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PubMed2005

Clostridium difficile: an important pathogen of food animals.

Human Clostridium difficile-associated disease (CDAD) is of unquestioned importance in humans, and has been a not-uncommon cause of enteric disease in horses, dogs, and ratites. Over the past 5 years, C. difficile has emerged as a major cause of neonatal enteritis in pigs. Piglets 1-7 days of age are affected, with gross lesions frequently including mesocolonic edema. Colonic contents may be pasty-to-watery and yellow, although some piglets are constipated or obstipated. Focal suppuration and segmental necrosis are seen on microscopic examination of cecal and colonic lamina propria, and exudation of neutrophils and fibrin into the lumen gives rise to the so-called volcano lesions. Results of one study revealed that more than one-third of piglets with enteritis were affected by C. difficile alone, while an additional quarter of affected piglets may have had mixed infections. C. difficile may be the most important uncontrolled cause of neonatal diarrhea in pigs.

Animals↗
PubMed2004

Blunt trauma to the gastrointestinal tract and mesentery: is there a role for helical CT in the decision-making process?

The CT diagnosis of bowel and mesenteric injuries is difficult and warrants optimal technique and skilled interpretation. We retrospectively reviewed 36 consecutive patients with blunt traumatic injuries to the bowel and mesentery at our regional level I trauma center during the past 3 years. Physical examination, laboratory, Computed tomographic (CT), and intraoperative findings were compared. Surgically proven bowel injuries (13 cases) occurred in the duodenum (three cases), ileum (two cases), jejunum (two cases), colon (three cases), and stomach (three cases). CT findings considered specific of bowel rupture were observed in 5/13 patients including: extraluminal oral contrast or luminal content extravasation (four cases) and discontinuity of hollow viscus wall (one case). In the remaining 8/13 CT findings considered suggestive of bowel injury consisted of: pneumoperitoneum (six), gas bubbles close to the injured hollow viscus (three), thickened (>4-5mm) bowel wall (five), bowel wall hematoma (three), intraperitoneal fluid of unknown source (three). Mesenteric injury (23 cases) were surgically observed at the level of the mesenteric vessels (17 cases), legament of Treitz (two cases), gastro-duodenal artery (one case), transverse (one case) and sigmoid mesocolon (one case). CT finding considered specific of mesenteric laceration was active extravasation of contrast material from the mesenteric vessels (10 cases). CT findings suggestive of mesenteric injury (13 cases) consisted of: mesenteric hematoma (five) and/or high attenuation fluid collections, within the mesenteric root (eight) and folds (four). Helical CT is sensitive in the identification of bowel and mesenteric injury after blunt trauma providing a wide spectrum of findings. However, CT cannot be used as the sole indicator in cases with isolated thichened bowel wall, mesenteric hematoma, bowel hematoma, pneumoperitoneum or gas bubbles. Persistent, active extravasation of intravenous constrast medium from the mesenteric vessels, in isolation or associated with further injuries, requires immediate exploration and repair; disruption of bowel wall and extravasation of oral contrast are definite signs of bowel rupture. Close clinical observation, monitoring, and surgical expertise are mandatory for appropriate management.

Contrast Media↗
PubMed2005

Atypical complications of gastric bypass surgery.

Although gastric bypass surgery continues to grow in popularity for weight loss and weight maintenance in the morbidly obese, there has been little attention given to the imaging of complications associated with these surgeries. The purpose of our study is to demonstrate the variety of gastric bypass surgery complications that can be identified radiographically, with attention to the more unusual complications. This study was performed with institutional Internal Review Board approval. We performed a 5-year retrospective review of all patients who had undergone gastric bypass surgery, had complications of the surgery, and had studies performed in our department to image these complications. These studies consisted of contrast fluoroscopy and CT. We identified the more common complications of anastomotic stenoses and anastomotic leaks. We also identified six unusual complications as follow: (1) internal herniation through the small bowel mesentery, (2) internal herniation through the transverse mesocolon, (3) external herniation through the abdominal wall incision, (4) enterocutaneous fistulas, (5) antiperistaltic construction of the Roux-en-Y, and (6) incorrect anstomoses of the Roux limbs resulting in a Roux-en-O configuration. Our findings show that a thorough understanding of expected postoperative bowel configuration is essential in the evaluation of these patients. In addition, fluoroscopic evaluation should assess not only anatomy, but also motility.

