Bacterial Translocation and Prognosis of Critically Ill Patients

PURPOSE: To identify Bacterial translocation (BT) from the gut to the blood in the critically ill patients by using the polymerase chain reaction (PCR) to confirm the sensitivity of PCR in the detection of intestinal bacterial deoxyribonucleic acid (DNA) in human blood. Further, to determine the relationship between the identification of BT and the prognosis of these patients. METHODS: The oligonucleotide primers used to amplify bacterial DNA from whole blood were the beta-galactosidase (BG) gene of E. coli, DNA coding for 16S ribosomal RNA (16S rRNA), and the glutamine synthase gene of Bacteroides fragilis (BFR). DNA was extracted from the blood of 45 cases of critically ill patients and 10 controls. PCR techniques were used to amplify the genes from E. coli, Bacteroides fragilis, and a region of 16S ribosomal RNA found in many gram-negative and positive bacteria. RESULTS: Bacterial DNA genes were not detected in any of the controls, but were found all in 6 cases of patients with positive blood cultures. Of the 39 cases with no growth in their blood culture, 11 cases in BG and BFR, and 13 cases in 16S rRNA had positive findings in bacterial DNA PCR. Fifteen cases (33%) in BG, 19 cases (42%) in BFR, and 16 cases (35.5%) in 16S rRNA of the critically ill patients had detectable bacterial DNA in their blood. Of those with a positive PCR, MOF developed in 11 cases (57.9%) and of these, 10 subsequently died of MOF. One case (3.8%) in the negative PCR was developed and died of MOF. Patients having positive translocated bacterial DNA had a worse prognosis than the group with a negative DNA. CONCLUSION: In order to confirm BT, the PCR method for detecting bacterial DNA in the blood of critically ill patients is more sensitive than blood cultures. BT from the gut can be a major factor in the development of multiple organ failures in critically ill patients. Therefore, early detection of BT with PCR can play a major role in the treatment of critically ill patients.

Diagnostic Efficacy of Diagnostic Scoring System and Ultrasonographic Examination in Acute Appendicitis: Retrospective and Prospective Study

BACKGROUND: As preoperative diagnosis of acute appendicitis is sometimes difficult, various diagnostic modalities are used for accurate diagnosis. The aims of this study were to define the diagnostic parameters of ultrasonographic (USG) examination and to evaluate the diagnostic efficacy of clinical scoring system in the patients with suspected acute appendicitis. METHODS: A consecutive 130 patients, admitted under impression of acute appendicitis, were underwent routine ultrasonographic examination (from December 1994 to July 1995), and analyzed the accuracy rate of ultrasonographic examination. Already applied diagnostic score (age> or =50 yrs; 1.5, steady pain in right low quadrant; 2, pain relocation to RLQ; 2, tenderness in RLQ; 2.5, rebound tenderness; 2.5, rigidity; 1, Rovsing sign; 2, Rosenstein sign; 2, and leukocyte> or =10,000/mm3; 1.5) in these same patients also analyzed for correlation with final diagnosis and ultrasonographic examination retrospectively. In the second prospective study (from August 1995 to December 1995), 102 patients were enrolled, and diagnostic scoring system was evaluated for the applicability in diagnosis of appendicitis. RESULTS: Of ninety-nine operated patients (clinical and sonography suggested appendicitis), 93 patients (94%) were confirmed as a acute appendicitis, and remaining 6 patients (6%) revealed mesenteric lymphadenitis and 31 patients were discharged without operation. Accuracy of the ultrasonographic examination was 91% of sensitivity, 86% of specificity, and 90% of accuracy rate, respectively. Diagnostic score (>10 point) of these patients revealed also a sensitive parameter in diagnosis of acute appendicitis with 94% of sensitivity, 71% of specificity, and 86% of accuracy rate. In the second prospective study, 85 patients (97% of 88 cases) with diagnostic score over 10 points had been confirmed as a acute appendicitis and only two cases (14% of 14 cases) having below 10 points in diagnostic score needed appendectomy. Over 10 ponits of diagnostic score in diagnosis of appendicitis revealed 98% of sensitivity, 80% of specificity, 96.5% of positive predict value, 85.7% of negative predict value, and 95% of accuracy rate, and relative risk 4.89 (p=0.000). Using multivariate analysis, age (> or =50 years),diagnostic score (> or =10), diameter of appendix (> or =6 mm) in USG, and Rovosing sign were significant independent factors in the diagnosis of acute appendicitis. CONCLUSION: Our results suggest that ultrasonographic examination is necessary in patients with low diagnostic score (10) can be operated without ultrasonographic examination.

