Biomedical subjects
C Vasilescu
Publications and source records attributed to C Vasilescu.
Laparoscopic subtotal splenectomy in hereditary spherocytosis : to preserve the upper or the lower pole of the spleen?
BACKGROUND: Clinical manifestations of hereditary spherocytosis can be controlled by splenectomy. The use of this procedure has been restricted due to concerns regarding exposure of patients to a lifelong risk of overwhelming infections. Subtotal splenectomy, which removes 85-90% of the enlarged spleen, is a logical alternative. In the first cases performed by laparoscopy we have chosen to preserve the upper pole. However, this technique showed some disadvantages, especially concerning the correct intraoperative evaluation of the splenic remnant volume. Therefore, we developed a new variant of the procedure by preserving the lower pole of the spleen. METHODS: Based on the authors' experience in laparoscopy (176 laparoscopic splenectomies), 10 laparoscopic subtotal splenectomies were performed in patients with hereditary microspherocytosis, preserving either the upper or the lower splenic pole. RESULTS: Patient age ranged between 5 and 35 years. The mean volume of the remnant spleen was 41.4 cm3. There were no complications, and no transfusions were needed. Follow-up for 1-30 months was available. CONCLUSIONS: Subtotal splenectomy appears to control hemolysis while maintaining splenic function. The laparoscopic approach is safe and effective and should be considered the procedure of choice in hereditary microspherocytosis. Laparoscopic subtotal splenectomy presents an advantage over open subtotal splenectomy, resulting in decreased blood loss, shorter hospital stay, no conversions, fewer operative and postoperative complications, and excellent remission rates. On the basis of our experience, the preservation of the lower pole of the spleen seems to be a first-line option for the optimal evaluation of the residual splenic mass.
Endotoxemia and acute-phase proteins in major abdominal surgery.
BACKGROUND: Translocation of endotoxin is a controversial issue. The ability of plasma to inactivate endotoxin is an indirect measure of endotoxemia. Endotoxin is a potent stimulator of the inflammatory response and affects the innate immune system. OBJECTIVE: To elucidate the kinetics of endotoxemia and the ability of plasma to inactivate endotoxin in patients with major abdominal operations. To demonstrate the early time course of the acute-phase proteins C-reactive protein (CRP), serum amyloid A (SAA), alpha(1)-antitrypsin, alpha(2)-macroglobulin, transferrin, and interleukin 6 (IL-6), and to correlate them with the amount of endotoxemia. METHODS: Twenty patients with elective major abdominal operation and 10 healthy controls were investigated. Blood was collected preoperatively, during the operation and regularly up to 12 days after surgery. Endotoxin was measured by Limulus amebocyte lysate test (LAL), the ability of plasma to inactivate endotoxin by modified LAL, the acute-phase proteins nephelometrically, and IL-6 by enzyme-linked immunosorbent assay (ELISA). RESULTS: Preoperative endotoxin plasma level (0.026 +/- 0.004 EU/mL) did not differ from healthy volunteers but increased during operation (0.09 +/- 0.02 EU/mL, P = 0.02). Endotoxemia peaked 1 hour after the surgical procedure (0.16 +/- 0.03 EU/mL; P <0.0001 versus preoperative) and decreased to almost normal values after 48 hours. The capability of plasma to inactivate endotoxin was significantly reduced during (recovery, 0.16 +/- 0.03 EU/mL), 1 hour (0.25 +/- 0.04 EU/mL) and 24 hours (0.16 +/- 0.02 EU/mL) after the operation compared with preoperative (0.068 +/- 0.01 EU/mL) values. Plasma IL-6 was significantly increased for 48 hours with a peak 1 hour after surgery (470 +/- 108 pg/mL). CRP peaked at 210 +/- 19 mg/L (P <0.0001 versus preoperative) 48 hours after operation and was significantly elevated for the rest of the observation period. SAA was significantly increased 24 hours after surgery (249 +/- 45 mg/L) and peaked additional 48 hours later (456 +/- 86 mg/L). alpha(1)-Antitrypsin, although a positive acute-phase protein, decreased initially to 1.38 +/- 0.1 g/L (preoperative, 2.33 +/- 0.18 g/L; P <0.0001) and increased thereafter until day 12 (3.05 +/- 0.35 g/L, P = 0.11 versus preoperative). The same was true for alpha(2)-macroglobulin (preoperative, 2.2 +/- 0.16 g/L; intraoperative, 1.36 +/- 0.13 g/L; day 5, 2.8 +/- 0.4 g/L). Transferrin decreased already during surgery (1.6 +/- 0.1 g/L versus preoperative 2.8 +/- 0.17 g/L, P <0.0001) and remained on this level for 5 days. Correlation analysis revealed a relationship between endotoxemia and the ability of plasma to inactivate endotoxin (r = 0.67, P <0.0001) and also a relation between intraoperative endotoxemia on one hand and alpha(2)-macroglobulin (-0.53 > r > -0.6, P <0.05) as well as alpha(1)-antitrypsin (0.64 > r >0.55, P <0.05) on the other. CONCLUSION: Major abdominal surgery is associated with transient endotoxemia and a transient reduced endotoxin inactivation capacity of the plasma. Endotoxemia correlates with the endotoxin inactivation capacity. The surgical procedure causes substantial changes in plasma concentrations of acute-phase proteins. alpha(2)-Macroglobulin and alpha(1)-antitrypsin correlate moderately with endotoxemia.
