Randomized clinical trial of the effect of pneumoperitoneum on cardiac function and haemodynamics during laparoscopic cholecystectomy.

BACKGROUND: Conventional laparoscopic cholecystectomy (CLC) with carbon dioxide pneumoperitoneum may cause major cardiovascular changes. The aim of this study was to evaluate the effect of carbon dioxide pneumoperitoneum and positional changes on haemodynamics and cardiac function in patients assigned randomly to CLC or gasless laparoscopic cholecystectomy (GLC). METHODS: Fifty patients with American Society of Anesthesiologists physical status I and II were randomly allocated to CLC (28 patients) or GLC (22). Left ventricular end-diastolic and end-systolic diameters, fractional shortening and cardiac output were determined by transoesophageal echocardiography. Measurements were performed before (phase 1) and 10 and 30 min (phases 2 and 3 respectively) after pneumoperitoneum or abdominal wall traction, and after desufflation or release of abdominal wall traction (phase 4) in supine, Trendelenburg and reverse Trendelenburg positions. RESULTS: Mean diastolic diameter, systolic diameter, mean arterial pressure and heart rate were significantly higher, and fractional shortening was significantly lower, with carbon dioxide pneumoperitoneum than with the gasless procedure during phases 2 and 3. There were no significant differences in cardiac output between the two groups. CONCLUSION: Carbon dioxide pneumoperitoneum was associated with increased preload and afterload in patients undergoing laparoscopic cholecystecomy. It also decreased heart performance (fractional shortening), but did not affect cardiac output.

Intraperitoneal and intraluminal microdialysis in the detection of experimental regional intestinal ischaemia.

BACKGROUND: The aim was to investigate the possibility of using intraluminal or intraperitoneal microdialysis to monitor regional intestinal ischaemia. METHODS: Microdialysis catheters were inserted in the lumen, in and outside the intestinal wall, and in the peritoneum of each of ten pigs. Regional occlusive ischaemia was induced in 100 cm of jejunum. Levels of glucose, pyruvate, lactate and glycerol in the microdialysate were measured at 20-min intervals before and after induction of ischaemia. Systemic haemodynamics were monitored and laser Doppler flowmetry (LDF) recordings made in each of the intestinal segments. RESULTS: Ischaemia caused a significant decrease in glucose level, and an increase in lactate and glycerol concentrations and lactate/pyruvate ratio, at all catheters, although glucose could not be detected by the intraluminal catheter. The metabolic changes occurred simultaneously and were statistically significant in almost all catheters after 100 min. LDF revealed a significant decrease in intestinal blood flow, but there was considerable individual variation. CONCLUSION: Regional occlusive ischaemia in 100 cm of small intestine could be detected and monitored by means of a microdialysis catheter placed in the peritoneal cavity or the bowel lumen.

Randomized study of coagulation and fibrinolysis during and after gasless and conventional laparoscopic cholecystectomy.

BACKGROUND: Carbon dioxide pneumoperitoneum may be an important pathophysiological factor stimulating the coagulation system during conventional laparoscopic cholecystectomy. The aim of this study was to test the hypothesis that gasless laparoscopy produces smaller changes in the coagulation and fibrinolytic system than carbon dioxide pneumoperitoneum in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty patients were allocated randomly to conventional (n = 26) or gasless (n = 24) laparoscopic cholecystectomy. Blood samples were obtained on admission, after induction of anaesthesia, after insufflation or traction, 30 min after introduction of the laparoscope, 10 min after exsufflation of carbon dioxide or traction, 4 h after extubation and 24 h after operation. RESULTS: The two groups were comparable with respect to age, sex, body mass index and duration of operation. Plasma levels of prothrombin fragment 1 and 2 (F1 + 2), soluble fibrin and D-dimer did not differ between the two groups. F1 + 2 levels varied significantly in both groups during and after operation (P < 0.001). Soluble fibrin and D-dimer levels did not change during operation in either group, but after operation the levels increased significantly in both groups (P < 0.001). CONCLUSION: Carbon dioxide pneumoperitoneum does not enhance the activation of coagulation and fibrinolysis associated with laparoscopic cholecystectomy. The coagulation and fibrinolytic systems are activated during and after gasless as well as conventional laparoscopic cholecystectomy.

