Postoperative Course Of Disease Research Articles

Clinico-otoneurological assessment of the early postoperative outcome in surgical treatment of Chiari malformation and syringomyelia

although the pathology of Chiari malformation is extensively studied, many questions have not yet been solved. In particular, the clinical manifestations of this pathology have not been studied in detail entailing the lack of the unified approach for the optimal complex of the diagnostic workup and the selection of the optimal surgical intervention. These questions remain the point of discussion in the scientific literature. The present study is based on the retrospective analysis of the diagnostic findings and treatment outcomes of 59 patients – 24 males (40.7 %) and 35 females (59.3 %) – treated in the Department of spinal cord pathology of the State Institution "Romodanov Neurosurgery Institute, the National Academy of Medical Sciences of Ukraine" in 2010-2020. The age of the patients ranged from 16 to 50 years (36.9 ± 3.7 on the average). All patients were examined according to the conventional standards allowing for the assessment of the pre- and postoperative disease course. The following surgical interventions were provided: bone decompression for the inferior parts of the cerebellum at the upper cervical level; the recovery of the CSF flow at the region of craniovertebral junction; the expansion of the space in the fossa cranii posterior and/or craniovertebral junction. The data were processed and analyzed with the aid of STATISTICA 13 software. The quantitative variables were compared by non-parametric methods. The aim of the study was to analyze the preoperative and early postoperative clinico-otoneurological status in patients with Chiari malformation and syringomyelia. The clinical aspects of the disease were evaluated. Most clinical signs and symptoms in patients with Chiari malformation were associated with otolaryngological disturbances (hearing impairment, tinnitus, hoarseness, vertigo, etc.) and cerebellar signs (ataxia, nystagmus). Taking into account non-specific signs and symptoms of the disease, the otoneurological evaluation in these patients is undoubtedly of high importance for the preoperative differential diagnosis as well as the postoperative assessment of treatment outcome. The further study of the problem will allow us to timely diagnose Chiari malformation, to predict the course of the disease and the risk of the possible complications providing the clinicians with important information for decision-making on the optimal treatment strategy. The clinical and instrumental otoneurological examination is an important component of the systemic assessment of the clinical-and-functional status of patients with syringomyelia caused by Chiari malformation that allows for objectifying the dynamics of the otoneurological aspects of the disease in the course of the treatment.

Long-term outcomes following ileocolic resection for Crohn's disease: does earlier elective resection affect disease recurrence rates?

Surgical resection in Crohn's disease is sometimes the only alternative treating disease complications or refractory disease. The implications of early resection on disease course are still debatable. We aimed to assess the influence of preoperative disease duration on long-term postoperative disease course. A retrospective analysis of all Crohn's disease patients who underwent an elective primary ileocolic resection between 2010 and 2021 in a single tertiary medical center. The cohort was divided based on disease duration, Group A (47 patients) had a disease duration shorter than 3 years (median of 1 year) and Group B (139 patients) had a disease duration longer than 3 years (median of 11 years). Surgeries were less complex among Group A as noted by higher rates of laparoscopic assisted procedures (68.1% vs. 45.3%, P = 0.006), shorter surgery duration (134 vs. 167 min, P < 0.0001) less estimated blood loss (72.5 vs. 333 mL, P = 0.016) and faster return of bowel function (3 vs. 4 days, P = 0.011). However, propensity score matching nullified all the differences. Younger age (OR = 0.86, P = 0.004), pre-op steroids (OR = 3.69, P = 0.037) and longer disease duration (OR = 1.18, P = 0.012) were found to be independently significantly associated with severe complications. After a median follow-up time of 71.38 months no significant differences were found between the groups in terms of endoscopic (P = 0.59), or surgical recurrences rates (P = 0.82). The main effect of preoperative short disease duration was noted within the surgical complexity; however, matching suggests confounders as cause of the difference. No significant long-term implication was noted on disease recurrence.

Mucosa-Associated Oscillospira sp. Is Related to Intestinal Stricture and Post-Operative Disease Course in Crohn's Disease.

