Hidrosadenoma of the anal canal: a case report with review of the literature.

Hidrosadenoma of the anal canal is an extremely rare tumour. Only nine cases with similar histologic structure have been described in the literature, most representing tumours resected from the anal or rectal mucosa. We present a case of anal hidrosadenoma with immunohistochemical staining features identifying it as a true sweat gland tumour.

[Endoscopic treatment of bleeding gastroduodenal ulcers]. / Endoskopisk behandling af blødende gastroduodenale ulcera.

INTRODUCTION: The aim of this study was to assess the extent to which GI endoscopic treatment of bleeding gastroduodenal ulcers is effective and whether it could reduce the need for surgery. METHODS: A retrospective evaluation was carried out. Over a period of three years (1995-1997), 122 patients with bleeding caused by a gastroduodenal ulcer, defined as fresh haematemesis with or without melaena, old haematemesis with melaena or melaena accompanied by a systolic blood pressure below 80 mmHg, underwent emergency GI endoscopy. Endoscopic therapy consisted of either injection therapy or electrocoagulation. RESULTS: Altogether 72 patients received endoscopic treatment. Primary haemostasis was achieved in 94%. Definitive haemostasis after one endoscopic treatment with either injection therapy or electrocoagulation was achieved in 63% and 62%, respectively. Including repeated endoscopic treatment, definitive haemostasis was achieved in 79%. No direct complications of the treatment were observed. DISCUSSION: Endoscopic treatment of bleeding gastroduodenal ulcers is the only alternative to an operation. Endoscopic treatment can reduce the need for surgery, as it was effective in about 80% of the patients.

[Hepatic metastases disclosed by laparoscopy and echographic laparoscopy. Impact of ultrasound-guided biopsy]. / Métastases hépatiques découvertes par laparpscopie et écho-laparoscopie. Impact de la biopsie échoguidée.

UNLABELLED: The aim of this prospective study was to study the impact of biopsies of liver metastases guided by laparoscopic ultrasound (LUS) and to evaluate various biopsy techniques. MATERIAL AND METHODS: Laparoscopy with LUS was performed on 18 consecutive patients with liver metastases considered to be surgically curable. Any new liver lesion which could lead to a therapeutic modification was biopsied, with a forceps or guided by LUS using four different techniques. RESULTS: Of 17 patients successfully examined, a biopsy was indicated in 12 cases (71%), extension of the surgical procedure was decided in four cases (24%), and laparotomy was avoided in six cases (35%). The preoperative staging was correct in 15 stages (88%) and incorrect in two cases (12%). The positioning of the puncture needle in the axis of the scanning plane by "free hand" or in association with an abdominal transducer was effective, without complications. CONCLUSION: Any liver lesion discovered by LUS which could lead to a modification or abstention of surgery should be biopsied, with LUS-guidance in the case of deep lesions. However, an optimal and universal guiding system for LUS-probes, has not yet been developed.

[Randomized trial and meta-analysis of somatostatin versus placebo in bleeding esophageal varices]. / Randomiseret undersøgelse og metaanalyse af somatostatin over for placebo ved blødende esophagusvaricer.

We studied whether somatostatin or its derivative, octreotide, is more effective than placebo in the treatment of bleeding oesophageal varices in a randomised, double-blind trial and a meta-analysis with blinded data analysis and manuscript writing. Patients suspected of bleeding from oesophageal varices and of having cirrhosis of the liver were eligible. Eighty-six patients were randomised; 16 died in each group within six weeks (95% confidence interval (CI) for difference in mortality -19% to 22%). There were no differences between somatostatin and placebo in median number of blood transfusions (8 vs 5, p = 0.07, CI 0 to 4 transfusions) or in numbers of patients who needed balloon tamponade (16 vs 13, p = 0.54, CI -11% to 28%). In a meta-analysis of three trials, involving 290 patients, somatostatin had no effect on survival compared with placebo (p = 0.59, odds ratio 1.16, CI 0.67 to 2.01). For blood transfusions and use of balloon tamponade there was heterogeneity between the trials with no convincing evidence in favour of somatostatin.

