Pregnancy-specific glycoproteins function as immunomodulators by inducing secretion of IL-10, IL-6 and TGF-beta1 by human monocytes.

PROBLEM: Low levels of pregnancy-specific glycoproteins (PSGs) in maternal serum have been correlated with complications of pregnancy. We investigated the ability of human PSGs to regulate in vitro production of cytokines. METHOD OF STUDY: Human monocytes and murine RAW 264.7 cells were treated with recombinant PSG1, PSG6, PSG11, or a truncated PSG6 consisting of only the N-terminal domain (PSG6N). Cytokine production in response to PSG-treatment was measured by ELISA and/or reverse transcriptase-PCR. RESULTS: All PSGs tested induced secretion of interleukin (IL)-10, IL-6 and transforming growth factor (TGF)-beta1 by both human and murine cells, but not IL-1beta, tumor necrosis factor (TNF)-alpha or IL-12. The N-terminal domain of PSG6 was sufficient for induction of monocyte cytokine secretion. Induction of IL-10 and IL-6 was preceded by an increase in the specific mRNAs. CONCLUSIONS: PSG1, PSG6, PSG6N, and PSG11 induce dose-dependent secretion of anti-inflammatory cytokines by human monocytes. Human and murine PSGs exhibit cross-species activity. Our results are consistent with a role for PSGs in modulation of the innate immune system.

Surgical results of secondary glaucomas in childhood.

OBJECTIVE: This study aimed to describe results of glaucoma surgeries performed at one institution over the past 20 years in children with aphakia, aniridia, anterior segment dysgenesis, and other secondary glaucomas. DESIGN: The study design was a retrospective review. PARTICIPANTS: Fifty-eight eyes of 40 patients were studied. INTERVENTION: Trabeculectomy with or without mitomycin C, Molteno implantation, goniotomy, sclerostomy, endolaser cyclophotocoagulation, and cyclocryotherapy were performed. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) control, defined as complete success (IOP < or = 21 without medications) or qualified success (IOP < or = 25 without medications or IOP < or = 21 with medications) and postoperative visual acuity stability were assessed. RESULTS: One hundred thirty surgical procedures were performed on 58 eyes of 40 patients; follow-up averaged 7.3 years. Intraocular pressure control was achieved in 40 (70%) of 57 eyes after 1 or more procedures. Intraocular pressure control and stabilization of visual acuity and optic disc appearance were achieved in 28 (51%) of 55 eyes. Five eyes had significant postoperative complications. Trabeculectomy with mitomycin C controlled IOP on last visit in 8 of 13 eyes with aphakic glaucoma. CONCLUSIONS: Surgical intervention can control IOP and prevent visual loss in children with secondary glaucomas. In the authors' experience, a filtering procedure is the most effective treatment in aphakic glaucoma and anterior segment dysgenesis.

Resolution of astigmatism after surgical resection of capillary hemangiomas in infants.

OBJECTIVE: The goal of the study was to assess the affect of early surgical resection of capillary hemangiomas on the induced astigmatism of infants. DESIGN: Cohort study. PARTICIPANTS: Three infants younger than 9 months of age are included. INTERVENTION: Total resection of the astigmatism-inducing hemangiomas was performed. MAIN OUTCOME MEASURES: Refractive change in the eye operated on was measured and the cosmetic results were observed. RESULTS: Preoperative and postoperative cylinder reduction in the three patients were 8 diopters (D) to 0 D, 3 D to 0 D, and 4.5 D to 1 D, respectively. All patients had excellent cosmetic results, and there were no postoperative complications. CONCLUSIONS: Surgical resection of adnexal hemangiomas in carefully selected infants can lead to excellent cosmetic results. If the mass-induced pressure on the infant sclera is relieved at a young enough age, anisometropia and resultant amblyopia can be eliminated.

Capsular management and refractive error in pediatric intraocular lenses.

BACKGROUND: Guidelines for intraocular lens (IOL) implantation in children regarding patient selection, age limitations, operative techniques, including management of the posterior capsule, and refractive goals are not universally agreed on. METHODS: The authors placed posterior chamber IOLs in the capsular bag of 79 eyes in 57 children. Patient age ranged from 10 months to 17 years. Follow-up averaged 2 years. Patients were selected on the basis of age, cataract morphology, laterality, and lack of potential complicating factors. In general, postoperative refractions were intended to be mildly hyperopic with the magnitude dependent on patient age. RESULTS: Seventy-nine percent of patients able to report a postoperative visual acuity showed 20/40 or better visual acuity. Vision was limited by amblyopia in the remaining patients. There were no significant complications. The posterior capsule opacified on average 2 years after surgery regardless of patient age. CONCLUSIONS: Implantation of posterior chamber IOLs in carefully selected children appears to be effective and safe. Consideration should be given to primary posterior capsulectomy-anterior vitrectomy at the time of lens implant in children who are not expected to be candidates for yttrium aluminum garnet (YAG) capsulotomy within 18 months of surgery.

