Impaired postural stability after laparoscopic surgery.

BACKGROUND: Early postoperative mobilisation may reduce patient morbidity and improve hospital efficiency by accelerated discharge. The aim of this study was to measure postural stability early after laparoscopic surgery in order to assess how early it is safe to mobilise and discharge patients. METHODS: We included 25 women undergoing outpatient gynaecological laparoscopic surgery in the study. Patients received standardised anaesthesia with propofol, remifentanil and rocuronium. Postural stability was assessed preoperatively, at 30 min after tracheal extubation, and at discharge from the post-anaesthesia care unit using a force platform where sway area, mean sway and sway velocity were determined. The assessments were done with eyes closed and with eyes open. The primary outcome was the change in sway area with eyes closed 30 min after extubation. Data are reported as median (25-75% range). RESULTS: Three patients could not perform all the test's 30 min after extubation. Thirty minutes after extubation, sway area with eyes closed had increased significantly with 84 mm(2) (9-172, P = 0.011) and 108 mm(2) with eyes open (25-295, P = 0.0017). Median mean sway had also increased significantly 30 min postoperatively. No significant changes were found for sway velocity. We found no significant changes in mean sway, sway area or sway velocity at discharge from the post-anaesthesia care unit approximately 2 h after surgery. CONCLUSION: Postural stability was significantly impaired 30 min after outpatient gynaecological laparoscopic surgery. However, the postural stability was normalised at discharge from the post-anaesthesia care unit 2 h after surgery.

Minimal impairment in pulmonary function following laparoscopic surgery.

BACKGROUND: Pulmonary function may be impaired in connection with laparoscopic surgery, especially in the head-down body position, but the clinical importance has not been assessed in detail. The aim of this study was to assess pulmonary function after laparoscopic hysterectomy and laparoscopic cholecystectomy. We hypothesised that arterial oxygenation would be more impaired after hysterectomy performed in the head-down position than after cholecystectomy in the head-up position. METHODS: We included 60 women in this prospective, observational study. The patients underwent elective laparoscopic cholecystectomy in the 20° head-up position or hysterectomy in the 30° head-down position. The primary outcome was the difference between arterial oxygenation (PaO2 ) 2 h postoperatively and the preoperative value. Two hours and 24 h after surgery, pulmonary shunt and ventilation-perfusion mismatch were assessed by use of an automatic lung parameter estimation system. RESULTS: Two hours after surgery, the mean change from baseline in PaO2 was -0.65 kPa [95% confidence interval (CI) -3.5 to 3.4, P = 0.14] in the hysterectomy group and -0.22 kPa [95% CI -3.4 to 2.0, P = 0.12] in the cholecystectomy group (P = 0.88). Shunt was significantly greater in the cholecystectomy group 24 h after surgery compared to the hysterectomy group [4%, 95% CI 0 to 9 vs. 0%, 95% CI 0 to 7, P = 0.02]. CONCLUSIONS: Minimal impairment in pulmonary gas exchange was found after laparoscopic surgery. Pulmonary shunt was larger after laparoscopic cholecystectomy, but no clinically significant differences in postoperative pulmonary gas exchange or spirometry were found between laparoscopic hysterectomy and laparoscopic cholecystectomy.

Comparison between local anaesthesia with remifentanil and total intravenous anaesthesia for operative hysteroscopic procedures in day surgery.

BACKGROUND: This study aimed at comparing total i.v. anaesthesia (TIVA) with monitored anaesthesia care (MAC) during day-surgery operative hysteroscopy regarding: operation time, time to mobilization and discharge, and patient satisfaction. METHODS: Ninety-one healthy women were randomized to MAC with paracervical local anaesthesia and remifentanil or to TIVA with propofol and remifentanil. Time from arrival to leaving the operating theatre, time from arrival in the recovery room to mobilization and discharge readiness, and patient satisfaction with MAC and TIVA were observed. RESULTS: Time from arrival to leaving the operating theatre showed no significant difference between groups (P=0.6). The time to mobilization {MAC: 53 min [inter-quartile range (IQR) 40-83], TIVA: 69 min (IQR 52-96) (P=0.017)} and the total time from arrival to discharge readiness [MAC: 118 min (IQR 95-139), TIVA: 138 (IQR 120-158) (P=0.0009)] were significantly reduced for patients in the MAC group. More patients in the MAC group 45 (91.8%) than in the TIVA group 24 (64.9%) responded positively to the question: would you like to receive the same kind of anaesthesia for a similar procedure in the future? (P=0.003). CONCLUSIONS: Paracervical local anaesthesia combined with remifentanil is suitable for operative hysteroscopy in day surgery.

