SURGERY OUTCOMES IN PATIENTS WITH SECONDARY HYPERPARATHYROIDISM AND IMPACT OF INTRA-OPERATIVE PTH MEASUREMENT.

CONTEXT: The current therapeutical management of secondary hyperparathyroidism (S-HPTH) is difficult to obtain due to the lack of kidney donors. Surgical intervention on the pathologic parathyroid tissue has been suggested as a method to alleviate symptoms in patients with chronic kidney disease (CKD). OBJECTIVE: The aim of our study was to evaluate the outcomes of parathyroid surgery in patients with S-HPTH and the advantages of intraoperative quick PTH (iqPTH) to improve surgical results. MATERIAL AND METHODS: In a real-life study, we compared one group of S-HPTH with iqPTH performed after removing all suspected glands and before wound suture (Group 1) and one group in that iqPTH was not assessed (Group 2). When iqPTH dropped less than 50%, additional exploration followed. RESULTS: Eight out of the 34 patients from Group 1, who underwent subtotal parathyroidectomy, showed elevated levels of serum PTH and calcium, which remained elevated during follow-up, thus, suggesting disease persistence. From the 21 patients in Group 2, none showed early postoperative disease persistence. Serum calcium, but not PTH was increased in one patient from the iqPTH group but normalized after one month. Overall, iqPTH allowed detection of a supplementary parathyroid gland in one case, thereby increasing early post-surgery remission to 100% in Group 2 compared to 76.47% in Group 1. Late postoperative remission of hyperparathyroidism with no further increase in the rate of hypoparathyroidism was obtained in Group 2. CONCLUSIONS: Assessment of intra-operative PTH levels proved to be a useful tool in augmenting the outcome of S-HPTH surgery. In patients which are eligible for renal transplantation who undergo a subtotal resection, iqPTH can enhance the post-operative quality of life by lowering disease recurrence rates until the kidney transplant procedure.

[Current methods for wound debridement]. / Metode curente de debridare a plagilor.

Wound management experienced significant changes in the last half century, while acknowledging the concept of "moist wound healing" and the strategy of "wound bed preparation". New solutions in this area have brought by developing new methods of debridement, exudates management and decrease of bacterial load. Debridement is the most widespread used method for conditioning wound and involves the application of interventions that accelerate the healing process. The main objective of this article is to identify current methods of debridement used worldwide in wounds treatment, their indications and recommended guidelines. For this purpose we analyzed reviews, randomized clinical trials, practical guides, meta-analysis, and clinical trials published in the Clinical Core Journals and Nursing Journals from 2006 to 2010. We identified six methods of wound debridement, each with its own advantages and limitations: surgical debridement, mechanical debridement, autolytic debridement, enzymatic debridement, chemical debridement and biological debridement. We found that in literature there is no consensus regarding the most effective debridement method or combination of debridement methods. According to various authors or expert groups' opinions, debridement methods are differentiated by specific properties, different costs and different levels of acceptance from medical staff.

New trends in breast reconstruction.

BACKGROUND: Breast reconstruction (BR) after radical mastectomy is intended to recreate symmetrical natural-appearing breasts while preserving patient safety and quality of life. PURPOSE: To evaluate the esthetic results and the complications of various BR methods after radical mastectomy. PATIENTS AND METHOD: Between August 2006 and March 2010, 36 women underwent BR after mastectomy in our institution. Their charts were reviewed retrospectively to evaluate the results and complications. We used immediate BR for Stage I and IIa breast carcinoma, and delayed BR for stage IIb and III breast carcinoma. RESULTS: We performed a pedicled Transverse Rectus Abdominis Muscle flap in 13 cases, pedicled Latissimus Dorsi with silicone implant in 10 cases, free Deep Inferior Epigastric Perforator (DIEP) flap in 9 cases, and other procedures in four cases. The encountered complications were: total flap failure--one case, partial edge flap necrosis--three cases, donor area wound dehiscence--one case, seroma--one case, local infection--one case. DISCUSSION: Trends in BR in recent years focus more on free perforator flaps, with the DIEP flap being the leader. Internal mammary vessels are most often used as recipient vessels for anasthomoses. Immediate BR when indicated has better aesthetic results. In less well-developed countries, insurance companies do not cover implant expenses and the autologous procedures remain the best option.