Open versus stereotactic breast biopsy.

BACKGROUND: Stereotactic breast biopsy has been developed as a less invasive means of performing biopsy for mammographic abnormalities. METHODS: From July 1994 through June 1995, 103 women with mammographic abnormalities requiring biopsy were prospectively evaluated. RESULTS: Fifty-one women had open biopsy, and 52 women had stereotactic biopsy. The average age in both groups was 60 years. Pathology revealed malignancy in 12% of stereotactic biopsies and 13% of open biopsies. Complications occurred in 6% of the open biopsies and 4% of the stereotactic biopsies and were limited to hematomas or seromas. The average cost was $2400 for open biopsy and $650 for stereotactic biopsy (P < 0.01). One hundred and one patients returned for a follow-up mammogram within 6 months, and 1 patient in each group required a second biopsy, which revealed benign pathology. A Patient Satisfaction Survey revealed no significant differences in patient satisfaction between the two types of procedures. CONCLUSION: There were no differences between open and stereotactic biopsies in regards to diagnostic accuracy, complications, or patient satisfaction. A significant difference was noted in charges during the time frame of our study.

A prospective randomized trial comparing open versus laparoscopic appendectomy.

OBJECTIVE: The authors determined whether there was an advantage to laparoscopic appendectomy when compared with open appendectomy. SUMMARY/BACKGROUND DATA: The advantages of laparoscopic appendectomy versus open appendectomy were questioned because the recovery from open appendectomy is brief. METHODS: From January 15, 1992 through January 15, 1993, 75 patients older than 9 years were entered into a study randomizing the choice of operation to either the open or the laparoscopic technique. Statistical comparisons were performed using the Wilcoxon test. RESULTS: Thirty-seven patients were assigned to the open appendectomy group and 38 patients were assigned to the laparoscopic appendectomy group. Two patients were converted intraoperatively from laparoscopic appendectomies to open procedures. Thirty-one patients (81%) in the open group had acute appendicitis, as did 32 patients (84%) in the laparoscopic group. Mean duration of surgery was 65 minutes for open appendectomy and 87 minutes for laparoscopic appendectomy (p < 0.001). There were no statistically significant differences in length of hospitalization, interval until resumption of a regular diet, or morbidity. Duration of both parenteral and oral analgesic use favored laparoscopic appendectomy (2.0 days versus 1.2 days, and 8.0 days versus 5.4 days, p < 0.05). All patients were instructed to return to full activities by 2 weeks postoperatively. This occurred at an average of 25 days for the open appendectomy group versus 14 days for the laparoscopic appendectomy group (p < 0.001). CONCLUSIONS: Patients who underwent laparoscopic appendectomies have a shorter duration of analgesic use and return to full activities sooner postoperatively when compared with patients who underwent open appendectomies. The authors consider laparoscopic appendectomy to be the procedure of choice in patients with acute appendicitis.

Laparoscopic-assisted bowel surgery.

The use of laparoscopic surgical techniques is now being applied to a variety of operations traditionally performed in an open fashion. Twenty patients underwent laparoscopic-guided large and small bowel surgery at our institution from March 1991 to April 1992. The indications for surgery included polyps, obstruction, bleeding, and perforation, and pathologic diagnoses included benign polyps, lipomas, inflammatory bowel disease, perforation of a jejunal diverticulum, colonic arteriovenous malformations, and adenocarcinoma. Mobilization of the colon, ligation of the mesentery, and closure of the mesenteric defect were performed using the laparoscopic equipment. One trocar site was enlarged to 3 cm to deliver the bowel through the abdominal wall. All anastomoses were hand-sewn. Postoperative hospitalization ranged from 2 to 31 days (median, five days). No mortality was noted, and morbidity was 20 percent. We conclude that laparoscopic-guided bowel surgery is technically feasible and should translate into shorter hospitalization and less patient discomfort.

Laparoscopic-directed small bowel resection for jejunal diverticulitis with perforation.

