[Supravaginal or total hysterectomy?]. / Supravaginal eller total hysterektomi?

There has been a decline in the rate of hysterectomies in Denmark in general over the last thirteen years, together with a rise in the number of supravaginal operations over the last two years. The literature concerning the relative merits of the supravaginal and the total abdominal operation is examined. It is concluded that the risk of developing carcinoma of the cervical stump is low, and no longer a weighty indication for the total in preference to the supravaginal hysterectomy as long as subsequent screening of the cervix is performed. At the same time it is important to inform the women carefully after the supravaginal operation in order to secure that subsequent screening actually is taking place. One must have a normal smear and offer a colposcopic examination before the operation. In general the rate of complications after both kind of hysterectomies is low. However, a few new studies indicate a reduced frequency of orgasm after the total hysterectomy compared with the supravaginal operation. When there are technical problems peroperatively with an increased urologic risk the supravaginal operation is recommended.

[Gallstones in children]. / Galdesten hos børn.

Children of all ages, including neonates, can have gallstones. According to international data the incidence seems to be increasing, but Danish data are missing. The most frequent associated conditions are haemolytic anaemia, children treated with total parenteral nutrition, and children who have undergone abdominal surgery, while older children with pregnancy or obesity are disposed. Between 40 and 65% have cholelithiasis on an idiopathic basis. When spontaneous dissolution of the gallstones is not to be expected, the treatment is surgery, and laparoscopic cholecystectomy is a well-described, safe and mini-invasive treatment, which can also be recommended for children.

[Lipomas and liposarcomas. 10-year incidence in a local area]. / Lipomer og liposarkomer. Ti års forekomst i et lokalområde.

The aim of this study was to show the clinical expression and histologic diagnosis in 105 patients, 46 males and 59 females, treated for lipomas of the extremities. The coincidence between the histological and peroperative diagnosis was also evaluated. The patients were successively treated at the Department of Orthopaedic Surgery, Glostrup county Hospital in the period 1978-88. Ninety-seven patients were found to have a lipoma and eight of the patients had a malignant tumour (liposarcoma). There were no significant differences in the appearance of malignancy with respect to age or sex. Tumours greater than 100 cm2 in size were significantly more often malignant than those less than 100 cm2. There was a considerable discrepancy between the surgeon's peroperative judgement of malignancy and the histological diagnosis. The tumours were located in the humeroscapular region (39), the femoral region (30), the crural region (10), and in the forearm region (7). We conclude that diagnostic clearing and treatment ought to be centralized in regional centres, where liposarcomas might also be diagnosed. However, the liposarcomas should afterwards be treated in oncological centres. Furthermore, we conclude that histological examination of lipomas in imperative.

[A local course on conventional and laparoscopic surgical techniques. A supplement to surgical education]. / Lokalt kursus i konventionel og laparoskopisk kirurgisk teknik. Et supplement til den kirurgiske uddannelse.

In order to increase the possibilities for learning accurate surgical technique in gastrointestinal surgery, we have established a local course for operative training of the registrars. We used organs from pigs--stomach, intestines and liver/gallbladder. They were collected from the local abattoir with assistance from a vet. Conventional gut anastomosis and gastroenteroanastomosis were performed with "two-layer" and "one-layer" techniques. Laparoscopic cholecystectomy was performed with the liver-gallbladder organ block placed in a "black box", in which the organ was perfused with red fluid--a Pulsatile Organ Perfusion System. The registrars' evaluations of the course were very positive. They all thought that the course gave them opportunities for surgical training that were not available in the busy daily routine. The course now forms part of the education programme for surgical registrars in our department.

[Effect of transcutaneous electric muscle stimulation on postoperative muscle mass and protein synthesis]. / Effekten at transkutan elektrisk muskelstimulation på postoperativ muskelmasse og proteinsyntese.

