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Herand Abcarian

Publications and source records attributed to Herand Abcarian.

17 recordsLinked to original sources
PubMed2007

Richter's hernia through a Spigelian defect of the abdominal wall.

A 78-year-old healthy woman with no previous surgeries or history of trauma presented with a painful abdominal mass for 1 day. The computed tomography (CT) scan of the abdomen demonstrated a partial herniation and strangulation of the cecum (Richter's hernia) between the internal and external oblique muscles through the linea semilunaris (Spigelian hernia). The challenging clinical diagnosis of Spigelian hernias and their surgical treatment options are discussed.

Aged↗
PubMed2006

Living related segmental bowel transplantation: from experimental to standardized procedure.

INTRODUCTION: Living donor bowel transplantation has recently emerged as a valuable alternative to cadaver bowel transplant. We herein present our single-center experience with this procedure. MATERIALS AND METHODS: From April 1998 to October 2004, 12 living donor intestinal transplants were performed in 11 patients (7 males, 4 females; average age, 26 years). Four of the patients were children under 5 years. A segment of distal ileum 150 to 180 cm long in pediatric recipients and 200 cm long in adult was used. The immunosuppressive protocol consisted of induction with thymoglobulin and maintenance with tacrolimus with or without mycophenolate mofetil and steroids. RESULTS: All donors recovered well and did not experience any early or late complications. The overall 1- and 3-year patient survival was 82% with a graft survival of 75%. In the last 8 patients, transplanted after January 2000, the 1-year patient and graft survival has been 100% and 88%, respectively. The median hospital stay was 36 days (range, 13-290 days). During the first year after transplant only, the patient who received a totally mismatched graft experienced one episode of rejection (8%). All the surviving patients are currently supported by enteral diet without fluid requirements. CONCLUSIONS: Living donor bowel transplantation is a valuable strategy in the treatment of irreversible intestinal failure. The results have improved over the years thanks to increased experience of the team.

Adult↗
PubMed2006

Successful identical-twin living donor small bowel transplant for necrotizing enterovasculitis secondary to Churg-Strauss syndrome.

Churg-Strauss syndrome (CSS) is a granulomatous small-vessel vasculitis with unknown etiology. Extra-pulmonary manifestations of CSS are currently treated with a combination of steroids and Cyclophosphamide. Its gastrointestinal complications may be devastating, occasionally requiring extensive bowel resection resulting in short-gut syndrome. Living-related small bowel transplantation (LRSBTx) is a relatively standardized procedure that, not only represents a valid alternative to cadaver bowel transplant in selected cases, but also portraits excellent results when performed in experienced centers. The availability of an identical twin as a donor, which allows avoidance of immunosuppressive therapy, is a major indication for this procedure. We present the case of a young individual affected by gastrointestinal necrotizing vasculitis that lost almost his entire small bowel requiring the immediate institution of total parenteral nutrition (TPN). However, within few weeks a significant hepatic dysfunction ensued. An identical twin-brother, not affected with CSS, became an immediate, optimal donor-candidate for LRSBTx, the first of this kind in a patient affected with CSS. Following the procedure, two main concerns were addressed: the recipient's ability to recover a regular intestinal function without immunosuppression and the possible recurrence of the primary disease. Twenty-seven months post-transplant, the patient enjoys a regular lifestyle without any clinical, endoscopic and histologic evidences of recurrent disease in the transplanted graft.

Adult↗
PubMed2005

Combined living donor liver/small bowel transplantation.

We are reporting the first known case of sequential combined living donor liver/small bowel transplantation (LDL/SBT). A 2-year-old boy born with gastroschisis and intestinal malrotation lost his entire small bowel and colon shortly after birth. He underwent a living donor small bowel transplant at 1 year of age that was lost 4 months after implantation for posttransplant lymphoproliferative disease (PTLD). He recovered from PTLD but developed total parenteral nutrition (TPN)-induced liver failure. He received a combined left lateral liver and terminal ileum transplant that we chose to perform sequentially due to the presence of preformed antibodies against his mother's tissues. The mother had no complications and a cumulative hospital stay of 7 days. At 9 months postsurgery, the patient is on full enteral nutrition and has suffered neither technical complications nor rejection. The technique described here is reproducible and makes combined living donor LDL/SBT an alternative to combined cadaveric liver-small bowel transplant.