The authors report a case in which an 87-year-old woman underwent diagnostic laparoscopy for abdominal pain of unknown etiology. Jejunal diverticulosis was discovered with diverticulitis and perforation into the mesentery. Visualization of the appendix, ovaries, uterus, colon, and liver ruled out additional pathology. The disease was serious enough that resection of the involved jejunum was necessary. With the aid of the laparoscope, the incision was directed nearer to the area of the disease. A 5 cm left upper quadrant transverse incision was made, allowing removal of perforation and the diseased bowel. Primary resection and anastomosis were performed. This case sets a precedence for use of exploratory diagnostic laparoscopy and particularly small bowel resection for symptomatic diverticulitis. The authors believe that this technique results in less postoperative pain, allowing for a prompt recovery with minimal morbidity and mortality, particularly in the elderly population.

Safety and efficacy of total thyroidectomy for differentiated thyroid carcinoma: a 20-year review.

Controversy continues to exist regarding the optimal extent of resection for differentiated thyroid carcinoma (DTC). Subtotal thyroidectomy has been advocated by some authors in expectation of lower complication rates, while others advocate total thyroidectomy to achieve better cure rates. To examine this issue, the medical records of 124 patients who underwent total thyroidectomy for DTC were retrospectively reviewed. Total thyroidectomy was the initial procedure in 115 patients, while nine patients had complete thyroidectomy following some type of subtotal resection. Concomitant procedures were performed in 47 patients. Ninety papillary, 20 mixed papillary-follicular variant, one Hürthle cell type, and 13 follicular carcinomas were performed. Tumors were bilateral or multicentric in 40 patients, with metastases present in one-third of patients at the same time of initial operation. Permanent hypoparathyroidism developed in two patients, and permanent ipsilateral recurrent laryngeal nerve palsy occurred in one patient, for an overall significant complication rate of 2.4 per cent. Tumor recurrence was noted at a mean of 19 months postoperatively in 14 patients. Ninety-six patients received adjuvant postoperative radioiodine therapy to ablate residual functioning thyroid tissue or suspected metastases. We conclude that total thyroidectomy as treatment for differentiated thyroid carcinoma carries a low rate of morbidity, treats occult contralateral disease, and should facilitate radioiodine scanning and ablation of residual functioning thyroid tissue or metastatic disease.

What are the contraindications for laparoscopic cholecystectomy?

Acute cholecystitis, morbid obesity, and previous upper abdominal surgery have been reported as relative contraindications to laparoscopic cholecystectomy. An analysis of 706 laparoscopic cholecystectomies performed at our institution was undertaken to determine if these relative contraindications led to increased morbidity, an increased rate of conversion to the open technique, or longer operating time. One hundred ninety-seven patients demonstrated one or more relative contraindications to laparoscopic cholecystectomy. Morbidity was not increased in patients with these risk factors, but conversion to open cholecystectomy was required in a greater percentage of patients with acute cholecystitis. We favor an attempt at laparoscopic cholecystectomy in patients with these risk factors; however, they should be counseled as to the increased risk of conversion to open cholecystectomy in the presence of acute cholecystitis.

Open versus laparoscopic cholecystectomy. A comparison of postoperative pulmonary function.

Upper abdominal surgery is associated with characteristic changes in pulmonary function which increase the risk of lower lobe atelectasis. Sixteen patients undergoing open cholecystectomy and 20 patients undergoing laparoscopic cholecystectomy were prospectively evaluated by pulmonary function tests (forced vital capacity [FVC], forced expiratory volume [FEV-1], and forced expiratory flow [FEF] 25% to 75%) before operation and on the morning after surgery to determine if the laparoscopic technique lessens the pulmonary risk. Fraction of the baseline pulmonary function was calculated by dividing the postoperative pulmonary function by the preoperative pulmonary function and multiplying by 100%. Postoperative FVC measured 52% of preoperative function for open cholecystectomy and 73% for laparoscopic cholecystectomy (p = 0.002). Postoperative FEV-1 measured 53% of baseline function for open cholecystectomy and 72% for laparoscopic cholecystectomy (p = 0.006). Postoperative FEF 25% to 75% measured 53% for open cholecystectomy and 81% for laparoscopic cholecystectomy (p = 0.07). It is concluded that laparoscopic cholecystectomy offers improved pulmonary function compared to the open technique.

Subacute sequelae of carbon monoxide poisoning.

