Hidrosadenoma of the anal canal: a case report with review of the literature.

Hidrosadenoma of the anal canal is an extremely rare tumour. Only nine cases with similar histologic structure have been described in the literature, most representing tumours resected from the anal or rectal mucosa. We present a case of anal hidrosadenoma with immunohistochemical staining features identifying it as a true sweat gland tumour.

[Hepatic metastases disclosed by laparoscopy and echographic laparoscopy. Impact of ultrasound-guided biopsy]. / Métastases hépatiques découvertes par laparpscopie et écho-laparoscopie. Impact de la biopsie échoguidée.

UNLABELLED: The aim of this prospective study was to study the impact of biopsies of liver metastases guided by laparoscopic ultrasound (LUS) and to evaluate various biopsy techniques. MATERIAL AND METHODS: Laparoscopy with LUS was performed on 18 consecutive patients with liver metastases considered to be surgically curable. Any new liver lesion which could lead to a therapeutic modification was biopsied, with a forceps or guided by LUS using four different techniques. RESULTS: Of 17 patients successfully examined, a biopsy was indicated in 12 cases (71%), extension of the surgical procedure was decided in four cases (24%), and laparotomy was avoided in six cases (35%). The preoperative staging was correct in 15 stages (88%) and incorrect in two cases (12%). The positioning of the puncture needle in the axis of the scanning plane by "free hand" or in association with an abdominal transducer was effective, without complications. CONCLUSION: Any liver lesion discovered by LUS which could lead to a modification or abstention of surgery should be biopsied, with LUS-guidance in the case of deep lesions. However, an optimal and universal guiding system for LUS-probes, has not yet been developed.

Peptic ulcer complications and how to treat them.

The main complications to peptic ulcer are perforation, stenosis and bleeding. Diagnosis and treatment are discussed with special reference to the principles of 1st Department, Kommunehospitalet, Copenhagen. The three main complications to peptic ulcer disease include perforation, stenosis and bleeding. The etiology to peptic ulcer disease and the pathogenesis of ulcer disease complications are still poorly understood, although an imbalance between mucosa-protecting and -destructing factors seems to be of major importance. However, the introduction of neither H2 receptor antagonists nor the so-called mucosaprotection agents during the seventies and eighties significantly have reduced the frequency of peptic ulcer disease or the frequency of its complications (perforation 10 per cent, stenosis 10 per cent and bleeding 20 per cent of patients with peptic ulcer disease. The unchanged frequency of operation for peptic ulcer complications was confirmed in a recent study by A. Christensen et al. 1987. Their data suggested unchanged frequency of operations for ulcer complications prior to and following the introduction of H2 receptor antagonists (Fig. I and II) in a well defined population in Copenhagen.

Uroflowmetry in asymptomatic elderly males.

Uroflowmetry is important in the evaluation of prostatism. We have investigated 93 men, selected at random from the National Register, who had no subjective voiding problems but who fell within the appropriate age range. The sample was representative of the male metropolitan population. Uroflowmetry was carried out and the data are presented graphically in nomograms where the Q max/volume, Q average/volume and Q max time/volume relations are given. Flow variables were evaluated to delineate possible correlations to age. It was found that the median Q max decreased from 18.5 ml/s at the age of 50 years to 6.5 ml/s at 80 years. Only one-third of the group had a Q max exceeding 15 ml/s. The median voided volume was 208 ml. Half of the subjects voided less than 200 ml and one-third less than 150 ml.

Some clinical aspects of uroflowmetry in elderly males. A population survey.

A random sample of 200 males aged 50 years or more was selected from the National Register in order to investigate various aspects of spontaneous uroflowmetry and to estimate the frequency of prostatism and symptoms of lower urinary tract dysfunction. All in all the data from 112 persons were analysed. The prevalence of prostatism was found to be 17% (95% confidence limits 11-26%), while 88% (95% confidence limits 83-95%) experienced various degrees of symptoms. Only few associations between single symptoms and uroflowmetry variables were demonstrated. However, statistically significant correlations were revealed between obstructive and total symptom scores on one hand and maximum and average flow rates on the other hand. As the correlations were modest and a considerable overlap of uroflow variables in persons with and without prostatism were proved, the diagnostic specificity and sensitivity of maximum flow rate as well as other uroflow variables were low in the screening for prostatism. In conclusion uroflowmetry appears inefficient to confirm a clinical impression of prostatism.

