Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer.

BACKGROUND: Intraoperative tumour perforation, positive tumour margins, wound complications and local recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer. An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor. The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients. METHODS: The principles of operation are that the mesorectum is not dissected off the levator muscles, the perineal dissection is done in the prone position and the levator muscles are resected en bloc with the anus and lower rectum. The perineal defect is reconstructed with a gluteus maximus flap. Between 2001 and 2005, 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital. RESULTS: Two patients had ypT0 tumours, 20 ypT3 and six ypT4 tumours. Bowel perforation occurred in one, the circumferential resection margin (CRM) was positive in two, and four patients had local perineal wound complications. Two patients developed local recurrence after a median follow-up of 16 months. CONCLUSION: The extended posterior perineal approach with gluteus maximus flap reconstruction in APR has a low risk of bowel perforation, CRM involvement and local perineal wound complications. The rate of local recurrence may be lower than with conventional APR.

Epidemiology of liver injuries.

BACKGROUND AND AIMS: The aim of this study was to investigate the epidemiology of liver injuries and to grade injuries according to the Organ Injury Scale in a population-based study in Stockholm County comprising 1.75 million inhabitants. MATERIAL AND METHODS: Cases were retrieved from the National Board of Forensic Medicine and Public Health and Medical Services Committee Register. Autopsy reports and patients files were studied for liver injuries, associated injuries, age, sex, trauma mechanism, location of the injury, description of the injury, diagnostic and treatment modalities when available. RESULTS: The incidence of traumatic liver injury in 1996 and 1997 was 2.95/100 000 annually. Seventy seven autopsies with liver injuries revealed injury pattern of grade I in 6 cases (8%), grade II in 10 cases (13%), grade III in 21 cases (27%), grade IV in 15 cases (19%), grade V in 16 cases (21%) and grade VI in 9 cases (12%). Twenty four patients revealed injury pattern of grade II in 13 cases (46%), grade III in 4 cases (14%), grade IV in 5 cases (18%) and grade V in 2 cases (7%). CONCLUSIONS: The results demonstrate a low incidence of liver injuries in the studied population. Grade II and III injuries prevail. Surgical management of liver injuries is an infrequent treatment option in Stockholm County and simple operative measures were applied. No complex hepatic injuries were operated upon.

Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance.

In severe catabolic states, such as burn injury, sepsis and accidental injury, a state of marked insulin resistance is encountered. Insulin resistance is also present after elective surgical treatment, more pronounced with increasingly greater magnitude of operation performed. Results of recent animal experiments have shown that even short periods of food deprivation, reducing carbohydrate reserves, alter responses to stress. This notion resulted in our questioning the rationale of carbohydrate depletion associated with overnight preoperative fasting. Twelve patients undergoing elective open cholecystectomy were randomly given no infusion (control group) or 5 milligrams per kilogram per minute of glucose infusion (glucose group) during preoperative overnight fasting. Insulin sensitivity (M value, milligram per kilogram per minute) was determined using the hyperinsulinemic normoglycemic clamp (plasma insulin level, 65 microunits per milliliter and blood glucose level, 4.5 millimoles per liter) before and the first postoperative day. Preoperative insulin sensitivity was similar in the two groups. Postoperatively, M values decreased by 55 +/- 3 percent (control group) and by 32 +/- 4 percent (glucose group) (p < 0.01). Plasma levels of insulin, c-peptide, glucagon, growth hormone, catecholamines and cortisol in connection with clamps were similar in both groups preoperatively and postoperatively. The present results indicate that active preoperative carbohydrate preservation may improve postoperative metabolism because postoperative occurrence of insulin resistance was reduced with preoperative glucose infusion.

Insulin resistance after abdominal surgery.