Intestinal stricture remains one of the most intractable complications in Crohn's disease (CD), and the involved mechanisms are poorly understood. Accumulating evidence suggests that the gut microbiota contributes to the pathogenesis of intestinal fibrosis. In this study, we investigated specific mucosa-associated microbiota related to intestinal strictures and their role in predicting postoperative disease course. Twenty CD patients who had undergone operative treatments were enrolled and followed up. Intestinal mucosa and full-thickness sections from stenotic and non-stenotic sites were sterilely collected. DNA extraction and bacterial 16s rRNA gene sequencing were conducted. Radiological and histological evaluations were performed to assess fibrosis. Microbial alpha diversity was significantly decreased in stenotic sites (p = 0.009). At the genus level, Lactobacillus, Oscillospira, Subdoligranulum, Hydrogenophaga, Clostridium and Allobaculum were decreased in stenotic segments (p < 0.1). The difference in Oscillospira sp. (stenotic vs. non-stenotic) was negatively correlated with the erythrocyte sedimentation rate (correlation coefficient (CC) -0.432, p = 0.057) and white blood cell count (CC -0.392, p = 0.087) and positively correlated with serum free fatty acids (CC 0.575, p < 0.05). This difference was negatively associated with intestinal fibrosis evaluated by imagological and histological methods (CC -0.511 and -0.653, p < 0.05). Furthermore, CD patients with a higher abundance of Oscillospira sp. in the residual intestine might experience longer remission periods (p < 0.05). The mucosa-associated microbiota varied between stenotic and non-stenotic sites in CD. Most notably, Oscillospira sp. was negatively correlated with intestinal fibrosis and postoperative disease course. It could be a promising biomarker to predict post-operative disease recurrence and a microbial-based therapeutic target.

P474 Postoperative disease course after appendectomy as experimental treatment for patients with therapy refractory moderate to severe ulcerative colitis

Abstract Background Increasing evidence suggests appendectomy as a potential experimental therapy for ulcerative colitis (UC). A prospective cohort study of laparoscopic appendectomy for treatment of therapy refractory UC showed a clinical response in nearly half of the patients with a substantial proportion of patients in endoscopic remission, after a postoperative follow-up of 3.7 years1. The current study aimed to explore disease course during long-term follow-up in patients undergoing appendectomy for therapy-refractory UC. Methods In this monocenter cohort series, all patients with therapy refractory UC referred for (procto)colectomy between 2012-2015 were counselled to undergo laparoscopic appendectomy instead. The primary endpoint was long-term clinical (≥3 points decrease in partial mayo score) and endoscopic response (Endoscopic Mayo score ≤1) displayed in individual time lines. Secondary endpoints included duration and loss of clinical and endoscopic response, de-escalation of medication, and failure (medical treatment switch or colectomy). Results A total of 25 patients (12 men; median age 41.0 years) underwent appendectomy. The median postoperative follow-up time was 7.5 [IQR 6.4-8.6] years. Clinical response was observed in 60% (15/25) after a median follow-up of 4.0 [IQR 3.0-7.0] months, and was 32% (8/25) at the end of follow-up. Endoscopic response was observed in 48% (12/25) after a median follow-up of 17.5 [IQR 3.3-38.8] months and was 24% (6/25) at the end of follow-up. The median duration of clinical and endoscopic response was 80.0 [20.0-93.0] an 45.5 [21.8-56.8] months, respectively. Six (24%) patients de-escalated medication during follow-up, five of which without subsequent failure. Seventeen (68%) patients failed during postoperative follow-up after appendectomy, of which nine patients (36%) required colectomy a median of 5.0 [IQR 2.0-13.5] months after appendectomy. Figure 1. Disease course after appendectomy per patient. Conclusion During the postoperative course following appendectomy for refractory UC, approximately half of the patients demonstrated long-lasting endoscopic response, more than half demonstrated long-lasting clinical response, and one third underwent colectomy. 1Stellingwerf ME, Sahami S, Winter DC, Martin ST, D'Haens GR, Cullen G, Doherty GA, Mulcahy H, Bemelman WA, Buskens CJ. Prospective cohort study of appendicectomy for treatment of therapy-refractory ulcerative colitis. Br J Surg. 2019 Nov;106(12):1697-1704.

