Epidural anesthesia? No of course.

Although the contraindications for thoracic epidural anesthesia (TEA) are well defined, the debate continues about whether TEA improves outcomes. Pro and con trials and a metaanalysis in the past have yielded equivocal results; they did not deal with new vascular intervention or drugs. The benefit of TEA in surgery is to provide analgesia. In subgroups, TEA can decrease the mortality and morbidity. In contrast, the cost can increase in the situation of a complication that is opposite to the side effects is rare, but the impairment caused by them is out of proportion to the benefits. Primary or secondary prophylaxis with antithrombotic drugs is increasing in developed countries because of the increasing cardiovascular interventions and aging of the population. The neuroaxial guidelines are useful, but the changing of the coagulation profile after hepatectomy is not included in them. The decision to use TEA in liver surgery must be individualized with steps planned from the beginning. TEA suitability is based on an evaluation of the contraindications, comorbidities, coagulation profiles, hepatic reserve, and balance of benefits and risks. The insertion or withdrawal of the epidural catheter should be made with care according to the neuroaxial guidelines and in the presence of a normal TEG. The decreasing level of prothrombin content and platelet counts after hepatectomy should be closely monitored every 2 to 5 days.

Evaluation of liver function for hepatic resection.

New limits have been established to decrease mortality and morbidity rates after liver resection in cirrhotic and non-cirrhotic patients. Various laboratory data and imaging techniques have been used to complement the Child-Pugh score to predict liver failure after hepatectomy and to assess functional hepatic reserve. The greatest experiences are with the aminopyrine breath test and the galactosyl elimination capacity, which are decreased among hepatic failure patients after liver resection. However, absence of these changes do not totally exclude it. The indocyanine green retention test is the most widely used clearance test. Nevertheless, it remains imperfect because it depends both on hepatic blood flow and on the functional capacity of the liver. Nuclear imaging of the asialoglicoprotein receptors with radiolabelled synthetic asialoglicoproteins provides volumetric information as well a functional assessment of the liver. In summary, while liver function is complex, a successful liver test to assess quantitative functional hepatic reserve still needs to be established. The combination of the Child-Pugh score, the presence of ascites, the serum bilirubin levels, the indocyanine green retention (ICG R15) value, and the remnant liver CT volumetry seems to avoid an index of liver failure after hepatic resection. Cases when ICG R15 is above 15% should be combined with portal vein embolization. If there is no possibility to perform an ICG clearance test, it may be replaced with other available, well known dynamic liver function tests.

[Current viewpoints on the evaluation of testicular biopsy]. / A herebiopsiák értékelésének új szempontjai.

The aim of this study was to analize clinical diagnoses and histopathological reports in 185 cases of male infertility, investigated by testicular biopsies in the period 1993-1997. The classical objective of such investigations has been to clarify either obstructive, or so-called secretory lesions resulting in azoospermia. Histologically normal spermatogenesis was reported in 8 patients (4.3%). Hypospermatogenesis proved to be the most frequent pathologic lesion (69 cases, 37.3%), followed by maturation arrest (61 cases, 33%). Germ cell aplasia (Sertoli-cell-only syndrome) was found in 28 cases (15.1%). Tubular atrophy was the dominant lesion in 5 cases (2.7%). Inflammatory change without other histologic abnormalities was seen only in 1 biopsy (0.5%). Further 13 specimens (7%) showed miscellaneous lesions, including one intratubular germ cell neoplasia. Retrospective histopathologic analysis revealed the coexistence of different basic lesions in 43 of our cases (21.7%). According to the novel requirements, pathologists should always report the presence of germ cell forms in the specimen, which are potentially suitable for fertilization. This is essencial because the new methods of testicular spermium extraction and intracytoplasmatic spermium injection offer the chance of assisted fertilization, even for some patients with smaller testicles and slightly elevated FSH levels.