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PubMed2004

Diaphragmatic rupture during labor.

Diaphragmatic rupture during labor is uncommon and generally occurs in patients with a history of congenital diaphragmatic hernia or traumatic abdominal or chest injury. We present a case of a 41-year-old woman who presented with abdominal pain, vomiting and hypoventilation four days after a full-term home delivery. Chest radiography suggested the presence of a ruptured diaphragm, and laparotomy revealed a congenital left Bochdalek defect with herniation of the stomach, transverse colon and spleen into the left pleural cavity. Diaphragmatic hernia rupture during labor is a serious but rare complication that requires emergency surgery to prevent visceral perforation and cardio-respiratory failure.

Electrocardiography↗
PubMed2005

Fournier's gangrene treated by simultaneously using colostomy and open drainage.

We report our findings and results on treating a patient with Fournier's gangrene by using colostomy along with open drainage. A 39-year-old male had noticed a swelling and experienced pain in the scrotal sac approximately 1 week before his admission. On admission, his symptoms aggravated and he experienced constipation and difficulty in urination. Local examination of the scrotum circumference revealed a remarkable swelling, and redness and sloughing that had extended to the perianal area. In an emergency operation, incision and drainage of the scrotum, double-barrelled colostomy at the transverse colon, and reconstruction of the percutaneous cystotomy were performed. Postoperative open wound was cleaned twice a day and intravenous infusions of 1g imipenem/cilastatin sodium and 1.2g clindamycin phosphate were administered daily. The patient was discharged 61 days after the operation. Fournier's gangrene has a high mortality rate, and in severe cases that are complicated with infection protracted from defecation, dyschezia and difficulty in urination, we believe that it would be most effective to perform an open drainage and a colostomy simultaneously.

Adult↗
PubMed2004

Lymphoid nodular hyperplasia and cow's milk hypersensitivity in children with chronic constipation.

OBJECTIVE: To investigate the incidence of cow's milk allergy as evidenced by milk challenge and the findings of endoscopic and immunohistochemical examinations in children with chronic and refractory constipation. STUDY DESIGN: Thirty-five study subjects (mean age, 8.3 +/- 3.3 years; range, 3-15 years; 17 girls) and 15 control subjects (mean age, 11.7 +/- 3.2 years; range, 2-15 years; 9 girls) were studied by colonoscopy and a 4-week cow's milk elimination and challenge. RESULTS: Lymphoid nodular hyperplasia was the most prominent endoscopic finding in half of the subjects (46%), mostly occurring patchily in the transverse colon. Histologic findings other than lymphoid accumulation and mildly increased density of eosinophils were few. During the milk elimination and with supportive medication, 83% of subjects remitted. Constipation and/or other gastrointestinal or skin symptoms relapsed only in one third (34%) during the cow's milk challenge, these having significantly higher densities of intraepithelial gammadelta + T cells ( P <.001) in the biopsy samples of the terminal ileum as compared with the control subjects. CONCLUSIONS: We were able to find formal evidence for the presence of cow's milk allergy in children with chronic constipation.

Adolescent↗
PubMed2004

Impaired absorption of marked oligopeptide Glycine-I Tyrosine-Glycine after successful autologous-allotopic ileal mucosa transplantation in beagles.

PURPOSE: After establishing a method for ileal mucosa transplantation in an animal model, the authors investigated the absorptive capacity for oligopeptides of the transplanted mucosa. METHODS: In 14 beagle dogs the authors transplanted ileal mucosa in a vascularized demucosed segment of the transverse colon. The colonic wall-ileal mucosa complex then was integrated in the ileal continuity. Six animals were lost owing to operative complications. Absorptive capacity for oligopeptides was measured in the remaining 8 animals with the iodine 131 (131I)-marked tripeptide glycine-tyrosine-glycine before and 4 weeks after transplantation. The results were compared and analyzed with the Student's t test for matched pairs. Blood concentrations of the marked tripeptide with P value less than .05 were considered as a significant reduction in the absorptive capacity of the transplanted ileal mucosa. After fixation with glutaraldehyd graft, uptake of the colonic wall-ileal mucosa complex was evaluated histologically in 8 animals. RESULTS: In all 8 animals, a 100% graft uptake was verified in all sections. Fifteen minutes after application of 15 MBc Glycine-131I-Tyrosine-Glycine there was no significant difference in the absorption between normal and transplanted ileal mucosa. After 30 minutes, the absorption of the transplanted ileal mucosa showed a tendency (P < .1) for an impaired uptake of the marked tripeptide. However, 60 minutes after application the difference in the absorptive capacity of the transplanted ileal mucosa was significant (P < .05). CONCLUSIONS: Autologous allotopic ileal mucosa transplantation is feasible; however, an impaired absorption of oligopeptides of the transplanted mucosa 4 weeks after transplantation could be observed.