STRUCTURAL ORGANIZATION OF COLLAGEN-CONTAINING CONNECTIVE TISSUE AS A PREDICTOR OF METASTATIC PROGRESSION OF PROSTATE CANCER

Summary. Aim: to determine at the optical level the role of the fibrillar organization of the collagen-containing connective tissue component of the primary tumor focus in prostate cancer (PCa) progression. Objects and methods: the morphological study is based on the analysis of the histological material of the primary tumor foci of 55 PCa patients without tumor progression in the postoperative period and bone metastases. The tumors were graded Gleason 6–9 at surgery. The features of the architecture of collagen-containing connective tissue in tumors were determined in histological slides stained by Van-Gieson. Results: the remodeling of the collagen-containing stromal component located both around the glandular structures (increase in the percentage of straight and aligned collagen fibers compared to the curved ones) and in the stroma itself has been found. Such remodeling is manifested by an increase in the total mass of fibrous structures, an increase in the width of collagen fibrils, their compaction in relation to the density of their location, peculiarities of desmoplasia, alignment and elongation. The specified features are consistent with the Gleason score and the postoperative disease course, namely, the occurrence of metastases. Conclusions: the desmoplastically changed collagen-containing connective tissue component of the PCa creates favorable conditions for the unimpeded migration and realization of the invasive potential of cancer cells, in particular those expressing bone tissue remodeling proteins.

Red blood cell distribution width in glioblastoma

IntroductionGlioblastoma (GBM) is the most common and deadly adult brain tumor. Red blood cell distribution width (RDW) has been found in non-central nervous system neoplasms to be associated with survival. This study aims to assess the prognostic value of pre-operative RDW and trends in RDW over time during the disease course. MethodsThis single-institution retrospective cohort study identified patients ≥ 18 years old with pathology-proved glioblastoma treated between April 2003-May 2017 from an institutional database. A Cox proportional hazards model was developed using known prognostic clinical variables to predict overall survival time; a second model incorporating continuously valued RDW was then created. The additional prognostic value of RDW was assessed with a joint model F-test. The variation of RDW-CV over time was evaluated with linear mixed model of RDW. A post-hoc exploratory analysis was performed to assess the trend in RDW lab value leading up to time of death. Results346 adult GBM patients were identified; complete survival data was available for all patients. The addition of RDW to the multivariable Cox proportional hazards model did not increase prognostic value. There was an upward trend in RDW throughout the post-operative disease course. In a post-hoc analysis, there was an upward trend in RDW leading up to the time of death. ConclusionAlthough RDW has been prognostic of survival for many inflammatory, prothrombotic, and neoplastic diseases, pre-operative RDW was not associated with overall survival in GBM patients. RDW trended upwards throughout the disease course, suggesting possible systemic inflammatory effects of either glioblastoma or treatment.

Surgical treatment of newborns with small bowel atresia (literature review)

Intestinal atresia is a congenital obstruction of the lumen of the jejunum or ileum and is one of the most common causes of congenital obstruction in newborns. This literature review is devoted to the surgical treatment of newborns with various types intestinal atresia. Causes of intestinal atresia are considered, where a special role is assigned to the genetic theory, the expression of the nucleotide sequences ITGA2 873G/A and NPPA 2238T/C and antenatal circulatory disorders of the developing intestine. Topographical-anatomical and morphological characteristics of the intestine in newborns with intestinal atresia are studied in detail in articles. A table of revealed histomorphological features of the small intestine in children with atresia was compiled. In addition, processes occurring in the mucosa, submucosa, muscle, and serous membranes are described in detail. A relationship was found related to the size of the atresia site and duration of ischemia. The theory of neuromuscular regulation of the intestine is considered, in which an important role is assigned to interstitial pacemaker cells of Cajal. Variants of anastomosis depending on the difference in diameters of the adductor and excretory parts of the intestine are analyzed, and results of treatment in patients with laparoscopic access are described. The postoperative course of disease, development of complications, recurrent operative interventions, duration of parenteral nutrition, and onset of enteral load was evaluated.&#x0D; Conclusion. The choice of surgical technologies used to restore the patency of the intestinal tube is determined by the degree of discrepancy between diameters of anastomosed segments. The prognosis is not determined by tactics of surgical treatment, type of atresia, time before treatment, and presence of associated anomalies.

