett's mucosa were observed. Digestive sequellae were minor and decreased with time. Assessment of pH and small bowel manometry showed that the reflux was controlled and no small bowel motility disturbance was observed when the standard technique was used including a small gastric resection. The main digestive sequellae, including lack of healing of esophagitis, dumping syndrome, and gastrojejunal anastomotic ulcer, occurred when a two-thirds gastrectomy was performed in order to avoid vagotomy.

Total duodenal diversion in patients with previous gastric surgery

Total duodenal diversion (TDD) was performed in 19 patients with severe post-gastric surgery symptoms. Previous operations were truncal vagotomy associated with pyloroplasty or antrectomy (n = 6), proximal esophagogastrectomy (n = 8) or total gastrectomy (n = 5). Technical adjustments to the standard procedure (truncal vagotomy, antrectomy and gastrojejunal anastomosis using a 70 cm Roux-en-Y loop) were required. There were no postoperative deaths, no anastomotic leakage or anastomotic ulceration. The main symptoms were eliminated, and endoscopic gastritis and esophagitis healed in all patients. Heartburn and bilious vomiting ceased in all patients, but in five out of 14 patients with a residual stomach some symptoms persisted. TDD proved a safe and effective treatment of disabling symptoms following gastric surgery.

Intrahepatic recurrence after resection of hepatocellular carcinoma complicating cirrhosis

To determine whether a careful evaluation of tumor extension by preoperative computed tomography scan after intra-arterial injection of ultrafluid lipiodol and by intraoperative ultrasound examination reduced the recurrence rate of hepatocellular carcinoma after resection, a series of 47 cirrhotic patients with a single tumor operated on from 1984 was studied. Alphafetoprotein level was less than 100 ng/mL in 26 patients (55%), size of the tumor was less than 5 cm in 28 patients (59%), and capsule was present in 30 patients (63%). The resection was performed with free margin measuring 1 cm or more. The overall cumulative survival rates at 3 and 5 years were 35% and 17%, respectively. Intrahepatic recurrence was observed in 28 patients (60%), located less than 2 cm from the resection margin in only four patients. The cumulative intrahepatic recurrence rate at 3 years was 81% and was significantly higher in patients with tumor greater than or equal to 5 cm and in patients with preoperative alphafetoprotein level of greater than or equal to 100 ng/mL. In this series the cumulative intrahepatic recurrence rate at 5 years was 100%. This high recurrence rate after resection, even with careful evaluation of tumor extension, indicates that liver transplantation might be envisaged for the treatment of cirrhotic patients with resectable hepatocellular carcinoma.

Mechanical sutures in perforation of the thoracic esophagus as a safe procedure in patients seen late

Between 1976 and 1988, we treated 13 perforations of the thoracic esophagus, excluding ruptured carcinoma and intraoperative wounds, by mechanical sutures without exclusion. The delay between perforation and treatment ranged from eight to 168 hours, more than 24 hours in 11. The length of perforation was 0.5 to 15.0 centimeters. Suture was covered with a flap in ten instances; an antireflux procedure was associated with five instances. No digestive ostomies were performed. There was one death; a patient who was comatose upon arrival. The results of this small series suggest that myotomy exposing the mucosa and a flap are two essential elements of the technique; perforations of less than 6 centimeters, even when seen late, may be treated by primary surgical closure.

Staging of esophageal carcinoma: comparison of results with endoscopic sonography and CT

We compared the results of endoscopic sonography and CT in the preoperative staging of 46 patients with esophageal carcinoma studied prospectively. All patients had surgery and 44 had pathologic examination of the mediastinal and celiac lymph nodes. The results of CT and endoscopic sonography were compared with surgical and pathologic findings. A total of 51 tumors were found in 46 patients. Sonographic estimation of tumor extension through the different layers of the esophagus was correct in 37 (73%) of all 51 tumors and in 22 (85%) of the 26 tumors in which the examination was complete. The echoendoscope (13-mm diameter) could not pass through the tumor in 23 cases (50%). Infiltration to adjacent organs was found in 15 cases at surgery. In four of these 15, the extension was detected by CT; in seven of the 15 cases, it was detected by sonography. False-negative determination of tumor extension occurred with endoscopic sonography in patients with stenotic tumor. There were no false-positive results with either CT or endoscopic sonography. For detection of mediastinal lymph-node involvement, the sensitivity of CT was 48%. The sensitivity of sonography was 50% if metastatic nodes unexplored by sonography were included, or 84% if only cases in which stenosis was passed were considered. Statistical comparison revealed that sonography was superior to CT for the detection of metastases to lymph nodes. CT and endoscopic sonography provide complementary information. When the echoendoscope can be maneuvered past the tumor, sonography can be used accurately to define extension through the layers of the esophagus, extension to the adjacent organs, and involvement of the lymph nodes. When the tumor cannot be passed by the echoendoscope, CT is superior to sonography for detection of mediastinal extension.

