[Laparoscopic fundoplication. A prospective assessment of 100 operations for gastroesophageal reflux]. / Laparoskopisk fundoplikation. En prospektiv vurdering af 100 operationer for gastroøsofageal refluks.

INTRODUCTION: Laparoscopic fundoplication was assessed in a prospective study. METHOD: One hundred patients with gastroesophageal reflux (GORD) were treated by a 360 degrees fundoplication. The number of operations completed as a laparoscopic procedure, the complication rate, the length of hospital stay and time of work and the effect on GORD symptoms were used as endpoints. RESULTS: The operations could be performed as a laparoscopic procedure in 97 cases. Complications were few: A left-sided pneumothorax in two patients. Median operating time was 100 min and postoperative hospital stay two days. Sufficient reflux control was obtained in 93 patients. Only minor side effects were encountered in three patients (dysphagia two, flatulence one). At three-month control 91 were satisfied. After 3-49 mo (median 19 mo) two have needed a re-operation for dysphagia (one due to tight suture and one for a rotated fundoplication). One patient had the fundoplication taken down for embarrassing flatulence in spite of successful reflux control. CONCLUSION: Laparoscopic fundoplication offers a good immediate control of GORD during a short hospitalization with few complications or side effects. No long term results are available at present.

[Dermatome-shaving of psoriasis. 7 years of experience]. / Dermatom-shaving af psoriasis. Syv års erfaring.

Data from the records of 112 patients who were treated with dermatome shaving for psoriasis vulgaris were analysed. One hundred and eight patients with 202 areas treated were included in the study. Complications occurred in nine patients. Thirty-seven patients and 104 areas did not recur during mean follow-up periods of respectively 1.4 years and 1.9 years. In all 108 patients the median recurrence free period was eight months (range: 0-5.6 years). The median recurrence free period for the 202 areas was 13 months (range: 0-8.2 years). Reshaving of partial recurrences in 46 patients led to 40% that did not recur.

Dermatome shaving of psoriasis. Seven years experience in 112 patients.

Data from the records of 112 patients who were treated by dermatome shaving for psoriasis vulgaris were analysed. A psoriatic "area" was defined as all psoriatic skin lesions present in a specific region at the first treatment, and 108 patients with 202 areas were included in the study. In 68 patients the treatment was limited to a single area, and 40 patients had from two to nine areas treated, mainly on the legs and arms. Complications occurred in nine patients; one had a wound infection that required treatment with an antibiotic, in five patients healing was prolonged, and three patients developed unsightly scars. Thirty-seven patients and 104 areas have not recurred during mean follow-up periods of 1.4 years and 1.9 years, respectively. In all 108 patients the median recurrence free period was eight months (range: 0-5.6 years). The median recurrence free period for the 202 areas was 13 months (range: 0-8.2 years). Reshaving of partial recurrences in 46 patients led to 40% that did not recur. The best prognostic factor available is to do a test shave before initiating more extensive treatment.

[Laparoscopic cholecystectomy]. / Laparoskopisk kolecystektomi.

Forty-one patients with uncomplicated gall stone disease were laparoscopied with the object of cholecystectomy. The procedure was accomplished in 36 patients, but the operation had to be transformed to a conventional open operation in five: Fibrosis made dissection of the gall bladder hazardous in four and bleeding during the procedure made immediate laparotomy necessary in one patient, whose postoperative course was uneventful. The median operating time was 100 minutes, range was 60-250 minutes. The only operative complication was bleeding from a trocar puncture hole on the first postoperative day which stopped spontaneously in one patient. Eighteen were sent home on the first postoperative day and 12 patients on the second day. Peroperative cholangiography was performed employing the Olsen-Reddick cholangiography forceps. We have designed a special catheter, which greatly facilitates the procedure. The procedure was accomplished in 27 of 32 planned cases. Two patients had common bile duct or common hepatic duct stones. A trans-sphincteric endoprosthesis was applied through the cholangiography forceps in both patients, to prevent postoperative bile duct outlet obstruction. The endoprosthesis made the following endoscopic sphincterotomy, which was performed at a convenient time rapid and safe. The stones were extracted and the prosthesis removed on the same occasion. A reliable flushing system was developed on the basis of the "Kidde" automatic tourniquet frequently used in orthopaedic surgery. All patients were seen in the outpatient clinic 1 month after the operation. Superficial infection in the trocar holes in ten patients were the only problem the patients had encountered and all had returned to their normal work.(ABSTRACT TRUNCATED AT 250 WORDS)

A comprehensive two-dimensional gel protein database of noncultured unfractionated normal human epidermal keratinocytes: towards an integrated approach to the study of cell proliferation, differentiation and skin diseases.