[Pancreaticoduodenectomy (Whipple's operation) for periampullary cancer]. / Pankreatikoduodenektomi (Whipples operation) for periampullaer cancer.

This study evaluated the indications for and effects of pancreaticoduodenectomy (102 patients) or total pancreatectomy (15 patients) with extensive lymph node dissection performed upon 117 patients with periampullary adenocarcinoma. Presenting symptoms and postoperative morbidity and mortality rates were recorded. Cumulative survival rates were evaluated in relation to origin, size, and staging of tumour. The postoperative mortality rate after Whipple's operation was 8% (eight patients). The median survival period was 1.1 year and the overall five year survival rate was 15% (confidence limits, 5 to 25%). The five year survival rate for patients without tumour extension beyond the pancreas was 25% (confidence limits, 5 to 50%), and in patients with adenocarcinoma of the ampulla af Vater, 34% (confidence limits, 3 to 65%). The median survival rate in patients with adenocarcinoma of the ampulla of Vater was 3.3 years, which was significantly longer than in the other patients. Fifty-nine patients with distant spread could be divided into 14 patients with para-aortic lymph node metastases who had a significantly shorter survival period than 45 patients without para-aortic lymph node metastases (p = 0.004). Resection of periampullary carcinoma provides a better palliation and survival rate than nonoperative biliary drainage or bypass operation. An improved preoperative verification of para-aortic metastases could restrict resection to patients with a prognostic five year survival rate of more than 25% and a postoperative mortality rate of less than 5%.

Somatostatin v placebo in bleeding oesophageal varices: randomised trial and meta-analysis.

OBJECTIVE: To study whether somatostatin or its derivative octreotide is more effective than placebo for treating bleeding oesophageal varices. METHODS: Randomised, double blind trial and meta-analysis with blinded analysis of data and writing of manuscripts. SETTING: Departments of medical and surgical gastroenterology in Copenhagen. SUBJECTS: Patients suspected of bleeding from oesophageal varices and of having cirrhosis of the liver. MAIN OUTCOME MEASURES: Survival, number of blood transfusions, and use of Sengstaken-Blakemore tube. RESULTS: 86 patients were randomised; in each group 16 died within six weeks (95% confidence interval for difference in mortality--19% to 22%). There were no differences between those treated with somatostatin or placebo in median number of blood transfusions (8 v 5, P = 0.07, 0 to 4 transfusions) or in numbers of patients who needed balloon tamponade (16 v 13, P = 0.54, -11% to 28%). In a meta-analysis of three trials involving 290 patients somatostatin had no effect on survival compared with placebo (P = 0.59, odds ratio 1.16; 0.67 to 2.01). For blood transfusions and use of balloon tamponade there was heterogeneity between the trials with no convincing evidence in favour of somatostatin. No placebo controlled trials have been performed with octreotide. CONCLUSION: Within the limited power of this study and meta-analysis we were unable to show a clinical benefit of somatostatin in the emergency treatment of bleeding oesophageal varices.

[Laparoscopic ultrasonography of liver, biliary tract and pancreas with flexible tip transducers]. / Laparoskopisk ultralydskanning af lever, galdeveje og pancreas med styrbart lydhoved.

The scanning procedure and the ultrasound-anatomy of the liver, gall-bladder, bile ducts and pancreas are presented. Ten consecutive patients referred for laparoscopic cholecystectomy were scanned through a 10/11 mm trocar inserted periumbilically. In two cases concrements in the bile ducts were found peroperatively. The flexible-tip enables operator steering of the transducer which ensures an optimal acoustic contact. Colour and spectral Doppler were frequently used to identify vascular structures. We conclude that a flexible-tip laparoscopic ultrasound-scanner provides valuable assistance in abdominal laparoscopic procedures, and may substitute the palpation of the abdominal organs in laparoscopic abdominal surgery.

Pancreaticoduodenectomy for periampullary adenocarcinoma.

