Randomized clinical trial of the effect of pneumoperitoneum on cardiac function and haemodynamics during laparoscopic cholecystectomy.

BACKGROUND: Conventional laparoscopic cholecystectomy (CLC) with carbon dioxide pneumoperitoneum may cause major cardiovascular changes. The aim of this study was to evaluate the effect of carbon dioxide pneumoperitoneum and positional changes on haemodynamics and cardiac function in patients assigned randomly to CLC or gasless laparoscopic cholecystectomy (GLC). METHODS: Fifty patients with American Society of Anesthesiologists physical status I and II were randomly allocated to CLC (28 patients) or GLC (22). Left ventricular end-diastolic and end-systolic diameters, fractional shortening and cardiac output were determined by transoesophageal echocardiography. Measurements were performed before (phase 1) and 10 and 30 min (phases 2 and 3 respectively) after pneumoperitoneum or abdominal wall traction, and after desufflation or release of abdominal wall traction (phase 4) in supine, Trendelenburg and reverse Trendelenburg positions. RESULTS: Mean diastolic diameter, systolic diameter, mean arterial pressure and heart rate were significantly higher, and fractional shortening was significantly lower, with carbon dioxide pneumoperitoneum than with the gasless procedure during phases 2 and 3. There were no significant differences in cardiac output between the two groups. CONCLUSION: Carbon dioxide pneumoperitoneum was associated with increased preload and afterload in patients undergoing laparoscopic cholecystecomy. It also decreased heart performance (fractional shortening), but did not affect cardiac output.

Intraperitoneal and intraluminal microdialysis in the detection of experimental regional intestinal ischaemia.

BACKGROUND: The aim was to investigate the possibility of using intraluminal or intraperitoneal microdialysis to monitor regional intestinal ischaemia. METHODS: Microdialysis catheters were inserted in the lumen, in and outside the intestinal wall, and in the peritoneum of each of ten pigs. Regional occlusive ischaemia was induced in 100 cm of jejunum. Levels of glucose, pyruvate, lactate and glycerol in the microdialysate were measured at 20-min intervals before and after induction of ischaemia. Systemic haemodynamics were monitored and laser Doppler flowmetry (LDF) recordings made in each of the intestinal segments. RESULTS: Ischaemia caused a significant decrease in glucose level, and an increase in lactate and glycerol concentrations and lactate/pyruvate ratio, at all catheters, although glucose could not be detected by the intraluminal catheter. The metabolic changes occurred simultaneously and were statistically significant in almost all catheters after 100 min. LDF revealed a significant decrease in intestinal blood flow, but there was considerable individual variation. CONCLUSION: Regional occlusive ischaemia in 100 cm of small intestine could be detected and monitored by means of a microdialysis catheter placed in the peritoneal cavity or the bowel lumen.

Validation of intramural intestinal microdialysis as a detector of intestinal ischaemia.

BACKGROUND: The purpose of this study was to validate intestinal microdialysis as a detector of intestinal ischaemia using measurements of glucose, lactate and glycerol from the jejunal wall. METHODS: Based on a previous study, the cut-off levels for the presence of regional intestinal ischaemia were defined for microdialysis glucose, lactate, glycerol and the lactate/glucose ratio. Changes of 60% in the metabolic compounds measured after 100 min were defined as the cut-off level for ischaemia. The cut-off levels were tested in a randomized, single-blinded study. Ten pigs were used; occlusive ischaemia was performed by clamping a segment of the mesentery to the intestine. Four catheters were inserted per pig, two in the ischaemic segment and two in the non-ischaemic segment. All catheters were numbered, randomly allocated and inserted in the intestine by the staff at the institute and unknown to the investigators. RESULTS: One pig was excluded because the clamping was insufficient. Technical problems with the catheters were registered in 15% of cases owing to damage of the microdialysis membrane, dislocation, or incorrect placement. The predictive values of presence of ischaemia for glucose, lactate, glycerol and the lactate/glucose ratio were: 0.91, 1,0.85 and 0.92, respectively. CONCLUSION: Using a 60% cut-off limit measured after 100 min, intestinal ischaemia can be detected and excluded using intestinal microdialysis, but some technical problems remain that need further investigation.