Four hundred esophageal anastomoses with a stapler

Four-hundred esophageal anastomoses were performed with a stapler in the Department of Digestive Surgery, Hospital Beaujon in Paris, in a six year period. The experience of the 14 different surgeons in esophageal surgery was very uneven (zero to 25 years). Two-hundred and sixty-eight esophagogastrostomies (220 in the chest and 48 in the neck), 83 esophagojejunostomies and 49 esophagocolostomies were done. The overall mortality rate was 9.2%, three per cent owing to leaks. The average incidence of leakage was 7% falling to 5.5% if cervical anastomoses were excluded. The incidence of stenoses was 8%. Several points which might account for problems are discussed. Stapled anastomoses seem to reduce the mortality and the morbidity rates of esophageal anastomoses, especially for surgeons with no experience in esophageal surgery.

[Experience with the use of the CO2 laser in surgical operations of the renal parenchyma]

The CO2 laser was used successfully for surgery in 43 nephrologic patients. Surgical operations, making use of the CO2 laser take less time than those using conventional techniques, while the damage to renal parenchyma is not so great and the surgical field is dry owing to the sealing of the vessels.

Results of esophagogastrectomy for carcinoma in cirrhotic patients. A series of 23 consecutive patients

Esophagogastrectomy for carcinoma of the esophagus or cardia has been performed in 23 patients with histologically proven hepatic cirrhosis. All but two patients were classified as Child's class A and all but three had a prothrombin time over 60% of normal values. Twenty-two esophagogastrostomies were performed through a separate abdominal and right thoracic approach in 15 patients, a left thoracoabdominal approach in five patients, and without thoracotomy in two patients. One patient had a colon interposition. Six patients died after operation (26%) as a result of anastomotic leakage in two patients, hepatorenal in three patients and portal thrombosis in one patient. The type of procedure did not influence mortality. The most common postoperative complication was the development of ascites (65%), and when associated with hepatorenal syndrome there was a significant mortality (p less than 0.05). Sepsis was present in the terminal stages of all nonsurvivors. A prothrombin time less than or equal to 60% of normal values was the only significant preoperative predictive factor of mortality, with none of the three patients surviving below this level (p less than 0.05). It is concluded that the presence of cirrhosis is not a contraindication to esophagogastrectomy for carcinoma when curative resection can be undertaken. Hepatic reserve is the determinant factor of operative prognosis. Operative risk is acceptable if patients are classified as Child's class A and prothrombin time is over 60% of normal values. Operation should be delayed when acute alcoholic hepatitis is present. Intraoperative discovery of cirrhosis is not a contraindication to resection where the above criteria are met. This strict selection allows one to anticipate a lower mortality rate.

[pH and the bacteriology of gastroplasties after esogastric resection]

A study of pH of digestive fluid in 24 patients six days after esophagogastric resection (EGR) showed conservation of acidity (pH: 3 or less) in one-thirds of cases. Immediate postoperative course was invariable with respect to incidence of pneumopathy and fistulae. Fungal infection is almost a constant finding in digestive grafts together with microbial pullulation, with a linear relation to pH. Ecology of germs was that of digestive flora of patients with obstruction, selected by the antibiotic cover administered. Group D streptococci and Gram negative bacilli were usually resistant to cephalosporins. Regurgitation pneumopathy therefore requires modification of antibiotic therapy and possible antifungal treatment. When functional disturbance is provoked by EGR, as for example a reflux syndrome; only those patients (1/3) with a pH of 3 or less can obtain relief from treatment with antacids.

Prevention of coagulopathy after placement of peritoneovenous shunt with replacement of ascitic fluid by normal saline solution

Consumptive coagulopathy may complicate the early postoperative course of peritoneovenous shunting and be responsible for diffuse bleeding or even death. Since this complications has been related to procoagulant substances in ascitic fluid getting access to the systemic circulation, it was demonstrated that the replacement of the ascitic fluid by normal saline solution during shunt insertion decreases the prevalence and severity of postoperative coagulopathy.