Hair removal in hirsute women with normal testosterone levels: a randomized controlled trial of long-pulsed diode laser vs. intense pulsed light.

BACKGROUND: Hirsutism is a common disorder in women of reproductive age, and androgen disturbances may aggravate the condition. Limited evidence exists regarding efficacy of hair removal in this specific population and no data are available for patients with verified normal testosterone levels. OBJECTIVES: To compare efficacy and safety of intense pulsed light (IPL) vs. long-pulsed diode laser (LPDL) in a well-defined group of hirsute women with normal testosterone levels. METHODS: Thirty-one hirsute women received six allocated split-face treatments with IPL (525-1200 nm; Palomar Starlux IPL system) and LPDL (810 nm; Asclepion MeDioStar XT diode laser). Testosterone levels were measured three times during the study period. Patients with intrinsically normal or medically normalized testosterone levels throughout the study were included in efficacy assessments (n = 23). Endpoints were reduction in hair counts assessed by blinded photoevaluations at baseline and 1, 3 and 6 months after final treatment, patient-evaluated reduction in hairiness, patient satisfaction, treatment-related pain and adverse effects. RESULTS: IPL and LPDL reduced hair counts significantly, with median reductions from baseline of 77%, 53% and 40% for IPL and 68%, 60% and 34% for LDPL at 1, 3 and 6 months, respectively. At 6 months follow-up, there was no significant difference between treatments in terms of hair reduction (P = 0·427), patient assessment of hairiness (P = 0·250) and patient satisfaction (P = 0·125). Pain scores were consistently higher for IPL [median 6, interquartile range (IQR) 4-7] than LPDL (median 3, IQR 2-5) (P < 0·001). CONCLUSION: Hirsute women with normal or medically normalized testosterone levels responded equally well to IPL and LPDL treatments of facial hairiness, but the efficacy declined over 6 months.

The human placenta from heavy smokers: evaluation of vasoactive peptides by immunohistochemistry.

The study aimed to demonstrate the expression of nitric oxide converting enzyme, nitric oxide synthase (e-NOS), and endothelin-1 (Et-1) in formalin-fixed paraffin-embedded placental tissue, and to demonstrate a difference in staining intensity between heavy smokers and non-smokers. Term placentas from pregnancies from otherwise healthy women smoking 15 or more cigarettes per day (heavy smokers) and term placentas from a matching group of non-smokers were included. The antibodies for Et-1 and e-NOS are recommended for cryostat sections. We evaluated the antibodies on paraffin-embedded tissue combined with the streptavidin-biotin-peroxidase technique. Et-1 and e-NOS were demonstrated in the placental vasculature, the trophoblast, and the amnion. A blinded comparative study showed no reproducible significant differences in the staining intensity of the antigen-antibody reaction to Et-1 and e-NOS between the two groups.

Vascular reactivity of the preplacental vasculature in Guinea pigs.

