Combining topical negative pressure and a Bogota bag for managing a difficult laparostomy.

A patient with a severe intra-abdominal infection required a laparostomy. A Bogota bag was combined with topical negative pressure therapy, saving nursing time and enabling successful management of wound fluid.

Combined immunotherapy with intracavital injection of activated lymphocytes, monocyte-derived dendritic cells and low-dose OK-432 in patients with malignant effusion.

We have conducted a pilot study with combined immunotherapy using autologous lymphocytes activated ex vivo and monocyte-derived dendritic cells in combination with low-dose OK-432, a streptococcal preparation, in five patients with peritoneal or pleural carcinomatosis who were resistant to standard chemotherapy. All patients were given 3 to 10 courses of the combined immunotherapy. No severe adverse reactions occurred. Effusion production was decreased in all of the patients. Significant decreases in tumor markers of both effusions and sera as well as effusion volume occurred in all of the patients. Cytological examinations revealed a marked decrease or disappearance of cancer cells in those effusions. Three patients showed increase in IFN-gamma levels in the effusions. The overall prognosis of the patients was acceptable and the mean survival time was more than 9 months. The locoregional immunotherapy seems to be encouraging in view of therapeutic modality in patients who are resistant to standard chemotherapy. Our study provides a new protocol for immunotherapy and warrants further phase I/II clinical study for chemo-resistant patients with malignant effusion.

[A patient with stage IIIc ovarian cancer with massive ascites who was chemotherapy resistant showed complete response with intraperitoneal hyperthermic chemoperfusion].

Intraperitoneal hyperthermic chemoperfusion (IHCP) was performed on a stage IIIc ovarian cancer patient with massive ascites who had been chemotherapy resistant. Complete response was observed after the treatment. A 59-year-old woman with advanced ovarian cancer complained of massive refractory ascites after 2 years' history of chemotherapy. The patient received IHCP combined with surgery to remove the primary tumors and omentum. Soon after the treatment, the massive ascites disappeared and CA125 level decreased to normal. The patient remained free of ascites for 14 months after the treatment.

[Bilateral pneumothorax and tamponade after acupuncture]. / Pneumothorax bilatéral et tamponnade après acupuncture.

INTRODUCTION: The "target" of acupuncture is usually the muscle, but it occasionally approaches other anatomical structures such as the pleura, which may subsequently suffer damage. OBSERVATION: During a session of acupuncture, a 25-year-old woman had a malaise with shock and neurological disorders. The initial examinations revealed a bilateral pneumothorax associated with pericardial and peritoneal effusions. Symptomatic reanimation combining dopamine, left pleural draining and pericardial puncture led to rapid haemodynamic improvement. The etiological exploration, having eliminated an underlying pathology, concluded in the diagnosis of tamponade and bilateral pneumothorax following a session of acupuncture. COMMENTS: Our patient presented the association of two traumatic complications of acupuncture: cardiac tamponade due to haemopericardium and bilateral pneumothorax. Although these complications are rare, they must be known.

Intraoperative placement of a self-retaining Foley catheter for continuous drainage of malignant ascites.

Malignant ascites in advanced cancer is usually treated by repeated paracentesis, causing both discomfort and inconvenience to patients in the terminal stages of disease. We present a case of advanced ovarian carcinoma in which intraoperative placement of a Foley's self-retaining catheter into the peritoneal cavity was used to facilitate long-term continuous drainage of malignant ascites. This is a simple, convenient and cost-effective method which decreases the need for repeated hospital admissions. The aim complication might be peritonitis, but with proper care of the device and the use of antibiotics, this was not seen in our patient.

Abdominal ultrasound examination in pregnant blunt trauma patients.

