Julian Willner

Glomerular endotheliosis in normal pregnancy and pre‐eclampsia

Objective To investigate the proportion of women with findings characteristic for pre‐eclampsia, as opposed to renal disease, in a controlled study of hypertensive pregnant women undergoing antepartum renal biopsy.

Dose-volume relationships between enteritis and irradiated bowel volumes during 5-fluorouracil and oxaliplatin based chemoradiotherapy in locally advanced rectal cancer.

Purpose. Radiation enteritis is the main acute side-effect during pelvic irradiation. The aim of this study was to quantify the dose-volume relationship between irradiated bowel volumes and acute enteritis during combined chemoradiotherapy for rectal cancer. Material and methods. Twenty-eight patients with locally advanced rectal cancer received chemoradiotherapy. The radiation therapy was given with a traditional multi-field technique to a total dose of 50 Gy, with concurrent 5-Fluorouracil (5-FU) and oxaliplatin (OXA) based chemotherapy. All patients underwent three-dimensional CT-based treatment planning. Individual loops of small and large bowel as well as a volume defined as “whole abdomen” were systematically contoured on each CT slice, and dose-volume histograms were generated. Diarrhea during treatment was scored retrospectively according to the NCI Common Toxicity Criteria scale. Results. There was a strong correlation between the occurrence of grade 2+diarrhea and irradiated small bowel volume, most notably at doses >15 Gy. Neither irradiated large bowel volume, nor irradiated “whole abdomen” volume correlated significantly with diarrhea. Clinical or treatment related factors such as age, gender, hypertension, previous surgery, enterostomy, or dose fractionation (1.8 vs. 2.0 Gy/fraction) did not correlate with grade 2+diarrhea. Discussion. This study indicates a strong dose-volume relationship between small bowel volume and radiation enteritis during 5-FU-OXA-based chemoradiotherapy. These findings support the application of maneuvers to minimize small bowel irradiation, such as using a “belly board” or the use of IMRT technique aiming at keeping the small bowel volume receiving more than 15 Gy under 150 cc.

Serum cystatin C reflects glomerular endotheliosis in normal, hypertensive and pre‐eclamptic pregnancies

Objective To study the correlation between serum cystatin C levels and renal structural changes in normal, hypertensive and pre‐eclamptic pregnancy to evaluate it as a marker of the degree of renal involvement in pre‐eclampsia.

Percutaneous cholecystostomy: A bridge to surgery or definite management of acute cholecystitis in high-risk patients?

Objective. Cholecystectomy is the standard treatment for acute cholecystitis, but in high-risk patients with serious comorbidity and in patients of advanced age there is substantial morbidity and mortality associated with the intervention. In these selected patients, percutaneous cholecystostomy (PCS) is an alternative mode of management. The aim of the present study was to evaluate the outcome of PCS in selected patients with acute cholecystitis. Material and methods. Thirty-five patients, representing 0.6% of all acute cholecystitis patients managed during the period 1994–2003, were subjected to PCS. Patients’ charts were reviewed retrospectively for age, gender, comorbidity, hospital stay, procedure, complications and final outcome, including requirement of additional interventions. Results. PCS was considered successful in 34/35 patients, 26 of whom responded within 3 days. Two patients required additional cholecystectomy 3 days and 20 months, respectively, after the PCS procedure. Two patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and one patient underwent rotation lithotripsy. Four patients suffered recurrent biliary complaints after the acute episode of cholecystitis, while the only serious procedure-related complication was bile leakage from the gallbladder in one patient, which necessitated cholecystectomy. Conclusions. PCS is a comparatively safe and efficient procedure in the treatment of acute cholecystitis in high-risk patients with serious comorbidity and in elderly patients, contraindicating the general anaesthesia required for laparoscopic or open cholecystectomy.

Antepartum percutaneous renal biopsy

Objective: To assess the value and adverse effects of an ultrasound‐guided renal biopsy technique in women with normal and pathologic pregnancies. Method: Biopsy samples were taken from 36 women with hypertensive disease (28 with pre‐eclampsia) and 18 healthy pregnant women using a thin needle and an ultrasound‐guided biopsy device. Results: Glomerular endotheliosis, a structural change typical of pre‐eclampsia, was found in all hypertensive women, but it was more pronounced in the 28 pre‐eclamptic women than in the 8 women with nonproteinuric hypertension. A similar change, however, was seen in 11 of the 18 controls. One serious adverse event occurred, retroperitoneal hematoma, in the woman with the most severe pre‐eclampsia. Conclusion: Glomerular endotheliosis is not to be considered pathognomonic for pre‐eclampsia. Few complications followed renal biopsy in this study, but complications arose in the sickest patient. It is probably not advisable to perform antepartum renal biopsies in pregnant women with a rapidly deteriorating renal function and swollen kidneys. In these women, the biopsy does not facilitate diagnosis and is hazardous.

