Multi-institutional Review Research Articles

Are concerns over right laparoscopic donor nephrectomy unwarranted?

To examine the ability of several large, experienced transplantation centers to perform right-sided laparoscopic donor nephrectomy safely with equivalent long-term renal allograft function. Early reports noted a higher incidence of renal vein thrombosis and eventual graft loss. However, exclusion of right-sided donors would deprive a significant proportion of donors a laparoscopically harvested graft. A retrospective review was performed among 97 patients from seven centers performing right-sided laparoscopic donor nephrectomy. Surgical and postoperative demographic factors were evaluated. Complications were identified and long-term renal allograft function was compared with historical left-sided laparoscopic donor nephrectomy cohorts. Right laparoscopic donor nephrectomy was performed for varying reasons, including multiple left renal arteries or veins, smaller right kidney, or cystic right renal mass. Mean surgical time was 235.0 +/- 66.7 minutes, with a mean blood loss of 139 +/- 165.8 mL. Conversion was required in three patients secondary to bleeding or anatomical anomalies. Mean warm ischemic time was limited at 238 +/- 112 seconds. Return to diet was achieved on average after 7.5 +/- 2.3 hours, with mean discharge at 54.6 +/- 22.8 hours. Two grafts were lost during the early experience of these centers to renal vein thrombosis. Both surgical and postoperative complications were limited, with few long-term adverse effects. Mean serum creatinine levels were higher than open and left laparoscopic donor nephrectomy on postoperative day 1, but at all remaining intervals the right laparoscopic donors had equivalent creatinine values. These results confirm that right laparoscopic donor nephrectomy provides similar patient benefits, including early return to diet and discharge. Long-term creatinine values were no higher than in traditional open donor or left laparoscopic donor cohorts. These results establish that early concerns about high thrombosis rates are not supported by a multiinstitutional review of laparoscopic right donor nephrectomies.

Mirizzi's Syndrome: Experience from a Multi-Institutional Review

P.L. Mirizzi described in 1948 a partial or spastic obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct or infundibulum of the gallbladder. The modern definition of Mirizzi's syndrome is thought to include four components: anatomic arrangement of the cystic duct at the gallbladder neck such that it runs parallel to the common hepatic duct; impaction of a stone in the cystic duct or neck of the gallbladder; mechanical obstruction of the common hepatic duct by the stone itself or by secondary inflammation; and intermittent or constant jaundice causing possible recurrent cholangitis and, if longstanding, secondary biliary cirrhosis. Intermittent symptomatology may make Mirizzi's syndrome difficult to diagnose preoperatively or intraoperatively. Bilio-biliary fistulas may or may not be present. Diagnosis and choice of operative repair may be best accomplished by open operative technique. Over a 24-year period two faculty members from Louisiana State University (LSU) Medical Center-Shreveport at Monroe and LSU Baton Rouge treated 4180 cases of cholelithiasis at six Louisiana university and private hospitals. Eleven cases of Mirizzi's syndrome were diagnosed on the basis of operative and preoperative notes with detailed description of size and extent of biliobiliary fistulas when they were present. These 11 cases were reviewed and followed from one to 20 years. Presentation, workup, operative findings, choice of operative repair, choice of operative approach, and complications were evaluated by retrospective chart review. Review of the pertinent literature for informative and comparative purposes was also completed. These 11 cases ranged from Csendes Type I to III. There were no Type IV cases. They were ultimately diagnosed and managed by classical open technique. Four laparoscopic procedures were converted to open technique following initial inspection. All four were converted to open as a result of inability to delineate structures in and adjacent to the triangle of Calot due to marked scarring in the subhepatic space. No iatrogenic injuries or major complications occurred. Mirizzi's syndrome occurs in fewer than 0.5 per cent of patients with cholelithiasis. Removal of stones with partial cholecystectomy and use of gallbladder or cystic duct remnant to oversew or repair Mirizzi fistulas should be considered. Roux-en-y hepaticojejunostomy becomes the procedure of choice when the vascularity or viability of the hepatic duct or tissues available for duct repair is questionable. Review of the literature reveals the increase in complications with laparoscopic versus open technique in Mirizzi's syndrome. Although very little direct evidence exists we believe that when this syndrome is diagnosed or strongly suspected open biliary operation is the procedure of choice because the increased potential for major complications with the use of laparoscopic technique far outweighs the potential slight increase in morbidity of an open procedure.