Randomized comparison of conventional and gasless laparoscopic cholecystectomy: operative technique, postoperative course, and recovery.

The positive CO2 pneumoperitoneum needed to create the working space for laparoscopic surgery induces cardiovascular, neuroendocrine, and renal changes. Concern about these pathophysiologic changes has led to the introduction of a gasless technique. Fifty consecutive patients with symptomatic gallstones were randomized to conventional (CLC) or gasless laparoscopic cholecystectomy (GLC), with special reference to overall patient satisfaction, technical difficulties, duration of surgery, postoperative pain, and recovery. The overall exposure of the operative field was extremely poor in the GLC group, whereas the duration of surgery, steps involved in the cholecystectomy technique, length of hospital stay, and postoperative pain score did not differ significantly. After discharge, the median time to complete relief of pain tended to be shorter in the gasless group (5 days [range 1 to 15]) vs. the conventional group (8 days [range 1 to 15]). The period to return to normal activity was shorter in the GLC group (6 days [range 1 to 15]) compared to the CLC group (8.5 days [range 1 to 15]) (P = 0.031). No differences were found in terms of fatigue, dizziness and nausea, and overall satisfaction with the outcome. This study demonstrates a significantly shorter convalescence after laparoscopic cholecystectomy by means of the gasless technique compared to the conventional CO2 technique. Exposure of the operative field was less than optimal using the gasless technique.

[Curative treatment of ventricular cancer]. / Kurativ behandling af cancer ventriculi.

Extended lymphadenectomy on connection with the surgical treatment of gastric cancer is gaining access in western centres especially since Japanese centres have shown an ever increasing rate of survival over several decades, coupled with the fact that operative procedures have become more sophisticated. The latest prospective studies in the west seem to confirm the value of lymphadenectomy in some patients. Furthermore, correct staging demands extended lymphadenectomy. For patients with gastric cancer, adjuvant preoperative chemotherapy is probably an asset.

[Treatment of morbid obesity with laparoscopic, adjustable gastric banding. Results after two years of experiences with a new surgical method for severe obesity]. / Behandling af sygelig overvaegt med laparoskopisk, justerbar "gastric banding". Resultater fra to års erfaring med en ny operation for svaer fedme.

INTRODUCTION: In the last decade, laparoscopic, adjustable silicone gastric banding for morbid obesity has gained widespread use, owing to two important improvements: The surgical procedure can be performed laparoscopically and the weight loss can be regulated by adjusting the silicone band by a simple percutaneous technique. MATERIAL AND METHODS: Over a 2-year period, we followed up 33 patients admitted to the clinic for morbid obesity. Sixteen patients preferred the conventional diet treatment (1), seven patients underwent an operation (2), and ten patients were motivated for operation, but were found to be unfit and were treated by diet (3). RESULTS: The excess loss of body weight was 25% in group 1, 60% in group 2, and 0% in group 3. CONCLUSION: Laparoscopic, adjustable gastric banding can help the severely obese patients when diets and pharmacological treatment have failed. The resulting loss of weight is highly dependent on careful follow-up by a professional obesity team.

Presence of uterine pinopodes at the embryo-endometrial interface during human implantation in vitro.

In order to study changes occurring on the surfaces of human endometrial epithelial cells in the presence of an implanted blastocyst, we used scanning electron microscopy for investigation of five endometrial biopsies and three human implantation sites obtained in vitro. All specimens showed areas with endometrial pinopodes, separated by cells displaying microvilli or cilia at the apical surface. Pinopode formation was more pronounced in endometrial biopsies than in cell cultures. All blastocysts adhered to pinopode presenting cells. Endometrial surface changes were not seen around the blastocysts. The results of this study demonstrate that cultured endometrial epithelial cells are capable of pinopode formation. Furthermore, endometrial epithelial pinopodes, generally considered as a marker of endometrial receptivity, seem to be directly involved in the adhesion of the blastocyst to the endometrial surface.

Coagulation and fibrinolysis during laparoscopic cholecystectomy.