Natural killer group 2 member D cell recruitment driven by major histocompatibility complex class I chain-related antigens A and B: a possible mechanism during acute intestinal allograft rejection in the mouse.

Intestinal allograft rejection occurs frequently despite potent T-cell depletion protocols. We investigated the interaction of major histocompatibility complex class I chain-related antigens A and B (MICA/B; a ligand for natural killer [NK] cells) and NK group 2 member D (NKG2D) cells as an alternative mechanism for acute rejection (AR) of the intestinal graft. Heterotopic intestinal allotransplantation was performed from BalbC to C57Bl mice. Samples of grafted and native intestine were obtained at days 1, 3, 6, and 8 after transplantation (n = 4-6). We performed immunostaining for MICA/B and NKG2D. Moderate AR with increased crypt apoptosis was observed at day 6 and advanced AR with crypt destruction and mucosal sloughing was present by day 8. Low MICA/B levels were observed in grafted and native intestines on day 1. MICA/B expression gradually increased in the grafts during AR but not in the native intestines. The up-regulation was found mostly in the crypts. NKG2D+ cell counts that increased in the graft colocalized with MICA/B. The increase was most prominent in the crypt and villus. Together, these results suggest that MICA/B up-regulation and its subsequent interaction with the NK cells may represent an important link between innate and adaptive immune responses early after intestinal transplantation.

Effects of the radiofrequency interference with modified titanium surgical clips on liver parenchyma--an in vivo experiment.

AIM: This study sets out to test the biocompatibility of titanium clips in liver, in the presence of radiofrequency. Biocompatibility is assessed at various distances from the RF electrode and different points in time. METHOD: It is an experimental study conducted on pigs and makes use of histological changes that occur at the liver-titanium interface in presence of RF to test hypotheses. The titanium clips were modified in high vacuum (10 -5 atm) by heating them at 1000 degrees C and 1150 degrees C. Titanium clips were placed in liver at 0.5, 1.5 and 2.5 cm from RF probe. At 7, 14 and 28 days the inflammation, necrosis and fibrosis were assessed. RESULTS: The histological alterations decrease with the distance of implantation of titanium clips. The inflammation and necrosis nearby the titanium clips decrease in time, but the fibrosis does not increased, as expected. The modified titanium at 1000 degrees C clips cause less necrosis than commercial titanium clips. The moderator role of clip type between distance and cell alteration is empirically supported only for fibrosis and necrosis. The moderator role between time and cell alteration is supported only for inflammation. CONCLUSIONS: Experimental data suggests there are no preferred surgical clips in all situations. The biocompatibility of the titanium clips depends on the distance from the RF probe. The commercial ones prove less damaging if they are placed close to the RF probe (less than 1 cm) and those that were treated at 1150 C have a better bio-compatibility if placed more than 1 cm from RF probe.

[Accessory renal allotransplantation with internal or external urinary drainage. An experimental model in pig]. / Allotransplantarea renala accesorie cu drenaj urinar intern sau extern. Model experimental la porc.

This study describes an experimental model of accessory renal allotransplantation in the big laboratory animal (pig). A total of 24 common-breed pigs were used. All allografts were transplanted in an accessory manner and revascularized at the level of the infrarenal abdominal aorta and inferior vena cava. The urinary drainage was performed either through a nexternal uretheroneostomy at the ipsilateral lumbar region (Group A--n=8) or by internal uretheroneocystostomy (Group B--n=8). All transplants were monitored for 8 days postoperatively using translumbar ultrasound-guided biopsies at 1, 4, 7 days. A total of 16 transplants were performed. 1 ectopic donor kidney was found and transplanted in the same fashion. Mean operative time was 125 minutes, immediate postoperative survival was 100% and at 72 hours, 87.5%. The onset of acute rejection was at day 4, by massive lymphocyte infiltration and was directly correlated with the abrupt decrease of the allograft diuresis in Group A, at day 3. At day 7, the rejection was complete. Both methods of urinary drainage are functional and can be employed. This experimental model is a useful tool for training of the transplant surgeons or for transplantation research. The surgical technique for accessory renal allotransplantation in pig is easy to learn and offers the possibility for allograft monitoring until complete rejection without influencing the receptor health condition.

