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PubMed2001

The kinetics of leptin in Meigs' syndrome.

OBJECTIVE: The aim of this study was to assess the kinetics and possible role of leptin in the pathophysiology of Meigs' syndrome. METHODS: We report on a 62-year-old patient admitted for a large ovarian tumor, hydrothorax, and ascites. The patient underwent abdominal hysterectomy and bilateral adnexectomy revealing a benign ovarian fibroma and no evidence of malignant cells in the pleural or peritoneal fluids. Analysis of serum, peritoneal, and pleural fluids from this patient was performed before, during, and after the operation. RESULTS: Preoperatively, the patient had low levels of leptin in the serum, peritoneal, and pleural fluids. Serum levels increased after removal of the ovarian tumor along with the resolution of ascites and hydrothorax. CONCLUSION: Leptin levels inversely correlate to tumor burden, third space fluid accumulation, and clinical status in Meigs' syndrome. These findings suggest the involvement of leptin in the pathophysiology of this syndrome.

Ascitic Fluid↗
PubMed2003

Pseudo-Meigs' syndrome caused by ovarian metastasis from colon cancer: report of a case.

We report an extremely rare case of pseudo-Meigs' syndrome caused by ovarian metastases from colon cancer, and review the literature on this unusual entity. A 41-year-old woman was admitted for investigation of abdominal fullness and dyspnea. Preoperative examinations revealed a huge pelvic tumor, adenocarcinoma of the sigmoid colon, marked ascites, and bilateral pleural effusion. Laparotomy confirmed that the huge mass was comprised of bilateral ovarian tumors. Resection of the sigmoid colon and bilateral oophorectomies were performed. Although short-term intrathoracic drainage was required, the hydrothorax and ascites rapidly resolved in the postoperative period. The patient died of disseminated liver and bone metastases 8 months after her operation; however, ascites and hydrothorax were not clinically noted until death. This and five other reported cases demonstrate that ovarian metastasis from colorectal cancer may occasionally cause pseudo-Meigs' syndrome, and that resection of the ovarian lesions could improve the prognosis.

Adult↗
PubMed1987

Single-dose and multiple-dose intravenous toxicity studies of BMY-25282 in rats.

Single-dose and multiple-dose (daily X 5 and weekly X 5) intravenous toxicity studies in rats were conducted to determine the possible acute and delayed toxicity of BMY-25282 (7-N-(dimethylaminomethylene) mitomycin C), a potential anticancer drug. Rats in the single-dose study received either 0.05, 0.25, or 0.50 mg/kg (0.3, 1.5, or 3.0 mg/m2) of BMY-25282; rats in the daily X 5 multiple-dose study received doses of 0.005, 0.025, or 0.050 mg/kg (0.03, 0.15, and 0.3 mg/m2) of BMY-25282 once each day for 5 days; and rats in the weekly X 5 multiple-dose study received 0.05 mg/kg of BMY-25282. All doses were in 0.1% Pluronic F-68 diluent. Acute toxicities included gastrointestinal epithelial necrosis, myelosuppression, and splenic lymphoid depletion in the high and intermediate dose groups in the single-dose study and myelosuppression in the high dose group of the daily X 5 multiple-dose study. One death in a high dose male of the single-dose study was attributed to acute gastrointestinal and lymphoid toxicity. Between the interim necropsy on Day 5 or 9 and termination of the 9-week dose-free observation period, 9/20 rats of the high and intermediate dose groups of the single-dose study and 4/10 high dose rats in the daily X 5 multiple-dose study died, primarily due to hydrothorax and congestive heart failure caused by delayed, drug-related myocardial degeneration. The most prominent drug-related histopathologic changes observed in rats of both the single-dose study and the daily X 5 studies were myocardial degeneration (cardiomyopathy), glomerulopathy with tubular degeneration, and necrotizing arteritis. These three changes, observed at 0.5 and 0.25 mg/kg in the single-dose study and at 0.05 mg/kg/day in the multiple-dose (daily X 5) study, were delayed in onset and irreversible. Drug-related tubular degeneration and slight glomerulopathy were observed in male BMY-25282-treated rats in the weekly X 5 study, but cardiotoxicity, pulmonary arteritis, hydrothorax, and lethality were not observed. The diluent, Pluronic F-68, was not associated with any morphologic or clinico-pathologic changes. A single-dose of 0.05 mg/kg or 5 daily doses of 0.025 and 0.005 mg/kg of BMY-25282 were considered nontoxic doses in rats. A cumulative dose of 0.25 mg/kg, which caused cardiotoxicity in the daily X 5 study, was not cardiotoxic in the weekly X 5 study. These results indicate that the delayed cardiotoxicity of BMY-25282 is schedule dependent.