Anastomosis, Roux-en-Y↗
PubMed2005

Systematic approach to the analysis of cross-sectional imaging for surveillance of recurrent colorectal cancer.

Recurrent disease in colorectal cancer occurs in approximately 50% of patients who undergo a "curative" operation. Tumor recurrence may occur locally (at the anastomotic site), in the mesentery or mesocolon adjacent to the post-operative site, in the nodal echelon downstream to the post-operative site, and as distant metastases to the peritoneal cavity, liver or lung. Local recurrence at the anastomosis is frequently diagnosed at follow-up endoscopic examinations as part of screening for metachronous lesions. Other types of recurrences require imaging studies, most frequently CT or MR imaging to diagnose. We developed an approach to analyze imaging obtained after curative resection of colorectal cancer. Our approach is based on the knowledge of patterns of disease spread, of types of surgical procedures and of pathologic staging. Using this approach has the potential to detect recurrent disease at an early stage because the locoregional and nodal spread of this disease is predictable. Early diagnosis of recurrent disease, even in asymptomatic cases, allows for more effective treatment that can improve the long-term survival of these patients.

Colorectal Neoplasms↗
PubMed2006

Spontaneous rupture of choledochal cyst with pseudocyst formation-report on 2 cases and literature review.

Spontaneous rupture and subsequent bile peritonitis are rare complications of choledochal cysts. Of these complications, the formation of a biliary pseudocyst is an unusual form, and its preoperative diagnosis is difficult. In this report, we describe 2 cases showing spontaneous rupture with biliary pseudocyst formation. Inflammatory tissue surrounded those pseudocysts, one of which was adjacent to the perforation and the other formed in the transverse mesocolon apart from the biliary tract. These pseudocysts were removed by careful dissection, and single-stage cyst excision with biliary reconstruction was successfully performed in both cases.

Anastomosis, Roux-en-Y↗
PubMed2005

A new periparturient disease in Eastern Europe, Clostridium difficile causes postparturient sow losses.

Postparturient sow losses caused by Clostridium difficile have not been reported in the veterinary literature. Recently in Croatia, in a large outdoor production unit with suboptimal environmental conditions, a sudden increase in postparturient sow mortality was diagnosed. After postpartal application of enrofloxacine to postparturient mastitis metritis agalactia (MMA) suffering sows, diarrhea, respiratory distress, and mortality of these sows were recorded. While 13% of MMA suffering and treated sows died, only 0.4% of the non-treated (no MMA suffering) sows died postpartum. Gross pathology revealed mesocolonic edema, hydrothorax, and ascites. Microscopic examination showed scattered foci of suppuration in the colonic lamina propria and accumulation of neutrophils and fibrin on colonic mucosa. Anaerobic cultures of the colon yielded heavy growth of C. difficile. Enzyme immunoassay revealed C. difficile toxins A and B. C. difficile infections of postparturient MMA suffering sows may be associated with environmental stress, the application of antibiotics, or both. C. difficile infections are an impending danger in Eastern Europe and does not only raise animal welfare issues, but seriously inflict the economical well being of outdoor production units.

Animals↗
PubMed1998

[Laparoscopic resection of the colon for adenocarcinoma. Report of a series of 218 cases].

STUDY AIM: The aim of this retrospective study was to report the results of a series of 218 laparoscopic resections for adenocarcinoma of the colon by the same surgical team over a 6-year period. PATIENTS AND METHODS: Laparoscopic procedures included, for the right and the left colon, at first a ligature of the vascular pedicles, secondarily a dissection of the mesocolons, and were almost identical to the conventional procedures. A conversion to open laparotomy was necessary in 8.3% of the patients. Among 218 patients, there were 117 men and 101 women; the mean age was 69 years. Twenty nine per cent of the patients had already undergone open laparotomy. Mean ASA grade was 2.1. An emergency operation was necessary for 9% of the patients in relation with colonic obstruction (n = 20) or peritonitis (n = 3). RESULTS: Colonic resections were considered curative in 180 patients (82.6%). The mean duration of surgery was 157 minutes for the right colectomies and 148 for the left. The proportion of A, B, C, D Dukes stage tumours was respectively 19.3%, 38.5%, 27.5% and 14.7%. There was one post-operative death related to a serious epileptic seizure due to unknown cerebral metastases. The morbidity rate was 5.5% and the early reintervention rate 2.8%. There was no lost to follow-up. With a mean 35-month follow-up. 82.2% of the patients were alive after curative surgery. Abdominal wall recurrence at port sites occurred in four patients operated on for a Dukes C cancer before 1994. Prognosis was significantly dependent on cellular differentiation, lymph node extension, pericolic extension and Dukes stage. The 5-year actuarial survival rate, according to Kaplan-Meier method was 65.36%. CONCLUSION: Laparoscopic colon cancer resection was used by the authors in 92% of patients during 1997. The conversion rate to open laparotomy has been lower than 5% since 1995. Post-operative mortality was 0.4% and post-operative morbidity 5.5%. After curative colonic cancer resection, the 5-year actuarial survival rate was 65%.