[Pancreatic cystadenoma: diagnostic value of ultrasonics and x-ray computed tomography]

We report six cases of pancreatic cystadenoma (three mucinous cysts, three microcystic adenomas). All patients were women. The mean age at the time of diagnosis was 50 years (with a range from 24 to 70 years). The mean age of patients having mucinous cysts (36.6 years) was lower than that of patients having microcystic adenomas (63.3 years). Abdominal pain was the first symptom in five patients. A palpable abdominal mass was found in three cases. The type of the tumor was demonstrated by ultrasonography and computed tomography and was confirmed by laparotomy in five cases. The tumors involved the body and tail of the pancreas. A distal pancreatectomy was performed in five cases, with a splenectomy in four cases. The post-operative course was uneventful. One patient was not operated. The histological examination of the three mucinous cysts showed benign tumors. This study emphasizes the usefulness of ultrasonography and computed tomography for the diagnosis of pancreatic cystadenomas. Surgical therapy is mandatory for mucinous cysts because of their potential malignancy, but a careful follow-up might be proposed for poor-risk patients having a microcyst adenoma, since this tumor is benign.

[Peroperative echotomography in the surgery of liver tumors]

Intra-operative ultrasonography was performed in 10 patients with apparently single malignant tumours of the liver without invasion of the portal or hepatic veins. Five patients had hepatocellular carcinoma associated with cirrhosis and 5 had a secondary liver cancer. At laparotomy other tumoral lesions in 3 cases, portal vein thrombosis in 2 cases and invasion of the left hepatic vein in 1 case were detected by ultrasonography. In 2 patients deep intra-hepatic tumours less than 2 cm in diameter, which were neither visible nor palpable, were also detected by this method. As a result of the examination, subsegmental resection was carried out in 3 cases and hepatic lobectomy in 2 cases. Intra-operative ultrasonography therefore is a useful method to locate invisible tumours and vascular structures, thus preventing vascular injuries during the operation, facilitating limited tumoral resections and generally improving prognosis in patients operated upon for malignant hepatic tumours.

[Mechanical anastomoses with the ILS stapler in surgery of the esophagus. 73 cases]

The authors report on their experience of 200 anastomoses of the oesophagus, 73 of which were performed with the ILS stapler. They describe the instrument and the way it should be used and insist on the check-ups required to make sure that the anastomosis is leak-proof. The results are reviewed by category of anastomosis (with the stomach, jejunum or colon). In view of its advantages and notably its safety, this type of instrument deserves to be widely used.

[Severe peptic esophagitis. Treatment by total duodenal diversion]

Total duodenal bypass, as described by Holt and Large and by Herrington consists of antrectomy with Y-loop gastro-jejunal anastomosis and total vagotomy. It is performed in patients with severe oesophagitis for which oesophageal resection often proves inadequate. It applies not only to acid reflux oesophagitis but to oesophagitis caused by alkaline or mixed reflux, the severity of which has been emphasized in numerous publications. This technique was used in 12 patients operated upon for severe oesophagitis consecutive to oesophageal resection or to Heller's operation for megaoesophagus or after failure of conservative treatment of peptic oesophagitis. Seven patients benefited from the operation performed by first-intention. Total duodenal bypass was considered indicated in severe peptic stenosis (impassable with an 11 mm fiberoscope) or in severe oesophagitis with moderate stenosis (passable with an 11 mm fiberoscope) or in severe non-stenotic oesophagitis on brady--or endobradyoesophagus. The favourable results obtained, based on clinical, radiological, endoscopic and pH-metric data, confirm that the technique is effective. The risk of anastomotic ulcer is avoided by truncular vagotomy, a procedure which must not be performed by the abdominal route in patients who previously underwent Heller's operation.

Surgical implications of malnutrition and immunodeficiency in patients with carcinoma of the oesophagus

A nutritional and immunological assessment was respectively performed in 75 patients with squamous cell carcinoma of the oesophagus. Abnormal nutritional and/or immunological values were present in 37 patients (50 per cent) and absent in 38. The tumour was resectable in 27 patients (71 per cent) with normal values and only in 11 among the 37 (29 per cent) with abnormal values (P less than 0.001). Complications after resection including death, pneumonia and anastomotic failure were not significantly different in the two groups of patients except for anastomotic failure. This observation suggests that reduction of surgical complications by preoperative nutritional therapy might be expected only in few patients with oesophageal carcinoma.