The pediatric trauma C-spine: Is the ‘odontoid’ view necessary?

Background/Purpose: The “odontoid view” is a difficult and often hazardous film to obtain in young children. The aim of this study was to determine if the transoral roentgenogram is necessary in the evaluation of the pediatric cervical spine. Methods: A retrospective, multiinstitutional review was performed of all patients 16 years of age and under with documented cervical spine injury in a large metropolitan area during the past decade. Fifty-one children with cervical spine injury were identified from the medical records at 4 hospitals. Results: The 0- to 8-year-old age group had a significantly higher incidence of upper (occiput to C3) cervical injury than the 9- to 16-year-old age group (67% v 39%; P <.05). In the 0- to 8-year-old group the initial lateral/anteroposterior radiograph made the diagnosis of cervical spine injury in 13 of 15 patients (87%), and in no patients was the transoral odontoid view used to make the diagnosis of cervical spine injury. In only 1 patient in the 9- to 16-year-old age group with a type III odontoid fracture was this view deemed useful. The overall mortality rate in this series was 7.8% with all deaths secondary to associated head injury. Conclusions: In the 0- to 8-year-old age group in whom the incidence of cervical spine injury is rare but frequently involves the upper cervical spine, the transoral odontoid roentgenogram may be of little value in the evaluation of the spine and should not be considered necessary in “clearing” the pediatric cervical spine. An alternative evaluation of these patients would include an initial lateral and AP radiograph, followed by computed tomography scan. J Pediatr Surg 35:994-997. Copyright © 2000 by W.B. Saunders Company.

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing

Objective: The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success.Methods: A multi-institutional review was undertaken at four university or university-affiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing.Results: Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound debridement in 50%. Infrainguinal bypass was performed for 81, patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed—all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P < .002), a palpable pedal pulse (85% healed vs 42%, P < .0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P < .02), and the number of patent tibial arteries after bypass to the ankle (P < .0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome.Conclusions: Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.

Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing.

The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success. A multi-institutional review was undertaken at four university or university-affiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing. Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound débridement in 50%. Infrainguinal bypass was performed for 81 patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed-all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P <.002), a palpable pedal pulse (85% healed vs 42%, P <.0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P <.02), and the number of patent tibial arteries after bypass to the ankle (P <.0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome. Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.

3D conformal radiation therapy (3DCRT) for high grade prostate cancer: a multi-institutional review

Purpose: To evaluate the results of 3DCRT and the effect of higher than traditional doses in patients with high grade prostate cancer, we compiled data from three institutions and analyzed the outcome of this relatively uncommon subset of prostate cancer patients. Methods and Materials: The 180 patients with Gleason score 8–10 adenocarcinoma of the prostate were treated with 3DCRT at the University of Michigan Health System, University of California-San Francisco, or Fox Chase Cancer Center. Eligible patients had T1-T4 N0 or NX M0 adenocarcinoma with a pretreatment PSA. Pretreatment characteristics included: median age 72 years, 60.6% Gleason score 8 tumors, 57.6% T1-T2, and median pretreatment PSA 17.1 ng/ml (range 0.3–257.1). The total dose received was <70 Gy in 30%, 70–75 Gy in 37%, and >75 Gy in 33%; 27% received adjuvant or neoadjuvant hormonal therapy. The median follow-up was 3.0 years for all patients and 16% of patients were followed up for at least 5 years. Results: The 5-year freedom from PSA failure was 62.5% for all patients and 79.3% in T1-T2 patients. Univariate analysis revealed that T-stage (T1-T2 vs. T3-T4), pretreatment PSA, and RT dose predicted for freedom from PSA failure. A 5-year overall survival for all patients was 67.3%. Only RT dose was predictive of 5-year overall survival on univariate analysis. Because a significant association was seen between T-stage and RT dose, the Cox proportional hazards model was performed separately for T1-T2 and T3-T4 tumors. None of the prognostic factors reached statistical significance for overall survival or freedom from PSA failure in T3-T4 patients or for overall survival in T1-T2 patients. Lower RT dose and higher pretreatment PSA predicted for PSA failure on multivariate analysis in T1-T2 patients. Conclusion: This retrospective study from three institutions with experience in dose escalation suggests a dose effect for PSA control above 70 Gy in patients with T1-T2 high grade prostate cancer. These results are superior to surgery and emphasize the need for dose escalation in treating Gleason 8–10 prostate cancer.