Adenocarcinoma↗
PubMed2001

Laparoscopic repair of superior mesenteric artery syndrome.

BACKGROUND: Superior mesenteric artery syndrome is duodenal obstruction by the superior mesenteric artery. It is caused by decreasing the angle between the aorta and superior mesenteric artery causing compression of the third part of the duodenum and usually occurs after a period of weight loss. METHODS: Between September 1999 and April 2000, 2 patients with superior mesenteric artery syndrome were treated laparoscopically. The laparoscope was placed in the umbilicus; the surgeon operated through two trochars on the left side of the abdomen, and an assistant retracted through one trochar on the right side of the abdomen. The dilated duodenum was seen below the transverse mesocolon and to the right of the superior mesenteric artery. A proximal loop of jejunum was anastamosed to the duodenum using the endoscopic gastrointestinal anastomotic (GIA) stapler. RESULTS: Average operating time was 113 minutes and average hospital length of stay was 3 days. There were no complications and both patients were pleased with their results. CONCLUSIONS: Laparoscopic duodenojejunal bypass is feasible with laparoscopic techniques. The operating time is acceptable and the postoperative length of stay is short.

Adult↗
PubMed2001

Outcome of extra-anatomic vascular reconstruction in orthotopic liver transplantation.

BACKGROUND: Portal venous and hepatic arterial reconstruction are critical to successful outcomes in orthotopic liver transplantation (OLT). With portal vein thrombosis or inadequate hepatic arterial inflow, extra-anatomic vascular reconstruction is required. However, the clinical outcomes following extra-anatomic vascular reconstruction are largely unknown. METHODS: To determine the outcomes associated with extra-anatomic vascular reconstruction, we performed a retrospective review of 205 OLT recipients transplanted between 1995 and 2000. RESULTS: Extra-anatomic portal venous inflow was based upon the recipient superior mesenteric vein using donor iliac vein graft in a retrogastric position (n = 12). Extra-anatomic arterial inflow was based on recipient infrarenal aorta using donor iliac artery graft through the transverse mesocolon (n = 25). OLT with routine anatomic vascular construction served as control (n = 168). Extra-anatomic vascular reconstruction was not associated with increased morbidity, mortality, operating room time, length of stay, or thrombosis. CONCLUSION: We conclude that extra-anatomic vascular conduits are associated with excellent long-term outcomes and provide acceptable alternatives for vascular reconstruction in OLT.

Female↗
PubMed2001

Omental transposition for low pelvic anastomoses.

Surgeons' opinions differ regarding the role of the omentum in low pelvic intestinal anastomoses. This study was undertaken to define the anatomy and surgical technique of omental transposition to the pelvis. We studied 45 cadavers to elucidate surgical aspects of omental mobilization, lengthening, and transposition into the pelvic cavity. In addition, intraoperative studies of omental transposition to the pelvis were performed in 20 patients with chronic ulcerative colitis, familial adenomatous polyposis, and rectal cancer who were undergoing ileal J-pouch anal anastomosis or low anterior resection. The most important anatomic variables for omental transposition are three variants of arterial blood supply: (1) In 56% of patients, there is one right, one (or two) middle, and one left omental artery. (2) In 26% of patients, the middle omental artery is absent. (3) In the remaining 18% of patients, the gastroepiploic artery is continued as a left omental artery but with various smaller connections to the right or middle omental artery. The first stage of omental lengthening is detachment of the omentum from the transverse colon mesentery. This must be performed carefully, as the omentum is closely adherent to the right transverse mesocolon. The second stage is the actual lengthening of the omentum. The third stage is placement of the omental flap into the pelvis. Creation of an omental pedicle is a simple surgical procedure. This procedure can be performed quickly, does not involve significant blood loss, and may reduce the frequency of complications after low pelvic anastomoses.