Animals↗
PubMed2005

Congenital paraesophageal hiatal hernia: pitfalls in the diagnosis and treatment.

PURPOSE: The aim of this study was to analyze pitfalls in the diagnosis and treatment of congenital paraesophageal hiatal hernia (PEHH). METHODS: Between 1992 and 2004, the records of 5 infants with PEHH were retrospectively reviewed for age, sex, presenting symptoms, radiological studies, operative findings and approaches, and outcomes. RESULTS: All cases (3 male, 2 female) had right-sided hernias. They had clinical features of recurrent chest infections and intermittent vomiting that were present since birth in 3. Three presented acutely ill with findings of respiratory distress and vomiting. Three were referred with misdiagnoses of reflux disease, thoracic mass, and bronchopneumonia. On the chest x-rays of 3 cases, there were paracardiac opacities suggesting a mass lesion. According to the upper gastrointestinal series and/or computed tomography findings, 4 cases had a combination of sliding and paraesophageal hernia, and the remainder one had pure rolling hiatus hernia. Three had obstruction owing to organoaxial volvulus and required an emergency operation. All cases had a large hernia orifice. Four had gastroesophageal junction (GEJ) displaced into the thorax, and in 3, the stomach was found to be twisted, and transverse colon with omentum was also in the thorax in 2. In the remainder, the GEJ was in its normal position with herniated stomach. None of the cases had normal gastrosplenic and gastrocolic ligaments. Surgical repair included resection of the sac, closure of the hiatal defect, and Thal procedure. Two had intestinal malrotation, with right ovarian torsion and ventricular septal defect, respectively. Postoperative ventilation was required in one who later died. At a mean follow-up of 2 years, the other 4 had no symptoms related to the disease, and no evidence of recurrence or reflux was noted on control upper gastrointestinal series. CONCLUSION: Congenital PEHH may be difficult to diagnose. It is frequently complicated and associated with morbidity and even mortality. If the defect is large and associated with displacement of GEJ into the thorax, adding an antireflux procedure to the repair is appropriate.

Diagnosis, Differential↗
PubMed2005

Ingestion of magnets: innocent in solitude, harmful in groups.

Foreign body ingestion is frequent in children and generally associated with little morbidity. However, some foreign bodies are innocent when ingested as a single object, but may have harmful effect if numerous. We report a 9-year-old girl who swallowed 5 magnets, causing acute intestinal obstruction. At laparotomy, 2 magnets were found in the cecum and 3 in the transverse colon, attracting each other and clasping a segment of ileum in between, causing a complete obstruction of the small intestine. If numerous magnets are ingested, particular concern is advised, and if signs of intestinal distress develop, prompt laparotomy to prevent serious gastrointestinal complications should be performed.

Acute Disease↗
PubMed2006

Primary paraesophageal hernia in children.

BACKGROUND: Paraesophageal hernias are uncommon in children and are distinctively different from the more common sliding hiatus hernias and those occurring after antireflux surgery in anatomy, pathology, symptoms, complications, and management. We reviewed a single institution's experience with the pathology of paraesophageal hernias. METHODS: We conducted a retrospective analysis of patient records. RESULTS: Fifty-nine children with paraesophageal hernias were treated during a 42-year period. Their mean age at presentation was 23.4 months (range, 1 day to 11 years). Presenting complaints were recurrent chest infections (n = 32), vomiting (n = 24), symptomatic anemia (n = 20), failure to thrive (n = 18), and dysphagia (n = 6). Five children were asymptomatic, and their diagnosis was established when they were investigated for incidentally noted asymptomatic anemia (n = 3), scoliosis (n = 2), and mumps (n = 1). Radiology typically showed cystic masses in the posterior mediastinum in the right lower chest and occasionally had an air-fluid level in the cystic mass or a dilated esophagus. None presented with strangulation or hematemesis. All patients were operated on. Surgical findings included a peritoneal lined sac and herniation through a widened diaphragmatic hiatus, containing the stomach and at times the transverse colon, spleen, and small bowel. The hernial sac usually occurred on the right. Principles of surgery included reduction of the contents, partial excision of the sac, crural approximation, and a fundoplication in 39 patients. No fundoplication was done in the earlier years in 20 patients, of whom 12 had recurrent reflux symptoms. Postoperative complications were bowel obstruction (n = 6), intussusception (n = 3), dysphagia (n = 3), breakdown of the repair (n = 3), and pneumothorax (n = 1). There was one mortality caused by preoperative aspiration. CONCLUSION: Paraesophageal hernias in children are uncommon and most likely caused by a congenital defect. They are associated with considerable morbidity. Strangulation is not a feature. Principles of repair are well established and should include an antireflux procedure.

