Surgical management of benign esophageal strictures.
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Adult↗
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[Therapeutic endoscopy of the upper portions of the digestive tract (review of the foreign literature since 1979)].
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Ampulla of Vater↗
The application of vascular technology to esophageal and airway strictures.
BACKGROUND/PURPOSE: Strictures of the esophagus and airway tract can be dilated if the strictures can be traversed and dilators passed. Unfortunately, using standard methods, not all strictures can be traversed. The authors set out to find a safe, expeditious, and reproducible way to traverse otherwise impassable strictures of the esophagus and airway. METHODS: Eight patients (n = 8), over a 2-year period, with strictures were entered prospectively into the study. One patient (n = 1) had a main stem bronchial stricture, and 7 patients (n = 7) had esophageal strictures from the following etiologies: esophageal atresia/tracheoesophageal fistula (EA/TEF) repair, Lye ingestion (n = 2), EA/TEF with gastroesophageal reflux, esophageal atresia without fistula, lye ingestion with colon interposition (n = 2), and iron pill inhalation lodged in left main bronchus. None of the strictures could be passed with conventional maneuvers or instrumentation including endoscopy, guide wires, Fogarty catheters, and filliform and followers. Results of barium studies showed no flow into the stomach. In the bronchial case, no lumen could be identified at bronchoscopy. RESULTS: Utilizing the "Vascular Surgery Glidewire/Berenstein Catheter System" under fluoroscopy and utilizing the "spinning top" dynamic maneuver intrinsic to this system, all of the strictures were traversed easily. The passage of the wire/catheter system thus allowed sequential dilation of the previously impassable strictures. The mean time to cross the strictures with the wire/catheter system was 1 minute, 10 seconds. (t = 70 seconds). All of the procedures were done in the operating room under general endotracheal anesthesia by the same 2 attending pediatric surgeons. CONCLUSIONS: The use of vascular surgical technology in difficult, otherwise impassable strictures of the esophagus and upper airway proved to be an extremely effective, easy-to-perform, and reproducible method of therapy. This procedure may obviate the need for resectional surgery in this setting.
Adolescent↗
[A 13-week subacute oral toxicity study of 6-amidino-2-naphthyl 4-[(4,5-dihydro-1H-imidazol-2-yl) amino] benzoate dimethanesulfonate (FUT-187) in rats].
The toxicity of FUT-187, a synthetic protease inhibitor, was investigated in Sprague-Dawley rats. FUT-187 was given orally to the rats at doses of 2, 10, 50, 250 and 1250 mg/kg/day for 13 weeks, then the drug was withdrawn for 5 weeks for recovery. The results are summarized as follows: In the 1250 mg/kg/day group, 9 out of 20 males died with decreased body weight and exhaustion. Histopathological examination revealed renal papillary necrosis, ulcer in the urinary bladder, hemostatic lesions in the lungs and liver, ulcer or erosion in the stomach, duodenum and jejunum. The surviving animals in this group showed swelling of the limbs due to synovitis, transient salivation immediately after administration, suppression of growth with decreased food consumption. Urinalysis revealed a low pH, increased ketones and bilirubin excretion, dark yellowish change in color, the appearance of "leaflet-shaped" crystals and increased red blood cells and epithelial cells in the urinary sediment, increased water intake, decreased specific gravity and decreased sodium, potassium and chloride in the urine. Hematologically, there was an increase in the white blood cell count. A biochemical analysis of the blood revealed decreased amylase activity, glucose and total protein levels and increased GOT activity and inorganic phosphorus levels. Pathological changes were observed in the pancreas, kidney, digestive tract, urinary bladder and liver. The pancreas showed macroscopical enlargement and increased organ weight. Histopathologically, there were several alterations in the acinar cells, such as vacuolization due to increased fat droplets, nuclear irregularity, prominent nucleoli, irregular arrangement and vesiculation of rough endoplasmic reticulum (rER), dilatation of developed Golgi apparatus and increased free ribosomes. In the kidney, increased weight and pigmentation in the proximal tubular epithelium were noted. Electron microscopically, these pigments were recognized as secondary lysosomes containing filamentous material and electron dense granules within a lucent matrix. In the digestive tract, ulcer or erosion in the stomach and duodenum, and villous proliferation in the small intestine were observed. Furthermore, hyperplasia and vacuolization were noted in the mucosal epithelium of the urinary bladder. In addition, loss of perilobular fat droplets in the liver and increased adrenal weight without histological change were observed. After a 5-week recovery period, these changes disappeared almost completely. In the 250 mg/kg/day group, slight suppression of growth the appearance of "leaflet-shaped" crystals in the urinary , sediment, increased water intake and decreased sodium in the urine were observed. The pancreas showed enlargement, increased weight, acinar cell hypertrophy with increased zymogen granules, fine vacuolization, slight derangement and vesicular of rER, and dilatation of Golgi apparatus.(ABSTRACT TRUNCATED AT 400 WORDS)
Administration, Oral↗
Cervical esophagogastric anastomosis with a new stapler in the surgery of esophageal carcinoma.