The functional correlates of structural remodelling of the preplacental arteries are not well known. We examined the responses of these vessels to vasoactive agents in guinea pigs at mid and late gestation, and attempted to relate them to changes in vessel structure. Segments were taken from the arcade artery, a mesometrial artery near its origin, and an artery near the placenta. They were mounted as rings in a myograph and concentration-response curves were obtained for U46619, endothelin-1 and arginine vasopressin. The vessel segments were then examined by histology and immunohistochemistry. Trophoblast was identified as immunopositive for cytokeratin, circular muscle stained positive for muscle actin and smooth muscle actin, and presumed myofibroblasts in the adventitial layer stained positive only for smooth muscle actin. At both gestational ages, arcade and mesometrial arteries had intact vessel walls. Midgestation placental arteries were characterized by partial or complete disruption of the internal elastic lamina and the presence of a large number of myofibroblasts and of periarterial trophoblast. In late pregnancy, the changes were more extensive, with almost complete dedifferentiation of the smooth muscle cells and trophoblast invasion of the adventitial layer. From midgestation to late gestation, the responses of placental arteries to U46619, endothelin-1 and arginine vasopressin, normalized to the response to K(+)depolarization, were significantly reduced. This suggests that the extensive changes in wall structure in late gestation, which accompany trophoblast invasion, modulate the responses of these vessels to vasoconstrictors. However, mesometrial arteries also demonstrated reduced responsiveness to U46619, suggesting the influence of factors other than trophoblast.

Stem villous arteries from the placentas of heavy smokers: functional and mechanical properties.

OBJECTIVE: The aim of the study was to compare the mechanical and functional properties of isolated small stem villous arteries from the placentas of women who smoked heavily (>/=15 cigarettes/d) during pregnancy with those from the placentas of nonsmokers. STUDY DESIGN: Isolated stem villous arteries were mounted in small-vessel myographs. Circumference-tension relationships were established with 124 mmol/L potassium chloride. Concentration-response curves were obtained for endothelin 1, prostaglandin F2alpha, vasoactive intestinal peptide, corticotropin-releasing hormone, sodium nitroprusside, and cadmium chloride. The effect of nitric oxide was examined with N omega-nitro-l -arginine. RESULTS: Stem villous arteries from the heavy smoking group developed a significantly lower tension than did those from nonsmokers at 6 of 9 steps of the circumference-tension experiment (P <.05). Endothelin 1 evoked a significantly greater maximum vasoconstrictive response in stem villous arteries from heavy smokers than in those from nonsmokers (P <.05). CONCLUSION: Stem villous arteries of heavy smokers have altered mechanical properties and a greater vasoconstrictive response to endothelin 1 than do those from nonsmokers. These changes may compromise fetal placental blood flow and thereby contribute to the lower birth weights seen among infants born to heavy smokers.

Patterns in expression of insulin-like growth factor-II and of proliferative activity in the normal human first and third trimester placenta demonstrated by non-isotopic in situ hybridization and immunohistochemical staining for MIB-1.

The expression of insulin-like growth factor-II (IGF-II) in normal human first and third trimester placental tissue was investigated by non-isotopic in situ hybridization (ISH). This is the first ISH study on IGF-II expression in placenta using an alkaline phosphatase-labelled probe. The expression was correlated with the proliferative activity of the cells using the proliferative marker MIB-1. In first trimester tissue, IGF-II was expressed in the cytotrophoblast, the extravillous trophoblast, the fetal endothelial cells and the mesenchymal fetal cells in the villi. In third trimester tissue, IGF-II expression was found in the amnion, the extravillous trophoblast and the mesenchymal fetal cells especially in the endothelial cells and the outer contractile sheet in the stem villi. In areas with perivillous fibrin deposits, strong expression of IGF-II was found in the cytotrophoblasts invading the fibrin. In first trimester tissue, the proliferative activity of the villous cytotrophoblast correlated well with the degree of IGF-II expression whereas in third trimester tissue, there was a discrepancy between MIB-1 positivity and the IGF-II expression. Expression of IGF-II does not seem to be correlated exclusively to the mitogenic activity of cells.

[Survival following microscopical radical resection of stomach cancer]. / Overlevelse efter mikroskopisk radikal resektion af ventrikelcancer.

In a series of 128 patients operated for gastric cancer, 27 were microscopically radically resected. The median age of the microscopically radically resected patients was 72.3 years (36-84) at operation, the median observation time was 3.8 years, the crude 5-year survival was 48.2%, and the median hospital stay after operation was 12.9 days. The older patients did remarkably well. We found no significant difference in the number of survivors, survival/observation time or hospital stay between the age groups 55-64, 65-74 or 75-84 years. Thus age in its own right should be no barrier when curative surgical treatment seems possible. When the study was closed, 12 of the 27 microscopically radically resected patients were still alive, six had died from recurrence of gastric cancer and nine from other causes. Instead of crude survival, we suggest the results stated in estimates of cancer deaths prevented. Five years after microscopically radical resection for gastric cancer, 77.1% of the patients had not died from gastric cancer (Kaplan-Meier life table).

