Progress in dodecafluoropentane emulsion as a neuroprotective agent in a rabbit stroke model.

Dodecafluoropentane emulsion (DDFPe) in 250 nm nanodroplets seems to swell modestly to accept and carry large amounts of oxygen in the body at >29 °C. Small particle size allows oxygen delivery even into hypoxic tissue unreachable by erythrocytes. Using permanent cerebral embolic occlusion in rabbits, we assessed DDFPe dose response as a neuroprotectant at 7 and 24 h post-embolization without lysis of arterial obstructions and investigated blood pharmacokinetics. New Zealand White rabbits (N = 56) received cerebral angiography and embolic spheres (diameter = 700-900 µm) occluded middle and/or anterior cerebral arteries. Intravenous DDFPe dosing (2 % w/v emulsion) began at 60 min and repeated every 90 min until sacrifice at 7 or 24 h post-embolization. Seven-hour groups: (1) control (embolized without treatment, N = 6), and DDFPe treatment: (2) 0.1 ml/kg (N = 7), (3) 0.3 ml/kg (N = 9), (4) 0.6 ml/kg (N = 8). Twenty-four-hour groups: (5) control (N = 16), and DDFPe treatment: (6) 0.1 ml/kg (N = 10). Infarcts as percent of total brain volume were determined using vital stains on brain sections. Other alert normal rabbits (N = 8) received IV doses followed by rapid arterial blood sampling and GC-MS analysis. Percent infarct volume means significantly decreased for all DDFPe-treated groups compared with controls, p = <0.004 to <0.03. Blood DDFP (gas) half-life was 1.45 ± 0.17 min with R = 0.958. Mean blood clearance was 78.5 ± 24.9 ml/min/kg (mean ± SE). Intravenous DDFPe decreases ischemic stroke infarct volumes. Blood half-life values are very short. The much longer therapeutic effect, >90 min, suggests multiple compartments. Lowest effective dose and maximum effective therapy duration are not yet defined. Rapid development is warranted.

Total gastrectomy with extended lymphadenectomy for "curable" stomach cancer: experience in a non-Japanese Asian center.

BACKGROUND: Gastrectomy with extended lymphadenectomy is the advocated treatment in Japan for patients with "curable" stomach cancer. Attempts in units elsewhere adopting this approach failed to show any survival advantage, and the high operative mortality has prevented global acceptance of the operation. This study examines the safety and efficacy of radical gastrectomy in a Far East center outside Japan. STUDY DESIGN: A consecutive series of 121 patients with gastric cancer who fulfilled criteria for radical surgery had total gastrectomy with extended lymphadenectomy equivalent to D3 dissection over a 6-year period in a single unit. RESULTS: The operation carried a morbidity of 50%, with a perioperative mortality of 5%. Survival was best predicted by tumor stage: 5-year survival for patients with intact gastric serosa was 64%, versus 10% for those with serosal penetration (p < 0.001). The majority of documented metastases occurred by transperitoneal route in serosa-positive patients, but via the hematogenous mechanisms in those who were serosa-negative. CONCLUSIONS: Radical gastrectomy with extended lymphadenectomy carries high operative morbidity. Increased mortality occurred because of loco-regional recurrence in patients with T3/T4 diseases. Novel approaches including neoadjuvant treatment or regional therapy should be explored.

Laparoscopic management of blunt diaphragmatic injury.

BACKGROUND: Diaphragmatic injury is difficult to diagnose using current radiological modalities, and missed diagnosis has been associated with a mortality of 20-36%. Laparotomy is the most sensitive of the standard diagnostic tools, but its unnecessary use can be up to 25% and carries a morbidity of 20%. METHODS: The use of the laparoscope in three cases of blunt diaphragmatic injury is reported here. Two cases were non-acute. The diagnosis of diaphragmatic injury could not be confirmed pre-operatively in any of the cases. RESULTS: One, a left-sided injury, was easily diagnosed and repaired laparoscopically. The second, right-sided, was confirmed laparoscopically but had to be repaired by open due to difficulty with liver retraction. The third case, an acute injury, was not diagnosed at laparoscopy. Findings of free blood and distended small bowel warranted laparotomy and prevented the establishment of a safe, satisfactory pneumoperitoneum. Repair was performed open. None of the cases was complicated by pneumothorax. CONCLUSIONS: Laparoscopy is a useful tool for diagnosis of non-acute blunt diaphragmatic injury but has limitations in the acute setting. Left-sided injuries can be repaired laparoscopically but right-sided injuries proved difficult and may be better dealt with thoracoscopically.

Assessment of blunt abdominal trauma.

Computerized tomography (CT) scanning and diagnostic peritoneal lavage have often been seen as competing modalities in the assessment of blunt abdominal trauma. Each has its own strengths and weakness. A judicious use of both modalities can result in improved diagnostic accuracy. An algorithm for their appropriate use is suggested.

A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer.

