Robotic-assisted resection of deep pelvic schwannoma.

INTRODUCTION: Schwannomas are a group of well differentiated benign tumors originating from the Schwann cells of the peripheral nervous system. Their localization in the pelvis is very rare. Schwannomas with expansive growth can cause wide neurologic symptoms or oppression of pelvic organs. CASE REPORT: The authors present a case study of a 60-year-old woman with a large, symptomatic deep pelvic schwannoma. The patient underwent robotic-assisted surgery resulting in complete tumor extirpation. The patient's postoperative course was uneventful with a total of two hospitalization days. The diagnosis of a schwannoma was confirmed by histopathologic analysis. At 11-month follow-up surveillance the patient did not present any neurological deficit or other symptoms. CONCLUSION: Robotic-assisted surgery allows safe and effective surgical treatment in difficult-to-access anatomical areas. Magnetic resonance imaging is required for preoperative imaging of neurogenic tumors. Histological verification is not recommended in cases where evidence of a schwannoma is found. Multidisciplinary cooperation of a dedicated team experienced in minimally invasive pelvic surgery is necessary.

Ten years of laparoscopic sleeve gastrectomy at the Military University Hospital in Prague.

INTRODUCTION: The aim of this study was to evaluate a group of bariatric patients operated at the Military University Hospital in Prague during the last 10 years (20112020), in whom laparoscopic sleeve gastrectomy was performed. METHODS: Retrospective survey of the internal operation database. The search used the following combination of keywords: “sleeve“, “LSG“ and the diagnosis “E6*“. A total of 279 operated patients were enrolled. We evaluated the sex, age at the time of surgery, complications, need for drainage, weight, BMI, presence of type two diabetes mellitus and any effect of the surgery on its improvement, length of hospital stay, follow-up duration and % excess weight loss. RESULTS: A total of 279 patients, including 195 women and 84 men, underwent laparoscopic sleeve gastrectomy in the period of 10 years. The mean age was 44.46 years. The average operating time was 111 minutes. The mean BMI of the patients before surgery was 42.24 and the weight was 123.4 kg. The mean BMI one year after the surgery corresponded to a decrease of approximately 10 and the mean weight of 93.8 kg. Rather severe acute postoperative complications occurred in 2.87% patients. An improvement or complete cure of type two diabetes mellitus was observed in 57.8% patients. CONCLUSION: Currently, laparoscopic sleeve gastrectomy is the most common bariatric operation at the Military University Hospital in Prague. This study demonstrates a satisfactory effect of bariatric surgery in terms of long-term significant weight loss and an improvement or even cure of associated diseases such as type two diabetes mellitus, arterial hypertension and others.

Intraosseous temperature changes during the use of piezosurgical inserts in vitro.

This study concerns intraosseous temperature changes during the use of piezosurgical inserts. On six fresh pig jaws heated to body temperature (36°C), osteotomies and osteoplasties were performed in vitro with the Piezosurgery(®) 3 device (Mectron, Carasco, Italy) and various inserts. The intraosseous temperature increases were measured at a depth of 3mm and at a distance of 1mm from the working site using nickel-chromium/nickel temperature sensors. 20°C Ringer's solution was used for cooling in an initial test series and 10°C Ringer's in a second series. The processed bone was examined using digital volume tomography images to determine the ratio of cortical to cancellous bone thickness. Mean temperature increases of 4.4-10.9°C were found; maximum temperature peaks were over 47°C for an average of only 8.5 s. The type of piezosurgical insert had a marked influence on intraosseous temperature generation (p=0.026); the thickness of the cortical bone and the temperature of the coolant did not. Coolant temperature had an influence on the bone cooling time (p=0.013). The results show that correct use of the piezosurgery device does not give rise to prolonged temperature increases over 47°C and hence does not cause any irreversible thermal damage in the bone.

[Role of androgen receptors in hormone-refractory prostate cancer: molecular basics and experimental therapy approaches]. / Die Rolle des Androgenrezeptors im hormonrefraktären Prostatakarzinom : Molekulare Grundlagen und experimentelle Therapieansätze.