OBJECTIVE: A new reusable circular stapler for cervical esophagogastric anastomosis (CEGA) has been used to substitute the traditional method of hand-sewn cervical anastomosis. METHODS: Over a 2-year period (09/1998-11/2000), the stapler was engaged on operations of 112 patients with thoracic esophageal carcinoma, and the anastomosis was performed through both cervical and thoracic incision. The operative approaches were through left thoracotomy in 85 cases, and through right thoracotomy in 27 cases. The results were analyzed retrospectively. RESULTS: All of the 112 CEGA operations were successfully performed on the patients who underwent esophageal resections, and no operative mortality and anastomotic leakage occurred. Excluding the two patients with the anastomotic recurrent carcinoma, anastomotic stricture occurred in 12 cases (10.9%, n=110). Median time to the presentation of anastomotic stricture was 4.3 months (range 2.6-25.3 months), and the median number of dilatations was 3 (range 1-5). When divided into the 24 and 26 mm groups, the respective incidences of stricture were 12.3 (7/57) and 9.4% (5/53), respectively, and the statistical results of the two sizes of staplers were essentially the same (P=0.6691). Eight patients experienced nonanastomotic-related complications (7.3%, n=110), in which there were three cases of recurrent laryngeal nerve injury, four cases of the left side pneumothorax, and one case of perforation of the proximal stomach. There was also a case of stapling gauze at anastomosis. Some of the complications were closely related to the initially improper use of the new stapler's craft. CONCLUSIONS: The results indicate that CEGA using the new circular stapling device in surgery of the esophageal carcinoma is a very effective procedure to improve the anastomotic technique from a traditional hand-sewn anastomosis to a stapled anastomosis and can reduce the incidence of complications.
Aged↗
[Pneumatosis intestinalis--histology, immunocytochemistry and new theory of morphogenesis].
Based on the light microscopical and immunocytochemical findings in two cases of pneumatosis intestinalis, a new theory is advanced on the morphogenesis of the cysts that can be observed in this disease. The cavities identifiable in both cases in the submucosa of the small intestine and of the colon, respectively, were partially lined by histiocytes and foreign-body giant cells. Most of the lumina found in the subserosa of the stomach, small intestine and colon had an identical aspect. In addition, there were numerous true cysts here with a narrow, single-layered cells seam, showing the immunocytochemical characteristics of the mesothelium, but not the capillary endothelia. Thus, contrary to previous assumptions, pneumatosis interstinalis apparently does not develop from cystic dilatation of gas-filled lymph vessels that shrink and disappear in the process of an inflammatory foreign body reaction. Rather, the disease initially seems to manifest itself through gas-filled pseudocysts partially bordered by histiocytes and foreign-body giant cells, which become secondarily mesothelialized in the subserosa. Lymph vessels would thus not have significance for the morphogenesis of this disease.
Aged↗
Influence of dietary composition on gastric emptying and motility in dogs: potential involvement in acute gastric dilatation.
Gastric dilatation-volvulus is a dramatic and life-threatening disease of large-breed dogs. The cause is unknown, but ingestion of dry cereal-based food is frequently incriminated as a predisposing factor. The purpose of this study was to examine the effect of commercial diets on gastric motility and emptying in the dog. Four large-breed dogs were fed 3 different diets (diet A = canned meat-based; B = cereal-based with 77% added water; and C = dry cereal-based) in a randomized block design. Each experiment was done in triplicate. Motility was assessed, using 5 AgAgCl electrodes and 2 strain gauges sutured along the serosa of the stomach and proximal duodenum. Dogs were fed at the same time each day and the time to change from the fed to the fasted pattern of gastrointestinal motility (changeover) was measured. Gastric emptying was assessed by recording gastric radioactivity. After feeding a meal mixed with 99mTc-labeled resin, the log of activity was plotted against time, and the half-time of gastric emptying (t1/2 GE) was calculated. Mean (+/- SEM) times from feeding to changeover for the 3 diets were: diet A, 9.7 +/- 0.9; B, 10.5 +/- 0.4; and C, 11.0 +/- 0.8 hours. Diet had minimal influence on the half time of gastric emptying (diet A, 2.2 +/- 0.3; B, 2.6 +/- 0.4; and C, 2.9 +/- 0.3 hours; P greater than 0.05). The data indicate that gastric motility and emptying in healthy large-breed dogs were not affected by dietary composition. Because most large dogs are fed cereal-based food for reasons of cost and ease of use, these diets may have been wrongly incriminated as a predisposing factor in gastric dilatation-volvulus.
