Intensive investigation in management of Hodgkin's disease.
Ninety-eight patients with clinically localised Hodgkin's disease underwent laparotomy and splenectomy to determine the extent of microscopic spread. In 68 patients the procedure was carried out for untreated disease apparently confined above the diaphragm. Abdominal disease cannot be confidently excluded on the basis of non-invasive investigation at presentation. Clinical assessment of splenic disease was unreliable unless gross splenomegaly was present. Pedal lymphography was accurate in assessing para-aortic and iliac disease but of no value in assessing other intra-abdominal lymph node involvement, including that of the mesenteric lymph node. Trephine bone marrow biopsy findings were normal in all patients before surgery, and only one patient was found to have diseased bone marrow by Stryker-saw biopsy at operation. Liver disease was identified at operation in nine patients, some of whom were asymptomatic with clinically undetectable splenic and nodal disease. Detailed clinical staging failed to detect disease in one-third of patients who underwent laparotomy. These studies show that if radiotherapy is to remain the treatment of choice for disease truly localised to lymph nodes a detailed staging procedure, including laparotomy and splenectomy, remains essential. The value of this potentially curative treatment is considerably diminished in the patient who has been inadequately staged. (+info)
Serum sErbB1 and epidermal growth factor levels as tumor biomarkers in women with stage III or IV epithelial ovarian cancer.
Epithelial ovarian cancer (EOC) has a high mortality rate, which is due primarily to the fact that early clinical symptoms are vague and nonspecific; hence, this disease often goes undetected and untreated until in its advanced stages. Sensitive and reliable methods for detecting earlier stages of EOC are, therefore, urgently needed. Epidermal growth factor (EGF) is a ligand for EGF receptor (ErbB1); this receptor is the product of the c-erbB1 proto-oncogene. ErbB1 overexpression is common in human ovarian carcinoma-derived cell lines and tumors, in which overexpression is thought to play a critical role in tumor etiology and progression. Furthermore, ErbB1 overexpression is associated with disease recurrence and decreased patient survival. Recently, we have developed an acridinium-linked immunosorbent assay that detects a approximately 110-kDa soluble analogue of ErbB1, ie., sErbB1, in serum samples from healthy men and women (A. T. Baron, et al., J. Immunol. Methods, 219: 23-43, 1998). Here, we demonstrate that serum p110 sErbB1 levels are significantly lower in EOC patients with stage III or IV disease prior to (P < 0.0001) and shortly after (P < 0.0001) cytoreductive staging laparotomy than in healthy women of similar ages, whereas EGF levels are significantly higher than those of age-matched healthy women only in serum samples collected shortly after tumor debulking surgery (P < 0.0001). We observe that the preoperative serum sErbB1 concentration range of advanced stage EOC patients barely overlaps with the serum sErbB1 concentration range of healthy women. In addition, we show that serum sErbB1 and EGF levels changed temporally for some EOC patients who were surgically debulked of tumor and who provided a second serum sample during the course of combination chemotherapy. Finally, we observe a significant positive association between sErbB1 and EGF levels only in serum samples of EOC patients collected prior to cytoreductive surgery (correlation coefficient = 0.61968; P = 0.0027). These data suggest that epithelial ovarian tumors concomitantly affect serum sErbB1 and EGF levels. In conclusion, these data indicate that serum sErbB1 and EGF (postoperative only) levels are significantly different between EOC patients and healthy women and that altered and/or changing serum sErbB1 and EGF levels may provide important diagnostic and/or prognostic information useful for the management of patients with EOC. (+info)
Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for the National Audit of Acute Upper Gastrointestinal Haemorrhage.
Most patients with acute upper gastrointestinal haemorrhage are managed conservatively or with endoscopic intervention but some ultimately require surgery to arrest the haemorrhage. We have conducted a population-based multicentre prospective observational study of management and outcomes. This paper concerns the subgroup of 307 patients who had an operation because of continued or recurrent haemorrhage or high risk of further bleeding. The principal diagnostic group was those with peptic ulcer. Of 2071 patients with peptic ulcer presenting with acute haemorrhage, 251 (12%) had an operative intervention with a mortality of 24%. In the non-operative group mortality was 10%. The operative intervention rate increased with risk score, ranging from 0% in the lowest risk categories to 38% in the highest. Much of the discrepancy between operative and non-operative mortality was explainable by case mix; however, for high-risk cases mortality was significantly higher in the operated group. In 78% of patients who underwent an operation for bleeding peptic ulcer there had been no previous attempt at endoscopic haemostasis. For patients admitted to surgical units, the operative intervention rate was about four times higher than for those admitted under medical teams. In patients with acute upper gastrointestinal haemorrhage operative intervention is infrequent and largely confined to the highest-risk patients. The continuing high mortality in surgically treated patients is therefore to be expected. The reasons for the low use of endoscopic treatment before surgery are not revealed by this study, but wider use of such treatments might further reduce the operative intervention rate. Physicians and surgeons have not yet reached consensus on who needs surgery and when. (+info)
Endogenous nitric oxide in the maintenance of rat microvascular integrity against widespread plasma leakage following abdominal laparotomy.