In an experimental study, 13 patients undergoing major elective abdominal surgery were given postoperative transcutaneous electrical muscle stimulation (TEMS) to the quadriceps femoris muscle on one leg, where the opposite leg served as a control. Changes in cross sectional area (CSA) and muscle protein synthesis were assessed by CT-scan and percutaneous muscle biopsies for ribosome analysis before surgery and on the sixth postoperative day. The percentage of polyribosomes in the ribosome suspension decreased significantly (p < 0.03) after operation in control legs, but not in stimulated legs (p > 0.16). The total concentration of ribosomes decreased significantly in TEMS legs (p < 0.03), but not in control legs (p > 0.16) CSA decreased significantly in both legs. The decrease in polyribosomes and CSA after operation was significantly less in TEMS legs than in controls (p < 0.05). TEMS may be a simple and effective method to improve muscle protein synthesis and muscle mass after abdominal surgery and should be evaluated in other catabolic states with muscle wasting.

Validation of pulse oximetry for monitoring of hypoxaemic episodes in the late postoperative period.

We monitored 12 patients undergoing major abdominal surgery using a pulse oximeter (Nellcor N-200) and a transcutaneous oxygen tension monitor (TINA, Radiometer A/S) on the second or third night after operation. Of the shortest hypoxaemic episodes measured with the pulse oximeter (< or = 30 s duration), 78% also occurred in the transcutaneous oxygen tension measurement. Episodes of longer duration (> or = 1 min duration on the pulse oximeter) were, in 95% of cases, reflected in the transcutaneous oxygen tension measurement also. Thus postoperative episodic desaturations lasting > or = 1 min are at least 95% likely to be a real phenomenon.

Body position and late postoperative nocturnal hypoxaemia.

Thirteen patients were monitored for nocturnal body position (supine vs. side) and arterial oxygen saturation pre-operatively and on the second postoperative night after major abdominal surgery. The number of positional changes were significantly decreased after operation (p < 0.05) with a trend towards more time spent in the supine position (p = 0.1). Individual mean arterial oxygen saturation decreased postoperatively (p < 0.05) but without a difference between the supine and side positions (p = 0.9). Pre-operatively, episodic desaturations were significantly more frequent in the supine position than on the side (p < 0.05) but not postoperatively. Pain was the most frequent reason for decreased nocturnal movements.

Treatment of recurrent urethral stricture by internal urethrotomy and intermittent self-catheterization: a controlled study of a new therapy.

A controlled study of the effect of treatment of recurrent urethral stricture by internal urethrotomy followed by clean intermittent self-catheterization for 3 months is reported. There were 28 men (median age 70 years, range 18 to 75) allocated to internal urethrotomy and clean intermittent self-catheterization for 3 months (treatment group) and 33 (median age 76 years, range 36 to 87) were randomized to undergo internal urethrotomy only (observation group). The groups were comparable in terms of patient age, etiology of the primary stricture, number of recurrences, length and site of the actual stricture, and preoperative maximum flow rate (p less than 0.01). After termination of the treatment all patients from both groups were evaluated by uroflowmetry 2, 4, 6 and 12 months later, and a new recurrence was defined as a maximum flow rate of less than 10 ml. per second (micturition volume greater than 100 ml.) and a characteristic flow curve. From the treatment group 23 patients could be assessed: 2 had discontinued clean intermittent self-catheterization due to urethral hemorrhage, 2 died during the observation period and 1 was lost to followup. From the observation group 28 patients were assessable: 3 died during the observation period and 1 was lost to followup. Treatment results were not significantly different (p less than 0.01). Of the patients in the treatment and observation groups 78% and 82%, respectively, had a new stricture. The median interval for this to occur was 4 months for both groups. Since no patient had clinical signs of stricture during clean intermittent self-catheterization, we conclude that for the treatment of recurrent urethral stricture clean intermittent self-catheterization following internal urethrotomy should be continued for a long duration, possibly permanently.

Time-dependent histamine release from stored human blood products.