The Role of Preoperative Fine Needle Aspiration Cytology (FNAC) in Differential Diagnosis of Thyroid Nodules

BACKGROUND: Fine Needle Aspiration Cytology (FNAC) is widely accepted as the most accurate procedure to differentiate malignant from benign thyroid nodules. It is a simple, safe, and inexpensive procedure, and the accuracy of FNAC is relatively high; however, its success usually depends upon the skill in using the aspiration technique and the experience and skill of the cytologist. The authors confirmed the diagnostic value of preoperative FNAC in differential diagnosis of thyroid nodules treated by the surgical resection. METHODS: Three hundred fifty specimens were taken in the Department of Surgery, Inje University College of Medicine, from July 1990 to June 1996. Fifty-one males and 299 females with ages ranging from 11 to 73 years were enrolled. The cytology of FNAC was compared to the final histologic diagnosis. RESULTS: The number of inadequate smears (or sampling error) was 15.7%. Preoperative cytologic diagnoses was consisted of 198 cases of benign disease (92 cases of nodular goiters, 96 cases of follicular lesion types III, and 10 cases of thyroiditis), 12 cases of highly suspicious malignant lesions (follicular lesions type II), and 85 cases of malignant disease (71 cases of papillary carcinomas and 14 cases of follicular lesions type I). Histologic diagnoses consisted of nodular goiters in 116 cases, adenomas in 66 cases, thyroiditis in 9 cases, papillary carcinomas in 84 cases, and follicular carcinomas in 20 cases. These results has an 84.6% sensitivity, a 95.2% specificity, a 15.3% false negative rate, and a 4.7% false positive rate. In the fifty-five cases of inadequate sampling, 13 cases (23.6%) were malignant lesions histologically. In the 16 cases proven as false negative, nine cases were papillary carcinomas, and 7 cases were follicular carcinomas histologically. Thirteen cases (16.1% of 27 cases of cystic lesions) of cystic nodules revealed malignant neoplasms histologically. CONCLUSION: FNAC is a single, useful diagnostic procedure for the initial screening for malignancy in thyroid nodules. Performing repeated aspiration in cystic nodules and clinically suspicious cases could reduce inadeguate sampling and the false negative rate.

Clinical Significance of Intrahepatic Biliary Stricture: The Impact on Efficacy of Hepatic Resection in Intrahepatic Stones

BACKGROUND: In the Far East, it is well known that hepatic resection is a best form of treatment for complicated intrahepatic stones (IHS). However, many investigators have reported that the associated intrahepatic biliary stricture is the main cause of treatment failure, requiring additional management because of recurrent cholangitis. PURPOSE: A retrospective comparative study was undertaken to clarify the long term efficacy of hepatic resection in IHS and to investigate the clinical significance of intrahepatic biliary stricture affected on treatment failure after hepatic resection. Patient and METHOD: The clinical records of 44 among 51 consecutive patients with symptomatic IHS who underwent hepatic segmentectomy or lobectomy between July 1986 and October 1996 were reviewed. We excluded 7 patients from study group because of postoperative death or incomplete follow- up. Patients were divided into two study groups: group A with intrahepatic biliary stricture (n=28) and group B without stricture (n=16). Residual or recurrent stones, recurrence of intrahepatic biliary stricture, late cholangitis, and final outcomes were analyzed and compared statistically between group A and B. Patients were followed up for a median duration of 65 months after hepatectomy. RESULTS: The overall incidence of residual or recurrent stones were 36% and 11%, respectively. The initial treatment failure rate was 50% in group A and 31% in group B. Intrahepatic biliary stricture was recurred in 46% of group A, but in none of group B (P=0.001). More than two thirds of restrictures were identified on the primary site. The incidence of late cholangitis was higher in group A (54%) than in group B (6%)(p=0.002). The late cholangitis was severe, recurrent and related to stones and strictures in 11 of the 15patients in group A. Twelve patients (ten in group A and two in group B) needed additional secondary multiple procedures at a median of 12 months after hepatectomy. These consisted of percutaneous fluoroscopic stone retrieval (n=6), postoperative cholangioscopy (POC) or percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL)(n=3), balloon dilatation (n=7)choledochotomy (n=3), S4 segmentectomy (n=1), Sphincteroplasty (n=1), drainage of the delayed subphrenic or liver abscess (n=2), and repair of prolonged biliary fistula (n=1). The final outcomes after hepatectomy with or without secondary management were good in 80%, fair in 16%, and poor in 4% of the cases. CONCLUSION: The majority of the recurrent cholangitis after hepatectomy in IHS were related to recurrent intrahepatic ductal strictures. Therefore, hepatic resection should be included the strictured duct. However, with hepatectomy alone, it is difficult to clean the IHS and relieve the ductal strictures completely, particularly in cases of bilateral IHS, so a perioperative team approaches, including both radiologic and cholangioscopic interventions, should be used for effective management of IHS.