Diagnosis and initial management of blunt pancreatic trauma: Guidelines from a multiinstitutional review: E.L. Bradley, P.R. Young, M.C. Chang, et al. Ann Surg 227:861–869, (June), 1998

Diagnosis and initial management of blunt pancreatic trauma: Guidelines from a multiinstitutional review: E.L. Bradley, P.R. Young, M.C. Chang, et al. Ann Surg 227:861–869, (June), 1998

A 3 TROCAR TECHNIQUE FOR TRANSPERITONEAL LAPAROSCOPIC NEPHRECTOMY

Additional trocars and retractor instruments may enhance the risk of iatrogenic injuries during laparoscopic nephrectomy. We describe a modified technique of laparoscopic nephrectomy requiring only 3 ports of entry and no extra instruments instead of the 5 ports, 2 of which are used for retractors, usually required. With the patient in full flank position a 10 mm. trocar is inserted between the umbilicus and subcostal margin, a 5 mm. trocar is placed subcostal in the midclavicular line and a 12 mm. trocar is inserted over the iliac crest in the anterior axillary line. The first step is incision of the line of Toldt and medial reflection of the colon. During the second step of vascular controls the posterosuperior attachments of the kidney are left untouched, keeping the renal vessels stretched, with no need for an extra instrument. The third step consists of severing the remaining posterior and superior attachments of the kidney followed by specimen retrieval. A total of 14 consecutive patients underwent laparoscopic nephrectomy with this technique. All 14 procedures were completed without an additional port. There were no intraoperative or postoperative complications, except 1 abdominal wall hematoma. Mean operating time was 120 minutes (range 70 to 230) and mean hospital stay was 5 days (range 3 to 7). Transperitoneal laparoscopic nephrectomy with laparoscopic access limited to 3 trocars is a reliable and safe technique.

The fetal inflammatory response syndrome

OBJECTIVE: The objective of this study was to determine the frequency and clinical significance of a systemic inflammatory response as defined by an elevated plasma interleukin-6 concentration in fetuses with preterm labor or preterm premature rupture of membranes. STUDY DESIGN: Amniocenteses and cordocenteses were performed in 157 patients with preterm labor and preterm premature rupture of membranes. Written informed consent and multi-institutional review board approvals were obtained. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as mycoplasmas. Amniotic fluid and fetal plasma interleukin-6 concentrations were measured with a sensitive and specific immunoassay. Statistical analyses included contingency tables, receiver operating characteristic curve analysis, and multiple logistic regression. RESULTS: One hundred five patients with preterm labor and 52 patients with preterm premature rupture of membranes were included in this study. The overall prevalence of severe neonatal morbidity (defined as the presence of respiratory distress syndrome, suspected or proved neonatal sepsis, pneumonia, bronchopulmonary dysplasia. intraventricular hemorrhage, periventricular leukomalacia, or necrotizing enterocolitis) among survivors was 34.8% (54/155). Neonates in whom severe neonatal morbidity developed had higher concentrations of fetal plasma interleukin-6 than fetuses without development of severe neonatal morbidity (median 14.0 pg/mL, range 0.5 to 900 vs median 5.2 pg/mL, range 0.3 to 900, respectively; P < .005). Multivariate analysis was performed to explore the relationship between the presence of a systemic fetal inflammatory response and subsequent neonatal outcome. To preserve a meaningful temporal relationship between the results of fetal plasma interleukin-6 concentrations and the occurrence of severe neonatal morbidity, the analysis was restricted to 73 fetuses delivered within 7 days of cordocentesis who survived. The prevalence of severe neonatal morbidity in this subset of patients was 53.4% (39/73). A fetal plasma interleukin-6 cutoff value of 11 pg/mL was used to define the presence of a systemic inflammatory response. The prevalence of a fetal plasma interleukin-6 level >11 pg/mL was 49.3% (36/73). Fetuses with fetal plasma interleukin-6 concentrations >11 pg/mL had a higher rate of severe neonatal morbidity than did those with fetal plasma interleukin-6 levels ≤11 pg/mL (77.8% [28/36] vs 29.7% [11/37], respectively; P < .001). Stepwise logistic regression analysis demonstrated that the fetal plasma interleukin-6 concentration was an independent predictor of the occurrence of severe neonatal morbidity (odds ratio 4.3, 95% confidence interval 1 to 18.5) when adjusted for gestational age at delivery, the cause of preterm delivery (preterm labor or preterm premature rupture of membranes), clinical chorioamnionitis, the cordocentesis-to-delivery interval, amniotic fluid culture, and anmiotic fluid interleukin-6 results. CONCLUSION: A systemic fetal inflammatory response, as determined by an elevated fetal plasma interleukin-6 value, is an independent risk factor for the occurrence of severe neonatal morbidity. (Am J Obstet Gynecol 1998;179:194-202.)