Animals↗
[Digestive tract dilation in mice infected with Trypanosoma cruzi].
This paper will analyze alterations in the digestive tract (DT) of mice with chronic Chagas' disease infection produced by Trypanosoma cruzi from different sources. X-rays of the DT of 18 mice infected with T. cruzi and 6 control mice were compared after the ingestion of a barium sulfate solution over a period of 6 hours. 120 days post-infection (pi) the X-rays of the DT of the 5 mice of group 1A infected with trypanosomes DMI isolated from the opossum Didelphis marsupialis, and 4 mice in group 2A infected with the isolate EP taken from a patient with acute Chagas' disease, showed swelling of the stomach and the colon (C). 180 days pi, the X-rays of the DT of the 5 mice of group 1B infected with isolated DMI and the 4 mice in group 2B infected with isolate EP, showed an even greater swelling of the C. Histological examination of the DT of all infected mice showed extensive changes of the intestinal muscle layer, such as the diminution of the muscular and mucous layers and the loss of colonic folds and myoenteric plexus. These results suggest that T. cruzi populations caused severe alterations in the digestive system of the mice used in the experiment, and that the same alterations could occur in the digestive organs of humans, especially those living in areas where Chagas' disease is endemic, but where these abnormalities have not yet been reported.
Animals↗
Laparoscopic resection of esophageal epiphrenic diverticulum.
Symptomatic esophageal epiphrenic diverticula are usually repaired with a diverticulectomy and esophagomyotomy via a left thoracotomy with substantial postoperative pain and morbidity. If a laparoscopic approach could be shown to be safe and effective, the decrease in postoperative pain and potentially shorter hospital stay would make this technique beneficial. We report three cases repaired via a transabdominal approach. The first two cases were done laparoscopically. The third case was attempted laparoscopically and completed via a midline laparotomy, demonstrating that thoracotomy is not necessary even if laparoscopy is not possible. All three patients had long-standing debilitating symptoms refractory to standard nonsurgical therapies (botulinum toxin injection, pneumatic dilation, antispasmodic medication) with abnormal esophageal motility. There was one intraoperative complication of a left pneumothorax that required neither laparotomy nor thoracostomy. An esophagram on the first postoperative day demonstrated no extravasation and good flow into the stomach. The postoperative course was uneventful for all three patients, with the laparoscopic patients discharged on the second postoperative day and the laparotomy patient discharged on the seventh postoperative day. In conclusion, laparoscopic repair of symptomatic esophageal epiphrenic diverticula is a safe and effective technique with minimal postoperative pain and morbidity. It should be considered as an alternative to the traditional transthoracic approach, and may become the standard technique.
Aged↗
Microsphere analysis of beta 2-adrenergic control of resistance in different vascular areas after hemorrhage.
In cats exposed to bleeding (exsanguination of 15 ml X kg bwt-1) the microsphere technique was used to determine regional vascular resistances in a large number of tissues before and after i.v. administration of the 'selective' beta 2-adrenoceptor antagonist ICI 118,551. beta 2-blockade significantly raised vascular resistance in the stomach (+ 26%), small (+ 25%) and large (+ 38%) intestine, pancreas (+ 29%), kidney (+ 39%), omental (+ 33%) and subcutaneous (+ 26%) fat, 'white' skeletal muscle (+ 19%), and skin (+ 24%). These findings indicate that, with intact beta-adrenoceptors, beta 2-adrenergic dilator interaction counteracted the hemorrhage evoked vasoconstrictor influences. beta 2-blockade also evoked quite a strong increase of total peripheral resistance (19%) and led to some redistribution of cardiac output. It is concluded that beta 2-adrenergic inhibition of vascular tone significantly seems to improve tissue perfusion during bleeding in several vascular areas. Such effects may be of special significance during severe hemorrhage. In the intestine, pancreas, and adipose tissue, for example, protection against excessive vasoconstriction may serve to minimize the severe metabolic disturbances with secondary release of toxic factors into the circulation reported during hemorrhagic shock.
Adrenergic beta-Antagonists↗
Experimental evaluation of techniques of gastric partitioning for morbid obesity.