Preoperative haemodynamic evaluation of patients submitted for renal artery stenosis.

The ECG, chest x-ray and haemodynamic parameters were investigated preoperatively in 19 patients subjected to surgery for renal artery stenosis (RAS) and in a control group comprising 19 normotensive patients subjected to other forms of major vascular surgery. Increased cardiac volume was demonstrated in 13 (68%) RAS patients and in two (11%) patients from the control group. Abnormal ECG (i.e. left ventricular hypertrophy or atrial fibrillation) was observed in 11 (58%) RAS patients and in one (5%) patient from the control group. In the RAS patients the following haemodynamic parameters were found to be statistically significantly increased, compared to the control group: systemic blood pressure, (systolic arterial pressure: +43%, diastolic arterial pressure: +38%, mean arterial pressure: +41%), pulmonary artery mean pressure (+64%), pulmonary capillary wedge pressure (+107%), heart rate (+15%), systemic vascular resistance (+27%), left ventricular minute work index (+46%) and right ventricular minute work index (+67%). The presence of increased cardiac volume and abnormal ECG were more closely related to the level of the pathologically increased pulmonary artery mean and wedge pressures than to the systemic blood pressure or central venous pressure. A preoperative haemodynamic evaluation is recommended to determine the degree of heart failure in RAS patients with: left ventricular hypertrophy and increased cardiac volume, or atrial fibrillation.

Haemodynamic effects of calcium chloride administered intravenously to patients with and without cardiac disease during neurolept anaesthesia.

During neurolept anaesthesia, calcium chloride (15 mg/kg) was administered intravenously to two different groups of patients undergoing vascular surgery on the abdominal aorta. The patients in group I all suffered from cardiac disease and were treated with digoxin, while the patients in group II had no cardiac symptoms. Cardiovascular measurements were made during steady-state anaesthesia. In group I, CaCl2 increased cardiac index (CI) significantly while systemic vascular resistance index (SVRI) remained unchanged. Mean arterial pressure (MAP) increased. In group II, both MAP and SVRI increased while CI remained unchanged. No significant changes in heart rate were observed and no arrhythmias occurred. It is concluded that CaCl2 administered intravenously is an effective means of improving cardiac function when it is depressed by anaesthesia, underlying cardiac disease, or both.

Haemodynamics in patients undergoing porto-caval shunt operations.

Haemodynamic parameters, including cardiac output, blood volume, and blood pressures in the systemic and pulmonary circulations, were followed in eight patients undergoing porto-caval shunt operations because of portal hypertension. Measurements were performed in the awake patients before premedication, during operation immediately before clamping of the portal vein, and immediately after opening of the porto-caval shunt. Further measurements were performed 2-4 h, and 22-26 h postoperatively. Preoperatively, cardiac index and blood volume were increased, whereas the blood pressures in the systemic and pulmonary circulations were within normal accepted limits. After opening the porto-caval shunt, increases in pulmonary arterial mean pressure of between 35 and 80% and in pulmonary capillary wedge pressure of between 40 and 200% were observed in the four patients in whom the pressure gradient between the caval vein and the portal vein was normalized, i.e. where a pressure gradient after opening the porto-caval shunt was measured between 0 and 0.67 kPa. Otherwise, the haemodynamic changes were only partly related to changes in the pressure gradient. The courses of the postoperative haemodynamic changes did not seem to be different from the courses in other categories of patients. The most important haemodynamic changes in patients undergoing porto-caval shunt operations seem to take place immediately after opening the shunt. To minimize the extent of changes in the pulmonary circulation, the shunt should be opened gradually.

Pre-operative exercise testing in patients suspected of arteriosclerotic heart disease: methods, risks and reproducibility.

In order to estimate the value of haemodynamic parameters in assessing impaired left ventricular function the reproducibility of haemodynamic measurements were investigated at rest and during supine exercise on a bicycle ergometer in fifty-one patients suspected of arteriosclerotic heart disease by means of a Swan-Ganz pulmonary artery thermodilution catheter and a radial artery catheter. Furthermore the minimal significant (P less than 0.05) change from rest to exercise was determined. In conclusion we found that haemodynamic measurements during exercise testing estimate left ventricular function in a safe and reproducible manner. A rise in pulmonary capillary wedge pressure (PCWP) of only 0.9 kPa during exercise was significant, whereas changes in stroke volume index (SVI) were considered significant only when exceeding 9 ml/m2.