1. The role of nitric oxide (NO) in the maintenance of microvascular integrity during minor surgical manipulation has been evaluated in the rat. 2. The NO synthase inhibitors, NG-nitro-L-arginine methyl ester (L-NAME, 5 mg kg(-1), s.c.) and N(G)-monomethyl-L-arginine (L-NMMA, 50 mg kg(-1), s.c.) had no effect on microvascular leakage of radiolabelled albumin over 1 h in the stomach, duodenum, jejunum, colon, lung and kidney in the un-operated conscious or pentobarbitone-anaesthetized rat. 3. In contrast, in anaesthetized rats with a midline abdominal laparotomy (5 cm), L-NAME (1-5 mg kg(-1), s.c.) or L-NMMA (12.5-50 mg kg(-1), s.c.) dose-dependently increased gastrointestinal, renal and pulmonary vascular leakage, effects reversed by L-arginine pretreatment (300 mg kg(-1), s.c., 15 min). These actions were not observed in anaesthetized rats that had only received a midline abdominal skin incision (5 cm). 4. Pretreatment with a rabbit anti-rat neutrophil serum (0.4 ml kg(-1), i.p.), 4 h before laparotomy, abolished the plasma leakage induced by L-NAME in all the organs investigated. 5. These results indicate that the following abdominal laparotomy, inhibition of constitutive NO synthase provokes vascular leakage in the general microcirculation, by a process that may involve neutrophils. Such effects could thus confound studies on the microvascular actions of NO synthase inhibitors using acute surgically prepared in vivo models. The findings thus suggest that constitutively-formed NO has a crucial role in the maintenance of acute microvascular integrity following abdominal surgical intervention. (+info)
The forgotten child--a case of heterotopic, intra-abdominal and intrauterine pregnancy carried to term.
Heterotopic pregnancies are estimated to be less frequent than one in 30,000 if no assisted reproduction technologies are performed. Here we report a case which occurred in Tanzania. An abdominal pregnancy at term was first misdiagnosed as an ovarian tumour and diagnosed on the first post-partum day of the intrauterine fetus, which was delivered spontaneously. The abdominal pregnancy was then treated by laparotomy and removal of the placenta. The fetus was alive and healthy. The follow-up of the twins was normal. (+info)
Pancreatic insulin-secreting neoplasm (insulinoma) in a West Highland white terrier.
A West Highland white terrier was evaluated because of persistent hypoglycemia and an acute episode of collapse. A pancreatic insulin-secreting neoplasm (insulinoma) was diagnosed on the basis of clinical signs, serum glucose levels, serum insulin levels, abdominal ultrasonography, and exploratory laparotomy with histologic evaluation of neoplastic tissue. (+info)
Serum concentrations of tramadol enantiomers during patient-controlled analgesia.
AIMS: Tramadol, a centrally acting analgesic, is used as a racemate containing 50% of a (+)- and 50% of a (-)-enantiomer. This paper presents the pharmacokinetic results of postoperative patient-controlled analgesia using (+)-tramadol, (-)-tramadol or the racemate. METHODS: Ninety-eight patients recovering from major gynaecological surgery were treated in a randomised, double-blind study with (+)-tramadol, (-)-tramadol or the racemate. Following an i.v. bolus up to a maximum of 200 mg, patient-controlled analgesia with demand doses of 20 mg was made available for 24 h. Prior to each demand, the serum concentrations of the enantiomers of tramadol and its metabolite M1 were measured in 92 patients. RESULTS: The mean concentrations of tramadol during the postsurgery phase were 470+/-323 ng ml-1, 590+/-410 ng ml-1 and 771+/-451 ng ml-1 in the (+)-, racemate- and (-)-group, respectively ((+) vs (-), P<0.05); the mean concentrations of the metabolite M1 were 57+/-18 ng ml-1, 84+/-34 ng ml-1 and 96+/-41 ng ml-1 in the (+)-, racemate- and (-)-group, respectively ((+) vs (-) and (+) vs racemate, P<0.05). The mean concentrations of (+)-tramadol and (+)-M1 were lower in the racemate- than in the (+)-group (P<0.05), those of (-)-tramadol and (-)-M1 were lower in the racemate than in the (-)-group (P<0.05). In the racemate group, the mean serum concentrations of (+)-tramadol were higher than those of (-)-tramadol (P<0.05), whereas the mean serum concentrations of (-)-M1 were higher than those of (+)-M1 (P<0. 05). CONCLUSIONS: The therapeutic serum concentration of tramadol and M1 showed a great variability. The lowest mean concentrations were measured in the (+)-group and the highest in (-)-group. This is in agreement with the clinical finding that (+)-tramadol is a more potent analgesic than (-)-tramadol. (+info)
Resection-line involvement in gastric cancer patients undergoing curative resections: implications for clinical management.
BACKGROUND: Resection-line involvement has been suggested as an important prognostic factor for gastric cancer. METHODS: The relationship between resection-line involvement and outcome was examined in patients undergoing potentially curative resection for gastric cancer. RESULTS: Tumor positive resection-lines were seen in 22 of the 259 evaluable patients (8.4%). Resection-line involvement was associated with tumor location (P = 0.01) and tumor differentiation (P = 0.02). Positive margins were associated with worse survival. However, if both groups of patients are stratified according to lymph node metastases, resection-line involvement determined a shorter survival only in patients with N0 stage disease. CONCLUSIONS: Our data suggest, in the case of positive margins, that re-laparatomy should be considered only for patients with N0 stage disease, while patients with metastatic lymph nodes should be watched closely without the need for a more aggressive surgical approach. (+info)