Fifty stapled gastric partitions were performed upon dogs using five techniques, three of which used strips of Marlex or Teflon to reinforce the staple line. At autopsy, five weeks after operation, 22 of 50 partitions were intact and 19 of 50 were completely disrupted. Nine of 50 dogs died of leak and peritonitis within three days of operation. The incidence of disruption was not significantly reduced by reinforcing the stapled partitions with Teflon or Marlex, but the incidence of leak and peritonitis which resulted in death was significantly higher with reinforced partitions, P less than or equal to 0.05. Disruption of the staple line appears to begin at the partition opening and proceeds laterally from that point. Distortion of staples was noted in most of the intact partitions, and in several, the staples remained closed but pulled through the full thickness of the anterior gastric wall. Dilation of the partition opening was noted with each technique. It is our impression from the experiments and the reported clinical experience with ever-changing operative techniques that mucosa-to-mucosa stapling of the undivided stomach is not a reliable technique for gastric partitioning and that additional measures to ensure the success of this simple technique may lead to other complications. At this point, we do not know of an operative technique for the treatment of morbid obesity which we consider to be both safe and effective enough for us to use.
Animals↗
Intussusceptive microvascular growth: a common alternative to capillary sprouting.
Intussusceptive capillary growth represents a new principle for microvascular growth as described in the lungs of growing rats. According to this concept, the capillary network expands by the formation of slender transcapillary tissue pillars, which give rise to new vascular meshes. The process was first observed in Mercox casts of the lung microvasculature, which revealed the existence of multiple tiny holes with diameters around 1.5 microns. Consecutive transmission electron microscopic investigation of serial sections demonstrated that the holes corresponded to slender tissue pillars (Burri and Tarek, 1990). The corrosion cast technique thus appears to be an adequate screening method for intussusceptive growth. In the present investigation, Mercox casts of various vascular systems, namely, those of the eye, submandibular gland, heart, liver, stomach, small and large intestine, trachea, kidney, uterus and ovary were prepared from rats aged between 4 and 9 weeks in order to screen them for the existence of the typical tiny holes representing tissue pillars. In all organs investigated, these structures were observed in various locations to a variable degree. They were mainly encountered within dilated vascular segments or at triple or quadruple branching points of the circulation. Even in capillary networks with a three-dimensional arrangement could these pillars be detected. Intussusception thus appears to be a principle of growth appertaining to many vascular systems.
Animals↗
[The hemodynamic effect of distention of the stomach in dogs with a normal and stenosed coronary artery].
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Angina Pectoris↗
Corrosive injuries of the oesophagus and stomach: experience in management at a regional paediatric centre.
In a 21-year period between June 1974 and May 1995, eight children required surgery for the treatment of complications after ingestion of corrosive substances. There were six oesophageal injuries due to alkali ingestion and two gastric injuries secondary to acid ingestion. Of those ingesting alkali, diagnosis of stricture was made at a mean of 28 days and all children underwent endoscopic dilatation with a mean of six treatments (range 2-13). Two children subsequently required oesophageal replacement and colonic interposition. One of the children ingesting acid presented as an emergency with peritonitis and required laparotomy at which partial gastrectomy and pyloroplasty were performed. The second child presented 3 weeks after ingestion with a gastric stricture and required gastrostomy. All children are currently alive and well and are asymptomatic. The details of management are discussed, together with a review of the literature.
Acids↗
[Iatrogenic injuries of the cardia antireflux system].
Among presented 18 patients with iatrogenic injury of the cardia antireflux system, 5 were females and 13 males aged 35-62 years of life. 13 cases were operated before for cardiospasmus, 5 had gastric resection B2 for duodenal ulcer. In consequence all the patients presented stricture of the thoracic lower and abdomen part of oesophagus. 16 patients required reoperations, 2 had dilatation. In 2 cases stricture were located in middle and lower part of oesophagus. In 4 cases in abdominal and supradiaphragmatic part of oesophagus, in 5 cases in abdominal part of oesophagus, and in 7 cases in the cardia. 11 patients required one corrective surgery, 4-two operations, and 1-three operations. As a final procedure: in 2 cases artificial oesophagus was formed with intestinal graft, in 8 cases the cicatrical part of the oesophagus was excised and replaced by a pedunculated graft by Merendino method, in 3 cases esophagogastric anastomosis were done using Heyrowsky method, in 2 cases bypass was made from pedunculated part of jejunum which connect the part of oesophagus above the narrowing with the prepyloric part of the stomach by the own method, in 1 case intrathoracic esophagogastric anastomosis was performed. The best results were obtained by oesophagogastric bypass.