A study was carried out to determine the time course and degree of postoperative insulin resistance in patients undergoing elective abdominal surgery. Mean(s.e.m.) insulin sensitivity was determined before and on the first (n = 10), fifth, ninth and 20th (n = 5) days after elective open cholecystectomy using the normoglycaemic (4.7(0.1) mmol/l), hyperinsulinaemic (402(12)pmol/l) glucose clamp technique. Preoperative insulin sensitivity expressed as the M value varied from 2.3 to 8.2 mg per kg per min. The relative reduction in insulin sensitivity was most pronounced on the first day after surgery, at a mean(s.e.m.) of 54(2) per cent. Thereafter, a large variation between individuals was found during the course of recovery, and insulin sensitivity returned to normal 20 days after operation. On the first day after surgery, plasma concentrations of glucose, C peptide, noradrenaline and glucagon were slightly but significantly higher than before operation (P < 0.05), whereas insulin, growth hormone, cortisol and adrenaline levels were unaltered. Marked insulin resistance thus develops after elective upper abdominal surgery and persists for at least 5 days after operation. Factors other than simultaneous changes in levels of the hormones studied seem to regulate the maintenance of postoperative insulin resistance.

Development of postoperative insulin resistance is associated with the magnitude of operation.

OBJECTIVE: To study the development of insulin resistance and changes in stress hormone concentrations in patients undergoing elective operations of different magnitude. DESIGN: Prospective open study. SETTING: University hospital, Sweden. SUBJECTS: 12 otherwise healthy patients, undergoing elective surgery for cholecystectomy (n = 6) and inguinal hernia repair (n = 6). INTERVENTIONS: Insulin sensitivity was measured by the normoglycaemic, hyperinsulinaemic glucose clamp technique before operation (control) and on the first postoperative day. MAIN OUTCOME MEASURE: Relative insulin sensitivity (compared with preoperative) on the day after each operation. Changes in stress hormone concentrations in relation to the relative change in insulin sensitivity. RESULTS: After hernia repair, mean (SEM) insulin sensitivity was reduced by 32 (4)%, p < 0.05 compared with baseline, and after open cholecystectomy by 56 (3)%, (p < 0.05). The difference between the two groups was highly significant (p < 0.01). The changes in concentrations of catecholamines, glucagon, cortisol and growth hormone after operation were only small, and did not correlate with the relative changes in insulin sensitivity. CONCLUSIONS: Insulin resistance develops even after a minor elective operation, (inguinal hernia repair). The degree of postoperative insulin resistance was more pronounced after open cholecystectomy. The alteration in insulin sensitivity could not be related to simultaneous changes in the hormones studied.

Effects of lower limb unloading on skeletal muscle mass and function in humans.

A model to simulate effects of microgravity on skeletal muscle mass and function in humans has been developed. Unilateral lower limb unloading that allowed ankle, knee, and hip joint mobility was conducted in six healthy men by suspending one lower limb and having the subjects walk on crutches. They performed maximal unilateral concentric or eccentric quadriceps actions at different angular velocities before and after 4 wk of suspension and after 4 days and after 7 wk of uncontrolled recovery. Peak torque (PT) and angle-specific torque (AST) were measured. Muscle cross-sectional area (CSA) and radiological density (RD) of the thigh were assessed by means of computerized tomography. Concentric and eccentric PT and AST across speeds decreased (P less than 0.05) by 22 and 16%, respectively, in response to unloading. At 4 days of recovery PT (-11%) and AST (-7%) were still lower (P less than 0.05) than before. Muscle CSA and RD decreased (P less than 0.05) by 7 and 6%, respectively. After 7 wk of recovery PT, AST, CSA, and RD had returned to normal. The control limb showed no changes over the experimental period except for a 6% decrease (P less than 0.05) in RD. It is suggested that this human model of unloading could serve to simulate effects of microgravity on skeletal muscle mass and function because reductions in muscle mass and strength were of similar magnitude to those produced by bed rest.

Aggressive mesenteric fibromatosis. Case report.

A 34-year-old man was found to have rectal adenocarcinoma 4 years after diagnosis of mesenteric fibromatosis. Radical excision of the fibromatosis was not feasible and the fibromatous infiltration slowly progressed retroperitoneally, obstructing ureters and colon. Patients with abdominal fibromatosis may be at a risk of developing colonic carcinoma due to coexisting colonic adenomatosis.