Child↗
PubMed2006

Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases.

BACKGROUND: It is common practice to close mesenteric defects in abdominal surgery to prevent postoperative herniation and subsequent closed-loop obstruction. The aim of this study was to review our experience with antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGBP) without division of the small bowel mesentery or closure of potential mesenteric defects. METHODS: Data for 1400 patients who underwent AA-LRYGBP between January 2001 and December 2004 was prospectively collected and retrospectively analyzed for the incidence of internal hernias. In all cases, an antecolic antegastric approach was performed without division of the small bowel mesentery or closure of potential hernia defects. RESULTS: Three patients (0.2%) developed a symptomatic internal hernia. Two of these patients had a 200-cm-long Roux limb, and the other had a 100-cm-long Roux limb. All three patients exhibited mild symptoms of partial small bowel obstruction. In all three cases the internal hernia was clinically manifested more than 10 months after the original AA- LRYGBP. Exploration revealed that the hernia site was between the transverse colon and the mesentery of the alimentary limb at the level of the jejunojejunostomy (Petersen's defect) in all three cases. All three patients underwent successful laparoscopic revision, hernia reduction, and mesenteric defect closure. CONCLUSIONS: AA-LRYGBP without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.

Aged↗
PubMedDate not supplied

Multivisceral harvest with in vivo technique: methods and results.

Multivisceral transplants are gaining acceptance worldwide for patients with chronic gastrointestinal failure with or without irreversible total parenteral nutrition (TPN)-related liver failure. We describe our experience with nine multivisceral harvests reporting our in vivo technique. Multivisceral grafts included stomach, duodenum, pancreas, small bowel, and part of large intestine with or without the liver. After a careful evaluation of the liver and the bowel, we isolated the superior mesenteric artery origin. Then we identified the distal part of the graft isolating the middle colic vein and stapling the transverse colon to its left. After esophagus isolation and stapling, we mobilized the graft, starting from the spleen to the pancreaticoduodenal block, near the celiac trunk. After cross-clamping and cold perfusion, we created an aortic patch including the superior mesenteric artery and celiac trunk as a multivisceral harvest without the liver. A total hepatectomy is added for a liver multivisceral graft. We harvested four multivisceral grafts without the liver and five multivisceral grafts with the liver. We performed seven multivisceral transplants on adult recipients, four without the liver and three with the liver, as well as two liver and one isolated small bowel transplants. Postreperfusion hemostasis was always satisfactory with a mean ischemia time of 6.5 hours. Four recipients died: there was one intraoperative death due to disseminated intravascular coagulopathy. Another patient underwent graftectomy 1 day after transplantation due to vascular thrombosis. In conclusion, our in vivo technique allows a shorter ischemia time with a minimal postreperfusion bleeding and reduced production of lymphatic ascites, without jeopardizing organ function.

Gastrectomy↗
PubMed2005

Treatment of short gut syndrome with early living related small bowel transplantation.