Animals↗
PubMed2003

Longitudinal observation of antenatally detected congenital lung malformations (CLM): natural history, clinical outcome and long-term follow-up.

OBJECTIVE: The objective of the study is to present longitudinal observations in antenatally detected congenital lung malformations (CLM), particularly pulmonary sequestration (PS) and cystic adenomatoid malformation (CAM). METHODS: Fetuses found to have a CLM on prenatal ultrasound (US) were included in this study and followed up until delivery. In all newborns radiographs and computerized tomography (CT) studies of the thorax were performed. Surgical procedures included sequesterectomy, lobectomy, segmentectomy, and non-anatomic resection. Based on prenatal US findings, intrauterine course, postpartum chest radiographs and CT scans, as well as clinical signs and surgical findings patients were divided into six groups. RESULTS: Over a period of 6 years, routine prenatal US revealed suggestion of CLM in a series of 35 consecutive fetuses. In six cases pregnancy was terminated or the fetuses suffered fetal demise. Another four fetuses became symptomatic in utero when sequential scanning revealed hydrops, hydrothorax, and enlargement of cysts or polyhydramnios. Three cases in this group received serial therapeutic amniocentesis and serial puncture of either the hydrothorax or intrapulmonary cysts. After postpartum treatment in the intensive care unit surgical procedures were performed uneventfully and confirmed the diagnosis of CAM, PS or hybrid type lesions. In 11 patients US findings were considered to demonstrate spontaneous resolution of the lesion, but disappearance without sequelae could be confirmed only in six infants. Five infants were shown to have persistent CLM on postpartum CT scans. These infants underwent resection of the lesion within the first year of life. In 11 fetuses CLM were continuously demonstrated during pregnancy with only slight changes in size and structure. Postpartum the infants were asymptomatic and were subjected to a systematic plan of diagnostic work-up and treatment. Surgery in these infants revealed a large number of hybrid type lesions (n=5). In three infants, the primary diagnosis of PS or CAM had to be corrected during the diagnostic and therapeutic work-up. CONCLUSION: CLM are diagnosed antenatally with an increasing frequency and are shown to be quite different from previously applied concepts. The expected clinical outcome is far better than thought to be possible.

Abortion, Legal↗
PubMed2002

The role of inflammatory cytokines in Meigs' syndrome.

BACKGROUND: Inflammatory cytokines are known to induce capillary leakage and third-space fluid accumulation in numerous gynecologic and nongynecologic disorders. This study aimed to assess their role in Meigs' syndrome. CASE: Evaluation of serum, peritoneal, and pleural fluids retrieved from a patient suffering from Meigs' syndrome revealed high interleukin (IL)-1beta, IL-6, IL-8, and tumor necrosis factor (TNF)-alpha levels. After surgical removal of the ovarian tumor and with resolution of ascites and hydrothorax, serum levels of IL-1beta, IL-6, and IL-8 declined, whereas tumor necrosis factor-alpha levels remained high. CONCLUSION: The correlation between these inflammatory cytokines and the clinical course of Meigs' syndrome suggests their involvement in the formation of ascites and hydrothorax in this disorder.

Cytokines↗
PubMed1999

Fetal pulmonary sequestration: a favorable congenital lung lesion.