3D conformal radiation therapy (3DCRT) for high grade prostate cancer: A multi-institutional review

3D conformal radiation therapy (3DCRT) for high grade prostate cancer: A multi-institutional review

Diagnosis and Initial Management of Blunt Pancreatic Trauma: Guidelines From a Multiinstitutional Review

Diagnosis and Initial Management of Blunt Pancreatic Trauma: Guidelines From a Multiinstitutional Review

THE ROLE OF COMPUTERIZED TOMOGRAPHY IN THE EVALUATION OF COMPLICATIONS AFTER LAPAROSCOPIC UROLOGICAL SURGERY

Radiographic evaluation may be necessary to assess the possible complications of laparoscopic procedures. We undertook a retrospective review to determine the indications for and findings of computerized tomography (CT) in symptomatic patients after urologic laparoscopic surgery. Of 400 laparoscopic urological procedures performed between July 1993 and September 1996, 20 patients (5%) had postoperative symptomatology that could not be explained by physical exam or routine clinical studies. An abdominal CT scan was obtained (1 to 120 days after the procedure) to help determine a diagnosis. CT findings were correlated with the indication for the study and clinical followup. The indications for CT were unexplained pain, fever, leukocytosis or falling hematocrit. Thirteen patients had significant findings related to their surgery that were identified by CT. In 2 cases, we identified pathology unrelated to the surgery. Therefore, CT identified a symptom-related diagnosis in 75% of patients (15 of 20). Each scan for decreasing hematocrit demonstrated a hematoma. In all patients with unexplained fever or leukocytosis, CT revealed the cause. CT evaluation of atypical postoperative pain demonstrated a pathological cause in 58% (7 of 12). Percutaneous or laparoscopic surgical intervention was required in 4 of 20 patients. In 8 patients scanned by postoperative day 6, intraperitoneal or retroperitoneal gas was identified in 3 who had an abdominal incision made for intact specimen removal and in 1 with a perforated ulcer. CT after urologic laparoscopy is indicated in patients with significant clinical findings in whom routine examination and tests are not diagnostic. CT can reliably identify postoperative bleeding, urinary leak or obstruction and can also detect nonurinary pathology.

Pediatric aerodigestive foreign body injuries are complications related to timeliness of diagnosis.

Foreign body (FB) injury from aspiration or ingestion is a common pediatric health problem. Diagnosis relies on clinical judgment plus medical history, physical examination, and radiographic evaluation. A multi-institutional review of 1269 FB events revealed that 85% were correctly diagnosed following a single physician encounter. However, 15% of the children had an elusive diagnosis (>1 week), despite previous evaluation. Delays in diagnosis were seven times more likely to occur in aspirations than in ingestions. Secondary injuries (e.g., pneumonia and atelectasis) occurred in 13% of airway FBs but in only 1.7% of esophageal FBs. Plain radiographs were used in 82% of children, and special studies (e.g., fluoroscopy) in only 7%. We conclude that diagnosis of FB injury in children is frequently achieved at the initial evaluation but that continued surveillance by follow-up visits to health care facilities from parents and other caretakers is important, to reduce pulmonary injuries.