Assessement by laser Doppler of the peripheral tumour perfusion after radiofrequency ablation for colorectal liver mestasis--experimental study.

Colorectal cancer became one of the most frequent malignant conditions of the past two decades. Non-resecable liver metastases might be destroyed in situ by radiofrequency although the local recurrence is still very important. Laser-Doppler flowmetry has proved to be a simple technique for monitoring the microcirculation, hereby the tissue perfusion at the edge of the post radiofrequency necrosis. The aim of the study was to evaluate microcirculation using lasser-Doppler for hepatic tissue and peripheral tumour perfusion after radiofrequency and the influence of local temperature increasing at 42 degrees C on tissular perfusion. Colorectal adenocarcinoma (CC531s) was used for liver tumour inoculationin on 15 Wag/Rij rats. Twenty-one days after inoculation, perfusion in hepatic tissue, on the tumour before and after radiofrequency treatment was mesured. When hepatic tissue was heated at 42 degrees C there was an increase in tissular perfusion, on the other part, heating the tumoural tissue do not increase perfusion. After radiofrequency in the periphery of necrosis the perfusion was still present, despite a clear drop towards initial level. Assessing the local microcirculation and tissue temperature during RF ablation by Laser-Doppler might be useful not only for RF efficiency evaluation but also as an indication for associating adjuvant local chemotherapy.

Laser-Doppler flowmetry in the monitoring of the human intestinal allograft: a preliminary report.

During acute rejection, graft endothelium becomes a prime target for recipient immune cells. Animal studies have shown reduced microvascular perfusion, probably due to increased endothelial-leukocyte interaction and endothelial impairment, leading to graft damage. Using laser-Doppler flowmetry (LDF), we correlated the microvascular blood flow in the intestinal mucosa of five patients receiving multivisceral grafts with clinical events and pathology results. Measurements (n = 75) were performed during the first 4 weeks posttransplantation by inserting the LDF flexible probe through the ileostomy for 25 to 30 cm. Forty-six of the 75 measurements were performed within 24 hours of endoscopy and biopsy. In uncomplicated cases, we recorded a gradual increase in mucosal perfusion during the first week posttransplantation that presumably reflected regeneration after reperfusion injury. Increased mucosal perfusion did not seem to correlate with rejection or other adverse clinical events. Sudden and sustained decreases in mucosal perfusion by 30% or more compared to the previous measurements were associated with septic episodes, rejection, or both. LDF revealed a good sensitivity in monitoring the intestinal microcirculation. It was able to indicate perfusion changes associated with acute rejection. The relatively low specificity of LDF may be compensated by the low invasivity, allowing frequent investigation. LDF may be an additional tool for routine monitoring of intestinal allografts.

Monitoring of the intestinal mucosal perfusion using laser Doppler flowmetry after multivisceral transplantation.

BACKGROUND: Graft endothelium constitutes a prime target during acute rejection. Infiltration of T cells, monocytes, and enhanced endothelial-leukocyte interactions result in microvascular impairment and altered perfusion. MATERIALS AND METHODS: We measured mucosal blood flow using a laser Doppler flowmeter in three patients undergoing multivisceral transplantation. Thirty-seven measurements were performed through the ileostomy over the first 4 weeks posttransplantation. Most measurements were performed within a 24-hour interval from endoscopy and biopsy. RESULTS: Mucosal perfusion increased throughout the first postoperative week and eventually stabilized around levels specific for each patient. Mucosal perfusion remained stable during graft pancreatitis, but decreased 35% to 55% from baseline (the average value of the previous measurements) during acute rejection and sepsis. During the first week posttransplantation there was a gradual increase in mucosal perfusion, which might reflect regeneration after reperfusion injury. Increased mucosal perfusion did not seem to correlate with rejection or other adverse clinical events. A sudden decrease in mucosal perfusion of 30% or more compared to the previous measurements was associated with septic episodes and/or rejection.