A two-dimensional (2-D) gel database of cellular proteins from noncultured, unfractionated normal human epidermal keratinocytes has been established. A total of 2651 [35S]methionine-labeled cellular proteins (1868 isoelectric focusing, 783 nonequilibrium pH gradient electrophoresis) were resolved and recorded using computer-aided 2-D gel electrophoresis. The protein numbers in this database differ from those reported in an earlier version due to changes in the scanning hardware (Celis et al., Electrophoresis 1990, 11, 242-254). Annotation categories reported include: "protein name" (listing 207 known proteins in alphabetical order), "basal cell markers", "differentiation markers", "proteins highly up-regulated in psoriatic skin", "microsequenced proteins" and "human autoantigens". For reference, we have also included 2-D gel (isoelectric focusing) patterns of cultured normal and psoriatic keratinocytes, melanocytes, fibroblasts, dermal microvascular endothelial cells, peripheral blood mononuclear cells and sweat duct cells. The keratinocyte 2-D gel protein database will be updated yearly in the November issue of Electrophoresis.

Molecular cloning, occurrence, and expression of a novel partially secreted protein "psoriasin" that is highly up-regulated in psoriatic skin.

Analysis of the protein patterns of normal and psoriatic noncultured unfractionated keratinocytes has revealed several low-molecular-weight proteins that are highly up-regulated in psoriatic epidermis. Here, we have cloned and sequenced the cDNA (clone 1085) for one of these proteins that we have termed psoriasin. The deduced sequence predicted a protein of molecular weight of 11,457 daltons and a pI of 6.77. The protein co-migrated with psoriasin as determined by two-dimensional (2D) gel analysis of [35S]-methionine-labeled proteins expressed by RK13 cells transfected with clone 1085 using the vaccinia virus expression system. Analysis of the predicted sequence revealed a potential calcium-binding sequence of the EF-hand type, as well as the absence of a signal sequence at its amino terminal. Psoriasin is not related to other proteins that migrate closely in 2D gels (MRP 14, also known as calgranulin B, L1 and calprotectin; MRP 8, or calgranulin A and cystatin A or stefin A), and bears no significant sequence homology with any other protein of known primary structure. Increased expression of psoriasin mRNA in psoriatic keratinocytes was confirmed by Northern blotting and in situ hybridization. Psoriasin showed a restricted occurrence in fetal human tissues as determined by 2D gel electrophoresis. Of 21 tissues analyzed, only ear, skin, and tongue showed significant levels of this protein. Psoriasin was not detected in normal human fibroblasts, lymphocytes, endothelial cells and transformed epithelial cells of keratinocyte origin. Granulocyte extracts contained this protein suggesting that its overexpression by psoriatic keratinocytes may be linked to the inflammatory stimuli.

A study of protein synthesis in cells cultured from involved psoriatic skin.

Using histochemical techniques an abnormal programme of epidermal differentiation has been well documented in psoriasis. In order to characterise further the biochemistry of this process we have cultured dermal fibroblasts and epidermal keratinocytes from involved psoriatic skin. This has facilitated metabolic radiolabelling of skin cells and analysis of protein synthesis by two-dimensional polyacrylamide gel electrophoresis. The expression of keratin and differentiation markers was identical to that of normal keratinocytes, suggesting that psoriatic epidermal differentiation is not truncated in vitro as has been postulated to be the case in vivo. Low molecular mass components (5-8.5 kDa), previously shown to be upregulated in suprabasal keratinocytes, were detected in epidermal fractions from psoriatic skin enriched for basal cells. Of special interest was a component of 26 kDa, pI 5.9, which was highly upregulated in psoriatic as compared to normal cultured keratinocytes and was not detected in fibroblasts. These findings are in accord with a qualitatively abnormal pattern of differentiation for keratinocytes in the involved psoriatic epidermis.

A two-dimensional gel protein database of noncultured total normal human epidermal keratinocytes: identification of proteins strongly up-regulated in psoriatic epidermis.