Fecal microbiota composition is linked to the postoperative disease course in patients with Crohn\u2019s disease

BackgroundThe role of the fecal microbiota composition for the postoperative disease course of patients with Crohn’s disease (CD) who have undergone ileocecal resection remains to be established. In this study, we investigated if the fecal microbiota composition, determined by a high throughput test quantifying a pre-selected set of bacteria, is associated with the postoperative disease course of CD patients.MethodsFecal samples were obtained from healthy subjects as well as from CD patients, 3–10 weeks and 1 year after ileocaecal resection. The fecal microbial composition was analyzed by Genetic Analysis GA-map Dysbiosis test, targeting ≥300 bacteria on different taxonomic levels. Postoperative disease status was assessed endoscopically according to Rutgeerts scoring system 1 year after surgery. Differences in fecal microbiota composition between groups were analyzed by multivariate factor analyses and cluster analysis. Microbial stability over time was determined using Bray-Curtis dissimilarity.ResultsOne year after surgery, the fecal microbiota composition differed between CD patients (n = 21) and healthy subjects (n = 7). At this time point, the microbiota composition of CD patients was associated with disease course, clearly separating patients with disease relapse (n = 8) and patients in remission (n = 13). Further, the microbial within-patient stability was high during the first year after surgery, irrespective of disease course.ConclusionThe fecal microbiota composition of CD patients, analyzed by GA-map Dysbiosis test, is subject to little variation over time, and may potentially be used as a non-invasive diagnostic tool for the postoperative disease course.

Drug reaction with eosinophilia and systemic symptoms after daclizumab therapy in MS.

In 2012, a 33-year-old woman was diagnosed with relapsing-remitting MS (RRMS) after fulfilling McDonald criteria and careful exclusion of other differential diagnoses. Five years later (EDSS 1), she changed her disease-modifying therapy after side effects to betaferon (flu-like symptoms) and dimethyl fumarate (erythema and pruritus) to daclizumab. Two months after 2 applications of 150 mg daclizumab, she developed a self-limiting rash (figure 1A), followed by fever, headaches, meningismus, photophobia, nausea, paraesthesia, and itching of her upper body 1 month later. Blood test showed decreased lymphocyte counts of 1.7/μL (17.1%) and increased eosinophil granulocytes of 1.5/μL (15.1%). CSF analysis revealed pleocytosis of 570/μL (1.8% eosinophilic granulocytes) and an initially negative, but 2 weeks later marked intrathecal immunoglobulin synthesis (IgM 85%, IgA 43%, and IgG 38%). MRI showed periventricular contrast-enhancing lesions and a multisegmental cervical myelitis (C1–4). After 10 days, she further deteriorated by severe infratentorial edema with compression of the fourth ventricle and obstructive hydrocephalus (figure 1, B–F). At admission to our hospital, she obtained an external ventricle drainage showing normal opening pressure. Two days later, she had sudden increase in intracranial pressure requiring intubation and emergency decompressive surgery of the posterior fossa. Increased intracranial pressure (up to 40 mm Hg) due to global brain edema and subsequently complicated by a postoperative bleeding into the right frontal lobe after a brain biopsy (see below) was controlled by CSF drainage, deep analgosedation, dexamethasone, and osmotherapy. The atypical clinical picture with brain edema, rhombenecephalitis, and high CSF cell count was incompatible with MS relapse as initially suggested by the periventricular lesions and cervical myelitis. Because careful examinations revealed no other autoimmune or infectious diseases, we initially treated polypragmatically with aciclovir/ganciclovir, ceftriaxone/ampicillin, voriconazole/posaconazole, and IV immunoglobulins. Brain biopsies of the right frontal lobe, cerebellum, and cerebellar leptomeninges showed inflammatory demyelinating lesions with pronounced inflammation, numerous T cells, eosinophils, plasma cells, and an eosinophilic and lymphoplasmacellular meningitis (figure 1, G–J). We diagnosed the patient with CNS manifestation of daclizumab-induced DRESS (drug reaction with eosinophilia and systemic symptoms) since 6 of 7 Registry of Severe Cutaneous Adverse Reaction Criteria (RegiSCAR)1 for DRESS were fulfilled (positive: hospitalization, reaction suspected to be drug-related, fever >38°C, skin rash, internal organ involvement, blood eosinophilia; negative: lymphadenopathy). Accordingly, the patient was treated with high-dose IV methylprednisolone (5 days with 1 g each) and 6 cycles of plasma exchange, followed by 1 mg/kg oral prednisolone with subsequent tapering. Thereafter, the patient improved dramatically and could be extubated 2 weeks after disease exacerbation. Postoperative disease course was complicated by wound infection, bacterial meningitis, persisting CSF effusion, and obstructive hydrocephalus that required a ventriculoperitoneal shunt. Four months later, neurologic syndromes with tetraparesis, choreoathetosis, cerebellar ataxia, and cognitive dysfunctions had regressed substantially (EDSS 3.5). The authors thank the patient for participation in the study.

