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Biomedical subjects

E W Fonkalsrud

Publications and source records attributed to E W Fonkalsrud.

At least 19 recordsLinked to original sources
PubMed1999

Repair of pectus excavatum and carinatum in adults.

BACKGROUND: There is sparse published information regarding the repair of pectus chest deformities in adults. This report summarizes our clinical experience with the surgical repair of pectus excavatum and carinatum deformities in 25 adults. METHODS: During the past 11 years, 25 patients 20 years of age or older (mean 31) with symptomatic pectus excavatum (23) or carinatum (2) deformities underwent surgical repair using a temporary internal sternal support bar. RESULTS: Each of the patients with decreased stamina and endurance or dyspnea with exercise experienced marked clinical improvement within 4 months postoperation. Exercise-induced asthma was improved in 6 of 7 patients; chest pain was reduced in each of 9 patients. Postoperative complications included pneumothorax (1), keloid (2), and discomfort from sternal bar (2). The sternal bar was removed 7 to 10 months postoperation in 19 patients; there has been no return of preoperative symptoms or recurrent depression in any patient with a mean follow-up of 4.8 years. CONCLUSIONS: For adults who have symptoms and activity limitations related to uncorrected pectus chest deformities, surgical repair can be performed with low morbidity, low cost, minimal limitation in activity, and a high frequency of symptomatic improvement. The operation in adults is more difficult than in children, although the results are similar.

Adult↗
PubMed1999

Antireflux surgery in children under 3 months of age.

PURPOSE: The aim of this study was to analyze the indications and results of fundoplication in 110 infants under 3 months of age. METHODS: A retrospective review was conducted on the charts of all infants operated on for gastroesophageal reflux disease (GERD) at the UCLA Medical Center from January 1980 to December 1997. There were 59 boys and 51 girls. Recurrent emesis was the indication for operation in 62 of 110 infants, and respiratory symptoms in 85 of 110, with 54 of 110 having both. Neurological impairment was present in 32%. Prematurity was present in 21%; 35% had associated anomalies. Overall, 81 of 110 infants (73.6%) had one or more associated major malformations or disorders. Reflux was confirmed by upper gastrointestinal series findings in 63 of 78, esophageal pH monitoring in 60 of 62, and endoscopy in five of seven. RESULTS: Mean age at operation was 1.8+/-0.1 months and mean weight was 3,686+/-90.2 g. A Nissen fundoplication was performed on 104 children, and six underwent a Thal procedure. Thirty-one had a gastric emptying procedure for delayed gastric emptying. Complications occurred in 7 infants. Emesis was controlled in 57 of 62 patients, aspiration in 38 of 48, and apneic spells in 54 of 57. Follow-up greater than 6 months was available for 73 patients. There were nine late deaths, all related to severe associated malformations. Seven patients required a redo fundoplication for recurrent reflux. CONCLUSIONS: Nissen fundoplication can be performed safely in symptomatic infants under 3 months of age with low mortality and morbidity rates and with resolution of the presenting symptoms in 79% of infants.

Female↗
PubMed1999

Gastric emptying procedures decrease the risk of postoperative recurrent reflux in children with delayed gastric emptying.