BACKGROUND: This study evaluates the indications for and effects of pancreaticoduodenectomy (102 patients) or total pancreatectomy (15 patients) with extensive lymph node dissection performed upon 117 patients for treatment of periampullary adenocarcinoma. STUDY DESIGN: Presenting symptoms and postoperative morbidity and mortality rates were recorded. Cumulative survival rates were evaluated in relation to origin, size, and staging of tumor. Postoperative follow-up of clinical symptoms was done after one year. RESULTS: The postoperative mortality rate after Whipple's operation was 8 percent (eight patients). The median survival period was 1.1 year and the overall five year survival rate was 15 percent (confidence limits, 5 to 25 percent). The five year survival rate for patients without tumor extension beyond the pancreas was 25 percent (confidence limits, 5 to 50 percent), and in patients with adenocarcinoma of the ampulla of Vater, 34 percent (confidence limits, 3 to 65 percent). The median survival rate in patients with adenocarcinoma of the ampulla of Vater was 3.3 years, which was significantly longer than in the other patients. Fifty-nine patients with distant spread could be divided into 14 patients with para-aortic lymph node metastases who had a significantly shorter survival period than 45 patients without para-aortic lymph node metastases (p = 0.004). Most patients surviving more than one year were doing well, although 60 percent needed exocrine pancreatic substitution therapy. CONCLUSIONS: Resection of periampullary carcinoma provides a better palliation and survival rate than nonoperative biliary drainage or bypass operation. An improved preoperative verification of para-aortic metastases could restrict resection to patients with a prognostic five year survival rate of more than 25 percent and a postoperative mortality rate of less than 5 percent.

[Endoscopic bipolar electrocoagulation in gastroduodenal hemorrhage]. / Endoskopisk bipolaer elektrokoagulation af gastroduodenal blødning.

During a one year period (1988-1989), 40 consecutive patients were submitted to emergency gastroduodenoscopy because of severe gastroduodenal bleeding. Indications for emergency endoscopy were red or black haematemesis with melaena or melaena with signs of haemodynamic instability. Twenty-nine of the patients fulfilled the criteria for emergency surgery because of major bleeding and alterated circulation. Twenty-five with surgery demanding gastroduodenal ulcer bleeding and one with Dieulafoy's erosion, were treated with endoscopic bipolar electrocoagulation. Primary haemostasis was achieved in 20 patients (80 per cent). Definitive haemostasis was obtained in 11 patients (44 per cent) with major ulcer bleeding. Nine patients bled again after electrocoagulation, and seven of these underwent surgery. The mortality was 20 per cent (five patients). In eight patients with minor active bleeding or visible vessels, electrocoagulation resulted in 100 per cent definitive haemostasis. No complications attributable to the electrocoagulation were observed. Endoscopic haemostatic treatment with e.g. bipolar electrocoagulation should be the first treatment in patients with gastroduodenal bleeding as emergency operation can be avoided in approximately 50 per cent of the cases.

Peptic ulcer complications and how to treat them.

The main complications to peptic ulcer are perforation, stenosis and bleeding. Diagnosis and treatment are discussed with special reference to the principles of 1st Department, Kommunehospitalet, Copenhagen. The three main complications to peptic ulcer disease include perforation, stenosis and bleeding. The etiology to peptic ulcer disease and the pathogenesis of ulcer disease complications are still poorly understood, although an imbalance between mucosa-protecting and -destructing factors seems to be of major importance. However, the introduction of neither H2 receptor antagonists nor the so-called mucosaprotection agents during the seventies and eighties significantly have reduced the frequency of peptic ulcer disease or the frequency of its complications (perforation 10 per cent, stenosis 10 per cent and bleeding 20 per cent of patients with peptic ulcer disease. The unchanged frequency of operation for peptic ulcer complications was confirmed in a recent study by A. Christensen et al. 1987. Their data suggested unchanged frequency of operations for ulcer complications prior to and following the introduction of H2 receptor antagonists (Fig. I and II) in a well defined population in Copenhagen.

Uroflowmetry in asymptomatic elderly males.

Uroflowmetry is important in the evaluation of prostatism. We have investigated 93 men, selected at random from the National Register, who had no subjective voiding problems but who fell within the appropriate age range. The sample was representative of the male metropolitan population. Uroflowmetry was carried out and the data are presented graphically in nomograms where the Q max/volume, Q average/volume and Q max time/volume relations are given. Flow variables were evaluated to delineate possible correlations to age. It was found that the median Q max decreased from 18.5 ml/s at the age of 50 years to 6.5 ml/s at 80 years. Only one-third of the group had a Q max exceeding 15 ml/s. The median voided volume was 208 ml. Half of the subjects voided less than 200 ml and one-third less than 150 ml.