A two-dimensional (2-D) gel database of proteins from noncultured total normal human epidermal keratinocytes has been established. A total of 1449 [35S]methionine labelled proteins (1112 isoelectric focusing, 337 nonequilibrium pH gradient electrophoresis) were resolved and recorded using computer assisted (PDQ-SCAN and PDQUEST software) 2-D gel electrophoresis. By matching the protein patterns of total keratinocytes and transformed human amnion cells (master database; Celis et al., Leukemia 1988, 2, 561-602) as well as by 2-D immunoblotting and microsequencing of keratinocyte proteins, it was possible to identify 72 polypeptides in the keratinocyte database. The database also includes data on polypeptides that are synthesized at a higher level by keratinocytes enriched in basal cells, and on six secreted proteins which are produced, albeit at a reduced rate, by normal keratinocytes and that are strongly up-regulated in psoriatic epidermis (Celis et al., FEBS Letters, in press).

Identification of a group of proteins that are strongly up-regulated in total epidermal keratinocytes from psoriatic skin.

Analysis using two-dimensional (2D) gel electrophoresis of the [35S]-methionine-labelled proteins synthesized by non-cultured total epidermal keratinocytes obtained from normal and psoriatic skin revealed 6 proteins that are strongly up-regulated (5 times or more) in psoriatic skin. These proteins are synthesized at albeit lower levels by keratinocytes from normal and normal-appearing (uninvolved) skin of psoriatic patients, and correspond to isoelectric focusing sample spot numbers 4311 (40.3 kDa), 4003 (12.4 kDa), 5008 (11.9 kDa), 3012 (11.6 kDa), 6016 (11.6 kDa) and 1015 (10.1 kDa) in the normal keratinocyte 2D gel protein database [Celis et al, (1990) Electrophoresis, in press]. These proteins are also detected in the labelling medium indicating that they are at least in part secreted. Given their striking regulatory behavior, these proteins may play a role in the pathogenesis of psoriasis.

[Mastectomy incisions and biopsy technics in view of subsequent reconstructive surgery in breast cancer]. / Snitføring ved mastektomi og biopsiteknik under hensyntagen til senere rekonstruktionskirurgi ved cancer mammae.

Patients are referred to departments for plastic surgery increasingly frequently for breast reconstruction following mastectomy for cancer of the breast. Successful results depend greatly on the primary mastectomy carried out by surgeons without experience in reconstruction. It is particularly important that the incisions are suitably placed so that the final result can be satisfactory. Our material consists of 119 patients who had been submitted to unilateral mastectomy for cancer of the breast at least one year previously. One fifth of the patients had hypertrophic breasts. The unequal distribution of weight following unilateral mastectomy is followed by such considerable discomfort from the remaining breast that this alone makes a reduction plastic operation necessary. Simultaneously, reconstruction is carried out on the side of the mastectomy. As the method of reconstruction, introduction of silicone prosthesis were carried out in 110 patients. Nine patients were, in addition, submitted to more complicated plastic flap procedures. The postoperative course was uncomplicated in 112 patients (94%). Reoperation proved necessary on seven occasions; in four patients on account of haematoma formation and rupture of the wound in three patients. In four patients, the prosthesis had to be renewed on account of rupture during the subsequent years. Guidelines for placing the incisions at the primary mastectomy are suggested to facilitate successful reconstruction. Finally, a suitable biopsy technique is described.

Large bile duct stones treated by endoscopic biliary drainage.

One hundred five patients with obstructive jaundice and cholangitis (49 patients), referred for diagnostic endoscopy, were found to have inextractable bile duct stones. Median age was 76 years and three quarters were more than 72 years of age. Insertion of an endoprosthesis with or without a sphincterotomy relieved jaundice in 94% and settled cholangitis in 90%. Antibiotic cover during the procedure seems essential inasmuch as pyrexia and septicemia occurred in 6 of 57 cases where it was not given. One case was lethal. Another patient died of acute pancreatitis. The patients were old. One quarter died before the follow-up, 1 to 5 years after the initial intervention. The results indicate that the combination of endoscopic sphincterotomy, insertion of an endoprosthesis, and, if feasible, stone extraction on a later occasion when the acute phase of the illness had subsided brought the disease sufficiently under control among three quarters of the patients with large common duct stones or stenoses in the biliary tract. One quarter of the patients were treated surgically. This was accomplished without mortality, but morbidity was not negligible. A policy with a surgical approach restricted to selected cases with persistent symptoms in spite of sufficient endoscopic drainage is recommended.

Prevention of erection after penile surgery. A double-blind trial of intracavernous noradrenaline versus placebo.