Cholangitis in the postoperative course after biliodigestive anastomosis.

Hepatobiliary surgery with biliodigestive anastomosis (BDA) results in a loss of the sphincter of Oddi with consecutive ascension of bacteria into the bile system which may cause cholangitis in the postoperative course. Patients who received reconstruction with a BDA after hepatobiliary surgery were analyzed retrospectively for their postoperative course of disease depending on intraoperatively obtained bile cultures and antibiotic prophylaxis. Two hundred forty-three patients were included in the analysis, 49.4% of whom had received endoscopic stenting before the operation. Stenting was significantly associated with the presence of drug-resistant bacteria in the intraoperatively obtained bile sample (p < 0.001, OR = 4.09). Of all patients, 14.4% developed postoperative cholangitis. This was significantly associated with the postoperative length of stay in the intensive care unit (p = 0.002, OR = 1.035). The highest incidence of postoperative cholangitis was found in patients with cholangiocellular carcinoma (n = 12, p = 0.046, OR = 2.178). Patients were more likely to harbor strains with resistance against the antibiotic that was given intraoperatively. The risk for the presence of drug-resistant bacteria is increased by preoperative stenting of the common bile duct. Bile culture by intraoperative swabs can be altered by the perioperative antibiotic prophylaxis as it induces microbiological selection in the common bile duct.

Molecular predictors of outcome in low-grade glioma

Recent and ongoing translational studies in neurooncology have investigated the role of molecular markers as potential predictors of outcome in patients with WHO grade I and II gliomas, commonly summarized as low-grade gliomas (LGGs). Here, we seek to highlight the most relevant molecular aberrations associated with these tumour types and update on recent findings on their potential prognostic and predictive value. So far, no biomarker discussed has any relevance for the postoperative course of disease without genotoxic treatment. Isocitrate dehydrogenase (IDH) mutations, 1p deletion or 1p/19q codeletion have the strongest prognostic impact on survival of patients with LGG, given a genotoxic treatment is provided. Recent findings from phase III clinical trials on anaplastic oligodendroglial tumours conducted in North America and Europe suggest that the addition of procarbazine, lomustine and vincristine to radiotherapy is beneficial in the treatment of anaplastic gliomas with 1p/19q codeletion. To decipher the role of 1p/19q codeletion in LGG will be challenging. Recent developments in v-raf murine sarcoma viral oncogene homolog B1 (BRAF)(V600E)-specific small molecule inhibitors and their clinical approval for other cancer types could turn BRAF(V600E) into a promising molecular predictor of outcome in pilocytic astrocytomas, given a treatment with a mutation-specific BRAF inhibitor is applied. Clinical prognostic factors such as age, tumour size and the presence or absence of clinical symptoms have long been recognized in the management of patients with LGGs. Molecular biomarkers are increasingly evolving as additional factors that facilitate diagnostics and therapeutic decision-making. However, further prospective randomized studies including multivariate analyses are needed to clearly distinguish between prognostic and predictive effects.

1908 Management of Pulmonary Hypertension after Paediatric Cardiac Surgery

IntroductionTreatment of pulmonary hypertension in children has significantly improved over the years. The Beatrix Children’s Hospital serves as the nationwide referral center for these children. Of importance, pulmonary hypertension occurs...