Child, Preschool↗
PubMed2005

Short-term outcomes with small intestinal submucosa for ventral abdominal hernia.

HYPOTHESIS: A bioabsorbable tissue scaffold of porcine submucosal small intestine extracellular matrix (Surgisis Gold [SIS]; Cook Biotech Inc, West Lafayette, Ind) mesh is safe and effective for ventral hernia repair. DESIGN: Retrospective case series at a university teaching hospital. PATIENTS: Fifty-three consecutive patients having 8-ply SIS mesh repair of ventral abdominal hernias. MAIN OUTCOME MEASURES: Early complications, reoperation, hernia recurrence, mesh or wound infection, or reaction. Outcomes reported and compared on an intention-to-treat basis. RESULTS: Patients were stratified by wound class: clean, clean-contaminated and contaminated, or dirty. Median follow-up was 14 months (range, 2-29 months) during which there were 22 complications (41%), 17 early reoperations (32%), 13 partial dehiscences (21%), 6 mesh reactions (11%), and 9 recurrent hernias (17%). Seven recurrent hernias (78%) in critically ill, patients with dirty wounds had the SIS mesh removed owing to infection or reoperation. In patients without SIS mesh removal or debridement, 1 (2.2%) of 44 developed a recurrent hernia at 6 months. Patients with dirty wounds were more likely to need early reoperation (P<.001), develop a complication (P<.01), partial wound dehiscence (P<.05), or recurrent hernia (P<.01) compared with patients with clean wounds. Critically ill patients were more likely to have hernia recurrence (P<.05), early reoperation (P<.001), and postoperative complications (P<.05). CONCLUSIONS: Eight-ply SIS mesh is safe in clean and clean-contaminated hernia repair with satisfactory short-term outcomes. However, delayed wound infection, repeated operation, and mesh debridement warrant cautious use of SIS mesh in critically ill patients and those with dirty wounds.

Critical Illness↗
PubMed2005

Treatment of fistulas-in-ano with fibrin sealant in combination with intra-adhesive antibiotics and/or surgical closure of the internal fistula opening.

PURPOSE: The treatment of fistulas-in-ano with fibrin sealant injection has been moderately successful. Failures can be caused by persistent infection within the tract or early expulsion of the clot. In an attempt to improve the success rate, we examined three modifications of the sealant procedure: the addition of cefoxitin to the sealant, surgical closure of the primary opening, or both. METHODS: A prospective, randomized, clinical trial was performed in which patients were treated with Tisseel-VH fibrin sealant according to previously published procedures. In addition, patients were randomized to receive intra-adhesive cefoxitin, surgical closure of the primary opening, or both modifications. Cefoxitin, 100 mg, was added to the sealant for patients randomized to receive intra-adhesive antibiotics. For the appropriate patients, the primary fistula opening was closed with a 3-0 absorbable suture. If fistulas failed to heal, patients were offered a single retreatment with sealant. RESULTS: Twenty-four patients were treated in the cefoxitin arm, 25 in the closure arm, and 26 in the combined arm. Median duration of fistulas was 12 months. Patients were followed for a mean of 27 months postoperatively. There was no postoperative incontinence or complications related to the sealant itself. Initial healing rates were 21 percent in the cefoxitin arm, 40 percent in the closure arm, and 31 percent in the combined arm (P = 0.35). One of five patients in the cefoxitin arm, one of seven patients in the closure arm, and one of six patients in the combined arm were successfully retreated; final healing rates were 25, 44, and 35 percent respectively (P = 0.38). CONCLUSIONS: Treatment of fistula-in-ano with fibrin sealant with closure of the internal opening was somewhat more successful than sealant with cefoxitin or the combination, however this did not achieve statistical significance. None of the three modifications were more successful than historic controls at our institution treated with sealant alone. Therefore, the addition of intra-adhesive cefoxitin, closure of the internal opening, or both are not recommended modifications of the fibrin sealant procedure.

Adult↗
PubMed2004

Living related small bowel transplantation: donor surgical technique.