BACKGROUND: The ability of abdominal ultrasound to detect intraperitoneal fluid in the pregnant trauma patient has been questioned. METHODS: Pregnant blunt trauma patients admitted to a Level I trauma center during an 8-year period were reviewed. Ultrasound examinations were used to detect intraperitoneal fluid and considered positive if such fluid was identified. RESULTS: One hundred twenty-seven (61%) of 208 pregnant patients had abdominal ultrasound during initial evaluation in the emergency department. Seven patients had intra-abdominal injuries, and six had documented hemoperitoneum. Ultrasound identified intraperitoneal fluid in five of these six patients (sensitivity, 83%; 95% confidence interval, 36-100%). In the 120 patients without intra-abdominal injury, ultrasound was negative in 117 (specificity, 98%; 95% confidence interval, 93-100%). The three patients without intra-abdominal injury but with a positive ultrasound had the following: serous intraperitoneal fluid and no injuries at laparotomy (one) and uneventful clinical courses of observation (two). CONCLUSION: The sensitivity and specificity of abdominal ultrasonography in pregnant trauma patients is similar to that seen in nonpregnant patients. Occasional false negatives occur and a negative initial examination should not be used as conclusive evidence that intra-abdominal injury is not present. Ultrasound has the advantages of no radiation exposure.

Transcatheter arterial embolization in blunt hepatic trauma.

Patients with blunt hepatic injury can safely be managed nonoperatively if they show hemodynamic stability. Transcatheter arterial embolization (TAE) is a useful adjunct in the treatment of patients who show evidence of continued hemorrhage or who have pooling of contrast material on computed tomography (CT). In these patients, TAE may reduce transfusion requirements and allow healing of the injury without operation. Complications are uncommon and are usually managed nonoperatively.

Cystogastric transmural drainage for the treatment of symptomatic cystic metastases from ovarian carcinoma.

Approximately 80% of ovarian cancers are discovered when they have already progressed to stage III or IV lesions. The prognosis is, therefore, poor despite intensive treatment. Intraperitoneal dissemination is one of the most frequent pathways of distant spread ovarian cancer and pseudocystic metastases usually occur. When such cystic metastases remain symptomatic despite antitumor treatment, viable options are limited because palliative surgery generates high operative morbidity and mortality. For many years, in patients in whom the risks associated with surgery are high, percutaneous drainage and sclerosis under radiologic guidance has been performed as an effective alternative option for various forms of abdominal fluid collection. Such a collection in pancreatic pseudocyst benefits from cystogastric transmural drainage to avoid external drainage and achieves the same results as surgical cystogastrostomy. We report this transmural drainage technique under image guidance used to drain a symptomatic cystic metastasis, which was compressing the stomach.

Multi-institutional randomized clinical study on the comparative effects of intracavital chemotherapy alone versus immunotherapy alone versus immunochemotherapy for malignant effusion.

The current prospective randomized study was designed to compare the effects of intracavitary (i.c.) chemotherapy vs immunotherapy vs immunochemotherapy for malignant effusion. Between 1992 and 1995, a total of 42 patients with malignant effusion were registered, and 41 patients were eligible for statistical analysis. The primary diseases of the eligible patients included 27 gastric, four colorectal, four pancreatic, three lung, two liver and one oesophageal cancers. The patients with malignant effusion were randomly assigned into one of three i.c. therapeutic regimens: chemotherapy alone with weekly injection of anticancer agents (ACAs: cisplatin, mitomycin-C, adriamycin, etc.) (Group A, n = 13); immunotherapy alone with weekly injection of streptococcal preparation OK-432 (Group B, n = 14); or immunochemotherapy with ACAs and OK-432 (Group C, n = 14). The response of the effusion, patient survival and the kinetics of cytokines in the effusion were compared. There were no differences in the patients' backgrounds. The side-effects of the regimens included pain, anorexia, fever, leucopenia and anaemia and there were no differences in their incidence among the three groups. One patient died after cisplatin (CDDP) administration in Group A. Cytologic examination revealed that tumour cells in the effusion disappeared in 23% of Group A cases, 36% of Group B cases and 36% of Group C cases. The malignant effusion did not disappear in any of the Group A cases; however, the effusion disappeared in 29% of Group B cases and 43% of Group C cases (P = 0.03, Group A vs Group C). Furthermore, the 50% survival period was 1.6 months for Group A, 2.4 months for Group B and 3.5 months for Group C. The 6-month survival rate was 7% for Group A, 6% for Group B and 34% for Group C, and the 1-year survival rate was 0%, 0% and 17% respectively (P = 0.048, Group A vs Group C by the log-rank test). The analysis of the cytokine kinetics revealed a prominent increase in the level of interleukin-6 in the effusion in Group C. These results suggest that i.c. immunochemotherapy with OK-432 and ACAs may be more beneficial than i.c. chemotherapy alone or immunotherapy alone.