OBJECTIVE: The authors determined if more radical surgery with extended lymphadenectomy improves the results of gastrectomy in patients with adenocarcinoma of the gastric antrum. SUMMARY BACKGROUND DATA: The overall survival in patients with gastric cancer is disappointing. Improved survival has been reported by Japanese authors. Whether this is because of a higher number of early gastric cancers in the Japanese series, different biologic behavior in Asians, or the adoption of radical surgery with lymphadenectomy remains unclear. METHODS: R1 subtotal gastrectomy with omentectomy and R3 total gastrectomy (omentectomy, splenectomy, distal pancreatectomy, lymphatic clearance of the celiac axis, and skeletonization of vessels in the porta hepatis) were evaluated in a prospective, randomized comparison. RESULTS: Fifty-five patients were randomized--25 to the R1 group and 30 to the R3 group. The two groups were comparable for age, sex, tumor size, TNM stage, and length of follow-up. The R3 group had a longer operating time (140 vs. 260 min; p < 0.05), a greater transfusion requirement (0 vs. 2 units, p < 0.05) and a longer hospital stay (8 vs. 16 days; p < 0.05) (medians; Mann-Whitney U test). The only postoperative death was in the R3 group and was caused by intra-abdominal sepsis. Fourteen patients in the R3 group developed left subphrenic abscesses. There were no major complications in the R1 group. Overall survival was significantly better in the R1 group (median survival estimated by Kaplan-Meier method, 1511 vs. 922 days, p < 0.05, log-rank test). CONCLUSIONS: R3 total gastrectomy can be performed with a low mortality, but it has a high morbidity because of intra-abdominal sepsis. The data do not support the routine use of R3 total gastrectomy for treatment of patients with antral cancer.

Laparoscopically assisted anterior resection for villous adenoma of the rectum.

A 57 year old female presented with symptoms from a large, sessile tubulovillous adenoma of the lower third of the rectum. Transanal excision was impracticable due to its size and anterior resection was necessary. The upper third of the rectum was mobilized percutaneously, using the laparoscope. The lower two-thirds of the rectum were mobilized transanally and a non-everted pull-through excision of the lower third was performed, with a hand sewn colo-anal anastomosis. A temporary loop ileostomy was established through a 2.5 cm abdominal incision. Postoperative recovery was uncomplicated. The operative technique, which may have other applications, is described in detail.

Early and late surgical complications of subtotal oesophagectomy for squamous carcinoma of the oesophagus.

The use of stapling devices in oesophagogastric anastomosis has markedly reduced the incidence of anastomotic leakage, but may be associated with a higher incidence of stricture formation. The purpose of this study was to review the incidence, morbidity, management and outcome of leakage and stricture in patients undergoing subtotal oesophagectomy. Seventy-two consecutive patients with proven squamous carcinoma of the thoracic oesophagus who underwent subtotal oesophagectomy and gastric pull-up with stapled anastomosis were studied. Thirty-six patients had the anastomosis constructed using the EEA size 25 mm circular stapler (group 1). Thirty-six patients had oesophagogastric reconstruction using the EEA size 28 mm circular stapler (group 2). Data were collected prospectively, but the groups were not randomized. One clinical/radiological anastomotic leak (3%) occurred using the 25 mm gun (group 1), but no dehiscence was demonstrated in group 2. There was no 30-day mortality, but two patients died before leaving hospital (overall hospital mortality rate, 3%). Early complications included anastomotic bleed, respiratory failure, chylothorax, transient bilateral recurrent laryngeal nerve palsy, and severe chest infections. After surgery, the patients were followed up at 1 month, at 3 months and then at 3-monthly intervals up to 1 year. Stricture formation occurred in 11 patients in group 1 and only four patients in group 2 (chi 2 test P less than 0.05). All benign strictures presented within 6 months of surgery. These strictures were satisfactorily treated by endoscopic dilatation. Two patients (one from each group) suffered anastomotic recurrence of their tumour at 8 and 10 months respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma of the cardia: treatment by thoracoabdominal R3 radical gastrectomy.

The complications and mortality rate of R3 radical gastrectomy using a left thoracoabdominal approach were studied in 38 patients with adenocarcinoma of the gastric cardia. There were two hospital deaths and two anastomotic leaks. There was a high rate of complications following surgery (subphrenic abscess, eight; severe chest infection, five; aspiration pneumonia, two; wound infection, two; and reactivation of tuberculosis, one). The hospital stay ranged from 11 to 39 days (median 21 days). Thirty-five patients had microscopic evidence of serosal involvement (S2). Thirty-three of the patients had lymph node metastases and 17 patients had involvement of N2 nodes. Four patients had histological evidence of residual suture line tumour, but only two of these returned with recurrence at the anastomosis. Follow-up (median 3 years) revealed that splenic artery nodal involvement (N2) did not worsen the prognosis after radical resection. Despite a high complication rate, thoracoabdominal radical gastrectomy is associated with an acceptable perioperative mortality rate, adequate symptom palliation and encouraging medium-term survival. The left thoracoabdominal approach gives excellent exposure for radical resection of cancer of the gastric cardia and should be the procedure of choice for curative resection of this tumour.

Deoxyglucose lumped constant estimated in a transplanted rat astrocytic glioma by the hexose utilization index.