PURPOSE: Although several centers often perform gastric emptying procedures (GEP) together with fundoplication for gastroesophageal reflux (GER) and delayed gastric emptying (DGE), the benefit of GEP is controversial. The present study addresses the question of whether adding a GEP in children with preoperatively diagnosed GER and DGE affects the recurrence rate of GER after Nissen fundoplication (NF). METHODS: A retrospective chart review was performed on all children under the age of 16 years, operated on for GER from 1980 to 1997, who had a preoperative diagnosis of DGE, and at least 6 months of follow-up. Gastric retention of more than 50% of a radiolabeled meal at 90 minutes was considered DGE. Recurrent reflux was defined as reappearance of GER symptoms, confirmed by postoperative esophagram or 24 hours of pH monitoring. RESULTS: Of the 183 patients with DGE, 92 were available for long-term follow-up. Of these, 20 had no gastric emptying procedure performed (no-GEP group) and 72 had a GEP performed together with an NF (GEP group). Groups were comparable as to age at operation, mean follow-up time, male to female ratio and prevalence of associated anomalies. A higher prevalence of neurological impairment (NI) was present in the GEP group (48.6% v20.0%). Mean preoperative gastric retention was significantly higher in the GEP group (69.9 +/- 1.3%) than in the no-GEP group (61.4 +/- 2.2%). No complications resulted from the GEP. Recurrent reflux rate was 18.1% in the GEP group (13 of 72) versus 35.0% (7 of 20) in the no-GEP group. Actuarial analysis disclosed a marginally significant difference in the rate of recurrent reflux between the groups (P = .057) and estimation of the relative risk showed a 1.94 increase of recurrent reflux risk in the no-GEP (0.89<RR<4.20). CONCLUSIONS: Children with DGE, who did not have GEP, had twice the frequency of recurrent reflux as those who had a GER Preoperative screening for DGE, as well as operative correction of DGE at the time of fundoplication, is therefore recommended.

Child, Preschool↗
PubMed1999

Reconstruction for chronic dysfunction of ileoanal pouches.

OBJECTIVE: A retrospective review was performed to determine the results after surgical reconstruction for chronic dysfunction of ileal pouch-anal procedures for ulcerative colitis and familial colonic polyposis at a university medical center. METHODS: During the 20-year period from 1978 to 1998, 601 patients underwent colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, familial colonic polyposis, or Hirschsprung's disease. A J pouch was used for 351 patients, a lateral pouch for 221, an S pouch for 6, and a straight pull-through for 23. Acute complications after pouch construction have been detailed in previous publications and are not included in this study. Chronic pouch stasis with diarrhea, frequency, urgency, and soiling gradually became more severe in 164 patients (27.3%), associated with pouch enlargement, an elongated efferent limb, and obstruction to pouch outflow, largely related to the pouch configuration used during the authors' early clinical experience. These patients were sufficiently symptomatic to be considered for reconstruction (mean 68 months after IPAA). Transanal resection of an elongated IPAA spout was performed on 58 patients; abdominoperineal mobilization of the pouch with resection and tapering of the lower end (AP reconstruction) and ileoanal anastomosis on 83; pouch removal and new pouch construction on 7; and conversion of a straight pull-through to a pouch on 16. RESULTS: Good long-term results (mean 7.7 years) with improvement in symptoms occurred in 98% of transanal resections, 91.5% of AP reconstructions, 86% of new pouch constructions, and 100% of conversions of a straight pull-through to a pouch. The average number of bowel movements per 24 hours at 6 months was 4.8. Complications occurred in 11.6% of reconstructed patients. Five of the 164 patients (3.1%) required eventual pouch removal and permanent ileostomy. The high rate of pouch revision in this series of patients undergoing IPAA is due to a policy of aggressive correction when patients do not experience an optimal functional result, or have a progressive worsening of their status. CONCLUSIONS: Although occasionally a major undertaking, reconstruction of ileoanal pouches with progressive dysfunction due to large size or a long efferent limb has resulted in marked improvement in intestinal function in >93% of patients and has reduced the need for late pouch removal.

Adolescent↗
PubMed1998

Long-term quantitative results following fundoplication and antroplasty for gastroesophageal reflux and delayed gastric emptying in children.