OBJECTIVE: To describe a standardized technique for ileal graft procurement in the setting of living related bowel transplantation. SUMMARY BACKGROUND DATA: Living donor transplantation has been successfully developed for kidney, liver, pancreas, and lung transplantation. More recently, living related small bowel transplantation (LR-SBTx) has been developed with the aim of expanding the pool of intestinal graft donors and reducing the mortality in patients on the waiting list. To date, a total of 25 LR-SBTx worldwide have been reported to the international registry. We herein report the largest single center experience. METHODS: A segment of ileum, 150 to 200 cm, is resected 20 cm proximal to the ileocecal valve (ICV), which is always preserved. The arterial inflow is given by the terminal branch of the superior mesenteric artery and venous outflow by a proximal segment of the superior mesenteric vein. The entire bowel is measured intraoperatively and at least 60% of intestine length is left in the donor. RESULTS: Since 1998, we have performed 9 terminal ileum resections for small bowel donation. None of the donors has experienced persistent alteration of bowel habits or malabsorption; only 1 minor wound complication has occurred. CONCLUSIONS: Terminal ileal resection with preservation of the ICV seems to assure fast functional recovery of the donor and has minimal postoperative complications.

Adult↗
PubMed2004

Successful treatment of trauma-induced short bowel syndrome with early living related bowel transplantation.

BACKGROUND: : Total parenteral nutrition (TPN) is a life-saving therapy for patients with short bowel syndrome. However, TPN is associated with a high incidence of serious complications, poor quality of life, and elevated cost. An attempt was made to avoid TPN-related complications associated with trauma-induced short bowel syndrome by using early living related donor bowel transplantation. METHODS: : Three men 27 to 30 years of age with trauma-induced short bowel syndrome received early living related donor bowel transplantation using segmental ileal grafts. RESULTS: : All the donors had an uncomplicated postoperative course. After a mean follow-up period of 40 months, all three recipients were alive and well, and did not require any TPN support. The ileal graft adapted perfectly to support fully the nutritional needs of young, active individuals. CONCLUSIONS: : Early living related donor bowel transplantation is a successful treatment for trauma-induced short bowel syndrome. It is associated with a lower incidence of complications, better quality of life, and lower cost than long-term TPN.

Abdominal Injuries↗
PubMed2004

Hand-sewn versus stapled intestinal anastomoses in a chronically steroid-treated porcine model.

Chronic steroid treatment is known to delay wound healing; however, there are no trials examining stapled intestinal anastomoses in subjects chronically treated with steroids. The current study compares mechanically stapled to manually sutured intestinal anastomoses in a steroid-treated porcine model. Twenty adult male pigs were treated with daily prednisolone (0.5 mg/kg IM) for 14 days. The pigs were divided between hand-sewn and stapled groups. All pigs underwent a laparotomy with construction of a jejunojejunostomy, an ileocecostomy, and a colocolostomy. Pigs were sacrificed on postoperative day 4. Bursting pressure, collagen content, and inflammatory scores were used to evaluate each anastomosis. Bursting pressure was greater for the hand-sewn group at the jejunojejunostomies only (1.52 vs 0.79 psi; P < 0.001). The collagen content and microscopic inflammatory scores were not significantly different at any location. The mean gross inflammatory score was greater for the hand-sewn colocolostomies only (5.20 vs 4.00; P < 0.01). Stapled ileocecostomies and colocolostomies appear to heal as well as hand-sewn anastomoses. This may not be true of the jejunojejunostomies as evidenced by the decreased bursting pressures. These data may provide evidence in support of the use of stapled anastomoses in steroid-treated patients.

Animals↗
PubMed2003

Muscle fragment welding for control of massive presacral bleeding during rectal mobilization: a review of eight cases.