The development of hormone-refractory prostate cancer cells is one of the major causes for the progression and high mortality rates in advanced prostate cancer (PCA). While the loss of the androgen receptor (AR) is the predominant mechanism for development of a hormone-insensitive disease in vitro, the first in vivo studies showed that the AR is still expressed or is even overexpressed in hormone-refractory PCA. In view of the increasing cases of PCA in the industrialized Western countries, a series of cell and molecular biological studies has led to the identification of various new factors and mechanisms that play a role during the development of hormone-refractory tumors. These findings should lead to the development of new therapeutic strategies.

Yield of colonoscopy in patients with nonacute rectal bleeding: a multicenter database study of 1766 patients.

OBJECTIVE: There are few data to guide the choice between colonoscopy and flexible sigmoidoscopy in patients with nonacute rectal bleeding, especially in younger age groups. Our aim was to determine the yield of colonoscopy for significant proximal large bowel disease in the absence of significant distal disease, with special reference to young patients. METHODS: This was a retrospective study of data collected prospectively in 1766 patients (median age 57 yr, 711 women). The endoscopic database (GI-Trac) contained 152 discrete fields for data input. Multiple logistic regression analysis was performed to identify variables independently associated with the presence of isolated significant proximal disease. RESULTS: Young patients had a higher percentage of normal examinations than did older patients. The incidence of diverticular disease, small polyps, large polyps, and cancer rose with increasing age. No patient aged <40 yr had an isolated proximal cancer, but 7% had other significant isolated proximal disease. There was no overall association between age and significant proximal disease in the absence of significant distal disease (p = 0.66). The only variable associated with isolated proximal disease was anemia (odds ratio = 1.81; 95% CI = 1.11-2.93; p = 0.02). CONCLUSION: The yield of colonoscopy (beyond the range of sigmoidoscopy) for neoplasia is low in patients aged <40 yr, but other significant disease may be missed if age is the only criterion determining colonoscopy use.

Age and alarm symptoms do not predict endoscopic findings among patients with dyspepsia: a multicentre database study.

INTRODUCTION: Symptoms of dyspepsia are common but most patients do not have major upper gastrointestinal pathology. Endoscopy is recommended for dyspeptic patients over the age of 45, or those with certain "alarm" symptoms. We have evaluated the effectiveness of age and "alarm" symptoms for predicting major endoscopic findings in six practising endoscopy centres. METHODS: Clinical variables of consecutive patients with dyspepsia symptoms undergoing upper endoscopy examinations were recorded using a common endoscopy database. Patients who had no previous upper endoscopy or barium radiography were included. Stepwise multivariate logistic regression was used to identify predictors of endoscopic findings. The accuracy of these for predicting endoscopic findings was evaluated with receiver operating characteristic analysis. The sensitivity and specificity of age thresholds from 30 to 70 years were evaluated. RESULTS: Major pathology (tumour, ulcer, or stricture) was found at endoscopy in 787/3815 (21%) patients with dyspepsia. Age, male sex, bleeding, and anaemia were found to be significant but weak independent predictors of endoscopic findings. A multivariate prediction rule based on these factors had poor predictive accuracy (c statistic=0.62). Using a simplified prediction rule of age > or =45 years or the presence of any "alarm" symptom, sensitivity was 87% and specificity was 26%. Increasing or decreasing the age cut off did not significantly improve the predictive accuracy. CONCLUSIONS: Age and the presence of "alarm" symptoms are not effective predictors of endoscopic findings among patients with dyspepsia. Better clinical prediction strategies are needed to identify patients with significant upper gastrointestinal pathology.

Anderson-Hynes pyeloplasty in horseshoe kidney in children: is it effective without symphysiotomy?

Contemporary reports on surgery for horseshoe kidney (HK) still recommend isthmotomy and lateropexy to complete an open pyeloplasty. To evaluate whether simple Anderson-Hynes pyeloplasty without symphysiotomy is effective for relief of ureteropelvic junction obstruction (UPJO) in HK, we studied the records of ten children, two of whom had bilateral UPJO. Only one child presented with calculi; 11 units were operated upon for UPJO, 1 needed a partial nephrectomy. The surgical outcome was evaluated with emphasis on the changes in renal drainage and function assessed by ultrasonography and diuretic renal scans. Associated vesicoureteral reflux was observed more often (25%) than with UPJO in normal kidneys. Obstruction was caused by a crossing lower-pole vessel in three cases, a high ureteral insertion in two and narrowing of the UPJ 7. Postoperative follow-up (mean 5.5 years) revealed improved renal function and good drainage in all cases. Hydronephrosis vanished in 7, whereas grade 2 hydronephrosis remained in two children with former refluxive megaureter and grade 3 in one. All children are doing well and have no symptoms due to the persistent isthmus (Rovsing syndrome). It is concluded that simple Anderson-Hynes pyeloplasty via a flank incision is a highly effective and safe procedure for treating UPJO in HK.