OBJECTIVE: We reviewed the perinatal clinical course of prenatally diagnosed pulmonary sequestrations to determine the natural history of this anomaly. METHODS: From January 1992 to August 1998, 192 women were referred to the University of California, San Francisco, Fetal Treatment Center because obstetric ultrasound had demonstrated fetal lung lesions. In 14 fetuses, the echogenic lung masses were pulmonary sequestrations deriving arterial blood supply from clearly identifiable systemic arteries rather than the pulmonary artery. We examined records of the 14 fetuses and documented the location of the lesion, gestational age at diagnosis, need for fetal intervention, prenatal and postnatal complications, gestational age at delivery, and survival. RESULTS: There were 16 intrathoracic pulmonary sequestrations in 14 fetuses (eight left-sided, four right-sided, two bilateral). Three fetuses had histologically mixed lesions (congenital cystic adenomatoid malformation and pulmonary sequestration). The mean age at diagnosis was 23 weeks' gestation (range 19-31 weeks). Two fetuses required prenatal intervention (placement of a thoracoamniotic shunt for drainage of an ipsilateral tension hydrothorax). The mean gestational age at delivery was 37 weeks (range 32-40 weeks). The large lesions of four fetuses regressed completely prior to birth, and the lesions of the remaining ten fetuses were electively resected after birth without causing morbidity or mortality. CONCLUSION: Pulmonary sequestrations are a subgroup of congenital lung lesions with a favorable outlook; many regress prenatally, and the persistent ones are resected safely postnatally. Pulmonary sequestrations cause hydrops only because of a tension hydrothorax, which can be drained prenatally, if necessary.

Algorithms↗
PubMed1999

Transjugular intrahepatic portosystemic shunt after adult liver transplantation: experience in eight patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunting (TIPS) has become an effective treatment for the complications of portal hypertension. We assessed the feasibility and outcome of TIPS in liver transplant recipients. METHODS: During the period from December 1992 to January 1998, eight adults presenting recurrent hepatitis C virus (five patients) and hepatitis B virus (one patient) infection, veno-occlusive disease (one patient), and secondary biliary cirrhosis (one patient) had TIPS because of refractory ascites (five patients), bleeding esophageal varices (one patient), refractory hepatic hydrothorax (one patient), retransplantation (two patients), and redo-biliary surgery (one patient). RESULTS: In two patients, the procedure was difficult due to cavo-caval implantation. Ascites, hydrothorax, and variceal bleeding were controlled in all patients. Moderate to severe encephalopathy developed in four patients; two patients had worsening of their existing encephalopathy. Three of five patients treated with cyclosporine needed a drastic dose reduction due to the development of severe side effects. No long-term survivor developed shunt stenosis or occlusion. Two patients did moderately well at 6 and 14 months, respectively; the former died due to chronic rejection while waiting for a retransplantation. Three did well at 14, 36, and 28 months, respectively; the latter patient died of liver failure 32 months after TIPS. One jaundiced patient died after 1.5 months due to necrotic pancreatitis. Two patients died after 4 and 8.5 months, respectively, due to liver failure; the latter was doing well until 7 months after TIPS. CONCLUSIONS: TIPS is feasible in transplant recipients in cases of decompensated allograft cirrhosis, of allograft veno-occlusive disease or when retransplantation or redo-biliary surgery are scheduled in the presence of portal hypertension. At transplantation, the surgeon should keep in mind the eventuality of a later TIPS procedure. Close immunosuppression monitoring is warranted because modified metabolization of cyclosporine (and probably tacrolimus) may cause serious side effects.

Adult↗
PubMed2005

Preoperative optimization of patients with liver disease.