Randomized study of coagulation and fibrinolysis during and after gasless and conventional laparoscopic cholecystectomy.

BACKGROUND: Carbon dioxide pneumoperitoneum may be an important pathophysiological factor stimulating the coagulation system during conventional laparoscopic cholecystectomy. The aim of this study was to test the hypothesis that gasless laparoscopy produces smaller changes in the coagulation and fibrinolytic system than carbon dioxide pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty patients were allocated randomly to conventional (n = 26) or gasless (n = 24) laparoscopic cholecystectomy. Blood samples were obtained on admission, after induction of anaesthesia, after insufflation or traction, 30 min after introduction of the laparoscope, 10 min after exsufflation of carbon dioxide or traction, 4 h after extubation and 24 h after operation. RESULTS: The two groups were comparable with respect to age, sex, body mass index and duration of operation. Plasma levels of prothrombin fragment 1 and 2 (F1 + 2), soluble fibrin and D-dimer did not differ between the two groups. F1 + 2 levels varied significantly in both groups during and after operation (P < 0.001). Soluble fibrin and D-dimer levels did not change during operation in either group, but after operation the levels increased significantly in both groups (P < 0.001). CONCLUSION: Carbon dioxide pneumoperitoneum does not enhance the activation of coagulation and fibrinolysis associated with laparoscopic cholecystectomy. The coagulation and fibrinolytic systems are activated during and after gasless as well as conventional laparoscopic cholecystectomy.

Randomized comparison of conventional and gasless laparoscopic cholecystectomy: operative technique, postoperative course, and recovery.

The positive CO2 pneumoperitoneum needed to create the working space for laparoscopic surgery induces cardiovascular, neuroendocrine, and renal changes. Concern about these pathophysiologic changes has led to the introduction of a gasless technique. Fifty consecutive patients with symptomatic gallstones were randomized to conventional (CLC) or gasless laparoscopic cholecystectomy (GLC), with special reference to overall patient satisfaction, technical difficulties, duration of surgery, postoperative pain, and recovery. The overall exposure of the operative field was extremely poor in the GLC group, whereas the duration of surgery, steps involved in the cholecystectomy technique, length of hospital stay, and postoperative pain score did not differ significantly. After discharge, the median time to complete relief of pain tended to be shorter in the gasless group (5 days [range 1 to 15]) vs. the conventional group (8 days [range 1 to 15]). The period to return to normal activity was shorter in the GLC group (6 days [range 1 to 15]) compared to the CLC group (8.5 days [range 1 to 15]) (P = 0.031). No differences were found in terms of fatigue, dizziness and nausea, and overall satisfaction with the outcome. This study demonstrates a significantly shorter convalescence after laparoscopic cholecystectomy by means of the gasless technique compared to the conventional CO2 technique. Exposure of the operative field was less than optimal using the gasless technique.

[Curative treatment of ventricular cancer]. / Kurativ behandling af cancer ventriculi.

Extended lymphadenectomy on connection with the surgical treatment of gastric cancer is gaining access in western centres especially since Japanese centres have shown an ever increasing rate of survival over several decades, coupled with the fact that operative procedures have become more sophisticated. The latest prospective studies in the west seem to confirm the value of lymphadenectomy in some patients. Furthermore, correct staging demands extended lymphadenectomy. For patients with gastric cancer, adjuvant preoperative chemotherapy is probably an asset.

[Treatment of morbid obesity with laparoscopic, adjustable gastric banding. Results after two years of experiences with a new surgical method for severe obesity]. / Behandling af sygelig overvaegt med laparoskopisk, justerbar "gastric banding". Resultater fra to års erfaring med en ny operation for svaer fedme.