Some clinical aspects of uroflowmetry in elderly males. A population survey.

A random sample of 200 males aged 50 years or more was selected from the National Register in order to investigate various aspects of spontaneous uroflowmetry and to estimate the frequency of prostatism and symptoms of lower urinary tract dysfunction. All in all the data from 112 persons were analysed. The prevalence of prostatism was found to be 17% (95% confidence limits 11-26%), while 88% (95% confidence limits 83-95%) experienced various degrees of symptoms. Only few associations between single symptoms and uroflowmetry variables were demonstrated. However, statistically significant correlations were revealed between obstructive and total symptom scores on one hand and maximum and average flow rates on the other hand. As the correlations were modest and a considerable overlap of uroflow variables in persons with and without prostatism were proved, the diagnostic specificity and sensitivity of maximum flow rate as well as other uroflow variables were low in the screening for prostatism. In conclusion uroflowmetry appears inefficient to confirm a clinical impression of prostatism.

Preoperative haemodynamic evaluation of patients submitted for renal artery stenosis.

The ECG, chest x-ray and haemodynamic parameters were investigated preoperatively in 19 patients subjected to surgery for renal artery stenosis (RAS) and in a control group comprising 19 normotensive patients subjected to other forms of major vascular surgery. Increased cardiac volume was demonstrated in 13 (68%) RAS patients and in two (11%) patients from the control group. Abnormal ECG (i.e. left ventricular hypertrophy or atrial fibrillation) was observed in 11 (58%) RAS patients and in one (5%) patient from the control group. In the RAS patients the following haemodynamic parameters were found to be statistically significantly increased, compared to the control group: systemic blood pressure, (systolic arterial pressure: +43%, diastolic arterial pressure: +38%, mean arterial pressure: +41%), pulmonary artery mean pressure (+64%), pulmonary capillary wedge pressure (+107%), heart rate (+15%), systemic vascular resistance (+27%), left ventricular minute work index (+46%) and right ventricular minute work index (+67%). The presence of increased cardiac volume and abnormal ECG were more closely related to the level of the pathologically increased pulmonary artery mean and wedge pressures than to the systemic blood pressure or central venous pressure. A preoperative haemodynamic evaluation is recommended to determine the degree of heart failure in RAS patients with: left ventricular hypertrophy and increased cardiac volume, or atrial fibrillation.

Haemodynamic effects of calcium chloride administered intravenously to patients with and without cardiac disease during neurolept anaesthesia.

During neurolept anaesthesia, calcium chloride (15 mg/kg) was administered intravenously to two different groups of patients undergoing vascular surgery on the abdominal aorta. The patients in group I all suffered from cardiac disease and were treated with digoxin, while the patients in group II had no cardiac symptoms. Cardiovascular measurements were made during steady-state anaesthesia. In group I, CaCl2 increased cardiac index (CI) significantly while systemic vascular resistance index (SVRI) remained unchanged. Mean arterial pressure (MAP) increased. In group II, both MAP and SVRI increased while CI remained unchanged. No significant changes in heart rate were observed and no arrhythmias occurred. It is concluded that CaCl2 administered intravenously is an effective means of improving cardiac function when it is depressed by anaesthesia, underlying cardiac disease, or both.

Haemodynamics in patients undergoing porto-caval shunt operations.

Haemodynamic parameters, including cardiac output, blood volume, and blood pressures in the systemic and pulmonary circulations, were followed in eight patients undergoing porto-caval shunt operations because of portal hypertension. Measurements were performed in the awake patients before premedication, during operation immediately before clamping of the portal vein, and immediately after opening of the porto-caval shunt. Further measurements were performed 2-4 h, and 22-26 h postoperatively. Preoperatively, cardiac index and blood volume were increased, whereas the blood pressures in the systemic and pulmonary circulations were within normal accepted limits. After opening the porto-caval shunt, increases in pulmonary arterial mean pressure of between 35 and 80% and in pulmonary capillary wedge pressure of between 40 and 200% were observed in the four patients in whom the pressure gradient between the caval vein and the portal vein was normalized, i.e. where a pressure gradient after opening the porto-caval shunt was measured between 0 and 0.67 kPa. Otherwise, the haemodynamic changes were only partly related to changes in the pressure gradient. The courses of the postoperative haemodynamic changes did not seem to be different from the courses in other categories of patients. The most important haemodynamic changes in patients undergoing porto-caval shunt operations seem to take place immediately after opening the shunt. To minimize the extent of changes in the pulmonary circulation, the shunt should be opened gradually.