Endotoxin and antiendotoxin antibodies in patients with acute pancreatitis.
OBJECTIVE: To elucidate the time course of endotoxaemia and antiendotoxin antibodies in patients with acute pancreatitis. DESIGN: Prospective clinical study. SETTING: University hospital, Germany. SUBJECTS: 25 patients with oedematous (n = 9) or necrotising (n = 16) pancreatitis, and 20 healthy controls. MAIN OUTCOME MEASURES: Concentrations of endotoxin and immunoglobulins (classes G, M, and A) directed at two lipid A molecules, four lipopolysaccharides, and alpha-haemolysin of Staphylococcus aureus measurements in plasma during a 12 day period. RESULTS: There were no differences in the degree of endotoxaemia between patients with oedematous and necrotising pancreatitis on admission. However, from the day after admission and throughout the observation period patients with necrotising pancreatitis had significantly higher concentrations of endotoxin than those with oedematous pancreatitis. Concentrations of IgM specific for endotoxin peaked at day 4, and then decreased in patients with oedematous pancreatitis while remaining high for those with necrotising pancreatitis. There was only a slight increase in IgA specific for endotoxin, and IgG and immunoglobulins to gamma-haemolysin remained steady throughout the observation period. There was strong cross-reactivity (r > 0.7) between IgM specific for endotoxin (70%), but this was less with IgA (52%), and IgG (20%). CONCLUSIONS: Necrotising pancreatitis is accompanied by persistent endotoxaemia with an extended rise in antiendotoxin antibodies. Patients with oedematous pancreatitis have a transient endotoxaemia with a temporary increase of Ig specific for endotoxin. Endotoxin stimulates the synthesis of specific antibodies (IgM) despite general immunosuppression.
Biliary cystadenocarcinoma: sonographic and cytologic findings.
Biliary cystadenocarcinoma is a rare hepatic cystic tumor. We report sonographic, CT, and MRI findings in an unusual case in an 87-year-old man. The diagnosis was aided by sonographically guided needle aspiration of the lesion, which revealed elevated levels of carcinoembryonic antigen and CA 19-9 in the cystic fluid.
Renal cell carcinoma with a fatty component mimicking angiomyolipoma on CT.
A very unusual CT appearance of renal cel carcinoma is presented, in which the fatty density mimicked a benign angiomyolipoma.
Endotoxin-induced release of interleukin 6 and interleukin 1 beta in human blood is independent of tumor necrosis factor alpha.