Human growth hormone: friend or foe in sports medicine?

The authors discuss the nature and potential of human growth hormone and the possibility that its misuse as a "doping" agent may lead to restrictions and hamper research.

Muscle fiber type changes in human skeletal muscle after injuries and immobilization.

Eight athletes operated on for knee injuries were followed with muscle biopsies before and at various intervals after surgery and immobilization. A statistically significant change of the muscle fiber distribution was found. The percentage type I fibers dropped from an average of 54% to 43%. One competitive cross-country skier showed a dramatic drop from 81% type I fibers at surgery to 58% type I fibers six weeks later. After beginning training he returned to 85% type I fibers. One athlete who had been operated and immobilized for long periods several times showed a drastic difference in fiber type distribution between his two thighs with 20% type I fibers in the injured leg and 69% type I fibers in his uninjured leg. After three years of training his fiber type composition in the injured leg returned toward the fiber type distribution of the uninjured thigh. It is evident that muscle fiber type composition can change. The most probable reason for this is that the drastic change from hard sports training to nearly complete immobilization influences both the muscle itself and its innervation and causes this change of fiber types.

Calf muscle atrophy and muscle function after non-operative vs operative treatment of achilles tendon ruptures.

Fifteen operatively and eight non-operatively treated subcutaneous achilles tendon ruptures were randomly selected from 120 surgically and 35 non-surgically treated patients. Their calf muscle function was studied three to five years after treatment. Non-operatively treated patients were found to have a significantly impaired dynamic muscle function of the calf muscles when tested in a specially constructed heel-raise test device. Operatively treated patients did not show any significant impairment of their muscle function. Measurement of muscle area with CT-scanning showed a significant reduction of the calf muscle in the non-operatively treated patient while no such difference could be found in the operatively treated patients. Isokinetic muscle torque did not differ in the two groups of patients, thus Cybex-measurements do not seem to be a discriminating method in studying muscle function after achilles ruptures. On the basis of our findings we recommend that all athletes with achilles tendon ruptures be treated surgically. In non-athletes and older patients non-operative treatment might be considered.

Knee arthroscopy with local anesthesia in ambulatory patients. Methods, results and patient compliance.

Knee arthroscopy in locally anesthetized ambulatory patients has been performed by filling the knee joint with 50 ml to 60 ml of 0.5% prilocaine, with adrenaline and with additional local infiltration at the sites of puncture. During the arthroscopic procedure the joint cavity is further distended with a mixture of the same local anesthetic diluted 1:10 with physiological saline or Ringer's acetate. During a normal arthroscopy of the knee joint about 500 mg of the local anesthetic is used. In 17 patients the blood concentrations of the local anesthetic used was measured 2.5 min to 135 min after instillation. The highest plasma levels found (after 60 min to 120 min) were still 10 to 15 times lower than an acceptable upper plasma level. These low blood levels probably depend on a slow absorption and that a considerable amount of the local anesthetic is washed out after the arthroscopy. A questionnaire was sent to 278 patients who during a two year period had undergone arthroscopy as an outpatient procedure. The degree of satisfaction for the anesthetic procedure was highest for general anesthesia where 97% were completely satisfied. Sixty-four percent were satisfied when given spinal anesthesia. However, 11% had to be put to sleep due to insufficient spinal block and 12% had headaches more than one day after outpatient spinal anesthesia. Seventy-seven percent were satisfied with local anesthesia. There was no statistical difference between the degree of satisfaction after local or spinal anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the posterior cruciate ligament.

Presented is a three to eight year follow up of reefing of the posterior cruciate in 20 cases, and reconstruction of the posterior cruciate with a patellar tendon, quadriceps tendon flap as a "reversed Jones' procedure" in 10 cases. Using the reefing procedure, there were six excellent results, ten acceptable, and four poor results. The reconstruction resulted in no excellent results, six acceptable, and four unchanged. Further improvements in present techniques are necessary before satisfactory results following reconstruction of the posterior cruciate ligament can be routinely expected.