Perioperative transfusion of whole blood has been shown to amplify trauma-induced immunosuppression, which could be attenuated by perioperative administration of histamine2 receptor antagonists. Supernatants from different blood products were, therefore, analysed for histamine content during storage. Whole blood (six units), plasma-reduced whole blood (six units), and plasma- and buffy coat-reduced (saline-adenine-glucose-mannitol) (SAGM) blood (six units) from unpaid healthy donors were stored in the blood bank for 35 days at 4 degrees C. Plasma histamine and total cell-bound histamine content at donation, and histamine concentration in samples drawn from the units on days 0, 2, 5, 9, 14, 21, 28 and 35 were analysed with an enzyme-linked immunosorbent assay. Median plasma histamine concentration was 4.8 (range 1.9-14.3) nmol/l (n = 18). Median total cell-bound histamine content was 417.0 (range 176.0-910.0) nmol/l in whole blood and 475.0 (range 360.0-1560.0) nmol/l in plasma-reduced whole blood, while it was undetectable in SAGM blood. Spontaneous histamine release increased in a time-dependent manner from a median of 6.7 (range 2.2-17.4) nmol/l at the time of storage to 175.0 (range 33.0-485.0) nmol/l at day 35 in whole blood, from 18.8 (range 8.2-38.5) to 328.5 (range 224.0-1137.0) nmol/l in plasma-reduced whole blood, and from 0.5 (range 0.5-1.5) to 2.2 (range 1.4-6.9) nmol/l in SAGM blood. These results show spontaneous histamine release during storage of human blood products which contain full amount of leucocytes, and this may play a significant role in detrimental effects of blood transfusion.

Effect of transcutaneous electrical muscle stimulation on postoperative muscle mass and protein synthesis.

In an experimental study, 13 patients undergoing major elective abdominal surgery were given postoperative transcutaneous electrical muscle stimulation (TEMS) to the quadriceps femoris muscle on one leg; the opposite leg served as control. Changes in cross-sectional area (CSA) and muscle protein synthesis were assessed by computed tomography and ribosome analysis of percutaneous muscle biopsies before surgery and on the sixth postoperative day. The percentage of polyribosomes in the ribosome suspension decreased significantly (P < 0.03) after operation in control legs, but not in stimulated legs (P > 0.16). The total concentration of ribosomes decreased significantly in legs treated with TEMS (P < 0.03) but not in control legs (P > 0.16). CSA decreased significantly in both legs. The decrease in polyribosomes and CSA after operation was significantly less in stimulated legs than in controls (P < 0.05). TEMS may be a simple and effective method for improving muscle protein synthesis and muscle mass after abdominal surgery and should be evaluated in other catabolic states with muscle wasting.

Bioactive substances in buffy-coat-derived platelet pools stored in platelet-additive solutions.

We studied extracellular accumulation in buffy-coat-derived platelet pools suspended in platelet additive solutions (PAS). 20 platelet pools were prepared from buffy coats of 60 donors and stored in either PAS I (n = 10) or PAS II (n = 10). Samples were drawn from the donors to determine the normal range of histamine, plasminogen activator inhibitor 1 (PAI-1), myeloperoxidase (MPO) and interleukin (IL)-6. After preparation samples were collected on days 0, 5 and 7 from the 20 platelet pools respectively, to determine extracellular accumulation of the same substances. Extracellular histamine, PAI-1 and MPO were detected in significant levels (P<0.0001) immediately after preparation of the platelet pools. Only the extracellular level of PAI-1 increased significantly during storage from day 0 to day 7 (P<0.01). After preparation and storage to day 7 IL-6 was found in only three of the 20 platelet pools. Even though platelets were prepared by the buffy-coat method, to produce a low leucocyte count and thereby low cytokine (IL-6) content, there was still significant contamination by other bioactive substances.

Extracellular accumulation of bioactive substances during preparation and storage of various platelet concentrates.