PURPOSE OF REVIEW: Recent papers relevant to the preoperative evaluation and optimization of patients with severe liver disease will be discussed. The emphasis will be placed on cardiovascular, pulmonary, and renal complications. Other aspects such as preoperative management of hepatitis B and C, other infectious issues, and liver cancer will not be discussed because this rarely involves the anesthesiologist. RECENT FINDINGS: Dobutamine stress echocardiography has been the cornerstone of cardiac evaluation of liver transplant candidates. Combining liver transplantation with cardiac procedures has been shown to be feasible. While mild hepatopulmonary syndrome is well-tolerated, severe hepatopulmonary syndrome carries a fairly high mortality rate. New treatment modalities of severe portopulmonary hypertension have been introduced, and may have advantages over epoprostenol administration. Hepatic hydrothorax requires similar therapy to ascites [repeated thoracentesis or paracentesis, and transjugular intrahepatic portosystemic shunt (TIPS)], but refractory hydrothorax may require other interventions. Hepatorenal syndrome may improve by increasing renal blood flow through the use of vasoconstrictors (vasopressin, norepinephrine) in combination with albumin administration. Interventional radiologists can now change the flow through an established TIPS. Hepatic encephalopathy may result in some irreversible changes in the brain. It remains difficult to predict whether a patient with acute fulminant failure will recover spontaneously. Support devices that include hepatocytes show early promising results. The coagulation changes in living donors are incompletely understood. Finally, autonomic neuropathy as a complication of severe liver disease results in more hemodynamic instability. SUMMARY: Recent advances in preoperative evaluation and optimization are presented and discussed.

Journal Article↗
PubMed2005

Use of reagent strips for the rapid diagnosis of spontaneous bacterial empyema.

GOALS: To assess the utility of reagent strips for rapid diagnosis of spontaneous bacterial empyema in cirrhotic patients with hepatic hydrothorax. BACKGROUND: Analysis of ascitic fluid using reagent strips is a useful diagnostic test for spontaneous bacterial peritonitis. METHODS: A reagent strip for leukocyte esterase designed for the testing of urine was used to evaluate pleural fluid analysis in 47 nonselected thoracenteses in 28 cirrhotic patients with hepatic hydrothorax. RESULTS: Twelve spontaneous bacterial empyemas were diagnosed. Simultaneous spontaneous bacterial peritonitis was present in 7 of 10 cases in which ascites fluid was analyzed. When a test result of 3 or 4 was considered positive, sensitivity was 83% (10 of 12), specificity was 100% (35 of 35), and positive predictive value was 100%. When result of 2 or more was considered positive, sensitivity was 92% (11 of 12), specificity was 80% (28 of 35), and negative predictive value was 97%. CONCLUSION: Analysis of pleural fluid with reagent strips is a rapid, easy to use, and inexpensive tool for the diagnosis of spontaneous bacterial empyema in cirrhotic patients. A positive result should be considered an indication for antibiotic therapy.

Bacteria↗
PubMed2000

Severe hypoproteinemia in a fetus after pleuro-amniotic shunts with double-basket catheters for treatment of chylothorax.

The prognosis of a fetus with hydrothorax at mid-trimester is extremely poor. We encountered a fetus who developed bilateral chylothoraxes at 23 weeks of gestation. Bilateral pleuroamniotic shunts with double-basket catheters were successfully installed at 25 weeks of gestation. Hydrothorax did not recur in this fetus. After the shunting, however, polyhydroamnios, fetal hypoproteinemia, and placental edema developed, and the hydrops worsened. The drainage of the fetal pleural effusion into the amniotic cavity was believed to have contributed to these complications. The infant, born at 29 weeks of gestation, died of cardiac failure and pulmonary hypoplasia. Thus, the shunts did not ameliorate the adverse conditions in this patient.

Adult↗
PubMed1991

Effect of thoracic duct drainage on hydrostatic pulmonary edema and pleural effusion in sheep.

Positive end-expiratory pressure (PEEP) increases central venous pressure, which in turn impedes return of systemic and pulmonary lymph, thereby favoring formation of pulmonary edema with increased microvascular pressure. In these experiments we examined the effect of thoracic duct drainage on pulmonary edema and hydrothorax associated with PEEP and increased left atrial pressure in unanesthetized sheep. The sheep were connected via a tracheostomy to a ventilator that supplied 20 Torr PEEP. By inflation of a previously inserted intracardiac balloon, left atrial pressure was increased to 35 mmHg for 3 h. Pulmonary arterial, systemic arterial, and central venous pressure as well as thoracic duct lymph flow rate were continuously monitored, and the findings were compared with those in sheep without thoracic duct cannulation (controls). At the end of the experiment we determined the severity of pulmonary edema and the volume of pleural effusion. With PEEP and left atrial balloon insufflation, central venous and pulmonary arterial pressure were increased approximately threefold (P less than 0.05). In sheep with a thoracic duct fistula, pulmonary edema was less (extra-vascular fluid-to-blood-free dry weight ratio 4.8 +/- 1.0 vs. 6.1 +/- 1.0; P less than 0.05), and the volume of pleural effusion was reduced (2.0 +/- 2.9 vs. 11.3 +/- 9.6 ml; P less than 0.05). Our data signify that, in the presence of increased pulmonary microvascular pressure and PEEP, thoracic duct drainage reduces pulmonary edema and hydrothorax.