INTRODUCTION: Although massive presacral bleeding during rectal mobilization is uncommon, it can rapidly destabilize a patient. Traditional attempts at control include tamponade with pelvic packing and application of sacral thumbtacks. The aim of this review is to describe the anatomic basis of injury and summarize our experience with this challenging problem, with emphasis on the simple, readily available, effective technique of rectus abdominis muscle fragment welding. METHODS: A retrospective review of eight patients who underwent muscle fragment welding for presacral bleeding incurred during rectal mobilization was undertaken. This technique involves harvesting a small piece of rectus abdominis muscle, which is held in place with a forceps to occlude the bleeding site. Electrocautery adjusted to the highest setting is then applied to the forceps to "weld" closed the bleeding point. RESULTS: Control of presacral bleeding was achieved in all eight patients (3 males) with this technique without complications attributable to this method. Previous attempts at pelvic packing failed in all eight patients. CONCLUSION: Muscle fragment welding is a safe, readily available, and highly effective method of controlling massive presacral bleeding.

Abdominal Muscles↗
PubMed2003

Retrorectal cyst: a rare tumor frequently misdiagnosed.

BACKGROUND: The rarity of retrorectal cysts and their nonspecific clinical presentations often lead to misdiagnoses and inappropriate operations. In recent years, several such patients have been referred to our institutions for evaluation and treatment of misdiagnosed retrorectal cysts. A review of these patients is presented. STUDY DESIGN: Medical records of the colorectal surgery divisions at two institutions were reviewed. Patients found to have previously misdiagnosed retrorectal cysts were identified. Preliminary diagnoses, radiologic examinations, operative procedures, and final diagnoses were obtained. RESULTS: Seven patients with retrorectal cysts who had been misdiagnosed before referral were identified. These patients had been treated for fistulae in ano, pilonidal cysts, perianal abscesses; psychogenic, lower back, posttraumatic, or postpartum pain, and proctalgia fugax before the correct diagnosis was made. Patients underwent an average of 4.1 operative procedures. Physical examination in combination with CT scanning made the correct diagnosis in all patients. All patients underwent successful resection through a parasacrococcygeal approach, and six of seven did not require coccygectomy. The resected tumors included four hamartomas, two epidermoid cysts, and one enteric duplication cyst. CONCLUSIONS: Retrorectal cysts are a rare entity that can be difficult to diagnose without a high index of clinical suspicion. A history of multiple unsuccessful procedures should alert the clinician to the diagnosis of retrorectal cyst. Once suspected, the correct diagnosis can be made with physical examination and a CT scan before a definitive surgical procedure.

Abscess↗
PubMed2003

Surgical approaches and intestinal transplantation.

The surgical treatment of short-bowel syndrome has been traditionally based on the correction of mechanical obstruction, which is responsible for bacterial overgrowth syndrome, or on intestinal expansion procedures. Since the introduction of clinical intestinal transplantation by Lillehei in 1964, there have been remarkable advances in the immunosuppressive regimens to control rejection and in preservation techniques, monitoring and critical care. Newer and more powerful immunosuppressants have helped to transform intestinal transplantation into a clinical reality-transplantation can now be a life-saving procedure for patients with intestinal failure. It is currently indicated in the event of life-threatening complications of an underlying disease or from total parenteral nutrition (TPN). Rehabilitation in successful cases is excellent.

Algorithms↗
PubMed2003

Virtual reality: new method of teaching anorectal and pelvic floor anatomy.

PURPOSE: A clear understanding of the intricate spatial relationships among the structures of the pelvic floor, rectum, and anal canal is essential for the treatment of numerous pathologic conditions. Virtual-reality technology allows improved visualization of three-dimensional structures over conventional media because it supports stereoscopic-vision, viewer-centered perspective, large angles of view, and interactivity. We describe a novel virtual reality-based model designed to teach anorectal and pelvic floor anatomy, pathology, and surgery. METHODS: A static physical model depicting the pelvic floor and anorectum was created and digitized at 1-mm intervals in a CT scanner. Multiple software programs were used along with endoscopic images to generate a realistic interactive computer model, which was designed to be viewed on a networked, interactive, virtual-reality display (CAVE or ImmersaDesk). A standard examination of ten basic anorectal and pelvic floor anatomy questions was administered to third-year (n = 6) and fourth-year (n = 7) surgical residents. A workshop using the Virtual Pelvic Floor Model was then given, and the standard examination was readministered so that it was possible to evaluate the effectiveness of the Digital Pelvic Floor Model as an educational instrument. RESULTS: Training on the Virtual Pelvic Floor Model produced substantial improvements in the overall average test scores for the two groups, with an overall increase of 41 percent (P = 0.001) and 21 percent (P = 0.0007) for third-year and fourth-year residents, respectively. Resident evaluations after the workshop also confirmed the effectiveness of understanding pelvic anatomy using the Virtual Pelvic Floor Model. CONCLUSION: This model provides an innovative interactive educational framework that allows educators to overcome some of the barriers to teaching surgical and endoscopic principles based on understanding highly complex three-dimensional anatomy. Using this collaborative, shared virtual-reality environment, teachers and students can interact from locations world-wide to manipulate the components of this model to achieve the educational goals of this project along with the potential for virtual surgery.