INTRODUCTION: In the last decade, laparoscopic, adjustable silicone gastric banding for morbid obesity has gained widespread use, owing to two important improvements: The surgical procedure can be performed laparoscopically and the weight loss can be regulated by adjusting the silicone band by a simple percutaneous technique. MATERIAL AND METHODS: Over a 2-year period, we followed up 33 patients admitted to the clinic for morbid obesity. Sixteen patients preferred the conventional diet treatment (1), seven patients underwent an operation (2), and ten patients were motivated for operation, but were found to be unfit and were treated by diet (3). RESULTS: The excess loss of body weight was 25% in group 1, 60% in group 2, and 0% in group 3. CONCLUSION: Laparoscopic, adjustable gastric banding can help the severely obese patients when diets and pharmacological treatment have failed. The resulting loss of weight is highly dependent on careful follow-up by a professional obesity team.

Messenger RNA for membrane-type 2 matrix metalloproteinase, MT2-MMP, is expressed in human placenta of first trimester.

An intimately regulated cell surface activation of matrix metalloproteinases (MMPs) is believed to be of critical importance for the control of trophoblast invasion. A histological investigation of the expression and localization of three different MMPs, the membrane-type matrix metalloproteinases 1 and 2 (MT1-MMP, MT2-MMP) and matrix metalloproteinase 2 (MMP-2/gelatinase A) was performed by in situ hybridization on consecutive sections from human placentae of first trimester pregnancies. Cytokeratin immunostaining identified trophoblast cells. Both normal and tubal implantation sites were studied. We observed a high degree of coexpression of MT2-MMP, MT1-MMP and MMP-2 mRNAs in single extravillous cytotrophoblasts that had invaded the endometrium and tubal wall. Furthermore, mRNAs for all three genes were also seen in cytotrophoblasts of cell islands. In contrast to this coexpression pattern, MT2-MMP expression was absent from cell columns and decidual cells, in which signals for MT1-MMP and MMP-2 mRNAs were seen. The present data on the cellular expression of MT2-MMP mRNA in placenta extend our knowledge of the proteolytic events that take place during early pregnancy. The data suggest that MT2-MMP, capable of activating MMP-2 in vitro, is involved in the invasion of extravillous cytotrophoblast, possibly related to the physiological activation of MMP-2.

[Early medical abortion. An update]. / Tidlig medicinsk abort. En opdatering.

Early medical abortion was introduced in Denmark in 1998. In countries in which this practice has been in use for several years, clinical studies have identified an effective and at the same time gentle regimen. For the time being, this regimen is a combination of the antiprogestogen "mifepristone" and a prostaglandin E1 analogue. Among women with pregnancies up to eight weeks of gestation, 95% will have a complete abortion on a regimen of 600 mg oral mifepristone combined 24 hours later with 1 mg vaginal gemeprost. About five percent will undergo evacuation due to incomplete abortion or heavy bleeding. Although many women experience moderate or severe pain, nausea or vomiting, the tolerability is generally good. Complications wuch as infection or excessive bleeding occur in less than one percent. It is concluded that medical abortion is a good alternative to surgical abortion, and that women who wish an abortion have to be referred to hospital as early as possible in order not to pass the time limit of medical abortion.

[The first 100 early medical abortions]. / De første 100 tidlige medicinske aborter.

Early medical abortion was introduced in Denmark in 1998. This article describes our experiences with the first 100 patients at Herlev University Hospital. The regimen was 600 mg mifepriston (RU486) given orally on day one. All women had an ultrasound examination before RU486 was given in order to ensure an intrauterine pregnancy and a gestationel age of eight weeks or less, and all had a quantitative P-hCG. On day three the patients received 1 mg gemeprost as vagitory as well as a paracetamol/-codein suppository. They were observed in the department for four hours, and were thereafter discharged no matter whether a complete abortion had occurred ot not. On day 14 a new P-hCG was taken. All women in whom the hCG value was not reduced to one half of the initial value or less underwent a new ultrasound examination. All women were given a questionnaire. The effectivity was 96%. Four of 100 women were evacuated: one due to severe vaginal bleeding four hours after application of gemeprost, two because of womiting soon after having taken RU486 and one due to incomplete abortion. Half of the women began to bleed before application of gemeprost, and 91% had bleeding for more than six days. One half had no side effects to mifepristone, the other half had mild nausea. Nine of ten patients were sufficiently relieved of pain without opioids, whereas 10% were insufficiently pain relieved. Eight of ten patients would choose the same method again, in case of a future need for an induced abortion. The reason for not preferring a medical abortion among the remaining 20% was primarily pain. Early medical abortion should be offered to all women referred for induced abortion with a gestational age of eight weeks or less.