Animals↗
PubMed2004

Outcome analysis of cirrhotic patients undergoing chest tube placement.

OBJECTIVES: Patients with cirrhosis can acquire pulmonary conditions that may or may not be related to their illness. Although posing a greater risk for complications, chest tubes are sometimes placed as treatment for hepatic hydrothorax and other pulmonary conditions. The aim of this study was to analyze the outcomes of chest tube placement in cirrhotic patients. METHODS: A retrospective analysis was performed of 59 adults with cirrhosis undergoing chest tube placement. Variables that were investigated included reason for chest tube placement, complications developing while having the tube in place, and outcome. RESULTS: The 59 subjects were classified as having Child-Turcotte-Pugh (CTP) class A cirrhosis (n = 3), CTP class B cirrhosis (n = 31), and CTP class C cirrhosis (n = 25). Indications for having a chest tube placed were hepatic hydrothorax (n = 24), pneumothorax (n = 9), empyema (n = 8), video-assisted thoracoscopy (VAT) [n = 7], non-VAT (n = 5), and hemothorax (n = 3). The CTP class A subjects had their chest tubes removed without further complications early in the course, and were excluded from further statistical analysis. Twenty-five subjects (42%) had significant pleural effusions requiring chest tube placement. Among the CTP class B and class C subjects, the median duration with chest tube in place was 5.0 days (range, 1 to 53 days). Serum total bilirubin levels, presence of portosystemic encephalopathy, and CTP C classification were predictors of mortality. Mortalities were seen in 5 of 31 CTP class B subjects (16%), and 10 of 25 CTP class C subjects (40%). The tubes were successfully removed in a total of 39 subjects (66%) with no further procedure. Forty-seven subjects (80%) acquired one or more of the following complications: renal dysfunction, electrolyte imbalances, and infection. CONCLUSIONS: When placed for all indications, chest tubes may be successfully removed in the majority of cirrhotic patients. However, a third of all patients still die with the chest tube still in place. Failure to remove the chest tube increases mortality in patients with increasing severity of liver disease.

Chest Tubes↗
PubMed1989

Interleukin-2 induced systemic toxicity: induction of mediators and immunopharmacologic intervention.

Interleukin-2 has been tested as an anti-cancer agent, either alone or in combination with immune cells, but severe dose limiting adverse toxic effects have been observed. Because the pathogenesis of the toxicity has remained uncharacterized, it has not been possible to determine whether the therapeutic and the toxic events could be separated. We have examined immunopharmacologic regulation of IL2 induced mediator induction and toxicity syndrome and have compared this data with our earlier information on IL2 enhancement of immune function in murine systems. The results of this study have shown that treatment with recombinant human interleukin-2 induced increased cellular TNF activity in lymphoid organs and this activity was abrogated by an anti-TNF antibody. Additionally, continuous daily treatment with interleukin-2 also induced increases in serum corticosterone but no detectable increases in serum IL1 or TNF. The increases in serum corticosterone occurred later in the treatment process and coincided with histopathologic changes in the adrenal glands and other tissues. Animals that died as a result of IL2 treatment had ascites and hydrothorax. Histopathologic changes were noted in the lungs, liver, adrenals, kidneys, gastrointestinal tract, heart and lymphoid organs. Cyclophosphamide, dexamethasone and anti-ASGM1 antibody were most effective in increasing survival and inhibiting immune enhancement but differentially effective in inhibiting TNF induction (or in certain cases gamma interferon induction), decreasing ascites or hydrothorax or affecting lymphoid proliferation in the lungs and spleen. Cyclosporin A and azathioprine were not as effective in enhancing survival and had differential effects on the other parameters. Possible mechanisms of both therapeutic and toxic events are discussed.