It has been suggested that tumor necrosis factor alpha (TNF alpha) acts not only by direct toxicity, but also as a proximal mediator which is able to induce the production of other cytokines, especially interleukin 6 (IL-6) and interleukin 1 beta (IL-1 beta). In order to test the dependence of the release of these two cytokines from leukocytes upon induction by TNF alpha, we stimulated whole blood in vitro with TNF alpha and compared the cytokine levels with those induced by endotoxin. The cytokine release was also determined after stimulation by endotoxin with added TNF alpha and by endotoxin with monoclonal antibodies against TNF alpha (anti-TNF alpha) added in order to reduce TNF alpha. Unstimulated blood samples were used as controls. The plasma levels of both IL-6 and IL-1 beta were significantly higher after stimulation with endotoxin than after stimulation with TNF alpha. TNF alpha did not induce cytokine levels significantly higher than controls. The cytokine levels were the same whether or not anti-TNF alpha was included together with the endotoxin. Plasma from samples with added anti-TNF alpha had no detectable TNF alpha. Our results indicate that the leukocyte-derived production of IL-6 and IL-1 beta in whole blood is stimulated directly by endotoxin and is not mediated by TNF alpha.
[Value of asymmetry criterion in MRI for the diagnosis of small pelvic lymphadenopathies (inferior or equal to 1 cm)].
The purpose of this study was to determine if lymph node asymmetry in small (< 1.0 cm) pelvic nodes was a significant prognostic feature in determining metastatic disease. 216 patients who presented pelvic carcinoma underwent MR imaging. They were correlated to pathological findings obtained by surgery. We considered on the axial plan the maximum diameter (MAD) of both round or oval-shaped suspicious masses. Two different cut-off values were determined: node diameter superior to 1.0 cm (criterion 1) and node diameter superior to 0.5 cm with asymmetry relative to the opposite side for nodes ranging from 0.5 cm to 1.0 cm (criterion 2). With criterion 1 MR Imaging had an accuracy of 88%, a sensitivity of 65%, a specificity of 96%, a PPV of 88% and a NPV of 88% in detection of pelvic node metastasis. By considering criterion 2, MR Imaging had an accuracy of 85%, a sensitivity of 75%, a specificity of 89%, a PPV of 71% and a NPV of 91%. Normal small asymmetric lymph nodes were present in 5.6% of cases. Asymmetry of normal or inflammatory pelvic nodes is not uncommon. It cannot be relied on to diagnose metastatic involvement in cases of small suspicious lymph nodes, especially because of its low specificity and positive predictive value.
Endotoxemia and mediator release during colonoscopy.
BACKGROUND AND STUDY AIMS: Previous clinical and experimental studies have shown evidence of a leakage of whole bacteria and bacterial products after major trauma through the gut barrier. By determining plasma endotoxin levels, products of the arachidonic pathway, interleukin-6, and the endotoxin-neutralizing capacity (ENC) of plasma during colonoscopy, we studied the gut barrier function and the pathogenetic sequelae of mediator release during a minimally invasive procedure. PATIENTS AND METHODS: Thirty-two patients were enrolled in a controlled prospective study. Endotoxin and ENC were determined by a chromogenic modification of the limulus amebocyte lysate test. Prostanoids and interleukin-6 were measured using commercially available ELISA tests. C-reactive protein levels were checked by nephelometry. RESULTS: Twenty-one of the 32 patients had elevated endotoxin plasma levels during colonoscopy. In one patient, gut-derived bacteria were detected in plasma. ENC decreased after 5 min, and thromboxane B2 levels also started to increase at that time. No acute-phase response took place after 24 h. CONCLUSION: During colonoscopy, endotoxin can be detected in blood. ENC measurement was shown to be even more sensitive. The pathogenetic sequelae leading to gut barrier failure remain unclear, because mediator release and endotoxemia, as checked by ENC, took place simultaneously.
[Change in the surgical strategy in acute and complicated colonic diverticulitis].
The records of 312 patients with acute colonic diverticulitis were reviewed. 129 patients required an operation. The operative management is presented and compared to the international literature. One-stage resection was performed in 79% of all patients. In 84% of patients with a localized inflammation a one-stage resection was possible. Fifty-seven percent of patients with peritonitis due to colonic perforation required a multiple stage procedure. In 70% the preferred surgical procedure of multiple stage treatment was Hartmann's operation. These therapeutical regimens are current standard. Lethality was 1.6% for all 129 patients and the postoperative morbidity was 22%.
[Amputation of the rectum via laparoscopy].