BACKGROUND: The operative management of children with combined gastroesophageal reflux and delayed gastric emptying is controversial. This study measures the long-term follow-up of gastric emptying in children who have undergone gastroesophageal fundoplication combined with antroplasty. METHODS: Fifteen randomly selected children with gastroesophageal reflux and scintigraphically demonstrated delayed gastric emptying underwent fundoplication and antroplasty. Each patient had another gastric emptying scintigraphic study performed an average of 3.6 years postoperation. RESULTS: All patients reported improvement of their symptoms compared with before the operation, and none required further medical therapy for gastroesophageal reflux or experienced dumping syndrome. Eleven of the 15 patients had significant long-term improvement of their gastric emptying postoperatively. The mean percent of isotope meal remaining in the stomach at 90 minutes improved from 72% preoperatively to 40% postoperatively (P = 0.0005). CONCLUSIONS: Gastric emptying in children with gastroesophageal reflux and delayed gastric emptying is significantly improved for several years in three-fourths of patients after fundoplication and antroplasty. Fundoplication and concomitant antroplasty are recommended for symptomatic children with documented gastroesophageal reflux and delayed gastric emptying.

Adolescent↗
PubMed1998

In vivo growth of transplanted genetically altered intestinal stem cells.

PURPOSE: Intestinal stem cell transplantation is a potential method of delivering genes to the small intestine. The authors have previously demonstrated the survival of transfected intestinal stem cells implanted into the rat small intestine. This study examines the growth of genetically altered intestinal stem cells that were grown on a polycarbonate membrane and implanted into the rat small intestine. METHODS: The IEC6 rat intestinal cell line serves as a model for intestinal stem cells. A subclone of the IEC6 cells was developed that stably expresses the lac Z gene introduced by a retroviral vector. The transfected cells were seeded at 500,000 cells/cm2 on a polycarbonate membrane. In 15 male Sprague-Dawley rats, a 0.75-cm enterotomy was created on the antimesenteric side of the small intestine 5 cm distal to the ligament of Treitz. A 0.5-cm2 segment of the membrane was sutured over the enterotomy with the cells facing away from the intestinal lumen. A segment of the omentum was wrapped around the patched enterotomy and sutured to the serosa. Three and 7 days after implantation, the implanted cells were retrieved, then fixed and stained with an X-gal solution. The number of cells was determined from the intensity of the X-gal staining. In five of the rats, frozen sections of the enterotomy sites were examined after staining with X-gal. RESULTS: All 15 rats survived the implantation procedure. Initially, 0.32 +/- 0.11 million cells were implanted. At both 3 and 7 days, the enterotomy site still contained viable transfected cells. The number of viable cells increased substantially to 1.52 +/- 0.46 and 3.52 +/- 1.87 million cells at 3 and seven days, respectively (P < .05). CONCLUSIONS: The polycarbonate membrane served as a good vehicle to efficiently deliver genetically altered intestinal stem cells to the small intestine. The transplanted cells continued to grow and stably expressed the gene product. This ex vivo approach to gene therapy has considerable therapeutic potential.

Animals↗
PubMed1998

The outcome of research training during surgical residency.

BACKGROUND/PURPOSE: The exposure to research during residency is currently an integral part of most academic surgical training programs. In this study, graduates of two surgical programs were surveyed to characterize their research experience and to determine the effects on their careers. METHODS: Between 1975 and 1990, 86 and 61 residents completed general surgical training programs at UCLA Medical Center and at Harbor-UCLA Medical Center, respectively. An anonymous survey was sent to each graduate regarding his research experience and current practice. RESULTS: Of the graduates who spent 2 years in research, 47% now hold academic positions, compared with 23% for those who spent less than 2 years (P = .18). When the graduates were segregated according to their desire to enter the laboratory, 49% of graduates who requested research time hold academic positions, whereas only 13% of those who would not request research are in academic positions (P = .01). CONCLUSIONS: Residents who strongly desire a period of research during surgical residency are also more productive in the laboratory. This information should be considered in selecting residents for research training in the current era of academic budget restriction and managed health care.

Attitude of Health Personnel↗
PubMed1998

Glucose uptake in dilated small intestine.

