Quantitative analysis of detected sentinel lymph nodes and the incidence of micrometastases using two different methods of surgical melanoma treatment--pilot study.

UNLABELLED: The aim of our study was to compare the number of detected sentinel lymph nodes and the incidence of micrometastases between two groups of patients with cutaneous melanoma. METHODS: 100 patients were divided in to two groups: group V and group D. Group V patients (50) with melanoma underwent a single-stage surgery--radical excision of the tumour with sentinel lymph node biopsy (study group "V"). Group D patients (50) with melanoma underwent two-stage surgery; initially primary diagnostic excision of the tumour (0.5 cm from margins of the lesion) followed by a radical re-excision of the post-operative scar and sentinel lymph node biopsy (study group "D"). RESULTS: Study groups "V" and "D" were tested for homogeneity with regard to age, melanoma thickness, location of melanoma, type of melanoma, and ulceration. The groups were found to be homogenous. The average number of removed sentinel lymph nodes in group "D" was 1.0 more than in group "V" (p < 0.05). The averages were 3.7 and 2.7 respectively with a SD of 1.8. The relationship between the SL node staining and type of surgery was (p < 0.05). 49.6% stained radioactive sentinel lymphnodes at the time of surgery was found in group "V", while 33.9% in group "D". CONCLUSIONS: Using two different early-stage cutaneous melanoma management techniques significantly more sentinel lymph nodes (p = 0.006) were detected using the two-stage surgery approach. However, there was no significant difference between the two approaches regarding the number of sentinel lymph nodes with micrometastases that were detected and excised.

Effects of different kinds of meshes on postoperative adhesion formation in the New Zealand White rabbit.

The aim of this study was to compare the effect of different kinds of surgical meshes on postoperative adhesion formation. Forty-two New Zealand White rabbits were studied. The rabbits were grouped into six groups, according to the type of surgical meshes (Prolene, Mersilene, Vypro, polytetraflouroethylene (PTFE), Proceed and control group) implanted into the peritoneum cavity. Thirty days after the operation, the relaparotomies were carried out, and any adhesions observed between the implanted mesh and tissues were evaluated and graded. The mean adhesion degree was 9.2 in the Mersilene mesh group, 9.5 in the Prolene mesh group, 9.7 and in the Vypro mesh group (P > 0.05). The mean adhesion degree was 1 in the control group, 2.75 in the Proceed mesh group and 2.25 in the PTFE mesh group. There was a significant difference in adhesion degree between the control, Proceed and PTFE groups and the Prolene, Mersilene and Vypro mesh groups. The adhesion degree was significantly lower in the Proceed and PTFE mesh groups when comparing them with the Prolene, Mersilene and Vypro meshes.

[Venous stasis and deep vein thrombosis prophylaxis during laparoscopic fundoplication]. / Prophylaxe der venösen Stase und tiefen Venenthrombose bei laparoskopischer Fundoplikatio.

AIMS OF THE STUDY: first, to study the effect of a pneumoperitoneum (12 mm Hg) on femoral venous outflow, second, to evaluate the efficacy of mechanical antistasis devices: intermittent pneumatic compression (IPC), intermittent electric calf muscle stimulation (IECS) and graded compression leg bandages (LB) in reducing venous stasis, third, to determinate the incidence of deep venous thrombosis (DVT) after laparoscopic fundoplications using venous occlusion plethysmography method. PATIENTS AND METHODS: 54 patients undergoing elective laparoscopic fundoplications were studied. They were randomized into three groups - 18 patients in each group. The first group received LB, the second group received IECS and the third group IPC during operations. Lower extremity venous blood velocity was evaluated using Doppler ultrasonography during operation. In all 54 patients leg venous outflow was measured 1 day before and 1 day after operation using venous occlusion plethysmography method, in order to detect possible DVT after operation. The blood velocity in the femoral vein without pneumoperitoneum was 20.1 +/- 2.4 cm/s in the IPC group, 20.3 +/- 1.4 cm/s in the IECS group, and 23.9 +/- 1.2 cm/s in the LB group. With the introduction of a pneumoperitoneum (12 mm Hg) and the reverse Trendelenburg position the femoral venous blood velocity was significantly reduced in all groups: 9.3 +/- 0.9 cm/s in IPC group, 9.4 +/- 0.9 cm/s in IECS group, and 9.2 +/- 1.1 cm/s in LB group (p < 0.05). The maximum blood velocity generated by the IPC when a pneumoperitoneum (12 mm Hg) was present was 17.4 +/- 1.9 cm/s, and in the IECS group 14.0 +/- 1.1 cm/s, whereas in the LB group the blood velocity remained the same (9.2 +/- 1.1 cm/s). Calf DVT and pulmonary artery microembolization developed in one patient of the LB group, detected by venous occlusion plethysmography and lung perfusion scintigraphy methods one day after operation. CONCLUSIONS: The femoral vein stasis which appears in laparoscopic fundoplications can be minimized by reducing the intraabdominal pressure during operation, and avoiding reverse Trendelenburg position as much as possible. IPC is more effective than IECS in reducing venous stasis induced by the pneumoperitoneum and the reverse Trendelenburg position. Graded compression by leg bandages is ineffective in patients undergoing laparoscopic gastrofundoplication. With a pneumoperitoneum in place, neither device was able to return the depressed blood flow velocity to the values recorded without a pneumoperitoneum. The incidence of DVT and pulmonary embolism after laparoscopic fundoplications was 1.8 % in our study.

Prospective randomised trial of computer-aided diagnosis and contrast radiography in acute small bowel obstruction.