Five- to ten-year follow-up evaluation after reconstruction of the anterior cruciate ligament.

Long-term follow-up evaluation of a large number of patients who had undergone reconstruction of the anterior cruciate ligament (ACL) was performed. Of these patients, 87 were treated by reconstruction with the medial one third of the medial patellar tendon, and they were examined a mean of 7.9 years after surgery. All patients were extensively evaluated and examined by standard clinical techniques and a machine specifically designed to quantify primary laxity during the anterior drawer and Lachman tests. Seventy-one percent of the patients were satisfied with the results, and 69% had good to excellent results by the authors' subjective functional criteria. Patients who had the least motion and the best check or end points to the Lachman and anterior drawer tests had the best functional results. Only ten of the 27 unsatisfactory results occurred because of complete failure of the graft. Arthrosis and parapatellar pain were the most frequently observed contributing factors to failure in the presence of a clinically intact ligament (11 instances each).

Studies on steroid receptors in human and rabbit skeletal muscle - clues to the understanding of the mechanism of action of anabolic steroids.

The mechanism of action of steroid hormones in target tissues include the binding of the steroid molecule to specific receptors in the cytoplasm. Steroid receptors may therefore be regarded as mediators of hormone action. The presence of such receptors in tissues reflects their hormone-sensitivity and the receptor levels are indicative of the relative potential for a direct hormonal action on the tissue in question. Using 3H-labeled synthetic ligands and a charcoal adsorption assay, the presence of specific androgen, glucocorticoid and estrogen (in rabbits only) receptors was demonstrated in human and rabbit skeletal muscle cytosol. These tissues can therefore be regarded as targets for these steroids. Scatchard analysis was then used to quantitate the receptors in muscle in different conditions. In back muscle of scoliotic patients, the concentrations of androgen and glucocorticoid receptors were similar on the convex and concave sides, except the concentration of glucocorticoid receptors (per g of wet weight), which was higher on the convex side. The tissue concentration (per g of wet weight) of glucocorticoid and estrogen receptors (but not of androgen receptor) was higher in rabbit soleus (slow-twitch) muscle than in the gastrocnemius/plantaris (fast-twitch) muscle complex. When the concentrations were related to the number of nuclei (i.e. expressed per mg of DNA), however, only the estrogen receptor concentration differed between the muscles (higher in soleus). Muscle atrophy in rabbit gastrocnemius muscle was induced by tenotomy or denervation and led to similar changes with an increase with time in androgen and glucocorticoid receptor levels (expressed per g of wet weight or per mg of protein) and a concomitant loss of muscle weight and protein. The total muscle content of receptors or the receptor concentration expressed per mg of DNA were also increased, but to a lesser extent. Synthetic anabolic-androgenic steroids can act directly on skeletal muscle in view of their capacity to bind to the androgen receptor as shown in the present study. Relative binding affinities of anabolic-androgenic steroids to the androgen receptor were similar in rabbit and rat skeletal muscle and in rat prostate. The protein/DNA ratio in the muscle samples was used as an estimation of the size of the "functional DNA-unit". The results indicate that slow-twitch fibers have smaller "DNA units", but also that muscle atrophy causes a decrease of the size of the "DNA unit".(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of electrical stimulation on human skeletal muscle.

The acute and adaptive effects of electrical stimulation of the quadriceps muscle were investigated in healthy male volunteers. The acute effects, i.e., depletion of phosphagen and glycogen stores and formation of lactate as well as decreases in certain enzyme activities, were similar to those found earlier for intense muscular exercise. Intermittent electrical stimulation for 4 to 5 weeks did not cause any significant changes in enzyme activities, muscle fiber characteristics, or mitochondrial properties. A 4-week period of electrical stimulation resulted in improvements of muscle strength comparable to the results of a corresponding program of voluntary training. However, the effects of electrical stimulation appeared more "position-specific" and less "speed-specific" than those of voluntary training with slow isokinetic contractions.