Two malignancies or an unusual presentation of a pleural malignancy?

Malignant mesothelioma is primarily located in the pleura. Progression usually involves adjacent tissue invasion. Both lymphatic and haematogenous spreads are possible, but rare. Bone involvement usually means locally invasive disease and rarely bone marrow metastases. In this report we presented two patients with a mesothelioma and bone marrow metastases.

[Donor nephrectomy: less fatigue and better quality of life following laparoscopic kidney removal compared with an open procedure by mini-incision: blind randomised study]. / Donornefrectomie: minder vermoeidheid en meer kwaliteit van leven na een laparoscopische uitname dan na een open ingreep met een mini-incisie: geblindeerd, gerandomiseerd onderzoek.

OBJECTIVE: Determining possible differences in living donor nephrectomy procedures: laparoscopy against mini-incision concerning discomfort to the donor and the maintenance of good graft function. DESIGN: Blind randomized study. METHOD: In two university medical centres, one hundred living kidney donors were randomly assigned to either total laparoscopic donor nephrectomy or mini-incision muscle-splitting open donor nephrectomy. Primary outcome was physical fatigue measured with the 'Multidimensional Fatigue Inventory' (MFI-20) during one-year follow-up. Secondary outcomes were physical function measured with the 'Short form-36' questionnaire, postoperative hospital stay, amount of pain, operating times and graft and patient survival. RESULTS: Donors who underwent laparoscopy experienced less fatigue (difference: -1.3; 95% CI: -2.4 - (-0.1)) and physical function was better (difference: 6.2; 95% CI: 2.0-10.3) during one-year follow-up. Those donors who underwent laparoscopy required less morphine (16 mg versus 25 mg; p = 0.005) and the duration of hospital stay was shorter (3 versus 4 days; p = 0.003). The laparoscopic procedure resulted in a longer operation time (221 versus 164 min; p < 0.001) a longer first warm ischaemia time (6 versus 3 min; p < 0.001) and less blood loss (100 versus 240 ml; p < 0.001). Recipient renal function and one-year graft survival rates did not differ. The number of preoperative and postoperative complications did not differ significantly between both surgery techniques. Conversions did not occur. CONCLUSION: Donor nephrectomy through laparoscopy led to less fatigue and a better quality of life compared with the open procedure. The safety factors for donors and recipients were comparable for both techniques. Laparoscopic donor nephrectomy is therefore the better surgical choice for kidney donor programmes with living donors.

Case report: retroperitoneoscopic tumor nephrectomy during pregnancy.

When considering laparoscopic tumor nephrectomy during pregnancy, questions will arise about the consequences of the increased abdominal pressure (IAP) for uterine-placental perfusion and the impact of carbondioxide insufflation on the fetus. These considerations should be weighed against the advantages for the mother, in term of shorter convalescence and decreased wound problems. This situation presents the urologists with a dilemma. At 16 weeks of gestation, a 30-year-old woman underwent a retroperitoneoscopic tumor nephrectomy. This case report and the following discussion highlight the key issues involved in laparoscopic surgery during pregnancy. In theory, laparoscopy in pregnancy carries some specific hazards, which may influence fetal outcome. First, the elevation of IAP may lead to alterations in placental perfusion, and second, CO2 insufflation may disturb the acid-base balance. However, in a study covering more than 2 million pregnancies, no difference was found in fetal mortality or malformations after laparoscopic surgery for non-obstetric reasons compared with open surgery. Animal experiments have demonstrated an IAP of 15 mm Hg or less to cause almost no reduction in the uterine-placental blood flow. According to our limited experience and with the support of the literature, pneumo(retro)peritoneum during pregnancy seems to be safe.

Randomized clinical trial of ultrasonic versus electrocautery dissection of the gallbladder in laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is frequently complicated by gallbladder perforation and loss of bile or stones into the peritoneal cavity. The aim of this study was to compare the use of ultrasonic dissection and electrocautery with respect to the incidence of gallbladder perforation and intraoperative consequences. METHODS: Between January 1998 and January 2000, 200 patients undergoing elective laparoscopic cholecystectomy were randomized to electrocautery or ultrasonic dissection of the gallbladder. The main outcome measures were gallbladder perforation, operating time and the number of times the lens was cleaned. Univariate and multivariate analyses were performed. RESULTS: The perforation rate differed significantly: 16 per cent for ultrasonic dissection (n = 96) and 50 per cent for electrocautery (n = 103) (P < 0.001). The operating time of the least experienced surgeons, who had performed fewer than ten laparoscopic cholecystectomies, was significantly shorter when ultrasonic dissection was used, compared with electrocautery. The number of times the lens needed to be cleaned was significantly lower when ultrasonic dissection was used in complicated gallbladders (P < 0.035). At logistic regression analysis, the risk of perforation in the electrocautery group was about four times higher (odds ratio 0.26, P < 0.001) than that in the ultrasonic group. When the groups were matched for prognostic factors, including body mass index and surgical experience, the results were similar to those obtained with univariate and multivariate analysis. CONCLUSION: The use of ultrasonic dissection in laparoscopic cholecystectomy reduces the incidence of gallbladder perforation and helps the operation to progress. Less experienced surgeons benefit most from ultrasonic dissection, particularly in complicated intraoperative circumstances.