Accelerated acute rejection of the intestinal graft in CD28-deficient mice.

OBJECTIVE: Multiple in vivo studies have shown that the pace and severity of graft rejection is little or not at all changed by deleting CD28 molecules in the recipient. These findings contrast with the effects of monoclonal antibody therapy aimed the same costimulatory target. The objective of the present study was to evaluate how the acute rejection process is affected in CD28-deficient mice using a fully allogeneic, highly immunologically reactive transplant model. METHODS: Heterotopic vascularized small bowel transplants were performed in 24 recipient mice divided into 4 groups: 2 wild-type and 2 knockout groups. Each group consisted of 5 to 7 animals in which BalbC mice were used as intestinal donors to either wild-type C57BL6 or C57BL6 background CD28-deficient recipient mice. Selected endpoints were 3 and 6 postoperative days (POD). Intestinal rejection was evaluated by mucosal laser Doppler flowmetry (expressed in perfusion units) and histology (expressed in rejection grades). RESULTS: Acute rejection occurred in both wild-type and CD28-deficient groups. At POD 3, no significant difference was noted between groups in terms of mucosal perfusion and histology. At POD 6, significant differences in graft mucosal perfusion and histology revealed a more aggressive rejection in the CD28-deficient group compared to the wild-type group. CONCLUSIONS: The present study showed that the severity of intestinal graft rejection responses was amplified by deleting CD28 molecules. Together with data from other studies, these results suggest a different pattern of distribution and/or activation of CD28/B7 receptors in various organs.

Intragraft heat shock protein-60 expression after small bowel transplantation in the mouse.

The time course of heat shock protein 60 (hsp 60) expression after intestinal transplantation in syngeneic and allogeneic combination was correlated with the degree of rejection. Hsp 60 expression was assessed by immunostaining; rejection degree was established by histologic examination on posttransplantation days 1, 3, 6, and 8. No signs of rejection occurred in syngeneic grafts at any time. In the allogeneic setting, rejection was absent in all but 1 case on postoperative day 3. Three days later moderate rejection was evident based on focal crypt destruction and focal mucosal ulceration, whereas at postoperative day 8 extensive mucosal sloughing was the dominant feature, consistent with advanced rejection. Hsp 60 remained undetectable in the syngeneic setting at all times. In allografts, hsp 60 was initially expressed on posttransplant day 3, increasing synchronously with the progression of rejection at days 6 and 8. Hsp 60 expression was localized almost exclusively to the crypt area and the lower third of the villi. In conclusion, the rejection of murine allogeneic intestinal grafts is characterized by a progressive expression of hsp 60 in the epithelium.

Heterotopic uterine transplantation by vascular anastomosis in the mouse.

A method of heterotopic uterine transplantation was developed in the mouse as a model system for studies of uterine function and transplant immunology of the uterus. The model involved transplantation of the right uterine horn and the cervix by vascular anastomosis to a donor animal with the intact native uterus remaining in situ. F1-hybrids of inbred C57BL/6 x CBA/ca (B6 CBAF1) mice of 6-8 weeks of age (n=42) were used. The specific pelvic vascular anatomy of these mice was first examined by intra-aortal injection of a two-component silicon-rubber curing agent. The surgery of the donor animal involved microsurgical isolation of the right uterine horn and the cervix, with preserved vascular supply from the aorta through the right uterine artery. After isolation of the uterine horn with vascular supply and venous drainage, including approximately 3 mm of the inferior vena cava and aorta, the organ was put on ice. The recipient animal was prepared by exposing and mobilizing the infrarenal part of the aorta and the vena cava. The grafted uterus was placed in the abdomen on the left side and the aorta and vena cava of the graft were anastomosed end-to-side to the aorta and vena cava of the recipient animal with 11-0 sutures. The total time for these procedures declined with time and was 125+/-4 min for the last 28 operations. Viability of the uterus was confirmed, several days later, by demonstrating a blood flow similar to that of the native uterus, and histology of the grafted uterus demonstrated normal morphology, including intact ultrastructure of the endothelial cells. The overall survival rate of the recipient animals increased with learning from approximately 40% in animals 1-21 to 71% in animals 22-42. The proportion of viable grafts, as judged by normal blood flow and histology among the surviving mice was 25% in animals 1-21 and 87% in animals 22-42. An undisturbed function of the transplanted uterus horn was finally demonstrated by its ability to implant inserted blastocysts and to carry pregnancy with fetal weight being similar to that of fetuses in the native uterus and controls. In conclusion, this is the first report of successful transplantation of the uterus with proven functionality in the mouse. The model should be useful for many aspects of research in uterine physiology and pathophysiology.