AIM: To investigate the results of treating short bowel syndrome with an early living related small bowel transplantation (SBT). METHODS: A 17-year-old boy with a 20-cm-long residual intestine due to necrotic volvulus received an early living related SBT from his mother. Donor-specific blood transfusion was performed for 8 weeks before transplantation, each time for 50 mL every week. Cytomegalovirus status in both donor and recipient was negative. A 160-cm distal ileal segment was removed from the donor. The graft ilecolic artery and vein were anastomosed to the recipient's infrarenal aorta and caval vein. The proximal end of the graft was anastomosed end-to-end to the residual recipient jejunum; the distal anastomosis, between the distal end of the graft and transverse colon. An ileostomy was also performed. Immunosuppression, infection prophylaxis, and antithrombotic and nutrition support were given postoperatively. RESULTS: The donor had an uneventful recovery. No technical complications were observed. The recipient was alive and well at 31 weeks after the operation. No graft rejection or infection was observed. He was off TPN 8 weeks after the operation and took low-fat food. The D-xylose test in the recipient was almost normal. CONCLUSIONS: Early living related small intestine transplantation is a good treatment for short bowel syndrome.

Adolescent↗
PubMed2001

A vertical stomach reconstruction after pylorus-preserving pancreaticoduodenectomy.

BACKGROUND: Pancreatic fistula (PF) and delayed gastric emptying (DGE) is a leading cause of morbidity after pylorus-preserving pancreaticoduodenectomy (PPPD), occurring in 20% to 40% of patients. METHODS: Between August 1994 and March 2000, 30 consecutive patients underwent our modified PPPD and were evaluated on their incidence of PF and DGE. The major modification of our technique was an antecolic reconstruction and setting the transverse colon between pancreaticogastrostomy and duodenojejunostomy RESULTS: Operative time and blood loss were, respectively, 5.2+/-0.93 hours and 730+/-330 mL. Hospital mortality was 0%. Postoperative morbidity was 23%. Delayed gastric emptying and pancreatic fistula were observed in 3 (10%) and 0 (0%) of 30 patients. Nasogastric suction was required for 7+/-2 days, and a solid diet could be tolerated on postoperative day 11+/-4. CONCLUSIONS: The results show that our reconstruction can minimize DGE.

Aged↗
PubMed2002

Establishing a laparoscopic gastric bypass program.

OBJECTIVE: To evaluate the outcomes for laparoscopic Roux-en-Y gastric bypass in a newly developed bariatric surgery program. METHODS: A prospective analysis of the initial 100 patients who underwent laparoscopic Roux-en-Y gastric bypass at a community based teaching hospital between December 2000 and October 2001 was performed. Study endpoints included operative time, early (less than 7 days) and late complication rates, hospital length of stay (LOS), time to initiation of oral diet, and percentage of excess body weight loss. RESULTS: There were 91 women and 9 men with a mean age of 39 years (range 21 to 57). Mean preoperative weight was 126.4 kg (range 92.3 kg to 214 kg), with a mean preoperative body mass index of 47.4 (range 37.3 to 75.7). Ninety (90%) patients had at least one significant medical comorbidity (median = 6 per patient). Mean operative time was 2.4 hours (range 1.0 to 6.5; 3.0 hours for the first 50 patients and 1.8 hours for the last 50 patients). Three patients required conversion to open gastric bypass, all due to equipment failure (two harmonic scalpel failures and one linear stapler malfunction). Seven patients had early complications, 3 with anastomotic hemorrhage requiring transfusion, 3 with intestinal leaks requiring reoperation, and 1 with transected nasogastric tube. Eleven patients had late complications: 5 patients with small bowel obstruction, all due to herniation through the transverse colon mesentery (these occurred early in the series, prompting a change in technique, with no subsequent occurrences), 3 with gastrojejunostomy strictures requiring endoscopic dilation, 2 superficial wound infections, and 1 port-site incisional hernia. No complications occurred in the last 40 patients. No deaths occurred. Median hospital stay was 2 days (range 1 to 37); 3 days in the first 50 cases and 1 day in the last 50 cases. The median number of days to the start of an oral diet was 1 day. Average excess body weight loss was 34% (median follow-up 4 months). CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Improved outcomes, shorter operative times, and fewer complications are associated with increased surgical experience.

Adolescent↗
PubMed1990

Intraoperative tissue oximetry in the human gastrointestinal tract.