Prophylactic digitalization preoperatively of patients with arteriosclerotic heart disease.

This study was undertaken to investigate the hemodynamic effect of prophylactic digitalization before major surgical procedures. Sixteen patients, all admitted for an elective vascular operation for arteriosclerotic disease and all with impaired left ventricular function, were investigated. In half of the patients, digitalis was given before the operation, the other half of the patients served as the control study. The measured parameters were pulmonary artery mean pressure, pulmonary capillary wedge pressure, central venous pressure, mean arterial blood pressure, heart rate, cardiac output, blood volume and arterial, as well as venous, oxygen content. Preoperatively, before digitalization, no significant differences were noted between the two groups at rest and during exercise. Before anesthesia and postoperatively, those given digitalis had improved cardiac function. Those in both groups, however, had a normal hemodynamic response to the surgical trauma. In this study, a definite answer is not provided concerning the usefulness of prophylactic digitalization but an increase in the ability of the digitalized heart to withstand the imposition of a pressure load postoperatively is suggested.

Pre-operative exercise testing in patients suspected of arteriosclerotic heart disease: methods, risks and reproducibility.

In order to estimate the value of haemodynamic parameters in assessing impaired left ventricular function the reproducibility of haemodynamic measurements were investigated at rest and during supine exercise on a bicycle ergometer in fifty-one patients suspected of arteriosclerotic heart disease by means of a Swan-Ganz pulmonary artery thermodilution catheter and a radial artery catheter. Furthermore the minimal significant (P less than 0.05) change from rest to exercise was determined. In conclusion we found that haemodynamic measurements during exercise testing estimate left ventricular function in a safe and reproducible manner. A rise in pulmonary capillary wedge pressure (PCWP) of only 0.9 kPa during exercise was significant, whereas changes in stroke volume index (SVI) were considered significant only when exceeding 9 ml/m2.

Acute postoperative digitalization of patients with arteriosclerotic heart disease after major surgery. A randomized haemodynamic study and proposal for therapy.

Twenty patients with impaired left ventricular function during exercise, who underwent major vascular surgery for arteriosclerotic disease, were randomly digitalized in the immediate postoperative period. All patients had a smooth postoperative course. Haemodynamic measurements showed improved left ventricular function in those who received digitalis, since 60 min after full digitalization the digitalized patients had a highly significant decrease in pulmonary capillary wedge pressure (PCWP) with unchanged stroke volume index (SVI) and left ventricular stroke work index (LVSWI). The same improvement in cardiac function was present the next morning. The present study provides haemodynamic data in support of clinical studies showing a beneficial effect of prophylactic digitalization in surgical patients with clinical signs of arteriosclerotic heart disease, though not in overt failure.

Digitalis induced haemodynamic changes in patients with vascular disease during a preoperative exercise test.

Haemodynamic studies at rest and during exercise before and after digitalization were carried out in 11 patients with vascular disease. Haemodynamic parameters at rest were within normal limits except for one patient, who had a cardiac index (CI) below 2.51/min/m2. During exercise 7 of the patients showed impaired left ventricular function. In the resting patients digitalization produced a significant decrease in pulmonary capillary wedge pressure (PCWP) and an increase of approximately 15% in left ventricular stroke work index (LVSWI) and total oxygen consumption. Myocardial oxygen consumption seemed unchanged as no significant changes were found in the product of mean arterial blood pressure and heart rate. After digitalization 6 of 7 patients with impaired left ventricular function showed improved haemodynamic response to exercise while the 4 patients with normal left ventricular function had an unchanged haemodynamic response.