BACKGROUND/PURPOSE: The development of dilated small intestine in patients with short bowel syndrome results in increased mucosal surface area. This study examines whether the incremental increase in surface area leads to a proportional increase in absorptive function of the small intestine. METHODS: Partial obstruction of the small intestine was created in rats by placing an intussusception valve in the proximal jejunum. Rats that underwent sham operations served as controls. One week postoperatively, the small intestine proximal and distal to the valve was removed. The intestinal diameter proximal and distal to the obstruction was measured. The rate of glucose uptake was measured by the everted sleeve technique. The results were analyzed by analysis of variance (ANOVA). RESULTS: The intestine proximal to the valve was significantly dilated and thickened when compared with the intestine distal to the valve. The wet mass per centimeter of the dilated segment was 2.5 times that of the control group (P<.001). The glucose uptake capacity of the dilated segment was slightly higher than that of the control group (540 v 420 nmol/min/cm, P<.05). However, the specific glucose uptake rate was reduced significantly in the intestine proximal to the valve (247 v 335 nmol/min/cm2, P<.01). CONCLUSIONS: Although the partial obstruction of small intestine resulted in a substantial increase in the intestinal surface area, the absorptive capacity of the dilated intestine per unit surface area was decreased significantly. This translated ultimately into a slight increase in the overall functional absorptive capacity of glucose in the small intestine. These results suggest that dilated small intestine may not enhance mucosal absorption.

Analysis of Variance↗
PubMed1998

Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients.

OBJECTIVE: To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States. DESIGN: During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients. RESULTS: Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used. CONCLUSION: The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

Child↗
PubMed1998

Surgical ligation of patent ductus arteriosus in very low birth weight infants: is it safe?

We evaluated the outcome of a combined medical and surgical treatment of patent ductus arteriosus (PDA) in newborns weighing less than 1500 g. Charts were retrospectively reviewed for 76 newborns with a PDA between 1993 and 1997. Thirteen infants had pre-existing conditions prohibiting the use of indomethacin; eight were managed surgically, five medically. The remaining 63 infants received indomethacin therapy. Thirty-two medical failures occurred, requiring surgical ligation of the PDA. Those requiring surgery had a lower average birth weight (847 versus 997 g) and gestational age (26 versus 28 weeks; P < 0.05). Indomethacin treatment was successful in 27 infants. There were only three operative complications: a small pneumothorax, wound bleeding, and a small aortic tear. All recovered uneventfully and no deaths were attributable to the surgical procedure itself. There was no difference in the incidence of respiratory distress syndrome, duration of intubation, sepsis, neonatal enterocolitis, renal dysfunction, bleeding disorders, or intraventricular hemorrhage among both groups. Surgical ligation of a PDA is associated with a high success rate, a low incidence of complications, and no additional morbidity than indomethacin alone. We propose that surgical ligation should be regarded as a first line therapy for very small premature infants who are at higher risk of medical failure.

Ductus Arteriosus, Patent↗
PubMed1997

Epidermal growth factor selectively enhances functional enterocyte adaptation after massive small bowel resection.

After massive small bowel resection, the intestine adapts to compensate. In addition to proliferation, enterocytes also undergo selective functional adaptation. In this study we examined the effect of intraperitoneal administration of epidermal growth factor (EGF) on the expression of the brush border dissacharidase sucrase, the sodium glucose cotransporter (SGLT1), and the sodium-potassium ATPase pump (NaK ATPase) by enterocytes in the remnant intestine after massive small bowel resection. Adult Lewis rats underwent either ileal transection or 70% proximal intestinal resection. These animals were subdivided into groups that received either saline or EGF intraperitoneally for 1 week. Ilea from each group were harvested 4 weeks postoperatively. Enterocytes were separated from these segments by calcium chelation. The total protein from the isolated cells was subjected to Western blot analysis. Administration of EGF to animals that underwent transection did not significantly alter the expression of sucrase, SGLT1, or NaK ATPase. After intestinal resection, the expressions of sucrase and SGLT1 were significantly increased. The combination of EGF administration and intestinal resection resulted in a further increase in SGLT1 expression. The intraperitoneal administration of EGF selectively enhanced the expression of SGLT1 by enterocytes after massive small bowel resection. Administration of EGF to sham-operated animals did not have similar effects. These results suggest that EGF augments the adaptive response and may therefore have a therapeutic role in the management of patients with short bowel syndrome.