Intravenous infusion ascitic fluid during hemodialysis: a study of 108 treatments in 13 uremic cases.

Nephrogenic ascites is a clinical diagnosis defined as persistent ascites in an uremic patient without evidence for a causative underlying disease. It imperils the patient's life with intradialytic hypotension, however there is no effective therapy other than renal transplantation so far. In 13 cases, 108 treatments with i.v. ascites infusion were performed with hemofilter alone or combined with plasmafilter during hemodialysis over past 7-years. The ascitic fluid was filtrated and dialyzed before it was intravenously infused into the blood compartment of the hemofilter. There were a mean of 8.38 treatments per patient in a period of 56 days and 3,275.9 +/- 1,359.5 ml of ascitic fluid were removed per treatment. The patients' appetite and physical ability were considerably improved and the intradialytic hypotensions disappeared immediately following the initiation of ascitic fluid infusions. In this study, one patient was transplanted successfully. The longest interval without ascitic fluid infusion was 127 days. Main side effect was light pyrogenic reaction, which was presented in 12.96% of the total treatments. It is concluded that this method permits to continue hemodialysis, improves the nutritional condition and prolongs the lifespan by conserving and reusing the ascites protein.

Ascitis: Diagnóstico, análisis del líquido, tratamiento y complicaciones / Ascites: Diagnosis, fluid analysis, treatment and complications

Un problema común en la gastroenterología y en otras áreas de la medicina interna es la ascitis. Esta entidad puede ser la manifestación de diversas patologías. Por esta razón, es necesario conocer el abordaje inicial de estos pacientes, así como sus complicaciones y tratamiento

[Complications after surgical resection of liver parenchyma]. / Powiklania po zabiegach resekcyjnych miazszu watroby.

The number of liver resection in Poland has recently increased. Most frequent indications are benign tumors of the liver, metastatic changes and primary hepatic carcinoma. The aim of work is to discuss incidence of complications which appeared after liver resections at our Department. Among 56 patients aged 19-76, 32 anatomical and 24 nonanatomical resections of hepatic tissue were performed. In the early postoperation period, 8 patients had peritoneal fluid collections and 3 laparotomies with drainage were necessary, while in 5 cases fluid was aspirated under usg guidance. The outflow of bile and blood contents from subhepatic space was prolonged to 9 days in 3 patients, gastric or duodenal 3 stress ulcerations complicated with bleeding were observed as well as transitory hemobilia in 3 and jaundice in 6 cases. Early hemorrhage from excision line of hepatic tissue was observed in 2 patients which needed additional surgical intervention. Atelectasis and inflammatory changes of the right lung appeared in majority of patients operated on. The postoperative mortality of 16% (9 patients of total 56) was mainly dependent on hepatorenal or cardiorespiratory failure, however myocardial infarction and DIC syndrome were also noticed. In spite of progress of surgical technique and intensive perioperative care, resection procedures of the liver are still accompanied with large percentage of serious complications.

Usefulness of a nonmachinery based system for the reinfusion of cell-free and concentrated autogenous ascitic fluid.

A nonmachinery based system using gravity dependent flow for the treatment and reinfusion of ascitic fluid was developed, and its usefulness was assessed. In a preliminary study using bovine plasma, samples with protein concentrations below 5.0 g/dl were found to be treatable with this system. Bovine plasma containing blood, prepared to 0.5% hematocrit and with a protein concentration of 3.0 g/dl, was also treatable. We conducted a clinical study of 1,799 treatment sessions (1,495 using a machinery based system and 304 using a nonmachinery based system) of 343 patients with ascites refractory to various treatments. The recovery ratio of protein from the original ascitic fluid was 96% using the nonmachinery based system and 77% with the machinery based system (p < 0.01). Of 253 continuous reinfusions of ascitic fluid using the nonmachinery based system, the original ascitic fluid at protein concentrations below 2.5 g/dl was treatable. Original ascitic fluid below a hematocrit of 0.7% (protein concentration, 1.4 g/dl) was also treatable. This new procedure was simple and time and labor saving; the high recovery ratio of protein also demonstrated the usefulness of the new system.

Local immunotherapy with interferon-alpha in metastatic pleural and peritoneal effusions: correlation with immunologic parameters.