Adult↗
Response properties of antral mechanosensitive afferent fibers and effects of ionotropic glutamate receptor antagonists.
The ionotropic glutamate receptors N-methyl-d-aspartate (NMDA) and alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors are present peripherally in the primary sensory afferent neurons innervating the viscera. Multiple studies have reported roles of glutamate receptors in gastric functions. However, no study has previously shown the direct influence of ionotropic glutamate receptor antagonist on vagal sensory neurons. The objective of this study was to investigate the effects of NMDA and AMPA receptor antagonists on mechanotransduction properties of vagal afferent fibers innervating the rat stomach. Action potentials were recorded from the hyponodal vagus nerve innervating the antrum of the Long-Evans rats. For antral distension (AD), a small latex balloon was inserted into the stomach and positioned in the antrum. The antral contractions were recorded with solid-state probe inserted into the water-filled balloon. Antral units were identified to isovolumic (0.2-1 ml) or isobaric AD (5-60 mm Hg). NMDA and AMPA receptor antagonists were injected in a cumulative fashion (1-100 micromol/kg, i.v.). After the conclusion of experiment, the abdomen was opened and receptive field was mapped by probing the serosa of the stomach. Thirty-two fibers were identified to AD. The receptive fields of 26 fibers were located in the posterior part of the antrum. All fibers exhibited spontaneous firing (mean: 7.00+/-0.97 impulses/s). Twenty fibers exhibited a rhythmic firing that was in phase with antral contractions, whereas 12 fibers exhibited non-rhythmic spontaneous firing unrelated to spontaneous antral contraction. Both groups of fibers exhibited a linear increase in responses to graded isovolumic or isobaric distensions. NMDA (memantine HCl and dizocilpine (MK-801)) and AMPA/kainate (6-cyano-7-nitroquinoxaline 2,3-dione; CNQX) receptor antagonists dose-dependently attenuated the mechanotransduction properties of these fibers to AD. However, competitive NMDA antagonist dl-2-amino-5 phosphopentanoic acid (AP-5) had no effect. The study documents that glutamate receptor antagonists can attenuate responses of gastric vagal sensory afferent fibers innervating the distal stomach, offering insight to potential pharmacological agents in the treatment of gastric disorders.
Action Potentials↗
The intramucosal cysts of the stomach. I. In Swedish subjects with gastric or duodenal ulcers.
Gastrectomy specimens from 51 patients operated on because of peptic ulcer disease were searched histologically for the presence of intramucosal cysts. The number of cysts for each cm of mucosa analyzed (cystic index) was calculated. Intramucosal cysts occurred in 34 per cent of the patients. The resultant cystic index was 0.19 (S.D. +/- 0.40). The cystic index was not correlated to age or sex. Comparative studies demonstrated significantly higher (p less than 0.001) proportions of intramucosal cysts in the non-tumoral mucosa from patients with early gastric cancer (cystic index 3.13 - S.D. +/- 3.55). The possible association between benign intramucosal cystic dilatation of the gastric glands and the occurrence of gastric carcinoma deserves further investigation. The occurrence of intramucosal cysts in a biopsy specimen should intensify the search for an early gastric cancer.
Adult↗
[Benign gastric strictures after transthoracic esophagectomy and esophagogastrostomy: an analysis of 9 cases].
OBJECTIVE: To investigate the manifestations,etiology,diagnosis and treatment of benign gastric strictures after transthoracic esophagectomy and esophagogastrostomy. METHODS: From January 1998 to December 2004, 9 cases with benign gastric strictures following esophagectomy were enrolled in the study. The manifestations,radiographic and endoscopic findings, treatment were analyzed retrospectively. RESULTS: The patients included 8 males and 1 female. Benign gastric stricture is characterized by mucosa absence and proliferation of fibrous tissue in the stomach below the stoma. The age ranged from 49 to 71 years old (median age 62). The common symptom was postoperative dysphagia. The length of stricture ranged from 1.5 to 5.0 cm, and the width from 0.1 to 0.5 cm. Seven cases were treated ineffectively with simple dilation,while esophageal stent placement was performed in 8 cases successfully. After follow- up from 5 to 60 months, restenosis occurred for 11 times including stent fall-off for 6 times,stent migration for 1 times, overgrowth of granular tissues for 4 times. Other complications included cervical incision infection and massive hemorrhage in one case respectively. Restenoses were all solved with stent replacement. CONCLUSIONS: Benign gastric stricture should be diagnosed through dysphagia, barium meal and endoscopy. Placement of non-self-expandable stent or whole covered self-expandable metallic stent is the primary treatment.
Aged↗