Adaptation, Physiological↗
PubMed1997

Improved survival of infants with omphalocele.

BACKGROUND: The surgical management of patients with omphalocele has evolved over the past 4 decades. Despite many improvements in care, the reported mortality has been over 10%. METHODS: This study reviewed the characteristics, management, and outcome of 31 patients with omphalocele who underwent surgical care between 1980 and 1995 at a single hospital. RESULTS: Twenty-five patients had additional congenital anomalies. All but 1 patient underwent operative repair; 13 of these patients with large defects had a silo chimney constructed initially. Fourteen patients underwent primary fascial and skin closure at the initial operation. Only 1 patient died perioperatively; another patient died without operation due to other major malformations. CONCLUSIONS: The results following surgical repair of omphalocele defects depend on the degree of visceroabdominal disproportion and on the severity of associated anomalies. The operative mortality for staged omphalocele repair with limited elevation of intraabdominal pressure is low, and the long-term quality of life of these patients is good.

Female↗
PubMed1997

Relationship of esophageal anastomotic tension to the development of gastroesophageal reflux.

BACKGROUND/PURPOSE: Gastroesophageal reflux (GER) is a common occurrence after repair of congenital esophageal atresia and is believed to be more frequent when the esophageal anastomosis is performed under tension. This study documents that esophageal anastomotic tension correlates directly with the severity of acid reflux into the esophagus in the rabbit model. METHODS: Eight adult rabbits underwent complete esophageal transection with immediate reanastomosis (EA) and 12 underwent resection of a 1-cm segment of the midesophagus with reanastomosis under mild tension (EAT). Three-weeks postoperation continuous lower esophageal pH (LEpH) values were recorded for a 24-hour period for each rabbit, and compared with five normal unoperated rabbits. RESULTS: The normal rabbit's average LEpH is 7.7. EA rabbits had LEpH values below 5.0 for a mean of 56 min/24 hr (3.8% of monitored time). EAT rabbits had LEpH values below 5.0 for a mean of 328 min/24 hr (25.5% of monitored time; P < .05). EA rabbits had a mean of 8.8 reflux episodes under 5.0/24 hr, whereas EAT rabbits had a mean of 29.6 reflux episodes under 5.0. All EAT rabbits had moderate to severe anastomotic strictures; no EA rabbits had strictures. There were no anastomotic leaks. CONCLUSIONS: Esophageal anastomosis with mild tension in the rabbit causes severe GER with resultant anastomotic strictures in almost all rabbits, in contrast to rabbits undergoing esophageal anastomosis without tension in whom strictures did not develop and had only small reduction in esophageal pH values.

Anastomosis, Surgical↗
PubMed1997

Combination of "patch, drain, and wait" and home total parenteral nutrition for midgut volvulus with massive ischemia/necrosis.

The successful use of a combination of "patch, drain, and wait" (PDW) and home total parenteral nutrition (TPN) in the management of a case of acute, catastrophic midgut volvulus in a 2-year-11-month-old boy with near-total ischemia/necrosis of his small intestine is reported. The PDW approach to the highly effective management of acute midgut ischemia/necrosis in infancy and childhood (necrotizing enterocolitis and midgut volvulus) involves maximum gut salvage by avoidance of resection, stoma formation, or both through the use of extensive peritoneal cavity drainage by Penrose drains, TPN, and broad-spectrum antibiotics. The extensive peritoneal drainage fosters capture of enteric fistulas with the formation of enterostomies at drain exit sites, while adhesions and ischemia/inflammation-induced hypervascular obliteration of the peritoneal cavity diminish the potential for peritonitis (no peritoneal cavity, no peritonitis) and facilitate impressive salvage of seemingly hopelessly lost ischemic/necrotic gut (a simulation of the in utero ischemic gut process leading to atresias and some varying, but generally mild, gut loss) while simultaneously contributing to the resorption of absolutely non-salvageable gut and the creation of a remarkably clean and adhesion-free peritoneal cavity resembling that of a newborn infant with midgut intestinal atresia.