Tissue oxygen tension was measured using a modified Clark oxygen electrode in the gastrointestinal tract of 33 patients undergoing laparatomy. The electrode, which incorporated a thermistor, had a linear response to oxygen tension (r = 0.995, p less than 0.001). The patients were all maintained on an inspired oxygen concentration of 33 +/- 3% and had a mean arterial oxygen tension (PaO2) of 124.9 +/- 31.9 mm Hg. Tissue oxygen tension measurements (mm Hg, mean +/- SD) were recorded from the serosal surfaces of the stomach (46.3 +/- 15.4), mid-ileum (36 +/- 9.7), terminal ileum (33.5 +/- 11.5), cecum (30.3 +/- 7.4), transverse colon (38.5 +/- 10), descending colon (29.3 +/- 11), and sigmoid colon (39.2 +/- 7.7) and tended to increase with increasing PaO2 (r = 0.70, p less than 0.001). Arterial occlusion resulted in a gradual decrease in tissue oxygen tension. It is concluded that intraoperative tissue oxygen tension measurement is feasible, and that the technique may have clinical applications in the assessment of intestinal viability.

Adult↗
PubMed1998

Extended surgical resection in T4 gastric cancer.

BACKGROUND: Some physicians still consider invasion of adjacent organs by the carcinoma of stomach as a sign of incurable disease. METHODS: This retrospective study has been done with particular reference to 353 T4 gastric cancer patients who underwent combined gastrectomies with adjacent organs. RESULTS: Subtotal gastrectomy was performed in 237 (67.1%) patients and total gastrectomy was performed in 116 (32.9%) patients. Organs most commonly resected with the stomach were the transverse colon in 159 (45%) cases, the tail of pancreas and spleen in 150 (42.5%), the left lobe of liver in 101 (28.5%), and the head of pancreas in 37 (10.5%) patients. A total of 110 postoperative complications occurred in this subset of patients corresponding to a complication rate of 31.2%. A total of 48 postoperative deaths occurred in this subset of patients corresponding to a mortality rate of 13.6%. The 5-year survival rate for all patients who underwent combined gastrectomy with adjacent organs was 25%. Of the node-negative T4 gastric cancer resections, 37% survived 5 years whereas the T4 node-positive resections have only a 15% 5-year survival. CONCLUSIONS: Patients who present with T4 gastric cancer (about 20% of the patient population) will benefit from aggressive en bloc surgical resection and should not be considered unresectable.

Adult↗
PubMed2003

[Solid-pseudopapillary tumor of the pancreas: a clinical study of five cases, and review of the literature].

INTRODUCTION: Solid pseudopapillary tumors of the pancreas are rare and their origin is unknown. The aim of this work was to report five new cases. MATERIAL AND METHODS: Retrospective study of data from patients operated on from 1983 to 2002 in a university hospital specialized in pancreatic surgery. Patients were identified in a prospectively constituted database of pathologic examinations. RESULTS: Five patients (three men and two women, aged from 15 to 69 years) underwent pancreatectomy for a solid pseudopapillary tumor, which was discovered fortuitously by imaging in three cases. Tumor diameter ranged from 4 to 15 cm. Diagnosis was made preoperatively in only one patient. There were three pancreaticoduodenectomies and two left pancreatectomies, with extension to the transverse colon due to vascular reasons in two cases. Only one significant complication occurred (one colonic fistula). With a follow-up ranging from 6 months to 6 years, all patients are alive without recurrence. CONCLUSIONS: Solid pseudopapillary tumors are not exceptional in men. Complete resection can need extension to neighboring organs but allows good long-term survival.

Adolescent↗
PubMed2002

Preoperative fenestration for type A acute aortic dissection with mesenteric malperfusion.

We report a case of a 71-year-old man presenting with acute type A aortic dissection and mesenteric ischemia due to extension of the intimal flap to the mesenteric artery. Because of the severity of the abdominal symptoms, surgical correction of the ascending aorta was delayed. Preoperative percutaneous fenestration was performed successfully, allowing ascending aortic replacement 6 days later. Transverse colon stenosis secondary to preoperative ischemia occurred in the postoperative course. The patient was discharged from hospital with normal intestinal transit 72 days later.

Aged↗
PubMed1984

Washout versus non-washout (Picolax) preparation for double-contrast barium enemas.

A non-washout preparation using Picolax in 40 patients, compared with a standard method using washouts in 38 patients, showed no significant difference in the contamination by residual formed or semiliquid faeces, although Picolax was associated with significantly more contamination due to adherent faeces and mucus. The overall differences in contamination were most marked in the transverse colon. Picolax also affected the smooth muscle tone of the bowel wall, causing an increase in 'mucosal crinkling'.

Barium Sulfate↗