Complications of Laparoscopic Nephrectomy in 185 Patients: A Multi-Institutional Review

Purpose We document the incidence of complications associated with laparoscopic nephrectomy in a multi-institutional study. Materials and Methods The study included the initial 185 patients undergoing laparoscopic nephrectomy at 5 centers in the United States between June 1990 and July 1993. Results A total of 30 patients (16 percent) had 34 complications. There was no mortality. Access-related complications included 2 cases of hernia formation at the trocar site, 1 abdominal wall hematoma and 1 trocar injury to a hydronephrotic kidney. Intraoperative complications included 5 cases of vascular injury, 1 splenic laceration and 1 pneumothorax. Postoperative complications involved the gastrointestinal tract in 6 cases, cardiovascular system in 6, genitourinary tract in 4, respiratory system in 4 and musculoskeletal system in 2. Miscellaneous complications occurred in 3 patients. Open surgical intervention was required electively in 8 patients and on an emergency basis in 2. The incidence of complications decreased with experience: 71 percent occurred during the initial 20 cases at each institution. Conclusions In our early experience the complication rate for laparoscopic nephrectomy was 12 percent in patients with benign renal disease and 34 percent in those with renal cancer. Based on this collective experience, recommendations for prevention, recognition and treatment of complications are made.

INTRACOMPARTMENTAL SEPSIS IN BURN PATIENTS

An uncommon cause of sepsis in patients with large burns is occult intracompartmental infection. A multi-institution review of 1171 burn admissions identified 5 patients (0.4%) who developed intracompartmental sepsis presenting with fever and purulent drainage or fever, erythema, and swelling on clinical examination. Contributing factors may have included high-volume resuscitation, delayed escharotomy, extravasated intraosseous infusion, cannulation-related arterial injury, and splinting or positioning difficulties. A high index of suspicion and an aggressive surgical approach facilitate successful management of this unusual problem.

Surgery for benign insulinoma: An international review

In a multiinstitutional review, data on 396 patients with benign solitary or multiple insulinomas operated on in 15 centers were collected. In these 396 patients, 419 laparotomies (375 primary procedures and 44 reoperations) were performed. The rate of unnecessary laparotomies was 1.7%. Complications occurred after 132 operations (31.5%), requiring 27 reinterventions (6.4%). Ten (2%) patients died within 30 days of surgery. The success rate of first procedures in the centers was 94.9%. After reoperation, all but 2 (99.5%) of these patients were cured. The overall cure rate including those patients who had their primary operations elsewhere was 97.5%.

Computed tomography of the clinically negative neck

Members of the New York Head and Neck Society conducted a multi-institutional review correlating preoperative computed tomography (CT) of the neck with postoperative pathology in 59 patients with squamous cell carcinoma of the oral cavity, pharynx, and larynx, without palpable lymphadenopathy. All underwent CT followed by surgery that included partial or complete cervical lymphadenectomy. Sixteen (28%) patients had occult cervical metastases including 6 (17%) of 36 patients with "early stage" (T1 and T2) primary tumors and 10 (44%) of 23 patients with "advanced" (T3 or T4) lesions. There was agreement of CT scan findings with presence or absence of metastatic disease in 41 (69%) of 59 studies, with sensitivity 38%, and with specificity 81%. Findings of central lucency and nodal confluence were highly reliable indicators of malignancy, whereas nodal size bore a less direct relationship. Intravenous contrast medium was useful for anatomical delineation, but not for identification of malignancy. Review of films by a single radiologist did not produce greater diagnostic accuracy than the original interpretations. The authors conclude that while it is not possible to identify all instances of cervical node involvement, employment of CT in addition to physical examination and prognostication based on primary tumor stage will facilitate appropriate selection of patients for elective treatment of the neck.