Presence of uterine pinopodes at the embryo-endometrial interface during human implantation in vitro.

In order to study changes occurring on the surfaces of human endometrial epithelial cells in the presence of an implanted blastocyst, we used scanning electron microscopy for investigation of five endometrial biopsies and three human implantation sites obtained in vitro. All specimens showed areas with endometrial pinopodes, separated by cells displaying microvilli or cilia at the apical surface. Pinopode formation was more pronounced in endometrial biopsies than in cell cultures. All blastocysts adhered to pinopode presenting cells. Endometrial surface changes were not seen around the blastocysts. The results of this study demonstrate that cultured endometrial epithelial cells are capable of pinopode formation. Furthermore, endometrial epithelial pinopodes, generally considered as a marker of endometrial receptivity, seem to be directly involved in the adhesion of the blastocyst to the endometrial surface.

Coagulation and fibrinolysis during laparoscopic cholecystectomy.

Laparoscopic surgery appears to be less traumatic to the patient than open surgery, but its influence upon coagulation and fibrinolysis is incompletely elucidated. Our aim was to measure markers of coagulation and fibrinolysis before, during. and after laparoscopic cholecystectomy (LC). Blood samples drawn on admission, on four occasions during operation as well as 2 hours after operation and on the first postoperative day in 50 patients undergoing elective LC were analyzed for prothrombin fragment 1+2 (F1+2), soluble fibrin (SF), D-dimer (DD), fibrin degradation products (FbDP), tissue-type plasminogen activator (tPA) activity and antigen, and plasminogen activator inhibitor (PAI) activity and antigen. F1+2, SF, DD, and FbDP levels increased significantly after LC. Differences between pre- and postoperative PAI and tPA levels were not significant apart from a transient increase in tPA antigen levels. tPA activity was significantly increased during operation.

[Laparoscopic cholecystectomy as a same-day surgical procedure]. / Laparoskopisk kolecystektomi som sammedagskirurgisk procedure.

The aim of this study was to describe the results of laparoscopic cholecystectomy as an outpatient procedure in a prospective, consecutive, descriptive study. The study included 50 patients selected in the period from April to December 1997, who accepted the outpatient procedure. Preoperative complications, morbidity during hospital stay, length of hospital stay, frequency of readmission and the satisfaction of the patients were registered. In our investigation we found a risk of preoperative complications of 6% (severe 0%), a morbidity during hospital stay of 6% (severe 2%) and an incidence of readmission of 4%. A total of 74% of the patient went home on the same day as the procedure, and 90% of all patients had been discharged 24 hours later. The patients showed a high degree of satisfaction. In conclusion laparoscopic cholecystectomy as an outpatient procedure may be performed with a low risk of complications, a low incidence of readmission, a high degree of satisfaction in patients, but with a high frequency of primary admission (26%).

[ERCP and laparoscopic cholecystectomy]. / ERCP og laparoskopisk kolecystektomi.

The use of perioperative endoscopic retrograde cholangiopancreatography (ERCP) for suspected common bile duct stones (CBDS) was investigated retrospectively in 153 of 477 patients undergoing laparoscopic cholecystectomy (LC). Pre- and postoperative ERCP was performed in 141 patients (29.6%) and 12 patients (2.5%), respectively. Successful cannulation of the CBD was achieved in 95%. Preoperative CBDS were found in 40/141 patients (28%), of whom 65% were successfully retracted during one session and 35% during two sessions. Twelve patients underwent postoperative ERCP of whom eight patients had CBDS. The complication rate of preoperative ERCP was 9.9%. There was no mortality. Prediction of CBDS diagnosed by preoperative ERCP, using history, liver biochemistry, ultrasonography and combination of biochemistry and ultrasonography showed values of 2.2%, 37.5%, 33.3% and 55.6%, respectively. The diagnostic and therapeutic success rate of ERCP is acceptable. However, the low rate of CBDS in patients undergoing ERCP preoperatively calls for a more selective use of ERCP in patients undergoing LC. History, liver biochemistry and ultrasonography are inefficient methods of patient selection.