From January 1980 to August 1983, 213 patients with carbon monoxide poisoning were seen; 131 received hyperbaric oxygen and had no sequelae. Eighty-two patients were treated with normobaric oxygen; ten (12.1%) returned with clinically significant sequelae. The specific neurological sequelae included headaches, irritability, personality changes, confusion, and loss of memory. This recurrent symptomatology developed within one to 21 days (mean, 5.7 days) after the initial exposure, although no reexposure occurred. These recurring symptoms resolved rapidly with hyperbaric oxygen therapy. We recommend that hyperbaric oxygen therapy be used whenever CO poisoning symptoms recur.

Cutaneous blisters and carbon monoxide poisoning.

We present the cases of three patients with skin blisters following carbon monoxide (CO) poisoning. Their blisters appeared to be related to the severity of the poisoning (HbCO levels of more than 40%). Two of the three patients died despite aggressive initial 100% surface oxygen followed by hyperbaric oxygen therapy. The pathophysiology of this type of blister remains unresolved. It could result from pressure necrosis alone or from a combination of pressure necrosis and direct CO inhibition of tissue oxidative enzymes. Although skin involvement as a result of CO poisoning is less frequently reported today than in the past (perhaps because of misidentified burns or because of more aggressive resuscitation and treatment protocols), the physician should recognize that such blisters may signal severe CO poisoning.

Surgical treatment of low-lying carcinoma of the rectum.

The standard operative treatment of low-lying rectal cancer has been abdominoperineal resection. In the elderly patient, this treatment has significant risk. One-fourth of the patients had major complications and another one-fourth had minor complications. The operative mortality was 6.8 per cent for patients 65 years of age and over and 7.7 per cent for patients 70 years old and over. Patients with metastatic disease at the time of diagnosis had a dismal prognosis despite treatment with abdominoperineal resection. Postoperative pelvic radiotherapy should help reduce pelvic recurrence. Generally, patients with tumors less than 5 cm in diameter and less than 5 cm from the dentate line should be considered for initial transanal excision. It appears that very good local tumor control can be achieved by transanal excision for tumors confined to the bowel wall. Only 6.9 per cent of patients with tumors confined to the bowel wall had lymph node metastasis. The low risk of occult lymph node metastasis from tumors confined to the bowel wall is offset by the operative risk of abdominoperineal resection. Further evaluation of transanal excision of selected rectal cancers is indicated. Patients with villous adenomas with superficial carcinoma can be adequately treated repetitively with transanal local excision. In this case, there was a 50 per cent local recurrence rate. Local recurrence occurred in some patients five or more years after the initial treatment, thus emphasizing the need for prolonged close proctoscopic follow-up.

Coexisting carcinoid tumor and Crohn's disease.

Several malignancies have been described occurring simultaneously with regional enteritis. Only four examples of coexistent carcinoid and Crohn's disease have been described worldwide. In this report, two new cases of simultaneous Crohn's disease and carcinoid tumor, diagnosed and treated within a single month, are presented. In one instance, a segment of terminal ileum contained regional enteritis, carcinoid tumor, and a small focus of adenocarcinoma.

Diagnosis and treatment of intra-abdominal abscess in critically ill patients.

Intra-abdominal abscess remains a challenging clinical problem. Patients are frequently critically ill with major organ system failure. An aggressive diagnostic and therapeutic approach is mandated. Application of newer imaging techniques should allow a better than 90 per cent accuracy of abscess localization. Clearer definition of the abscess cavity by ultrasound or computerized tomography facilitates planning of surgical drainage route preoperatively. Ultrasound and computerized tomography have also allowed directed percutaneous aspiration of intra-abdominal fluid collections for diagnosis. In selected patients, percutaneous drainage has the proven capability to completely resolve a large percentage of intra-abdominal abscesses. Final application of this technique awaits further study.

Value of hyperbaric oxygen in suspected carbon monoxide poisoning.

The cases of four patients included sufficient circumstantial evidence to suspect carbon monoxide poisoning as the principal etiologic agent, although the diagnosis was unconfirmed. In two other patients, CO poisoning was proven by elevated carboxyhemoglobin levels. All six patients were transferred from outlying hospitals for failure to respond adequately to standard therapy and recovered completely following treatment with hyperbaric oxygen. Hyperbaric oxygen should be used for severe cases of suspected CO poisoning, regardless of the time between exposure and presentation, especially when the delay is sufficient to preclude a diagnosis by standard laboratory methods.