Adolescent↗
PubMed2003

Midline laparotomy and right retroperitoneal dissection is an alternative exposure for routine aortic surgery.

BACKGROUND: In most atlases of vascular surgery, laparotomy and right retroperitoneal dissection with reflection of the right colon and a wide Kocher maneuver is either briefly described as an alternative exposure for the abdominal aorta under special circumstances or not described at all. This approach offers certain advantages over the two more commonly described and widely used exposures, however, and should be considered for use in both routine and complex cases. The author reports his experience with the use of midline laparotomy and right retroperitoneal dissection (MLRRD) for elective aortic operations. METHODS: Review of 100 consecutive abdominal aortic operations by the author was performed. During this period, the author changed from using a standard approach of midline retroperitoneal incision below the transverse mesocolon for routine aortic surgery to using MLRRD as the exposure of choice for routine aortic surgery. Measured outcomes included operative time, complications, perioperative blood transfusions, and length of hospital stay. RESULTS: Outcomes were equivalent between the two approaches. CONCLUSIONS: Use of MLRRD results in no significant difference in outcomes compared with the standard infracolic aortic approach and affords unique advantages. Surgeons may wish to routinely consider this alternative exposure of the abdominal aorta.

Aorta, Abdominal↗
PubMed1985

Endoscopic decompression in partial small bowel obstruction.

Upper gastrointestinal endoscopy has been applied successfully in the management of patients with small bowel obstruction. In one group of patients after gastrectomy with a Roux-Y limb obstructed at the level of the transverse mesocolon, the endoscope was manipulated into this segment, and the tip was deflected in four directions with release of the kink. Conventional wisdom depends heavily on the interpretation of the upper gastrointestinal series, which in all five patients in this report proved to be incorrect. It was only through the endoscopic examination that the anastomoses were found to be patent, and the kinked segment of jejunum, once identified, could be released by endoscopic manipulation. Two patients required repeat endoscopy, and at last follow-up, all patients were eating well with no recurrence of symptoms. In the second group of patients with distal small bowel obstruction who normally would be considered for Miller-Abbott tube management, it was possible to decompress the stomach, duodenum, and upper jejunum endoscopically with immediate clinical and radiographic improvement. In addition, it was also possible to place the Miller-Abbott tube into the small bowel at the same time and thus avoid the 2 to 3 days of delay in advancing the tube beyond the pylorus. All patients had improvement and there were no complications. Although two required laparotomy several weeks later, they too were improved by the endoscopic procedures. The immediate decompression and rapid intubation represent significant advances in the management of patients with small bowel obstruction.

Aged↗
PubMed1998

The effects of hyperbaric oxygen on normal and ischemic colon anastomoses.

BACKGROUND: Leakage from colonic anastomoses is a major complication causing increased mortality and morbidity, and ischemia is a well-known cause of this event. Inadequate tissue oxygenation could be reversed by using hyperbaric oxygen. This study was designed to investigate the effects of hyperbaric oxygen on the healing of ischemic and normal colon anastomoses in the rat model. METHODS: Standardized left colon resection 3 cm above the peritoneal reflection and colonic anastomosis were performed in 40 Wistar rats divided into four groups. The control group (I) received no further treatment. To mimic ischemia, 2 cm mesocolon was ligated on either site of the anastomosis in group II and IV rats. Hyperbaric oxygen therapy was started immediately after surgery in group III and IV rats (therapeutic groups). All animals were sacrificed on the fourth postoperative day. After careful relaparotomy, in situ bursting pressure was measured. The hydroxyproline contents of the anastomotic segments in equal length were determined. RESULTS: The hydroxyproline assay revealed that rats in group II with ischemic colonic anastomosis have significantly lower levels (P <0.05). The highest levels are in the group III rats with normal colonic anastomosis treated by hyperbaric oxygen (P <0.05). There was no significant difference in hydroxyproline levels between group II and group IV animals (P >0.05). Group III animals had significantly higher bursting pressures than any other group (P <0.05). Group II rats had lowest bursting pressures (P <0.05). Group IV animals had significantly higher levels than group II (P <0.05). Mean bursting pressure values both in groups III and IV and hydroxyproline levels in group III were significantly increased by hyperbaric oxygen therapy (P <0.05). CONCLUSIONS: Ischemia impairs anastomotic healing. Hyperbaric oxygen increases anastomotic healing of both normal and ischemic colonic anastomosis and reverses ischemic damage. This study demonstrated that hyperbaric oxygen improves anastomotic healing.

