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PubMed2003

Massive ischemic intestinal necrosis at the onset of diabetes mellitus with ketoacidosis in a three-year-old girl.

A previously healthy 3-year-old girl had severe diabetic ketoacidosis complicated by hypovolemic shock. When her abdominal pain and acidosis failed to improve despite vigorous fluid resuscitation and insulin therapy, further investigation found an intestinal perforation. At laparotomy, gangrenous bowel was found, requiring an extensive enterectomy from the distal jejunum to the transverse colon; less than 90 cm of viable small intestine remained. The child survived a complicated postoperative course and currently is thriving on a normal diet.

Child, Preschool↗
PubMed1986

Idiopathic colo-colic intussusception.

A three-month-old infant presented with transverse colon intussusception. Rapid progression of the illness and inability to reduce the intussusception by hydrostatic barium examination characterize the clinical course of this condition. At operation, no leading point was found, however, the entire colon was not fixed to the parietal peritoneum. Mobility of the colon may have contributed to the formation of this peculiar intussusception.

Colonic Diseases↗
PubMed1989

Idiopathic intestinal perforations in the newborn: an increasingly common entity.

Between 1982 and 1987 seven neonates ranging in age from 24 hours to 1 week were treated for idiopathic intestinal perforations at the Montefiore Medical Center, Albert Einstein College of Medicine. Four of the infants were born prematurely; three were full term. Five were being treated in an intensive care nursery when the perforation was diagnosed. All infants whose perforations were due to necrotizing enterocolitis, appendicitis, Hirschsprung's disease, meconium ileus, intestinal atresias, or drug therapy are excluded from the series. None of the infants had associated anomalies. The sites of the perforations were as follows: two in the jejunum, two in the ileum, one in the cecum, and two in the transverse colon. Six of the perforations were on the antimesenteric aspect of the bowel; one was on the mesenteric aspect. The sizes of the perforations ranged from pinhole to 1 cm in diameter. All the infants did well. Pathologic examination of the resected specimens failed to reveal an etiology for the perforations. There were no cases of duplication or muscular hypoplasia. We believe the etiology of this condition may be ischemic necrosis, secondary to a localized vascular accident in the wall of the affected viscus, but we do not have a good explanation for the upsurge in cases we are seeing.

Colonic Diseases↗
PubMed1996

Intestinal neuronal dysplasia as a cause of surgical failure in Hirschsprung's disease: a new modality for surgical management.

Two hundred fifteen cases of Hirschsprung's disease (HD) had follow-up after definitive surgical treatment, which had been performed between September 1983 and August 1994. Of these, 20 (9.3%) had recurrence of obstructive symptoms that was unresponsive to conservative treatment. Nine cases were improved by posterior anorectal myectomy (PARM). The other 11 patients, who did not have improvement after PARM, had a re-pull-through. Reoperation consisted of excision of the descending and left transverse colon with pull-through of the right colon, regardless of the histology of the colon. The blood supply was based on the ileocolic vessels, with or without division of the right colic artery. To provide a smooth course for these blood vessels, without kinking, and to obtain adequate length of the right colon with less dissection, the entire bowel was derotated clockwise. Re-pull-through was then performed from the left side of the abdomen. The excised bowel from both operations was examined, using H&E staining, for possible evidence of intestinal neuronal dysplasia (IND) or acquired aganglionosis. All had ganglion cells in the remaining colon and at the distal limit of the pull-through. Histological signs of IND were present in all patients in the previously pulled-through colon. Apart from one mentally retarded child, all had satisfactory bowel movement in a 10 to 54-month follow-up period. IND should be considered a cause of surgical failure in HD. Subtotal colectomy and pull-through of the right colon after clockwise derotation of the entire bowel appears to be effective when symptoms persist after conservative therapy or PARM.

Anastomosis, Surgical↗
PubMed1996

Intractable constipation with a decrease in substance P-immunoreactive fibres: is it a variant of intestinal neuronal dysplasia?