Laparoscopic surgery appears to be less traumatic to the patient than open surgery, but its influence upon coagulation and fibrinolysis is incompletely elucidated. Our aim was to measure markers of coagulation and fibrinolysis before, during. and after laparoscopic cholecystectomy (LC). Blood samples drawn on admission, on four occasions during operation as well as 2 hours after operation and on the first postoperative day in 50 patients undergoing elective LC were analyzed for prothrombin fragment 1+2 (F1+2), soluble fibrin (SF), D-dimer (DD), fibrin degradation products (FbDP), tissue-type plasminogen activator (tPA) activity and antigen, and plasminogen activator inhibitor (PAI) activity and antigen. F1+2, SF, DD, and FbDP levels increased significantly after LC. Differences between pre- and postoperative PAI and tPA levels were not significant apart from a transient increase in tPA antigen levels. tPA activity was significantly increased during operation.

[Laparoscopic cholecystectomy as a same-day surgical procedure]. / Laparoskopisk kolecystektomi som sammedagskirurgisk procedure.

The aim of this study was to describe the results of laparoscopic cholecystectomy as an outpatient procedure in a prospective, consecutive, descriptive study. The study included 50 patients selected in the period from April to December 1997, who accepted the outpatient procedure. Preoperative complications, morbidity during hospital stay, length of hospital stay, frequency of readmission and the satisfaction of the patients were registered. In our investigation we found a risk of preoperative complications of 6% (severe 0%), a morbidity during hospital stay of 6% (severe 2%) and an incidence of readmission of 4%. A total of 74% of the patient went home on the same day as the procedure, and 90% of all patients had been discharged 24 hours later. The patients showed a high degree of satisfaction. In conclusion laparoscopic cholecystectomy as an outpatient procedure may be performed with a low risk of complications, a low incidence of readmission, a high degree of satisfaction in patients, but with a high frequency of primary admission (26%).

Co-ordinated expression of MMP-2 and its putative activator, MT1-MMP, in human placentation.

The spatial expression of mRNA for matrix metalloproteinase 2 (MMP-2), its putative activator, the membrane-type 1 matrix metalloproteinase (MT1-MMP), and the MMP-2 substrate type IV collagen was investigated in human placentas of both normal and tubal ectopic pregnancies and in cyclic endometrium using in-situ hybridization. Cytokeratin staining applied to adjacent sections was used to identify epithelial and trophoblast cells. In both normal and tubal pregnancies MT1-MMP, MMP-2 and type IV collagen mRNA were highly expressed and co-localized in the extravillous cytotrophoblasts of anchoring villi, in cytotrophoblasts that had penatrated into the placental bed and in cytotrophoblastic cell islands. In addition, the decidual cells of normal pregnancies in some areas co-expressed MT1-MMP and MMP-2 mRNA, with moderate signals for both components. Fibroblast-like stromal cells in tubal pregnancies were positive for MMP-2 mRNA but generally negative for MT1-MMP mRNA. The consistent co-localization of MT1-MMP with MMP-2 and type IV collagen in the same subset of cytotrophoblasts strongly suggests that all three components co-operate in the tightly regulated fetal invasion process. The co-expression of MT1-MMP and MMP-2 mRNA in some of the decidual cells indicates that these cells are also actively involved in the placentation process.

[Improved prenatal diagnostic possibilities for congenital abnormalities and chromosomal disorders. Advantages and disadvantages of screening and diagnostic methods]. / Bedre praenatale undersøgelsesmuligheder for medfødte misdannelser og kromosomsygdomme. Fordele og ulemper ved screening og diagnostik.

Significant progress has taken place in recent years regarding prenatal screening and diagnosis of severe foetal malformations and chromosomal disorders. This review describes blood sample screening in 15-16 week of pregnancy compared with the other prenatal examinations such as amniocentesis and chorionic villus sampling. Serological screening of all pregnant women based on a blood sample taken at 15-16 weeks of pregnancy would lead to identification of about 70% of the screened women having to undergo a conclusive investigation i.e. either a thorough ultrasound examination or an amniocentesis. This is compared with the present Danish prenatal program, where invasive examinations are carried out in about 13% pregnant women without a high detection rate for malformations and chromosome disorders. The Danish National Health Board has recently published new guidelines where the blood test is primarily offered to pregnant women over 34 years of age and not to all pregnant women as in many other countries.