Anastomosis, Surgical↗
PubMed1981

Penetration into spleen by benign gastric ulcers.

Penetration of the wall of the stomach by a benign ulcer may result in free perforation into the greater or lesser peritoneal cavities. A "confined perforation" occurs when a penetrating ulcer is walled-off by an adjacent structure or organ. The commonest sites of secondary involvement are the pancreas, gastrohepatic omentum, liver, biliary tract, colon and mesocolon. Penetration into the spleen by a benign gastric ulcer is relatively rare and the literature contains few reports of this complication. We report three cases of penetration of the spleen by benign gastric ulcers. In one patient, splenic penetration was predicted pre-operatively by the recognition of splenic tissue in endoscopic biopsy material.

Female↗
PubMed1996

Staging of ampullary and pancreatic carcinoma: comparison between endosonography and surgery.

BACKGROUND: The aim of the study was to update our previously published data on the clinical TNM staging of ampullary and pancreatic carcinoma by endosonography. METHODS: Endosonography was performed in 70 patients with pancreatic cancer and in 32 patients with ampullary carcinoma. TNM staging was carried out before surgery and compared with findings of histology and/or surgery. RESULTS: Endosonography was accurate in staging the depth of tumor invasion. Early-stage carcinomas could be distinguished from advanced cancers. Nonresectability was accurately assessed on the basis of vascular involvement using real-time ultrasound. Tumor compression due to peritumoral pancreatitis and direct tumor invasion into the base of the mesocolon could not be diagnosed by endosonography. The overall accuracy in tumor staging for pancreatic and ampullary carcinomas was 83.6% and 84.4%, respectively. Endosonography was accurate in diagnosing regional lymph node metastases but not accurate in defining nonmetastatic lymphadenopathy and distant metastases. CONCLUSION: Endosonography was accurate in staging tumor stage and lymph node metastases. Minimally invasive methods of resection for superficial ampullary cancers should be based on endosonography staging.

Ampulla of Vater↗
PubMed1996

Equine adenocarcinomas of the large intestine with osseous metaplasia.

Large intestinal adenocarcinoma with osseous metaplasia was diagnosed in two horses, a 15-year-old standard bred gelding and a 9-year-old Haflinger mare. Clinically, both animals had displayed weight loss and anaemia. A presumptive diagnosis of abdominal neoplasia was made and the horses were humanely killed. At necropsy, the gelding and the mare were found to have ulcerated tumours growing into the lumen of the caecum and colon, respectively. In the mare, the mass extended through the mesocolon and was evident in the left dorsal and ventral colon. Histopathologically, the tumours consisted of well-differentiated cords of single-layered columnar to cuboidal epithelial cells. Mitotic figures were very uncommon. In both lesions, well-formed bony spicules and osteoid were present in the fibrovascular stroma. The tumours were well-demarcated from surrounding mucosal tissue but had invaded the intestinal wall. Metastases were not observed.

Adenocarcinoma↗
PubMed1988

Extensive aganglionosis: further experience with the colonic patch graft procedure and long-term results.

During the period from 1979 to 1986, seven patients have been treated for extensive aganglionosis involving the colon and distal ileum (5 to 40 cm) employing the colonic patch graft (CPG) procedure. This consists of (1) ileostomy; (2) creation of a longitudinal side-to-side ileocolostomy between normal ileum and aganglionic ascending colon, forming a CPG; and (3) the definitive pull-through procedure. In all patients, the initial course after ileostomy was complicated by severe diarrhea, which was significantly improved by creation of the CPG. At the definitive operation several months later, the mesocolon attached to the CPG was severed to mobilize the ileocolostomy segment to the distal pelvis. Four patients in this series have been followed for 5 to 8 years. No patient has developed enterocolitis requiring hospitalization. Body weight became normal for age in all patients within 4 years of the definitive operation.

Colon↗