After Hirschsprung's disease was ruled out for 25 children who had severe chronic constipation, the authors studied the distribution of immunoreactivity for substance P (SP) and vasoactive intestinal peptide (VIP) in the intestinal wall, using immunofluorescence. SP and VIP immunoreactivity identify excitatory and inhibitory nerve fibres, respectively. Full-thickness rectal biopsy specimens were unsatisfactory, so seromuscular biopsies of the caecum, transverse colon, and sigmoid colon were obtained (by laparoscopy and laparotomy; n = 10 patients). SP-immunoreactive fibres were markedly reduced in seven, with concomitant reduction of VIP-immunoreactive fibres in four. In two other patients, there was no obvious reduction in SP- or VIP-immunoreactive fibres. In a patient who subsequently was found to have multiple endocrine neoplasia type 2b, the myenteric plexus was markedly hyperplastic, with an increase in nerve cells and nerve fibres. VIP-immunoreactive fibres were increased, but SP-immunoreactive fibres were markedly decreased. Surgical options included proximal stoma, Malone operation, and subtotal colectomy with preservation of the rectum. Three children with subtotal colectomy have had improvement over short-term follow-up. The combination of seromuscular laparoscopic biopsies and immunofluorescence demonstration of neuropeptides may identify new variants of intestinal neuronal dysplasia than can be treated successfully with surgery.

Adenomatous Polyposis Coli↗
PubMed1997

Esophageal replacement in children who have caustic pharyngoesophageal strictures.

Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx, and esophagus is a challenging reconstructive problem. The authors report on seven patients who required total esophageal replacement from the pharynx to the stomach. Injury occurred from alkali in six and acid in one. Age at injury ranged from 14 months to 14 years (mean, 4.5 years.) in five boys and two girls. Time from injury to esophageal replacement was 6 months to 10 years (mean, 3.5 years). Two required pharyngeal reconstruction before and one after esophageal replacement. Six patients had an isoperistaltic right or transverse colon interposition. One who had gastric necrosis had an ileo-right colonic substernal interposition with creation of a jejunal reservoir. Results of barium swallows showed intact anastomoses in all patients. There were no leaks. Most had some degree of mild to moderate aspiration, and one who had left vocal cord paralysis had initially massive aspiration. Three patients currently eat regular diets; four eat but still require supplemental tube feeds. The authors conclude that children who have hypopharyngeal scarring and obliterated esophageal inlet can undergo a successful colonic esophageal replacement with high proximal pharyngocolic anastomosis.

Adolescent↗
PubMed1997

Blunt abdominal trauma in children: risks of nonoperative treatment.

This retrospective study includes 203 children who had intraabdominal injuries after blunt trauma, mainly bicycle accidents and falls. Of 145 patients with splenic injury, seven underwent surgery. There was a 100% splenic salvage rate. Twenty-nine children had hepatic injury and four underwent laparotomy. One patient who was initially treated conservatively had a complicated clinical course with rebleeding that led to two laparotomies. Three of 10 pancreatic injuries were operated on; one of them 4 weeks after the trauma because of a pseudocyst. Nineteen patients had gastrointestinal tract injuries. Of seven intramural hematomas, five were treated nonoperatively. Twelve patients had gastrointestinal perforations. Seven underwent laparotomy without delay. Three patients underwent surgery 24 hours after admission because of severe abdominal rigidity or pneumoperitoneum. There was one case of severe in-hospital delay in which splenic and hepatic injuries were thought to account for the physical findings. At laparotomy 36 hours after admission, a jejunal rupture and necrosis of the transverse colon were found. Nonoperative management of blunt abdominal trauma has been very successful regarding splenic ruptures. Conservative management of hepatic injuries is more hazardous, and treatment of pancreatic injuries is a matter of controversy. Gastrointestinal-tract perforations are difficult to diagnose and important to bear in mind while keeping a conservative attitude toward abdominal trauma.

Adolescent↗
PubMed1999

The association of absent suspensory ligaments of the liver and Marfan syndrome.

Gastrointestinal manifestations of collagen diseases are very rare. The authors report on a patient who has features of Marfan syndrome with mobile liver caused by the absence of its suspensory ligaments. This patient presented with an acute intestinal obstruction secondary to a congenital band across the distal transverse colon. Recurrent intestinal obstruction after resection of the band necessitated the performance of partial colectomy with ileotransverse anastomosis. The patient's phenotypic features are suggestive but not diagnostic of Marfan syndrome. Nevertheless, isolated skeletal manifestations of Marfan syndrome with documented FBN1 gene mutation have been reported, suggesting the existence of milder forms of the syndrome not exhibiting the classic diagnostic criteria. The authors postulate that the absence of suspensory ligaments of the liver in this patient could be attributed to the defective connective tissue of Marfan syndrome.