Plasminogen activators and plasminogen activator inhibitor in portal blood from patients with and without gastric malignancy.

BACKGROUND: Plasminogen activators (PA) may be released by the gut and eliminated by the liver. Patients with liver disorders or malignancy often have abnormal plasma levels of PAs. Some tumours may produce PAs. METHODS: In patients undergoing gastric surgery for malignant (n = 18) or benign (n = 21) disorders., blood drawn from the portal vein and a peripheral vein was analysed for tissue-type plasminogen activator antigen and activity (tPA: Ag, tPA: Act), single-chain urokinase-type plasminogen activator activity (scuPA: Act), and plasminogen activator inhibitor antigen and activity (PAI: Ag, PAI: Act). RESULTS AND CONCLUSIONS: In both groups tPA: Act and scuPA: Act levels were significantly higher in portal blood than in peripheral blood, but tPA: Ag and PAI: Act levels did not differ. PAI: Act levels were significantly lower in patients with malignant disease, but levels of the other markers did not differ in the two groups.

Ultrastructure of endometrial epithelial cells in a three-dimensional cell culture system for human implantation studies.

PURPOSE: A three-dimensional cell culture system imitating normal uterine endometrium has previously been established. To what degree do cultured epithelial cells retain their morphological characteristics as compared to in vivo material obtained simultaneously from the same tissue donor. RESULTS: We found a high degree of similarity between the in vivo and in vitro situations. The present culture system furthermore imitates the day-to-day morphology of the cycle. CONCLUSIONS: This indicates, that a correct timing of the biopsy tissue is important for future human implantation studies.

Plasminogen activators and plasminogen activator inhibitor before and after surgery in patients with and without gastric malignancy.

Pre- and postoperative plasma levels of tissue-type plasminogen activator (t-PA), single-chain urinary plasminogen activator, and plasminogen activator inhibitor 1 (PAI-1) were measured in 40 patients undergoing gastric surgery in order to compare patients operated for benign (n = 21) and malignant (n = 19) disease. On the 1st postoperative day, the PAI-1 activity was significantly increased and the t-PA activity significantly decreased in the malignant group, whereas only insignificant changes were seen in the benign group. In contrast, the t-PA activity was significantly increased 1 week after surgery in patients without malignancy. In both groups, the single-chain urinary plasminogen activator activity decreased on the 1st postoperative day, but was significantly increased 1 month after operation. Thus, the two groups reacted differently, but it remains to be determined whether this bears any relationship to the well-known high risk of postoperative venous thromboembolism in cancer patients.

Isolation and culture of human endometrial cells in a three-dimensional culture system.

A cell culture system was established in which endometrial stromal cells were embedded in a collagen matrix and separated from the endometrial epithelium by basement membrane material (Matrigel). The epithelium, seeded on top of the collagen matrix, grew in a monolayer. The cultures were evaluated by light microscopy and transmission and scanning electron microscopy. Light and transmission electron microscopy indicated a polarized columnar epithelium in monolayer with basally positioned nuclei. Scanning electron microscopy revealed a confluent epithelium with an abundance of microvilli and cilia, as well as pinopodes on the apical surface. Immunohistochemical staining for cytokeratin confirmed the epithelial origin of the surface cells, and staining for human collagen IV demonstrated its presence underneath the epithelial cells. This culture system represents a three-dimensional system that imitates the normal endometrium.

Haemostatic activation before and after surgery in patients with and without gastric malignancy.

Pre- and postoperative plasma levels of Prothrombin Fragment 1 + 2 (F1 + 2), Thrombin-antithrombin III complex (TAT), Fibrinopeptide A (FpA), Fibrin and Fibrinogen Degradation Products (FbDP, FgDP) and Soluble Fibrin (SF) were measured in 40 patients undergoing gastric surgery in order to compare patients operated for benign (n = 21) and malignant (n = 19) disease. Plasma levels of F1 + 2, TAT, FbDP and SF on the first postoperative day were significantly higher than before operation. F1 + 2 and FbDP levels were further increased one week after surgery, at which time FgDP levels were also higher than preoperatively. A significant postoperative increase in FpA levels was found only in patients with malignant disease. When age was taken into consideration, significant differences between patients with and without malignancy were found only in the late postoperative period, as cancer patients had higher FpA and FbDP levels one week after surgery and higher FbDP levels one month after discharge from hospital.