Interferon-alpha (IFN-alpha) has been found to exert multiple enhancing effects in the immune response in vitro, IFN-alpha has been also used in clinical trials with variable response rates. The aim of the present study was to assess the effectiveness of IFN-alpha in the treatment of 25 patients with malignant pleural or peritoneal effusions caused by lung, and metastatic breast and ovarian cancer. Clinical responses were correlated with a) the ratio of malignant effusion (ME)-associated tumor cells to ME-associated mononuclear cells (MEMNC), b) MEMNC-derived cytotoxic responses against autologous or allogeneic tumor targets, and c) major histocompatibility complex (MHC) antigen expression on tumor cells. After partial drainage of pleural or peritoneal fluid, the patients were allocated to receive 10 million units of IFN-alpha by intrapleural or intraperitoneal injection at weekly intervals. The treatment was terminated if the malignant effusion disappeared or the patients had received four to six consecutive procedures. None of the patients received concomitant systemic chemotherapy or radiation therapy. MEMNC and tumor cells were isolated by centrifugation on discontinous percoll density gradients. Cytotoxic and phenotypic profiles of MEMNG were analyzed before and after treatment with IFN-alpha. An improvement was observed in patients with increased ratios of tumor cells to malignant effusion-associated mononuclear cells (MEMNC) in the effusions. In the same patients MEMNC were overpopulated by CD8+ T lymphocytes. In this group of patients the administration of IFN-alpha was associated with 25% complete response and 75% partial response rates. In contrast only 17% partial responses were achieved in patients whose effusions had decreased tumor cell to MEMNC ratios. The immunomodulation induced by IFN-alpha in vivo was also tested. Thus in a group of 6 patients, treatment with IFN-alpha resulted in the induction of CD8+ cell-mediated lysis against autologous tumor cells which was associated with PR (two patients). Natural killer (NK)-cell activity, and MHC class I antigen expression on effusion-associated tumor cells were also enhanced during treatment, but were not correlated with the outcome of the therapy since similar findings were also observed in the 4 non-responders. Local infusions of IFN-alpha provide an effective alternative treatment for malignant effusion in patients with lung, breast, and ovarian cancer. Increased ratios of tumor cells to MEMNC and the presence of CD8+ T lymphocytes within the malignant effusions may play an important role in the outcome of such a treatment with IFN-alpha but more patients need to be studied for definite conclusions.

Induction of inflammatory cytokines in effusion cavity by OK-432 injection therapy for patients with malignant effusion: role of interferon-gamma in enhancement of surface expression of ICAM-1 on tumor cells in vivo.

The intracavitary injection of OK-432, a streptococcal preparation, has been shown to be an effective immunotherapy for patients with malignant effusion. We found that this therapy increases surface expression of intercellular adhesion molecule-1 (ICAM-1) on tumor cells, and that the degree of increased ICAM-1 was correlated with therapeutic effects. In the present study, we investigated the ability of OK-432-induced inflammatory cytokines, such as interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), and interleukin-1 beta (IL-1 beta), to enhance ICAM-1 expression. We treated 17 patients who had a malignant effusion with OK-432. At 24 hr after OK-432 injection, ICAM-1 levels on tumor cells were increased significantly in responders except in one case (n=9), whereas no change was evident in nonresponders except in two cases (n=8). Induced maximum levels of IFN-gamma in responders were significantly higher than those in nonresponders. In contrast, there was no significant difference in the induced TNF-alpha or IL-1 beta levels between the two groups. Two types of cultured tumor cells derived from responder patients were successfully established from the 17 different tumor cells in effusion. We performed an in vitro study using these cultured tumor cells. Treatment of the two cultured tumor cells with recombinant IFN-gamma, but not recombinant TNF-alpha or IL-1 beta, significantly increased their ICAM-1 expression to a clinically detectable level. Direct treatment of the tumor cells with cell-free effusion samples obtained from the same patients 24 hr after the therapy successfully increased ICAM-1 expression and this action was blocked completely only by a pretreatment with anti-IFN-gamma mAb. Our results suggests that in this therapy IFN-gamma plays a crucial role in enhancing ICAM-1 expression by tumor cells and that induced IFN-gamma levels may be a useful marker for evaluation of the therapeutic effect.