[Stapled anastomoses in colorectal surgery]. / Anastomoze mecanice în chirurgia rectocolica.

The purpose of this paper was to analyze the advantages, indications and results of stapled circular anastomoses in colorectal surgery. In the last four years (1995-1998), fifteen patients underwent stapled anastomoses after Dixon's anterior rectal resection for cancers of upper and midrectum (11 patients), total colectomy with ileorectal anastomosis for malignant familial polyposis (1 patient), segmental colectomy of transverse and descending colon (1 patient with synchronous colic and rectal cancers, having concomitant rectal resection for cancer), previous Hartmann's resection for perforated upper rectal cancer (1 patient) or distal sigmoid diverticulitis (1 patient). The anastomoses have been performed in end-to-end fashion (11 patients), according to the Knight's technique (2 cases) or in side-to-end fashion (2 patients). As most frequent associated technique with stapled anastomoses, anterior rectal resection for cancer was performed with 2 cm of clearance beyond the macroscopic margin of tumor. Distal margin of resection was histologically verified and it proved to be free of tumor cells. There was no operative mortality. Anastomotic leakage occurred in three patients because of imperfection of stapled anastomosis (2 cases) or after local irradiation (1 case). Spontaneous closure was seen in one patients. The other two patients needed reoperation for suture or colostomy. Late clinical, endoscopic and X-ray controls did not discover local recurrences. Functional results were good in terms of stool frequency and continence. In conclusion, stapled fashioned anastomoses have the main indication in sphincter saving Dixon's and Hartmann's procedures. In these cases, stapled anastomoses are easier than manual technique, reduce operative time and improve suture reliability.

[The indications for celiostomy in acute necrotizing pancreatitis]. / Indicatiile celiostomiei în pancreatitele acute necrotice.

The aim of this study was to analyze the indication and results of open pancreatic drainage by celiostomy in severe necrotizing pancreatitis (SNP). 44 patients with SNP were treated surgically by open lesser-omental sac drainage (celiostomy) in the last nine years (1989-1997). They were classified into three groups according to date (timing) of celiostomy: a group of 23 patients with early celiostomy (in the first week after the onset of pancreatitis); second group of 11 patients with celiostomy in the second and third week after SNP; the third group of 10 patients with late celiostomy (4-12 weeks after pancreatitis). Drainage procedure consisted in marsupialization of lesser omental sac by suturing open gastrocolic ligament to anterior peritoneum, with drains inserted via celiostomy. The indications of celiostomy in the first group were: diagnostic laparotomy for unknown acute abdomen (18 patients), severe acute cholecystitis (1 patient), common bile duct stones (2 patients), persistent MOSF (1 patient). The necrosectomy was technically possible only in eight patients (34.7%) at date of laparotomy. Postoperative infection of necrosis occurred in seven patients (30.4%) and nine patients died postoperatively (39.1%) because of aggravated MOSF. In the second group, celiostomy was carried out for extensive sterile (2 patients) or infected necrosis (9 patients). Good results were obtained in 9 patients and two patients with infected necrosis died postoperatively. In the third group late celiostomy was performed for treatment of the pancreatic abscess, with good results in all patients (0% mortality). In conclusion, celiostomy is drainage procedure of choice for patients with extensive infected pancreatic necrosis or pancreatic abscesses and stable biologic condition. It facilitates intermittent debridements of residual necrosis and purulent foci, without relaparotomies. Early celiostomy is not recommended as it is proved ineffective (nondemarcated necrosis) and may cause aggravation of SNP or exogenous infections of necrosis.