Prophylactic digitalization preoperatively of patients with arteriosclerotic heart disease.

This study was undertaken to investigate the hemodynamic effect of prophylactic digitalization before major surgical procedures. Sixteen patients, all admitted for an elective vascular operation for arteriosclerotic disease and all with impaired left ventricular function, were investigated. In half of the patients, digitalis was given before the operation, the other half of the patients served as the control study. The measured parameters were pulmonary artery mean pressure, pulmonary capillary wedge pressure, central venous pressure, mean arterial blood pressure, heart rate, cardiac output, blood volume and arterial, as well as venous, oxygen content. Preoperatively, before digitalization, no significant differences were noted between the two groups at rest and during exercise. Before anesthesia and postoperatively, those given digitalis had improved cardiac function. Those in both groups, however, had a normal hemodynamic response to the surgical trauma. In this study, a definite answer is not provided concerning the usefulness of prophylactic digitalization but an increase in the ability of the digitalized heart to withstand the imposition of a pressure load postoperatively is suggested.

Acute postoperative digitalization of patients with arteriosclerotic heart disease after major surgery. A randomized haemodynamic study and proposal for therapy.

Twenty patients with impaired left ventricular function during exercise, who underwent major vascular surgery for arteriosclerotic disease, were randomly digitalized in the immediate postoperative period. All patients had a smooth postoperative course. Haemodynamic measurements showed improved left ventricular function in those who received digitalis, since 60 min after full digitalization the digitalized patients had a highly significant decrease in pulmonary capillary wedge pressure (PCWP) with unchanged stroke volume index (SVI) and left ventricular stroke work index (LVSWI). The same improvement in cardiac function was present the next morning. The present study provides haemodynamic data in support of clinical studies showing a beneficial effect of prophylactic digitalization in surgical patients with clinical signs of arteriosclerotic heart disease, though not in overt failure.

Digitalis induced haemodynamic changes in patients with vascular disease during a preoperative exercise test.

Haemodynamic studies at rest and during exercise before and after digitalization were carried out in 11 patients with vascular disease. Haemodynamic parameters at rest were within normal limits except for one patient, who had a cardiac index (CI) below 2.51/min/m2. During exercise 7 of the patients showed impaired left ventricular function. In the resting patients digitalization produced a significant decrease in pulmonary capillary wedge pressure (PCWP) and an increase of approximately 15% in left ventricular stroke work index (LVSWI) and total oxygen consumption. Myocardial oxygen consumption seemed unchanged as no significant changes were found in the product of mean arterial blood pressure and heart rate. After digitalization 6 of 7 patients with impaired left ventricular function showed improved haemodynamic response to exercise while the 4 patients with normal left ventricular function had an unchanged haemodynamic response.

Thin fluid-filled catheters for more accurate determination of pressures and their time derivatives.

A catheter-transducer system consisting of a thin fluid-filled teflon catheter and a transducer with a low displacement volume is presented. The thin catheter is especially suited for registration of pressure and the time derivatives in small caliber vessels. From theoretical considerations it is concluded that the best way of obtaining a correct damping ratio in the range of 0.6-0.7 in the system is to adjust the diameter of the catheter empirically to the characteristics of the transducer. Residual gas bubbles are a problem in most catheter-transducer systems, but due to the design of the catheter and to a special flushing method, reproducible results are rapidly and easily obtained. The damping ratio of the system is 0.6 and the band width is 35 Hz. In repeated experiments an identical influence of the temperature on the damping ratio could be demonstrated.

Measurement of central hemodynamic parameters during preoperative exercise testing in patients suspected of arteriosclerotic heart disease. Value in predicting postoperative cardiac complications.