A stereologic study of postmature placentas fixed by dual perfusion.

OBJECTIVE: Placental insufficiency has been considered the cause of increased morbidity in infants delivered postmaturely. Former quantitative studies have indicated a decrease in some placental structures just before term. In this study we describe a method of dual perfusion fixation to provide tissue for stereologic examination. Postmature placentas were examined with this method. STUDY DESIGN: Eleven postmature placentas and 14 placentas delivered at term were fixed by dual perfusion. The volume and the surface area of villi, the trophoblast volume, and the volume, surface area, and length of villous capillaries were estimated by stereologic examination. The Mann-Whitney test (p < or = 0.05) was used for statistical analysis. RESULTS: Morphologic features were normal in all placentas. No significant differences were disclosed in the stereologic estimates of placentas delivered at term and postmature placentas. CONCLUSION: No morphologic or significant quantitative changes were found in postmature placentas.

Clinical effects of preoperative oestradiol treatment before vaginal repair operation. A double-blind, randomized trial.

The objective of the study was to assess the effects of low-dose vaginal treatment with oestradiol before vaginal operation. In a double-blind randomized study including 43 postmenopausal women scheduled for vaginal repair operation for genital descensus, it was found that 7 patients suffered from concomitant urinary stress incontinence. Vagifem (25 micrograms oestradiol) or placebo was administered as vaginal pessaries daily, 3 weeks prior to surgery and the clinical effects evaluated. One month postoperatively the prevalence of bacteriuria (> 100,000 CFU/ml urine) was significantly lower when using oestradiol than in the placebo group. At follow-up 3 years later 40 women (93%) answered the questionnaires. None received hormone replacement therapy. Nineteen percent in the preoperative oestradiol group and 11% in the preoperative placebo group had had more than two episodes of cystitis treated with antibiotics. This difference is not statistically significant (p > 0.05). Recurrent cystitis was not correlated to bacteriuria postoperatively. Seventy-nine percent of the women with genital prolapse but only 29% of the women with concomitant urinary stress incontinence were cured (p < 0.05). Neither preoperative oestradiol treatment nor body weight had any influence on relapse. Preoperative low-dose vaginal oestradiol treatment may reduce the incidence of bacteriuria in the immediate postoperative period but no long-lasting effects on recurrent cystitis or relapse were seen. Longer-lasting hormone replacement therapy may be necessary to achieve lasting effects.

Malignant rhabdoid tumour of the kidney in an adult: a case report with immunohistochemical and ultrastructural investigation.

Rhabdoid tumours (RT) are highly aggressive neoplasms most often occurring in kidneys of children. Few cases of extrarenal RT have been reported among adults. This paper describes the first case of a RT in the kidney of an adult.

Survival following microscopically confirmed radical resection of N0 gastric cancer.

In a series of 128 patients operated on for gastric cancer, 27 satisfied microscopic criteria for radical resection. The median age of these patients was 72.3 (range 36-84) years at operation; the median hospital stay after surgery was 12.9 days. The median observation time was 3.8 years and the crude 5-year survival rate 48 per cent. Older patients did remarkably well. No significant difference was found in the number of survivors, survival-observation time or hospital stay in the age groups 55-64, 65-74 or 75-84 years. Thus, age alone should not be considered a barrier to curative surgical treatment. When the study was ended, 12 of the 27 patients who underwent microscopically confirmed radical resection were still alive; six had died from recurrent gastric cancer and nine from other causes. At 5 years after microscopically confirmed radical resection for gastric carcinoma, the gastric cancer-specific mortality rate was 23 per cent.

Preoperative treatment with oestradiol in women scheduled for vaginal operation for genital prolapse. A randomised, double-blind trial.