Abdomen, Acute↗
PubMed1996

Long-term results after colectomy and ileoanal pull-through procedure in children.

OBJECTIVE: To review the clinical experience with colectomy and ileoanal pull-through procedure in children from 1 hospital. DESIGN: Since 1977, 116 children 18 years of age or younger underwent colectomy and ileoanal pull-through procedure at University of California-Los Angeles Medical Center. Ninety-four children had ulcerative colitis, 17 had familial polyposis coli, and 5 had Hirschsprung disease. Sixty-two children had a lateral pouch, 47 a J-pouch, and 7 a straight pull-through. A diverting ileostomy was used for 4 months for all patients except 9 with polyposis coli and 2 with Hirschsprung disease. During the same period, an additional 414 patients older than 18 years underwent the ileoanal pull-through procedure. RESULTS: Forty-eight children (41%) developed complications; the most common was pouchitis, which occurred in 18 patients with ulcerative colitis. Forty-two children underwent reoperation; 38 had ulcerative colitis. There were no deaths. Six children (5.2%) (3 with Crohn disease) required a permanent ileostomy. Six straight pull-throughs were converted to J-pouches because of stool frequency; 19 patients with lateral pouches underwent pouch reconstruction or spout resection because of stasis. With a mean follow-up of 7.1 years, 107 children (92.2%) were progressing well. CONCLUSIONS: Ulcerative colitis is a more severe disease in children. The ileoanal pull-through procedure is the preferred operation for children with ulcerative colitis, polyposis coli, and selected patients with Hirschsprung disease. The J-pouch is preferred because of simplicity of construction and scarcity of complications.

Adenomatous Polyposis Coli↗
PubMed1996

Delayed effects of epidermal growth factor after extensive small bowel resection.

Epidermal growth factor (EGF) is produced in the gastrointestinal tract and has been shown to have a transient stimulatory effect on mucosal growth and uptake of glutamine. This study investigated the delayed effects of EGF on mucosal brush-border membrane enzymes and glutamine uptake after extensive small bowel resection. Twenty-four New Zealand White rabbits underwent a 50% to 60% midjejunoileal enterectomy. One group of 12 had a subcutaneous osmotic pump inserted, delivering EGF at 0.3 microgram/kg/h for the first 7 postoperative days. The other group of 12 served as controls. Six rabbits from each group were killed at 3 weeks, and the remaining 12 were killed at 6 weeks. Six additional rabbits served asd nonsurgical controls. There was a twofold increase in mucosal dry weight at 3 weeks without EGF, and an almost fourfold increase with EGF, over control rabbits. This effect of EGF on the mucosa persisted for 6 weeks. Enzymatic activity per gram of protein in each group of rabbits was similar between the four groups of rabbits, although maltase activity increased approximately fourfold over that of nonoperative control animals. However, enzyme capacity of maltase and aminooligopeptidase (AOP) increased threefold and twofold (respectively) at 3 weeks without EGF, and sixfold and fourfold with EGF. Functional capacity is a measure of the load of nutrients that the intestine can digest and absorb, and therefore the derivable benefit to the animal. Glutamine uptake capacity increased 60% in 3 weeks without EGF, then declined by 6 weeks. However with EGF it increased 200% by 3 weeks, and further increased 400% by 6 weeks over control levels. The authors conclude that EGF markedly increases the functional capacity of the small intestine in rabbits that have undergone extensive small bowel resection; this effect persists for up to 6 weeks after a small initial dosage of EGF.

Animals↗