Development of pouchitis following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis: A role for serological markers and microbial pattern recognition receptor genes

Background and Aims Pouchitis, the most common complication after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, has been attributed to altered composition of faecal flora. We investigated the role of antimicrobial and antiglycan antibodies and polymorphisms in microbial pattern recognition receptor genes. Methods Clinical charts of all 184 patients with ulcerative colitis who underwent IPAA between 1990–2004 were reviewed for pre- and post-operative disease course. Results Follow-up data were available in 172 patients [67 female, median age at proctocolectomy 39.1 years]. During a median follow-up of 6.7 (interquartile range 3.7–10.5) years, 80 patients (47%) developed at least one episode of pouchitis. Cox proportional-hazard regression identified extra-intestinal manifestations [HR 1.78 (95%CI 1.10–2.88), p = 0.020], a GT/TT genotype at Toll-like-receptor-1 S87I [HR 1.64 (1.01–2.66), p = 0.047], anti-chitobioside carbohydrate antibodies [HR 2.03 (1.11–3.70), p = 0.021] and young age at diagnosis [ p = 0.003] to be independently associated with pouchitis. Factors associated with chronic pouchitis, diagnosed in 33 patients (19%), were extra-intestinal manifestations [HR 2.45 (1.07–5.62), p = 0.034], backwash ileitis [HR 3.15 (1.10–9.00), p = 0.032], outer-membrane porin antibodies [HR 2.67 (1.20–5.94), p = 0.016] and young age at proctocolectomy [ p = 0.008]. Conclusions: The reported association with antibodies and Toll-like-receptor-1 supports the pathophysiological role of the faecal flora in the development of pouchitis.

Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

During the course of their disease, about 30% of patients with ulcerative colitis (UC) will undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). We evaluated the outcome of IPAA in a Belgian referral center. Clinical charts were reviewed for pre- and postoperative disease course, functional outcome, and complications in all patients with UC (n = 182) and indeterminate colitis (n = 2) who underwent IPAA in 1990-2004. Follow-up data were available in 173 out of 184 patients (67 female, median age at proctocolectomy 39.0 years). Median functional Oresland score 1 year after IPAA was 3 (range 0-11). Early postoperative complications were seen in 27% of patients. After a median (interquartile range) follow-up of 6.5 (3.4-9.9) years, 35% of patients developed septic and/or obstructive complications. Forty-six percent of patients developed at least 1 episode of pouchitis. Risk factors for pouchitis were the presence of extraintestinal manifestations (odds ratio [OR] 1.92 (1.23-3.01), P = 0.004) and younger age at proctocolectomy (P = 0.004). Chronic pouchitis was present in 33 patients and associated with extraintestinal manifestations (OR 2.93 (1.13-7.62), P = 0.027), backwash ileitis (OR 9.28 (1.71-50.49), P = 0.010), and length of follow-up (P = 0.004). Pouch failure occurred in 5% of patients. Although proctocolectomy with IPAA surgery has a good functional outcome, postoperative complications, especially pouchitis, remain considerable in patients with UC.

Surgical therapy of recurrent vulvar cancer

The success of various surgical interventions in 201 cases with recurrent vulvar carcinoma was examined in the light of patients' pretreatment, surgical therapy, plastic reconstruction, and postoperative disease course. A databank of standardized clinical data was analyzed using statistical procedures. Therapy was selected on an individual basis according to tumor status. Recurrence at a site distant from the primary tumor, particularly in the inguinal region, indicated a markedly unfavorable prognosis. In contrast, tumors recurring locally did not exhibit any significant differences. Plastic surgery reconstruction led to improvements with respect to operability, wound healing, and survival. Individualized reconstructive surgery of the vulva leads to good results in patients with recurrent vulvar cancer. To an even greater extent than is the case for primary therapy, plastic surgery enlarges the spectrum of feasible surgical alternatives so that a more favorable oncological outcome and excellent cosmetic results may be expected.

Reconstructive surgery following resection of primary vulvar cancers

Objective. This study describes the surgical treatment and follow-up of 213 patients with primary vulvar cancer; particular attention is given to reconstructive surgical procedures. Methods. The clinical and pathological parameters of the patients were recorded according to standardized procedures, and the data concerning type of operation, surgical reconstruction and postoperative course of disease (recurrence-free and overall survival) were analyzed. Results. In about one-third of the cases, plastic surgery reconstruction involving skin-flaps was performed. In the present group of patients, plastic surgery procedures led to an elevated degree of operability as well as to more satisfactory results in terms of wound healing. For minor cosmetic defects, local (fasciocutaneous) skin-flaps resulted in excellent wound healing and short periods of in-patient treatment, even in patients with larger tumors. In cases exhibiting more severe wounds extending over larger areas of the vulva and its surrounding regions, similarly encouraging results were achieved using regional (myocutaneous) skin-flaps. Conclusion. The present study shows that reconstructive surgery of the vulva leads to good results in patients with vulvar cancer. Plastic surgery enlarges the spectrum of available operative therapy in vulvar cancer, especially in large tumors, and its application leads to a favorable oncological outcome as well as excellent cosmetic results in patients with vulvar cancer.