Ultrasonographic Measurement of the Diameter of Internal Inguinal Ring and Prediction of Bilaterality in Pediatric Inguinal Hernia

BACKGROUND: It has been reported that bilateral pediatric inguinal hernias (PIH) are around 10% and that a late contralateral herniorrhapy is needed in up to 34% of ipsilateral operations. However, clinical prediction of the contralateral patent processus vaginalis (PPV) is difficult. The aims of this study were to measure the mean diameter of the internal inguinal ring (IIR) of the PIH at rest and during straining and to define the diagnostic criterion for positive contralateral PIH (or PPV) by using ultrasonography (USG). METHODS: The diameters of both ipsilateral and contralateral IIRs at rest and during straining were measured preoperatively by USG in 104 consecutive pediatric patients (75 male, 29 female; mean age of 3 years) who had undergone an ipsilateral herniorrhaphy with contralateral exploration from March 1997 to December 1997. Fifty-seven right inguinal hernias (RIH), 43 left inguinal hernias (LIH), and 4 bilateral inguinal hernias were enrolled. The contralateral PPV was defined as a sac greater than 3 mm in diameter and longer than 2 cm in length measured intraoperatively. Statistical analysis was performed by using the t-test and the chi-square test. RESULTS: Contralateral exploration showed positive PPV in 44% of RIH and 47% of LIH (p>0.05). In RIH, the mean diameter of right IIR (RIIR) was wider than that of left IIR (LIIR) (5.02+/-0.27 mm vs 2.94+/-0.12 mm at rest and 7.50+/-0.52 mm vs. 3.82+/-0.23 mm during straining, p<0.01), and the difference in diameters between straining and rest were also significant (2.38+/-0.37 mm in RIIR and 0.76+/-0.14 mm in LIIR, p<0.01). In LIH, the mean diameter of LIIR was wider than that of RIIR (4.59+/-0.27 mm vs. 3.13+/-0.19 mm at rest, 6.82+/-0.43 mm vs. 3.61+/-0.26 mm during straining, p<0.01). The diameter difference between straining and rest of LIIR and RIIR were also significant (2.17+/-0.28 mm in LIIR, 0.60+/-0.12 mm in RIIR, p<0.01). Cases of positive contralateral PPVs in RIH had significantly wider LIIRs than those of negative PPV (3.5+/-0.16 mm vs. 2.5+/-0.14 mm at rest and 4.70+/-0.32 mm vs. 2.97+/-0.20 mm during straining, p<0.01). The difference of diameter between strainingand rest of positive and negative PPVs were significant (1.16+/-0.25 mm and 0.38+/-0.09 mm, respectively, p<0.01). Cases of positive contralateral PPVs in LIH had wider RIIRs than those of negative PPV significantly (3.83+/-0.27 mm vs. 2.52+/-0.18 mm at rest and 4.58+/-0.38 mm vs. 2.68+/-0.19 mm during straining, p<0.01). The diameter difference between straining and rest of positive and negative PPVs was significant (0.93+/-0.21 mm and 0.3+/- 0.09 mm, respectively, p<0.05). CONCLUSION: In most negative PPVs, the diameter of the IIR did not exceed 3.0 mm. Therefore, contralateral IIR with diameters wider than 3.0 mm and diameters of difference more than 1.0 mm between straining and rest, as determined by using USG need to be explored.