We report the case of a 66-year-old woman with a bleeding adenocarcinoma of the lower thirty of the rectum. The laparoscopic procedure was initiated with mobilization of the sigmoid colon. The left ureter was identified as it crosses the left iliac vessels. The peritoneum along the right side of the rectosigmoid mesentery was transected. The superior rectal artery was divided utilizing extracorporeal ligatures. The anterior rectum was separated from the uterus, the pararectal tissue was mobilized, the middle rectal arteries were ligated and the posterior rectum was dissected from the presacral tissue. The perineal component of the procedure was simultaneously performed. The sigmoid loop was extracorporeally transected with a linear stapler. The proximal sigmoid end was exteriorized through the colostomy site (site of the left superior port). The distal sigmoid end was replaced in the abdominal cavity and was grasped through the perineal wound; the anus, rectum and sigmoid were removed through the perineal wound. The feasibility of this procedure has been well established. However, it seems to be an alternative for the classical abdominoperineal resection as treatment for adenocarcinoma of the lower rectum. His superiority has yet to be confirmed by future studies.
[Primary solid tumors of the mesentery].
The interest for the primary solid tumors of the mesentery (TSPM) is justified by the difficulties of preoperative diagnosis and surgical treatment of these unusual lesions. We analyzed 68 TSPM operated in the Department of General Surgery of Fundeni Hospital between 1960-1993. In the study were included only the lymphoma presented as mesenteric masses (n = 17); the enlarged mesenteric lymph nodes were excluded. The most common malignant tumor was the fibroma (n = 8) and lipoma (n = 10). In the resection of mesenteric tumors exposure of the superior mesenteric vessels is important. The relation between tumoral and superior mesenteric vessels is the necessary criterion of resectability: in 41 cases from 43 unresectable lesions the reason of unresectability was the invasion of the superior mesenteric vein and artery; in only two cases the reason was the presence of liver metastases. The resectability was not influenced by the multiplicity of the lesions: in all cases with multiple mesenteric tumors (6 patients) the resection was performed. The distant metastases of TSPM are rare; on the contrary, the local invasion is common.
[Echographic and radiological comparisons in biliary pathology].
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Charcot-Marie-tooth syndrome associated with cerebello-extrapyramidal manifestations in a patient with tomaculous neuropathy.
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[Truncal vagotomy with antrectomy in the surgical treatment of ulcerous pyloroduodenal stenosis].
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Valproic acid in Isaacs-Mertens syndrome.
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Muscle hypertrophy and a syndrome of continuous motor unit activity in prednisone-responsive Guillain-Barré polyneuropathy.
The clinical, electrophysiological and morphological findings (light and electron microscopy of the sural nerve and gastrocnemius muscle) are reported in an unusual case of Guillain-Barré polyneuropathy with an association of muscle hypertrophy and a syndrome of continuous motor unit activity. Fasciculation, muscle stiffness, cramps, myokymia, impaired muscle relaxation and percussion myotonia, with their electromyographic accompaniments, were abolished by peripheral nerve blocking, carbamazepine, valproic acid or prednisone therapy. Muscle hypertrophy, which was confirmed by morphometric data, diminished 2 months after the beginning of prednisone therapy. Electrophysiological and nerve biopsy findings revealed a mixed process of axonal degeneration and segmental demyelination. Muscle biopsy specimen showed a marked predominance and hypertrophy of type-I fibres and atrophy, especially of type-II fibres.
Neuronal type of Charcot-Marie-Tooth disease with a syndrome of continuous motor unit activity.
The clinical, genetic and electrophysiological study of 3 patients with an association of a neuronal form of Charcot-Marie-Tooth Disease (CMTD) with a syndrome of continuous motor unit activity (CMUA) are reported, with light and electron microscopy of muscle and sural nerve biopsies in 2 patients. The unusual clinical features of CMTD were associated with fasciculation, cramps, myokymia, impaired muscular relaxation and percussion myotonia with their electromyographic (EMG) correspondent, responsive to valproic acid (VPA) therapy. In Case 3, an important muscle hypertrophy which was confirmed by morphometric data, was noted in addition. Nerve biopsy and electrophysiological findings indicated that axonal degeneration with secondary demyelination and remyelination underlie the hereditary motor and sensory neuropathy (HMSN) in our patients. The hyperexcitability and hyperactivity of peripheral motor axons probably induced by the hereditary neuropathy may, in this instance, be the causative condition of the syndrome of CMUA in our patients.