Treatment and outcome in pancreatic pseudocysts

Objective. Pancreatic pseudocyst is a common complication of both acute and chronic pancreatitis. The aim of the present study was to evaluate the efficacy and complications of different treatment regimens. Material and methods. All patients ≥15 years of age admitted to Lund University Hospital from 1994 to 2003 with pancreatic pseudocysts were analysed retrospectively. Pseudocysts were defined according to the Atlanta classification. Results. Forty-four patients (29 M (66%), mean age 55±14 years) were included in the study, and all were subjected to treatment on 88 occasions. Mean size of pseudocysts at diagnosis was 9.6±6.8 cm (1.5–40 cm). Recurrence after treatment was 1.0±1.1 times (range 0–4). No difference was found in recurrence rate or pseudocyst size when comparing conservative versus interventional treatment, but patient weight was higher (p=0.013) and acute pancreatitis was more frequent (p=0.046) in conservatively treated patients. Surgical treatment tended to be associated with a lower recurrence rate as compared with percutaneous treatments. The rate of hospital admissions was a median 3 (0–16) and median length of stay (LOS) was 12 days (0–141 days). Six patients (14%) had complications and 3 died (7%). Pseudocysts ≥8 cm did not differ significantly from smaller pseudocysts regarding the choice of conservative treatment, LOS, recurrence and gastrointestinal obstruction, but there was a trend towards more complications in the group with larger pseudocysts (5 versus 1). Conclusions. Patients with pancreatic pseudocysts require frequent hospital admissions and repeated treatments. Larger pseudocysts do not imply more recurrences. The lowest recurrence rate overall was seen after open surgery.

Perforated peptic duodenal ulcer in a paraesophageal hernia--a case report of a rare surgical emergency.

BackgroundParaesophageal hernias are quite common and sometimes feared due to the risk of incarceration and strangulation of any herniated organ. The hereby reported combination of an incarcerated paraesophageal hernia containing a perforated peptic ulcer is extremely rare.Case presentationAn elderly man with multiple medical conditions was admitted due to severe upper abdominal pain. The patient was found to have a paraesophageal hernia and underwent a laparotomy. In the hernia, a perforated benign peptic duodenal ulcer was found. The duodenal defect was over-sewn, the hernial defect was closed and the former hernial cavity was drained by a right-sided chest tube. The patient was discharged one month after surgery and was found to do well at follow-up one month after discharge.ConclusionThis is the first report of a patient surviving the extremely rare and life-threatening combination of a perforated peptic duodenal ulcer in a paraesophageal hernia.

Antepartum Percutaneous Renal Biopsy

Percutaneous needle biopsy of the kidney has long been the definitive means of determining the cause of hypertension in pregnant women, even though its safety remains controversial. Diagnosing underlying renal disease might appropriately postpone delivery, whereas preeclampsia (PE) might indicate for immediate delivery. This study evaluated ultrasound-guided thin-needle renal biopsy in 36 women with hypertensive disease (but a diastolic blood pressure no higher than 105 mm Hg and a blood platelet count of no less than 100 X 10 9 /liter) and 18 healthy pregnant women. The former group included 28 women with PE and 8 with nonproteinuric hypertension. PE was rated as severe in 13 women at the time of biopsy. The same highly experienced physician did all biopsies following a standardized procedure. Glomerular endotheliosis-a structural condition typical of PE-was found in all hypertensive women but was more marked in those with PE. Similar changes were observed in 11 of the 18 nonhypertensive women. Discomfort from the biopsy procedure was most often minor; 3 women described loin pain. One woman had a rim of blood about the lower kidney but recovered fully within 2 days. The patient with the most marked glomerular changes had severe pain and was found to have a retroperitoneal hematoma and 2 small bleeding arteries. She recovered well following arterial embolization with metal coils and emergency cesarean delivery. Few complications of note followed thin-needle renal biopsy in this study, but complications can occur and glomerular endotheliosis is not pathognomonic for PE. It probably is best not to do an antepartum renal biopsy when renal function is deteriorating rapidly and the kidneys are swollen. If biopsy is mandatory, an ultrasonographically guided procedure should be performed by a skilled and experienced practitioner.