Markers of coagulation and fibrinolysis in portal blood from patients with and without gastric malignancy.

BACKGROUND: The origin of coagulation and fibrinolysis abnormalities in cancer patients is unknown. The aim of this study was to measure markers of coagulation and fibrinolysis in portal and peripheral blood from patients with and without gastric malignancy. METHODS: Blood samples were drawn from the portal vein and a peripheral vein in 39 patients undergoing elective gastric surgery, 18 for gastric malignancy and 21 for benign disorders, and analyzed for prothrombin fragment 1 + 2 (F1 + 2), thrombin-anti-thrombin III complex (TAT), fibrinogen and fibrin degradation products (FgDP, FbDP), and fibrinopeptide A (FpA). RESULTS AND CONCLUSIONS: In portal blood, levels of F1 + 2, TAT, FpA, FgDP, and FbDP did not differ in the two groups. In peripheral blood, levels of FpA and FbDP were higher in cancer patients, but in a multiple regression model malignancy did not contribute significantly to variation in peripheral FpA or FbDP levels. In both groups FpA levels were higher in portal blood than in peripheral blood.

[Urease test for rapid demonstration of Helicobacter pylori in biopsies from the pyloric antrum]. / Ureasetest til hurtig påvisning af Helicobacter pylori i biopsier fra antrum ventriculi.

Helicobacter pylori (HP) is an important etiological factor in chronic gastritis and duodenal ulceration. Demonstration of HP by means of culture and histological examination is relatively time-consuming. The object of this investigation was to assess the validity of two rapidly read chemical tests: the buffered urease reagent (BR) and the unbuffered urease reagent (UBR) in demonstration of HP among patients referred for gastroscopy on account of upper abdominal dyspepsia. In 230 sets of biopsies investigated for HP by culture and histology, the following results were obtained by reading of the BR test three hours later at room temperature: Nosographic sensitivity 0.54, nosographic specificity 0.97, PVpos 0.93 and PVneg 0.71. In another material consisting of 57 sets of biopsies, both BR and UBR were performed. Reading of UBR after 15 minutes yielded the following results: Nosographic sensitivity 0.56, nosographic specificity 1.00, PVpos 1.00 and PVneg 0.61. It is concluded that positive results of the urease tests indicate the presence of HP. If the urease tests are negative, supplementary culture and/or histological examination for HP should be performed. UBR is preferable rather than BR.

Assessment of intermittent claudication by means of the transcutaneous oxygen tension exercise profile.

Transcutaneous oxygen tension was measured simultaneously on both feet during exercise (TcpO2 exercise profile) in patients with claudication. The following groups were studied: 1) 21 control subjects; 2) 25 patients with bilateral claudication of whom eight had unilateral predominance; 3) 40 patients with unilateral claudication. The control group showed no significant decrease in TcpO2 during exercise. Patients with bilateral claudication and unilateral predominance showed a significant decrease in the TcpO2 exercise profile of both feet (P less than 0.05), the decrease in the more affected leg being significantly greater than that of the less affected leg (P less than 0.05). In patients without unilateral predominance of claudication there was a slight, yet significant decrease in TcpO2 of both legs. Patients with unilateral claudication were classified into three groups based on a constant work load of 50 W, which provoked typical leg pain during exercise (group I: 0-2 min; group II: 2-4 min; group III: greater than 4 min). The decrease in the TcpO2 exercise profile was always significant on the symptomatic leg. In the asymptomatic leg TcpO2 did not decrease. The changes in TcpO2 relative to values at rest of the symptomatic leg showed significant differences after 1 min in groups I, II, and III (P less than 0.05). In conclusion, the TcpO2 exercise profile appears to be a suitable objective method by which the peripheral arterial insufficiency during exercise in patients with intermittent claudication can be quantified.