To prevent nocturnal erections after penile surgery a randomized, double blind trial of nocturnal intracavernous infusion of noradrenaline (10 micrograms per hour) versus placebo in 20 patients was carried out. During infusion the corpus cavernosum pressure was continuously registered. The patients made a record of nocturnal erections and associated pain. The pressure registration confirmed total absence of erections in the noradrenaline group. In the placebo group half of the patients were devoid of nocturnal erections. No signs of ischaemia was seen, but in four patients receiving noradrenaline infusion was stopped due to pain. This treatment seems effective in preventing nocturnal erections after penile surgery.

Endoscopic biliary drainage.

Endoscopic biliary drainage (EBD) has become an established method of relieving posthepatic jaundice. This study comprises 399 patients in whom 472 EBD procedures were performed during a 5 year period; 272 patients had malignant obstruction, 36 had a benign stricture, 79 had common duct stones and 12 patients had other benign conditions requiring drainage. A 7F double pigtail endoprosthesis was used in the majority of patients and was inserted with an Olympus JF-1T duodenoscope. Ninety-two per cent of the prostheses were correctly positioned, and 88 per cent of these functioned well with relief of symptoms. The 30-day mortality was 22 per cent and one-third of these deaths were due to the procedure, septicaemia being the dominant hazard. This was more marked if the obstruction was not relieved satisfactorily. Antibiotic cover was not used routinely and had not been prescribed in any of the fatal cases. This omission probably made a significant contribution to the septicaemia. Acute pancreatitis and haemorrhage were rare complications and both were probably related to the coincidental sphincterotomy. Prostheses intended for permanent relief of malignant obstruction remained patent for 2-3 months (median) with a wide range of 1-618 days. Survival among these patients is so short, that one or two EBD procedures will keep the majority of patients free from symptoms related to biliary obstruction, and only two patients needed more than three procedures. Fifty-one patients with pancreatic head carcinoma had EBD as a bypass before an intended operation. Only 16 patients actually had a resection. The median survival among the 51 patients was 106 days (compared with 59 days among 100 patients with a permanent prosthetic bypass). Only one patient with a very small periampullary carcinoma has survived for more than 3 years. Forty-seven patients are dead. Among the 51 patients in whom radical resection was intended two-thirds were actually treated by permanent surgical or prosthetic bypass.

Peroperative cefuroxime v. long-term ampicillin and metronidazole in high-risk biliary and gastric surgery. A multicentre trial.

Randomization to cefuroxime in a two-dose peroperative regimen or to combined peroperative and postoperative (4 days) ampicillin and metronidazole was performed in a series of 418 high-risk patients undergoing biliary or gastric surgery. Postoperative wound infection appeared in 9 of the 210 patients who received ampicillin and metronidazole and in 2 of the 208 given cefuroxime (p less than 0.05). Four intraabdominal abscesses occurred in the former group and one in the latter. Three of these abscesses probably were attributable to complications of surgery as such, leaving one intraabdominal abscess in each group. Peroperative cefuroxime is concluded to be more effective than longer administration of ampicillin/metronidazole as protection against wound infection in high-risk patients undergoing biliary or gastric surgery.

Heterogeneous distribution of lipoxygenase products in psoriatic skin lesions.

Several biologically active lipoxygenase products or arachidonic acid (AA) have been demonstrated in psoriatic skin lesions. The purpose of the present study was to determine the amounts of the different lipoxygenase products simultaneously in psoriatic skin. Slices of psoriatic skin were obtained at different levels with a keratome. Extracted lipids were identified by high performance liquid chromatography, UV-absorption spectrum, radioimmunoassay, and chemokinesis. Leukotriene B4 (LTB4), and 12- and 15-hydroxy-eicosatetraenoic acid (HETE) were detected in most psoriatic lesions. However, there was a remarkable variation from lesion to lesion. The biopsy specimens contained: 276.2 +/- 126.0 pg/g wet tissue of LTB4, 3,130.0 +/- 2,898.0 ng/g wet tissue of 12-HETE, and 3,633.0 +/- 1,692.0 ng/g wet tissue of 15-HETE. No correlation was found between the levels of the different lipoxygenase products. The content of each of the identified lipoxygenase products was higher in the superficial part of the biopsy specimen consisting of approximately two-thirds of the epidermis plus papillary dermis than in the lower part consisting of approximately one-third of the epidermis plus some reticular dermis. Also, there was a great variation from one anatomical region to another within the same patient. Because these lipoxygenase products possess different biological activities, the variation in their occurrence may be important for understanding their potential role in psoriasis. To determine which lipoxygenase products may be of pathogenic importance, analysis of early psoriatic lesions is warranted.