The lumped constant (LC) for calculating the regional glucose (glc) metabolic rate by the deoxyglucose (DG) method was estimated in a transplanted rat glioma and normal rat brain. First, the hexose utilization index (HUI) was measured at 1.5, 3.0, and 4.5 min in right hemisphere glioma implants and uninvolved contralateral hemisphere following bolus intravenous injections of [3H]DG and [14C]glucose. At these times, the glioma HUI values were 0.639, 0.732, and 0.712, respectively, and the coordinate left hemisphere values were 0.432, 0.449, and 0.418. Second, the volumes of distribution of DG and glucose were determined to be 0.436 and 0.235 in glioma implants and 0.402 and 0.237 in left hemisphere, respectively. Third, following simultaneous intracarotid injections of [3H]DG and [14C]glucose, the ratio K1/K1 was 1.1 in glioma grafts and 1.3 in left hemisphere. With these values for HUI, volume of distribution, and K1 ratio, the LC in this rat glioma was estimated to be 2.1 times higher than the left hemisphere LC (p less than 0.02). These results suggest that measurement of brain tumor CMRglc using a normal brain LC may significantly overestimate the true tumor CMRglc.

Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: detection by pulse oximetry.

Oxygen saturation and pulse rate were recorded using pulse oximetry during 50 consecutive endoscopic retrograde cholangiopancreatography (ERCP) examinations. Oxygen saturation dropped to below 90% in 22 patients at some point during the procedure. Multiple regression analysis revealed that increasing age and weight were the most significant variables in predicting tachycardia or hypoxia. These problems cannot be reliably predicted or detected clinically. The use of a pulse oximeter during ERCP is recommended.

Intrathoracic stapled anastomosis after oesophagectomy for cancer.

Fifty consecutive oesophagectomies for cancer are reported which were performed using a two-stage technique with an intrathoracic stapled anastomosis. The oesophagus was resected through a right thoracotomy. Continuity was restored using orthotopic stomach, mobilized through an abdominal incision and anastomosed to the oesophagus at the apex of the thorax. No deaths occurred within 30 days, but two patients died without leaving hospital. Routine contrast study revealed no anastomotic leaks. Major complications were: chylothorax (one), transient bilateral recurrent laryngeal nerve palsy (one), anastomotic bleed (one), respiratory failure (one) and brain abscess (one). Four upper resection margins contained tumour (all in middle third tumours). With this technique, a reliable anastomosis can be made high in the chest. The amount of oesophagus removed is comparable with that obtained with the 'three-stage' or transhiatal procedures. The problem of occult submucosal spread in oesophageal tumours remains.

Cholecystoduodenostomy in the management of complicated duodenal ulcer.

The use of end-to-end cholecystoduodenostomy to close a difficult duodenal stump is described in a patient with duodenal ulcer complicated by haemorrhage, chronic perforation and penetration of the common bile-duct.

Delayed return of gastric emptying after gastroenterostomy.

A retrospective study of patients having gastroenterostomies was undertaken to identify predictive factors for the development of postoperative delayed return of gastric emptying (DRGE). A total of 322 consecutive patients underwent 324 gastroenterostomies; 35 experienced delayed return of gastric emptying. Regression analysis demonstrated preoperative obstruction to be the most significant factor (P less than 0.001). Vagotomy was not an independent variable. Age, sex, size of stoma, anastomotic technique, albumin and experience of the operator were not significant factors. Gastroenterostomy in the presence of 'gastric atony' was likely to produce DRGE. In all, 86 per cent of cases resolved spontaneously. Only one case of DRGE was found to have a mechanical cause. Most patients were supported by parenteral nutrition but, with a knowledge of the identified risk factors, more thought could be given to establishing a route for jejunal feeding at the time of surgery.

Resampling estimates of precision in emission tomography.

Methods for estimating the regional variance in emission tomography images which arise from the Poisson nature of the raw data are discussed. The methods are based on the bootstrap and jackknife methods of statistical resampling theory. The bootstrap is implemented in time-of-flight PET (positron emission tomography); the same techniques can be applied to non-time-of-flight PET and SPECT (single-photon-emission computed tomography). The estimates are validated by comparing them to those obtained by repetition of emission scans, using data from a time-of-flight positron emission tomograph. Simple expressions for the accuracy of the estimates are given. The present approach is computationally feasible and can be applied to any reconstruction technique as long as the data are acquired in a raw, uncorrected form.

Aggressive angiomyxoma of the female pelvis.

A 42 year old female presented with a 6 year history of a perineal mass. Clinically it had all the features of a perineal hernia. Two previous attempts to repair the 'hernia' had been performed. At operation an aggressive angiomyxoma of the female pelvis was identified and resected via an abdomino-perineal combined approach. The case is discussed with reference to the literature.

Leiomyoma of Meckel's diverticulum.

Meckel's diverticulum is a common developmental abnormality of the midgut which may present clinically because of complications. This report describes an unusual clinical presentation of a patient with a large leiomyoma of a Meckel's diverticulum.