Adrenal Glands↗
PubMed1999

[Meigs' syndrome with high blood levels of CA 125. Clinical case and review of the literatureø].

A case of Meigs' syndrome is reported. The patient presented with: hydrothorax, ascites, benign ovarian tumor (thecoma) and increased serum levels of CA 125. Ovarian thecoma is a rare tumor, accounting for less than 1% of all ovarian tumors. When associated with Meigs' syndrome, it can produce a clinical picture similar to that of ovarian carcinoma, but the prognosis is much more favourable. The condition was managed by bilateral salpingo-oophorectomy and hysterectomy. The ascites and hydrothorax disappeared spontaneously after removal of the ovarian tumor and CA 125 level decreased.

CA-125 Antigen↗
PubMed2000

[Pseudo-Meigs' syndrome].

Cytologic examination of the body cavity effusions in patients with ovarian tumours is performed to differentiate between reactive processes and tumour spread. While detection of malignant cells is a marker of metastatic disease and a sign of bad prognosis, benign effusions affect neither disease stage nor the patient's prognosis. Determination of the presence or absence of tumour spread is based primarily on cellular morphology. As distinction between reactive mesothelial and cancer cells can be difficult, immunocytochemistry may be employed in equivocal cases. The case of a 42-year-old woman who presented with a large pelvic mass accompanied by ascites and hydrothorax is described. Cytomorphology of preoperative pleural fluid specimen was inconclusive. Immunocytochemical examination of cell block sections using: BerEP4, B72.3, CA 125, CD15, CEA, E-cadherin and calretinin was done. No epithelial cells were detected and diagnosis of reactive mesothelial cells was made. Laparotomy was performed and adnexal tumour removed. Borderline mucinous tumour of the ovary was diagnosed. There was no recurrence of the ascites or hydrothorax. The clinicopathologic features and terminology of pseudo-Meigs' syndrome are briefly reviewed. The role of ancillary studies in diagnosis of body cavity effusions is emphasized.

Adult↗
PubMed1989

Meigs' syndrome--a case report.

Bilateral ovarian fibromas combined with as and hydrothorax is a rare disorder. A case of bilateral ovarian fibromas combined with ascites and hyrothorax is presented. The ascites and hydrothorax disappeared spontaneously after removal of the ovarian tumors.

Aged↗
PubMed1988

Pneumomediastinum on a surgical service.

Mediastinal emphysema results from multiple etiologies and is associated with a variety of underlying disease entities. Twenty five patients with pneumomediastinum treated on a surgical service over a 6 year period were reviewed. The cause of the mediastinal emphysema was related to trauma in seven patients, attempted central venous access in four patients, cardiopulmonary resuscitation in four patients and some type of Valsalva maneuver in ten patients. Besides the mediastinal emphysema, air may dissect into the peritoneal cavity, the pericardium, and the subcutaneous tissues within the neck and chest wall. Treatment of the mediastinal emphysema, per se, is expectant; success or failure is determined by treatment of the associated underlying problems. Deaths occurred in three patients after cardiopulmonary resuscitation and in one patient after crushing chest injury. One patient with an associated hydrothorax was found to have a perforated distal esophagus which was treated by emergency fundoplication. When associated diseases are absent and there is no evidence of pleural effusion or hydrothorax, no special diagnostic tests are indicated. Sequential chest x-rays are used to follow the pneumomediastinum through resolution, which usually occurs within 72 hours.

Adult↗
PubMed1986

[Surface activity of the surfactant in experimental compression atelectasis].

Surface surfactant activity was studied at different time periods of compression atelectasis, induced by hydrothorax in 35 guinea pigs. The animals were slaughtered 30 and 60 minutes or 3, 12 and 24 hours after hydrothorax. It has been demonstrated that experimental compression atelectasis is accompanied by surface activity lowering, associated with disorders in surfactant secretion into the alveolar lumen. The qualitative composition of surfactant phospholipids remains unchanged, which may play an essential role in the recovery of lung tissue aeration.

Animals↗