Prognostic Significance of Vascular and Perineural Invasion in Urothelial Bladder Cancer Treated With Radical Cystectomy

Data on the prognostic significance of tumor invading lymphatic and blood vessels in bladder cancer are controversial, while little is known about perineural invasion in this tumor. We determined the prognostic value of these parameters in radical cystectomy specimens. Slides of 283 radical cystectomy specimens obtained from 1986 to 1997 were examined retrospectively with respect to tumor invasion in lymphatic and blood vessels, and perineural spaces. This review was performed while blinded to lymph node tumor involvement or the postoperative disease course. The Kaplan-Meier probability analysis of tumor-free survival and the log rank test were used to determine the prognostic effects of vascular and perineural invasion. Multivariate analysis using the Cox proportional hazards model was also performed. Lymphatic, blood vessel and perineural tumor invasion were present in 54.1%, 13.1% and 47.7% of specimens, respectively. Tumor progressed in 46.3% of patients. On univariate analysis all 3 factors showed strong prognostic significance. However, on multivariate analysis only blood vessel invasion, invasion depth and regional lymph node status were independent prognostic factors (p <0.05). Lymph node metastases, pT classification and blood vessel invasion are independent prognostic parameters of tumor-free survival that should be used to guide patient treatment after radical cystectomy. Invasion of the blood and lymphatic vessels should be commented on separately in the pathology report.

Fístulas traqueoesofágicas benignas adquiridas

Benign acquired tracheoesophageal fistula (TEF) is a rare though serious occurrence associated with a high degree of morbidity and mortality. We review 18 cases of TEF treated over 16 years in our hospital. The variables analyzed descriptively were demographic (age, sex and others), clinical (etiology, time of intubation, time and symptoms leading to clinical suspicion, diagnostic techniques, and others), and therapeutic (dependence on mechanical ventilation, location of tissues, tracheal resection, tissue interposition, postoperative course of disease, and others). Fifteen of the 18 patients required surgery. The rate of success (80%) was high in terms of respiration, swallowing and phonation. Surgery involved simple closure of the TEF, with half the patients requiring a second operation to correct tracheal stenosis. Resection and anastomosis were performed in the remaining 11 cases, with only one requiring a second operation for recurrence of stenosis. Two cases of perioperative mortality and one TEF recurrence related to assisted ventilation were recorded. Tracheoscopy was the most effective diagnostic technique, complemented by computerized tomography of the trachea. Presurgical evaluation of tracheal stenosis, the absence of mechanical ventilation, preoperative preparation and postoperative care are the factors that determine success in this type of surgery. When tracheal stenosis is associated with TEF, resection and anastomosis should be performed in the affected zone.

Valor pronóstico de la citología positiva hallada en el lavado pleural de pacientes con cáncer de pulmón. Estudio prospectivo

Pulmonary neoplasms can deposit malignant cells in the pleural cavity by a variety of mechanisms, depending not only on histological type but also on clinical stage. We investigated the effect on survival rate of a finding of malignant cells in pleural lavage. We also investigated the effect of the presence of pleural metastasis on postoperative course of disease. Two hundred surgical patients at Hospital General Universitario in Valencia between 1 February 1990 and 30 March 1993 were studied. Two groups were formed. Group one: 150 patients with lung cancer, none of whom had had pleural effusion prior to suffering transthoracic puncture during the preoperative study. Patients treated with parallel chemotherapy or radiotherapy were excluded in order to circumvent false positives. Group two: 50 patients with no tumors who underwent thoracotomy for reasons other than lung cancer. All patients underwent pleural lavage with saline before and after lung exeresis. We found 26.6% (40/150) positive cytologies in the pre-and postoperative lavages in the first group. None were found in the control group.