Small cell carcinoma of the urinary bladder. A clinicopathologic, morphometric, immunohistochemical, and ultrastructural study of 18 cases

A multiinstitutional review of 3778 patients with a primary malignancy of the urinary bladder revealed 18 cases (0.48%) of small cell carcinoma which were histologically and morphometrically identical to pulmonary small cell undifferentiated carcinoma. Age, sex, and symptoms at first presentation were comparable to that known in transitional cell carcinoma. Sixteen patients (89%) developed metastatic disease, with most frequent involvement of regional lymph nodes, liver, skeleton, and abdominal cavity. The unfavorable clinical outcome was worse as compared with that reported in advanced stage poorly differentiated transitional cell carcinoma, and was similar to the rapidly fatal outcome of pulmonary small cell undifferentiated carcinoma. Fourteen patients (78%) died by tumor at a mean follow-up period of 9.4 months, and only one patient was free of recurrent disease more than 5 years after cystectomy. This apparent aggressive tumor behavior was independent of the presence of neuroendocrine differentiation characteristics at immunohistochemical (13 cases, 72%) or electron microscopic study (eight cases, 44%). The prolonged survival periods (15-38 months) of the five patients who received combination chemotherapy suggested that, just as in small cell lung carcinoma, chemotherapy may be profitable. A unified concept of histogenesis of bladder cancer with a common origin from a multipotent mucosal stem cell is proposed.

Septic shock during pregnancy

A multiinstitutional review of 10 pregnancies complicated by septic shock was undertaken to identify the clinical characteristics and hemodynamic alterations associated with this condition. Prolonged rupture of membranes with the subsequent development of chorioamnionitis or postpartum endometritis were risk factors that commonly preceded the diagnosis of septic shock. The majority of septic shock cases occurred during the puerperium. There were two maternal deaths in this selected series. Associated complications included pulmonary edema, adult respiratory distress syndrome, disseminated intravascular coagulation, pulmonary emboli, and cardiac arrest. The primary hemodynamic derangements were reduced systemic vascular resistance with depressed myocardial function. The mean initial systemic vascular resistance index in eight surviving women was 885 ± 253 dyne · sec/cm 5 · m 2 . Despite an overall presenting cardiac index of 4.20 ± 2.01 L/min/m 2 , five patients (50%) had evidence of myocardial depression based on analysis of their left ventricular function curves. Mean arterial pressure, systemic vascular resistance, and left ventricular stroke work index all showed significant improvement after therapy. A hemodynamic algorithm based on volume therapy, inotropic agents, and peripheral vasoconstrictors is offered. This therapeutic approach is designed to optimize cardiac performance and maintenance of organ perfusion in the critically ill patient with septic hypotension during pregnancy.

Septic shock during pregnancy

A multiinstitutional review of 10 pregnancies complicated by septic shock was undertaken to identify the clinical characteristics and hemodynamic alterations associated with this condition. Prolonged rupture of membranes with the subsequent development of chorioamnionitis or postpartum endometritis were risk factors that commonly preceded the diagnosis of septic shock. The majority of septic shock cases occurred during the puerperium. There were two maternal deaths in this selected series. Associated complications included pulmonary edema, adult respiratory distress syndrome, disseminated intravascular coagulation, pulmonary emboli, and cardiac arrest. The primary hemodynamic derangements were reduced systemic vascular resistance with depressed myocardial function. The mean initial systemic vascular resistance index in eight surviving women was 885 +/- 253 dyne.sec/cm5.m2. Despite an overall presenting cardiac index of 4.20 +/- 2.01 L/min/m2, five patients (50%) had evidence of myocardial depression based on analysis of their left ventricular function curves. Mean arterial pressure, systemic vascular resistance, and left ventricular stroke work index all showed significant improvement after therapy. A hemodynamic algorithm based on volume therapy, inotropic agents, and peripheral vasoconstrictors is offered. This therapeutic approach is designed to optimize cardiac performance and maintenance of organ perfusion in the critically ill patient with septic hypotension during pregnancy.