OBJECTIVE: To disclose a clinical and histopathological effect of local low-dose oestradiol treatment on the vagina. DESIGN: A randomised, double-blind trial. SETTING: Two gynaecological departments at University Hospitals. SUBJECTS: Forty-eight postmenopausal women scheduled for surgery because of genital prolapse. INTERVENTION: 25 micrograms oestradiol or placebo, administered as vaginal pessaries daily, 3 weeks prior to surgery. MAIN OUTCOME MEASURES: Cytological, histological and clinical changes of the vaginal mucosa. RESULTS: The thickness of the vaginal wall increased as did the oestrogenic index. No clinical effect was seen apart from decreased incidence of recurrent cystitis postoperatively. CONCLUSIONS: Preoperative oestrogen treatment has been shown to reduce the incidence of recurrent cystitis and may be needed for stimulation of vaginal mucosa; the short-term clinical effect is not convincing, however.

Retroperitoneal abscess and vena cava thrombosis following normal pregnancy and delivery.

A 24 year old primigravida underwent a normal pregnancy and delivery, and developed a retroperitoneal abscess and thrombosis of the vena cava late in the puerperium. A transvaginal drainage of the abscess was performed and the thrombosis of the vena cava treated with Heparin and thrombectomy. Full recovery was obtained.

[An apparatus for intravesical chemotherapy]. / Et apparatur til anvendelse ved cytostatikaskylning i urinblaeren.

To prevent spillage of cytostatic drugs when administering intravesical chemotherapy, a closed apparatus for preparation, instilling and disposal of the cytostatic drugs has been developed. After use, the apparatus is disposed of intact.

[The value of routine check-ups of patients after radical surgery of colonic cancer or rectal cancer]. / Vaerdien af rutinemaessig postoperativ kontrol efter radikal operation for cancer coli eller cancer recti.

UNLABELLED: In this retrospective study, the efficiency of the postoperative follow-up regimen was evaluated in patients, radically operated for cancer of the colon or cancer of the rectum. The follow-up regimen consisted of clinical examination, including sigmoidoscopy every six months, supplemented by an X-ray of the colon every year. Two-hundred and eighty-nine patients were included in the study. Twenty-three local recurrences and 19 new malignant tumors were diagnosed 20 and 13 months (mean) after the primary operation, respectively. About one third of the local recurrences and half of the new malignant tumors were diagnosed at the planned follow-ups. Among these patients, a significantly higher success rate as regards radical operation was observed at the second operation. IN CONCLUSION: more frequent follow-ups during the first two years after the primary operation are recommended in order to improve early diagnosis.

Tallysomycin S10b--a phase I trial.

Tallysomycin S10b is a new bleomycin analogue. In animal studies it has shown the same degree of antineoplastic activity as bleomycin; however in contrast to that of bleomycin, its dose-limiting effect in animal systems is renal toxicity and its pulmonary toxicity is less pronounced. A total of 16 patients received tallysomycin S10b at three exploratory levels: 3 patients were given a dose of 1.25 mg/m2, 9 received 2.5 mg/m2 and 4 were given 5 mg/m2 as i.v. bolus injections twice weekly. Before treatment and every 3 weeks, plain chest X-rays, pulmonary function tests, renography and 51Cr-EDTA clearance were carried out. No renal toxicity was found in any of the treatment groups. In the first two groups no changes in chest X-rays were observed during treatment, whereas in the third group a decrease in single-breath carbon monoxide diffusion capacity (DLCO) was seen in one patient until the treatment was discontinued. Two of four patients receiving 5 mg/m2 developed interstitial pneumonitis at total doses of 104 and 160 mg, respectively. During the trial no haematologic or hepatic changes occurred due to the drug. The frequency of occurrence of skin changes, stomatitis and fever increased with the cumulative dose of tallysomycin S10b, and these side effects were similar to those seen with bleomycin. No tumor regression was seen during the trial. In contrast to the findings in previous animal studies, we found that the dose-limiting effect was pulmonary and not renal toxicity. The recommended dose for further phase II trials is 2.5 mg/m2 twice weekly, with careful monitoring of the pulmonary function.