The object of this study was to investigate whether the history, general clinical examination, chest radiography, ECG, and preoperative exercise haemodynamics afforded a basis for pointing out individuals who were likely to develop postoperative cardiac complications. Particular emphasis was placed on whether haemodynamic testing yielded a major contribution to predicting such complications. 48 patients carried out preoperative exercise tests. The hemodynamic parameters were obtained by using a Swan-Ganz pulmonary artery thermodilution catheter. The clinical examinations, laboratory findings, and haemodynamic parameters were assessed by comparing the results with the outcome of the postoperative course. In assessing the results, the same diagnostic accuracy was found for the history (0.56-0.65), laboratory findings (0.50-0.65), and hemodynamic parameters (0.44-0.71). By combining the various parameters, however, it was possible to achieve a very high sensitivity (0.86) as regards the prediction of postoperative cardiac complications, but this was at the cost of many false positives and consequently a low accuracy (0.46). We conclude that haemodynamic exercise testing is not better than conventional means of prediction individual patient's postoperative cardiac complications.

Red cell 2.3-diphosphoglycerate in pregnancy.

In normal, primigravidae red cell 2.3-diphosphoglycerate (2.3-DPG) concentration was found to be increased significantly from the third month of pregnancy. The 2.3-DPG concentration remained elevated throughout pregnancy. Increase in the 2.3-DPG concentration leads to a decrease in the oxygen affinity of the maternal red cells. The combination of low pCO2 and low oxygen affinity of the maternal blood facilitates the transport of oxygen as well as that of carbon dioxide across the placenta. The weight of the delivered children was not significantly correlated to the 2.3-DPG changes, and no significant variation of the measured variables could be detected in 9 women with abnormal pregnancies.

Reduced myocardial blood flow in acute and chronic digitalization.

The myocardial blood flow was measured by the 133Xenon disappearance curve from the left ventricular wall following an injection of 133Xenon in the left coronary artery in 8 dogs without digoxin pretreatment and in 8 chronically digitalized dogs. The myocardial blood flow was significantly less (30%) in the digitalized dogs than in the dogs without pretreatment. In the digitalized dogs as well as in those without pretreatment an intravenous injection of digoxin resulted in a further significant decrease of the myocardial blood flow of about 20% and a significant increase of the coronary vascular resistance. The reduced myocardial blood flow both during acute and chronic digitalization is beleived to be of clinical importance.

Hemodynamic observation in relation to extensive surgical treatment of patients with increased operative risk.

In 25 patients, considered high surgical risks according to clinical criteria, systemic and pulmonary hemodynamic parameters were monitored using a flow-directed pulmonary arterial thermodilution catheter before, during and after major vascular surgery. During and after the operation, hemodynamic complications were observed in 13 patients. The following conditions were dealt with: hypovolemia, increased systemic vascular resistance, and left ventricular failure in hypervolemia and in normovolemia. Tachy-arrhythmias seen in six of the patients were associated with left ventricular failure, hypovolemia or normal hemodynamics. Operation for renovascular hypertension and thoracolaparotomy carried the highest risk. Two of the patients died from primarily surgical complications.

Postoperative haemodynamics in patients with and without cardiac disease.

The cardiovascular reaction to primarily major vascular surgery was examined in 39 patients without cardiac disease and in 11 patients with cardiac disease. In the immediate postoperative period (24 h), patients without cardiac disease showed significant increases in heart rate and cardiac index and a decreased blood volume. The central pressures were increased during the first postoperative hour. Systemic blood pressure and vascular resistance remained unchanged, or decreased slightly. Postoperative haemodynamics in patients with cardiac disease followed the same trends as in normal patients; there were, however, no significant changes in cardiac index or central pressures, and in general the cardiovascular reaction to operation was less conspicuous than in the group of normal patients. The preoperative haemodynamic differences between the two groups were diminished in the immediate postoperative period because therapy could be guided by measuring central pressures.

Central haemodynamics during induction of neurolept anaesthesia in patients with arteriosclerotic heart disease.

The haemodynamic changes occurring during induction of neurolept anaesthesia and intubation in patients with reduced cardiac reserve were compared with the haemodynamic changes observed prior to operation during the stress of moderate physical exercise in the same patients. Anaesthesia consisted of droperidolum NFN (Dehydrobenzperidol), fentanyli citras NFN (Haldid) and nitrous oxide-oxygen with suxamethonium for intubation. The haemodynamic parameters measured were mean arterial blood pressure, central venous pressure, pulmonary artery mean pressure, pulmonary capillary wedge pressure and cardiac output. Blood volume was also measured, as were arterial blood-gas tensions and pH. The haemodynamic changes observed during induction with intubation were significantly smaller than those observed preoperatively during exercise.