Co-ordinated expression of MMP-2 and its putative activator, MT1-MMP, in human placentation.

The spatial expression of mRNA for matrix metalloproteinase 2 (MMP-2), its putative activator, the membrane-type 1 matrix metalloproteinase (MT1-MMP), and the MMP-2 substrate type IV collagen was investigated in human placentas of both normal and tubal ectopic pregnancies and in cyclic endometrium using in-situ hybridization. Cytokeratin staining applied to adjacent sections was used to identify epithelial and trophoblast cells. In both normal and tubal pregnancies MT1-MMP, MMP-2 and type IV collagen mRNA were highly expressed and co-localized in the extravillous cytotrophoblasts of anchoring villi, in cytotrophoblasts that had penatrated into the placental bed and in cytotrophoblastic cell islands. In addition, the decidual cells of normal pregnancies in some areas co-expressed MT1-MMP and MMP-2 mRNA, with moderate signals for both components. Fibroblast-like stromal cells in tubal pregnancies were positive for MMP-2 mRNA but generally negative for MT1-MMP mRNA. The consistent co-localization of MT1-MMP with MMP-2 and type IV collagen in the same subset of cytotrophoblasts strongly suggests that all three components co-operate in the tightly regulated fetal invasion process. The co-expression of MT1-MMP and MMP-2 mRNA in some of the decidual cells indicates that these cells are also actively involved in the placentation process.

[Improved prenatal diagnostic possibilities for congenital abnormalities and chromosomal disorders. Advantages and disadvantages of screening and diagnostic methods]. / Bedre praenatale undersøgelsesmuligheder for medfødte misdannelser og kromosomsygdomme. Fordele og ulemper ved screening og diagnostik.

Significant progress has taken place in recent years regarding prenatal screening and diagnosis of severe foetal malformations and chromosomal disorders. This review describes blood sample screening in 15-16 week of pregnancy compared with the other prenatal examinations such as amniocentesis and chorionic villus sampling. Serological screening of all pregnant women based on a blood sample taken at 15-16 weeks of pregnancy would lead to identification of about 70% of the screened women having to undergo a conclusive investigation i.e. either a thorough ultrasound examination or an amniocentesis. This is compared with the present Danish prenatal program, where invasive examinations are carried out in about 13% pregnant women without a high detection rate for malformations and chromosome disorders. The Danish National Health Board has recently published new guidelines where the blood test is primarily offered to pregnant women over 34 years of age and not to all pregnant women as in many other countries.

Plasminogen activators and plasminogen activator inhibitor in portal blood from patients with and without gastric malignancy.

BACKGROUND: Plasminogen activators (PA) may be released by the gut and eliminated by the liver. Patients with liver disorders or malignancy often have abnormal plasma levels of PAs. Some tumours may produce PAs. METHODS: In patients undergoing gastric surgery for malignant (n = 18) or benign (n = 21) disorders., blood drawn from the portal vein and a peripheral vein was analysed for tissue-type plasminogen activator antigen and activity (tPA: Ag, tPA: Act), single-chain urokinase-type plasminogen activator activity (scuPA: Act), and plasminogen activator inhibitor antigen and activity (PAI: Ag, PAI: Act). RESULTS AND CONCLUSIONS: In both groups tPA: Act and scuPA: Act levels were significantly higher in portal blood than in peripheral blood, but tPA: Ag and PAI: Act levels did not differ. PAI: Act levels were significantly lower in patients with malignant disease, but levels of the other markers did not differ in the two groups.