BACKGROUND: Side effects of platelet transfusion may be associated with infusion of bioactive substances. We therefore studied extracellular accumulation of histamine, plasminogen activator inhibitor (PAI)-1, vascular endothelial growth factor (VEGF), and interleukin (IL)-6 during preparation and storage of various platelet concentrates. METHODS: Twenty buffy-coat-derived platelet pools (BCPC) were prepared and stored in platelet additive solutions (PAS). Twelve apheresis platelet (APC) units were prepared using the COBE Spectra LRS, and 14 were prepared using the Fenwal Amicus Separator. After preparation half of the content was drawn from each APC unit. The normal ranges of the substances were determined in plasma from all donors, and the extracellular concentrations of the substances were determined in supernatants collected on days 0, 1, 3, 5, and 7 of storage from all platelet preparations. RESULTS: The platelet counts were not significantly different in BCPC units and APC units. The BCPC units had a significantly higher white cell count than the APC units (P < 0.0001), but the count was significantly higher in the Amicus APC units than in the COBE APC units (P < 0.0001). The extracellular histamine concentration was significantly (P < 0.001) increased in BCPC units after preparation and without further increase during storage, while there was no accumulation of histamine in APC units. After preparation the PAI-1 concentration was significantly (P < 0.02) higher in BCPC units than in APC units, but during storage PAI-1 increased significantly (P < 0.05) more in APC units than in BCPC units. Similarly, VEGF concentration was significantly (P < 0.05) higher in BCPC units than in APC units after preparation. During storage, however, VEGF increased more in BCPC units compared with COBE Spectra APC units (P < 0.05), but compared with Amicus Separator APC units only for the first 3 days of storage. At days 5 and 7 of storage the VEGF concentration was significantly higher in the Amicus APC units than in the COBE APC units (P < 0.05). IL-6 was not detectable in any of the concentrates after preparation or during storage. CONCLUSION: Platelet concentrates prepared by the apheresis method may contain less white cell derived bioactive substances than platelet concentrates prepared by the buffy-coat method. However, a substantial storage time dependent platelet derived bioactive substance accumulation takes place in all platelet concentrates tested, presumably due to platelet disintegration.

Time-dependent, spontaneous release of white cell- and platelet-derived bioactive substances from stored human blood.

BACKGROUND: The mechanisms of the detrimental effects of perioperative allogeneic blood transfusion are still unclear. Previous studies have suggested a higher incidence of adverse effects after the use of blood stored for prolonged time. Therefore, a possible time-dependent release of various white cell- and platelet-derived bioactive substances in stored human red cell suspensions was studied. STUDY DESIGN AND METHODS: Whole blood (6 units), plasma-reduced whole blood (6 units), and saline-adenine-glucose-mannitol blood (6 units) from 18 unpaid, normal blood donors were stored under standard blood bank conditions at 4 degrees C for 35 days. After refrigeration, samples were collected from all blood bags on Days 0, 2, 5, 9, 14, 21, 28, and 35 of storage. Extracellular concentrations of eosinophil cationic protein, eosinophil protein X, plasminogen activator inhibitor 1, myeloperoxidase, and interleukin 6 were analyzed by enzyme-linked immunosorbent assay and radioimmunoassay. The total intracellular and donor plasma levels of these substances also were analyzed at the time of blood donation. RESULTS: Eosinophil cationic protein, eosinophil protein X, and myeloperoxidase increased 10- to 25-fold (p < 0.05) in a time-dependent manner in whole blood, plasma-reduced whole blood, and saline-adenine-glucose-mannitol blood during storage for 35 days. Plasminogen activator inhibitor 1 increased threefold to sixfold (p < 0.05) in whole blood and plasma-reduced whole blood, but not in saline-adenine-glucose-mannitol blood. Interleukin 6 was not detected in either plasma or samples obtained from the blood bags. CONCLUSION: Stored whole blood, plasma-reduced whole blood, and saline-adenine-glucose-mannitol blood may release white cell- and platelet-derived bioactive substances in a time-dependent manner, which may be related to the detrimental effects of perioperative blood transfusions. Therefore, prestorage white cell reduction should be considered for further improvement of red cell suspensions.