Anal Canal↗
PubMed2002

Superselective mesenteric embolization with microcoils in a porcine model.

PURPOSE: There is a lack of data regarding the degree of ischemic change that may occur in small and large bowel after superselective arterial embolotherapy with platinum microcoils. The purpose of this study was to gain a clearer understanding of the ischemic complications of superselective embolization of peripheral mesenteric arteries with microcoils by gross and histologic examination of postembolectomy bowel specimens at several time intervals in an adult porcine model. METHODS: Two-millimeter platinum microcoils with fibrils were superselectively deployed into six isolated mesenteric branch vessels in each of nine adult pigs. The animals were observed for two days (n = 3), one month (n = 3), or three months (n = 3) and then killed. At necropsy, intestines were examined for gross abnormalities. Sections of bowel containing microcoils were identified under fluoroscopy, resected, and evaluated histologically. RESULTS: A total of 54 microcoils were deployed into the distal arterial mesentery supplying the jejunum (n = 14), ileum (n = 26), and colon (n = 14) of nine adult pigs. Each animal received six microcoils. There were no clinical complications, and all pigs gained weight during their observation periods. Gross examination of the intestines did not reveal any evidence of acute or chronic ischemia. The coils were found in the distal arterial vasculature of the intestine. Histologic examination revealed mild superficial necrosis of villous tips in several samples; however, this finding is likely related to a fixation artifact rather than ischemic injury. There was no other histologic evidence suggestive of ischemic injury. CONCLUSIONS: Gross and histologic findings after superselective arterial embolotherapy demonstrated minimal changes in the bowel, and there were no significant clinical consequences to the animals. We conclude that transcatheter arterial embolotherapy in pigs is safe and may be applicable in the control of massive lower gastrointestinal hemorrhage in humans.

Angiography↗
PubMed2002

Early experience with stapled hemorrhoidectomy in the United States.

INTRODUCTION: We report the early results of patients treated with stapled hemorrhoidectomy, which has recently been introduced into the United States. METHODS: Sixty-eight patients with symptomatic hemorrhoids were treated at two institutions with the Proximate HCS Hemorrhoidal Circular Stapler supplied by Ethicon Endo-Surgery. Patients were prospectively evaluated for functional recovery and postoperative pain on a 1 to 10 scale. RESULTS: There were 45 (66 percent) males and 23 (34 percent) females with a mean age of 56 years and median duration of symptoms of 5 years. The mean operative time was 22.2 minutes. The operation was performed with spinal (50 percent), local (40 percent), or general (10 percent) anesthesia and as an outpatient (56 percent) or overnight admission (44 percent). Ninety-three percent of patients remained asymptomatic with a mean follow-up of 34 weeks, whereas the remaining 7 percent required either surgical excision or rubber band ligation for persistent symptoms. There was no mortality, new incontinence, fecal impaction, or persistent pain. The total morbidity was 19 percent, with urinary retention as the most common complication (12 percent). The mean pain score decreased from 3.6 on postoperative Day 1 to 1.4 at postoperative Day 7. Ninety-nine percent of patients made a complete functional recovery by postoperative Day 7. CONCLUSIONS: Stapled hemorrhoidectomy is safe, effective, and can be performed as an outpatient procedure with local or regional anesthesia. There seems to be minimal postoperative pain and early recovery, although a benefit over traditional hemorrhoidectomy needs to be proven in a randomized trial.

Adult↗