OBJECTIVE: to compare the ability of computer-aided diagnosis and contrast radiography for the diagnosis of acute mechanical small bowel obstruction. DESIGN: Prospective randomised trial. SETTING: Kaunas University of Medicine, Lithuania. SUBJECTS: 80 patients with small bowel obstruction with no clinical evidence of strangulation who were randomised into two groups (n = 40 in each) to be investigated by computer-aided diagnosis and contrast radiography. INTENVENTIONS: 37 patients required operation (46%). MAIN OUTCOME MEASURES: specificity, sensitivity, false positive and negative predictive values of the 2 methods; time necessary to make the diagnosis; and morbidity and mortality. RESULTS: The specificity, sensitivity, positive and negative predictive values in the diagnosis of complete acute small bowel obstruction for the computer-aided group were 100%, 87.5%, 100% and 92.3%, and for the contrast radiography group 100%, 76.9%, 100% and 90%, respectively. The mean time period for making the diagnosis was 1 hour in the computer-aided group and 16 hours in the radiography group (p < 0.001). The overall mortality was 3% and morbidity 9%. CONCLUSION: Computer-aided diagnosis had no significant advantage over contrast radiography in the accuracy of diagnosis of the character of small bowel obstruction. However, significantly less time was needed to make the diagnosis in the computer-aided group.

Computer-aided diagnosis of the character of bowel obstruction.

A computer programme for the differential diagnosis of bowel obstruction was created and put into clinical practice to accelerate and simplify the diagnostic process. The training material was 503 cases of bowel obstruction admitted to the Surgical Clinic of Kaunas Medical University during 1990-1996. Based on 36 statistically significant anamnestical, clinical, laboratory investigations and plain abdominal X-ray findings, the computer programme was built up using a Bayesian formula. Retrospectively, the prognostic diagnosis was compared with the final clinical diagnosis based on instrumental or operative findings. Then, in a control group of 136 patients, the prospective prognostic diagnosis was obtained. The accuracy of the prognostic diagnosis in the control group of patients with complete small bowel obstruction amounted to 88.7% and for the patients with complete large bowel ileus 95.8%. Prognostic accuracy for partial small bowel obstruction was the most precise (96.1%) and for partial large bowel ileus (87.5%). The overall diagnostic accuracy of the computer algorithm was 92.6%. All cases were classified. This computer algorithmic programme for the differential diagnosis of the character of mechanical bowel obstruction has markedly shortened and facilitated the process of diagnosis of ileus.

Experimental studies of injection agents for peptic ulcer bleeding endoscopic control.

AIM: To evaluate haemostatic effectiveness and tissue effects of injected therapy agents used for peptic ulcer bleeding endoscopic control. METHODS: Bleeding gastric mucosa lesions were produced during operation in 11 heparinised dogs. Bleeding lesions were treated with injections of 1 ml of epinephrine (1:10000), ornipressin (0.2 IU/m]), 98% ethanol, 1% polidocanol, thrombin (1000 U/ml), or fibrin sealant. In another 18 dogs, gastric submucosal injections of tested agents were performed during operations. Dogs were killed 48 h after injections and tissue effects were studied. RESULTS: The agents tested had similar effectiveness in achieving initial control of experimental bleeding (chi2 = 1.43). Vasoconstrictors caused no tissue injury or thrombosis in vessels after 48 h. Ethanol produced mucosa and submucosa necrosis and thrombosis in vessels. Polidocanol caused mucosa necrosis, submucosa oedema and thrombosis in vessels. Thrombin tissue effects were mucosa oedema, submucosa thrombosis in vessels. Fibrin sealant caused agent insertion between mucosa and submucosa, but no tissue injury or thrombosis in vessels. CONCLUSIONS: Experiments did not show significant differences between investigated agents in achieving initial bleeding control. The investigated agents, according to the stomach tissue injury they caused in our experiment, would produce series: epinephrine = ornipressin < fibrin sealant < thrombin < polidocanol < ethanol, and according to their effect on vascular thrombosis: epinephrine = ornipressin = fibrin sealant < polidocanol < ethanol < thrombin.

Clinical and endoscopic signs for the prediction of recurrent bleeding from gastroduodenal ulcers.

OBJECTIVE: To evaluate the prognostic importance of various clinical and endoscopic signs in patients who rebled after endoscopic treatment of gastroduodenal ulcers, and to create a predictive index using regression analysis. DESIGN: Retrospective study. SETTING: Teaching hospital, Lithuania. SUBJECTS: 659 patients whose bleeding peptic ulcers were treated endoscopically (out of a total of 949 with bleeding peptic ulcers seen from 1982-1991). INTERVENTIONS: Endoscopic haemostasis (laser or electrocoagulation, or injection sclerotherapy). MAIN OUTCOME MEASURES: Mortality, incidence of rebleeding, and identification of prognostic factors. RESULTS: Of the 75 patients who rebled 25 died (33%), compared with 23 of the 584 who did not (4%). 57 patients (76%) rebled within two days of endoscopy, and 70 (94%) within a week. 59 variables from the group of 75 who rebled and from a control group of 100 who did not were analysed by logistic regression to construct a predictive index. The following 12 variables were found to be significantly associated with recurrent haemorrhage: frequency and type of bleeding; length of time between episodes of bleeding at home; shock index on admission; speed of reduction in haemoglobin concentration; size and type of ulcer, and whether it was complicated; endoscopic appearance of ulcer; number of ulcers, sex of the patient, and presence of associated diseases (liver disease, coagulopathy, hypertension, or heart disease). The accuracy of the index varied from 78.4% in the prediction of a high risk of rebleeding to 100% in the prediction of a low risk. CONCLUSION: By using the predictive index we have been able to improve our management of patients with bleeding peptic ulcers.