Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies.

OBJECTIVE: Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies. We evaluated the feasibility and oncologic value of laparoscopic transperitoneal pelvic and paraaortic lymphadenectomy in correlation to complication rate and body mass index. METHODS: Between August 1994 and September 2003, pelvic and/or paraaortic transperitoneal laparoscopic lymphadenectomy was performed in 650 patients at the Department of Gynecology of the Friedrich-Schiller University of Jena. Retrospective and prospective data collection and evaluation of videotapes were possible in 606 patients. Laparoscopic lymphadenectomy was part of the following surgical procedures: staging laparoscopy in patients with advanced cervical cancer (n = 133) or early ovarian cancer (n = 44), trachelectomy in patients with early cervical cancer (n = 42), laparoscopic-assisted radical vaginal hysterectomy in patients with cervical cancer (n = 221), laparoscopy before exenteration in patients with pelvic recurrence (n = 20), laparoscopic-assisted vaginal hysterectomy or laparoscopic-assisted radical vaginal hysterectomy in patients with endometrial cancer (n = 112), and operative procedures for other indications (n = 34). RESULTS: After a learning period of approximately 20 procedures, a constant number of pelvic lymph nodes (16.9-21.9) was removed over the years. Pelvic lymphadenectomy took 28 min, and parametric lymphadenectomy took 18 min for each side. The number of removed paraaortic lymph nodes increased continuously over the years from 5.5 to 18.5. Right-sided paraaortic, left-sided inframesenteric and left-sided infrarenal lymphadenectomy took an average of 36, 28, and 62 min, respectively. The number of removed lymph nodes was independent from the body mass index of the patient. Duration of pelvic lymphadenectomy was independent of body mass index, but right-sided paraaortic lymphadenectomy lasted significantly longer in obese women (35 vs. 41 min, P = 0,011). The overall complication rate was 8.7% with 2.9% intraoperative (vessel or bowel injury) and 5.8% postoperative complications. No major intraoperative complication was encountered during the last 5 years of the study. CONCLUSION: By transperitoneal laparoscopic lymphadenectomy, an adequate number of lymph nodes can be removed in an adequate time and independent from body mass index. The complication rate is low and can be minimized by standardization of the procedure.

[Unidirectional axillary lymph node swelling in a 31-year-old woman]. / Einseitige axilläre Lymphknotenschwellung bei einer 31-jährigen Frau.

BACKGROUND: Swelling in the lymph nodes leads one to think at first in terms of diagnostic differentials such as local inflammation, tumor metastases, or lymphomas. Kikuchi-Fujimoto lymphadenitis is a rare cause of feverish lymphadenitis. CASE REPORT: A 31-year-old woman was admitted with painful axillary feverish swelling of the lymph nodes. There had been no previous illnesses and n the case history of her mother, a mammary carcinoma could be found. Ultrasonic and MRI tests showed the lymph node conglomerate to be located in the left axilla. Laboratory tests revealed a constellation of inflammation with lymphomonocytosis. Serologic tests for viral causes were negative. A necrotizing lymphadenitis of the Kikuchi-Fujimoto type was described in the histological reclamation of a lymph node. Within 2 weeks, spontaneous regression of the feverish lymphadenitis occurred. CONCLUSIONS: In cases of unclear lymphadenitis, an attempt at achieving histological reclamation of a lymph node is desirable in order to realize rare differential diagnosis such as Kikuchi-Fujimoto lymphadenitis.

[Value of malarone in therapy of malaria tropica]. / Stellenwert von Malarone in der Therapie der Malaria tropica.

BACKGROUND: A widespread resistance of falciparum malaria to common antimalaria drugs is observed during the last years. Long-distance travel to high-risk destinations of falciparum malaria will contribute to increased exposition of travelers to highly resistant parasites. PHARMACOLOGY: Malarone (GlaxoSmithKline) is a fixed combination of atovaquone and proguanil licensed for prophylaxis and treatment of falciparum malaria. Both atovaquone and proguanil demonstrate synergistic activity against liver and blood schizonts. Malarone is well tolerated with a low rate of side effects. Malarone has an excellent efficacy profile in nonimmune subjects. CONCLUSIONS: Malarone appears to be a valuable alternative malaria prophylaxis in case of intolerance of other antimalaria drugs. Atovaquone/proguanil is effective in treating acute uncomplicated malaria caused by multiresistant strains of Plasmodium falciparum.

[Fever after travel to the tropics]. / Fieber nach Tropenaufenthalt.

BACKGROUND: Fever in travellers returning from the tropics may be caused not only by tropical infection but also by travel associated non-specific infections and cosmopolitan infective diseases. DIAGNOSTIC PROCEDURE: A rational out-patient step by step procedure needs clinical data and a small account of laboratory investigations. A parasitological screening is mandatory. The results refer to parasitological, bacterial or viral diseases. Epidemiological aspects of the travelled country and incubation periods of tropical or other diseases have to be considered. CONCLUSIONS: Plasmodium falciparum infection has to be excluded first because of vital damage. Following malaria (30%) respiratory infections (11%) are common. Fever as a symptom of non-infective disease occurred in 9%. Other diseases (typhus, Dengue fever, tuberculosis) are rare but have to be considered.

[Autochthonous strongyloidosis in an 81-year-old woman]. / Autochthone Strongyloidose bei einer 81-jährigen Frau.

Strongyloidosis is an parasitic disease, caused by an intestinal nematode endemic in tropic and subtropic regions. In Central Europe it occurs only sporadically. The infective larvae in the soil penetrate the human skin. Following circulation through the lungs the larvae settle in the small intestine and mature into adult worms. Chronic strongyloidosis recurring up to 15 years is possible through endogenous autoinfection. Clinical feature of the disease are gastrointestinal symptoms, hypereosinophilia and skin rashes. We describe the case of an 81-year-old woman who presented with scaly exanthema, fever and perianal fistulation. A microscopic examination of a stool sample demonstrated filariform larvae of Strongyloides stercoralis. An autochthonous mode of infection was assumed. After starting treatment with mebendazole eosinophilia and rash gradually disappeared. The laboratory finding of eosinophilia in patients with gastrointestinal symptoms or exanthema should prompt the differential diagnosis of a parasitosis. Stool examination is necessary to find rare autochthonous infections by intestinal nematodes. Pathogenesis, clinical manifestation and treatment of strongyloidosis are discussed along with the clinical picture.