Successful endoscopic removal of a severed, impacted Dormia basket.

We report the successful removal of a severed and impacted Dormia basket from an elderly patient with choledocholithiasis. One aspect of the case that increased its difficulty is that the basket had become trapped in the bile duct by attaching to an immobile stone that had formed on suture material from a prior biliary operation. Severed baskets that become entrapped in the bile duct are unusual complications of endoscopic bile duct stone removal which used to require surgical intervention. More recent reports suggest that retained baskets can be removed endoscopically in conjunction with some form of lithotripsy. The method used to remove the retained basket in our case involved advancing a Soehendra lithotripter over a looped guidewire after first shrinking the stone with extracorporeal shock wave and laser lithotripsy.

[Anxiety and stress reaction and its management in ambulatory gastrointestinal endoscopy: is premedication justified?]. / Angst- und Stressreaktion und ihre Bewältigung bei ambulanter gastrointestinaler Endoskopie: Ist eine Prämedikation gerechtfertigt?

This study is a contribution to the the question, whether the fear of ambulant gastrointestinal endoscopy generally justifies an anxiolytic premedication. Intensity of the stress reaction (subjective stress reactions, cardiovascular and endocrinological stress parameters), situation-specific determinants and coping behavior were analyzed one week and immediately before and immediately after the diagnostic procedure in N = 135 patients. The results showed significant effects of the procedure on subjective, cardiovascular and endocrinological stress parameters. Furthermore, other stress-eliciting conditions like former experiences with the procedure, behavior of the doctor and the assisting staff, organisational conditions could be identified. All in all, for most of the patients the endoscopy examination was less aversive as reported in the literature. According to our results, the amount of fear and stress reactions cannot justify the risks of an anxiolytic premedication. Only for a small group of patients (about 25%) the question of premedication should be proved individually. These patients can be identified by a questionnaire or by a rough screening of the anxiety level by behavior observation during a preparating anamnesis.

Adenosine nucleotides in bile.

Activation of purinergic receptors by ATP stimulates Cl- efflux in biliary epithelial cells. To determine whether purinergic agonists are present under physiological conditions, we have assayed mammalian bile for nucleotides and assessed whether hepatoma and cholangiocarcinoma cell lines are capable of nucleotide release. Bile samples were collected from human, rat, and pig donors and assayed for nucleotide concentrations by luminometry. ATP, ADP, and AMP were present in bile from each species, and the average total nucleotide concentration in human bile was 5.21 +/- 0.91 microM (n = 16). In an in vitro model of HTC rat hepatoma cells or Mz-ChA-1 cholangiocarcinoma cells on a superfused column, nucleotides were present in the effluent from each cell type. Addition of alpha, beta-methyleneadenosine 5'-diphosphate (50 microM) to inhibit 5'-nucleotidase activity increased AMP concentrations two- to threefold. Exposure to forskolin (100 microM) or ionomycin (2 microM) stimulated nucleotide release from cholangiocarcinoma but not hepatoma cells. These studies indicate that adenosine nucleotides are present in bile in concentrations sufficient to activate purinergic receptors. Purinergic receptor activation by local nucleotide release might constitute an autocrine and/or paracrine mechanism for modulation of biliary secretion.

Clues to patient dissatisfaction with conscious sedation for colonoscopy.

OBJECTIVES: Most colonoscopy is performed using conscious sedation to facilitate the procedure. However, little is known about which patients are dissatisfied with sedation and why. The goal of this study was to examine whether certain patient- and procedure-specific variables are associated with patient dissatisfaction. METHODS: A total of 403 consecutive outpatients underwent colonoscopy during a 4-month study period. Of 342 patients who met entrance criteria, 328 completed the initial questionnaire and were enrolled. Subjects received standard conscious sedation; after colonoscopy, the primary endoscopist and nurse recorded the level of sedation as adequate or inadequate. Twenty-four to 72 hr after the procedure, an independent observer contacted the subjects by telephone and asked whether they were satisfied with the level of sedation achieved during the colonoscopy. A number of patient- (age, gender, anxiety level, and educational background) and procedure-specific variables (waiting time and procedure type, difficulty, and duration) were analyzed to determine their association with patient dissatisfaction. RESULTS: Forty-eight patients (15%) were dissatisfied with sedation. Univariable analysis showed that females, anxiety, higher education (at least 1 yr of college), procedure duration > or = 60 min, and procedure difficulty were all associated with the dissatisfaction with sedation (p < 0.05). Multivariable analysis revealed that only higher education (p = 0.009) and longer procedure duration (p = 0.018) were associated with patient dissatisfaction. CONCLUSIONS: Highly educated patients and those who underwent longer procedures were more likely to be dissatisfied with conscious sedation used for colonoscopy. A thorough discussion of expectations and/or patient-controlled sedation might improve satisfaction with colonoscopy in educated patients. Regular supplementation of sedation, termination of a lengthy procedure with the offer of a further attempt at a later date, and referral to a more experienced endoscopist when appropriate might all improve patient satisfaction with colonoscopy.

Celiac sprue. Diagnosis and diet: keys to recovery.

Celiac sprue is a devastating disease that can have fatal consequences if untreated. Fortunately, if diagnosed correctly and promptly, it can be effectively treated with very satisfactory outcomes. A careful history will often suggest the diagnosis, but definitive diagnosis requires finding the typical lesion on small bowel biopsy and clinical improvement with a gluten-free diet. If symptoms and mucosal abnormalities persist, glucocorticoids should be tried. Malignancy is a rare complication of longstanding CS that should be looked for if there is no response to gluten withdrawal or if symptoms relapse despite adherence to diet.

Atypical presentation of inflammatory bowel disease in the elderly.

Despite multiple invasive diagnostic procedures including exploratory laparotomy and surgical resection, our patient's diagnosis remained an enigma. However, given the clinical scenario and the documented PG, a trial of steroids was warranted. The patient has fared well since her treatment, with resolution of all her symptoms. We feel confident that her disease process is most consistent with, and is most likely, Crohn's disease. There are several lessons to be learned from this case: 1) Inflammatory bowel disease can present at any age and belongs in a clinician's differential diagnosis of fever and diarrhea. 2) Failure to consider IBD in an elderly patient may lead to significant delay in diagnosis, and may expose the patient to unnecessary and sometimes dangerous intervention. 3) IBD in the elderly generally follows the same clinical patterns seen in younger patients. 4) Appropriate therapy can lead to prompt control or even resolution of the signs and symptoms of IBD.

[Results of transabdominal placental biopsy in the 2nd and 3d trimester]. / Ergebnisse der transabdominalen Plazentabiopsie im II. und III. Trimenon.

From August 1988 to October 1990, 115 transabdominal placental biopsies were performed in the second (68%) and third trimenon (32%). The main indication (80%) was the detection of pathological ultrasonographic findings (foetal malformation, growth retardation, oligohydramnios and polyhydramnios). The success rate of chorionic villus sampling (89%) was independent of the localisation of the placenta. A definite cytogenetic result was found in 83% of patients. By combination of placental biopsy and amniocentesis (n = 77) karyotyping was successful in 97% of pregnancies. Chromosomal abnormalities were observed in 15 (13%) cases (7 autosomal and 2 gonosomal aneuploidies, 1 unbalanced translocation, 1 autosomal deletion, 4 structural variants). The outcome of the pregnancies was substantially influenced by the indication for the procedure and by the cytogenetic result. Foetal and peri-/neonatal losses were found in 53% (3% spontaneous abortions) of patients with sonographic abnormalities (n = 92) and in 9% (abortion rate 4%) of pregnancies with regular findings (n = 23). The pregnancy loss rates were 37.7% and 5.9%, respectively. The results confirm the clinical significance of placental biopsy in the management of pregnancies with pathological ultrasonographic findings.

Growth control in mammalian cells by cell-cell contacts.

Growth of normal diploid mammalian cells in vitro is strongly regulated by the actual cell density. Cell-cell contacts via specific plasma membrane glycoproteins whose glycan moieties interact with specific receptors has been found to be a main growth regulatory principle. Malignant growth is suggested to result from impaired function of these receptors.