Adolescent↗
PubMed1999

Congenital absence of the superior mesenteric artery.

Atresias of the intestinal tract are one of the causes of congenital intestinal obstruction. The superior mesenteric artery supplies the midgut from the fourth portion of the duodenum to the midportion of the transverse colon. Absence of the superior mesenteric artery (SMA) with subsequent absence of jejunum, ileum, appendix, and right colon is a previously unreported condition. A fetal vascular accident might result in this intestinal catastrophe.

Appendix↗
PubMed2003

Laparoscopic omental flap for the treatment of major sternal wound infection after cardiac surgery.

BACKGROUND: The ideal reconstructive procedure after sternal debridement is still a matter of debate. The omentum might be theoretically preferable for its favorable properties, but it is seldom used because it entails the added trauma of a laparotomy. METHODS: Three female patients with severe osteomyelitis after myocardial revascularization underwent sternal debridement and filling of the defect with a laparoscopically prepared omental flap. Sternal wound closure was achieved as a single-stage procedure in 2 patients. The third patient had a poststernotomy septicemia and required a 2-stage procedure. The abdominal procedures were conducted through 3 operating 5-mm ports. Omental flaps were developed by complete separation from the transverse colon and lengthening by division of some anastomosing arteries between gastroepiploic vessels and Barkow's arcade. Thoracic transposition of the omentum was achieved through a 5-cm diaphragmatic incision. The flaps were able to reach the base of the neck and fill the sternal defect in all patients. RESULTS: A smooth postoperative course was observed. Oral intake was started from day 2; sole oral nutrition was maintained from day 3 or 4. Optimal wound healing was observed with minimal or absent local discomfort. Minor transient paradoxical movements of the anterior chest wall disappeared within 1 month. Postoperative hospital stay was 9, 14, and 14 days, respectively. CONCLUSIONS: Laparoscopic omentoplasty, compared with the open procedure, entails several advantages for the treatment of sternal osteomyelitis. The introduction of minimally invasive techniques may widen the indications for the use of the omentum in the treatment of major sternal wound infections.

Coronary Artery Bypass↗
PubMed1990

Tapered intraluminal versus imbricated extraluminal valve: comparison of two continence mechanisms for urinary diversion.

One of the major limitations of continent intestinal reservoirs currently in use is failure of the efferent continence mechanisms. Unsatisfactory results have been reported in the literature in up to 40% of cases. While progress has been made toward better continence in urinary diversions, evolution of the actual continence mechanisms has been along two rather distinct paths: those with a valve mechanism placed inside the pouch (either by intussusception or surgical insertion), and those with the valve outside to the pouch (by imbrication of an externally located ileal segment). A canine experimental model was used to investigate a type of intraluminal continence mechanism and to compare it to an extraluminal imbricated ileocecal valve. In eight mongrel dogs a reservoir was made out of ascending and transverse colon with two different valve mechanisms--one intraluminal and one extraluminal--connected via separate stomas to the skin. Radiographic, sonographic, endoscopic and urodynamic studies of the pouch and its outlets were performed. Results showed that, in contrast to the extraluminal valve, continence in the intraluminal valve was volume dependent. The valve closing pressure of the intraluminal continence mechanism increased far beyond the values of the extraluminal valve (50.38 vs. 30.12 cm. H2O) at maximum pouch filling. Leakage of the intraluminal valve was observed at significantly higher pouch volumes than in the extraluminal valve (348 cc vs. 215 cc). In view of these results, the volume dependent intraluminal valve mechanism appears superior to an extraluminal type, especially at higher pouch volumes.

Animals↗
PubMed1987

Transitional cell carcinoma in the Muir-Torre syndrome.

The association of multiple sebaceous neoplasms and visceral malignancies is known as the Muir-Torre syndrome. We describe a patient who had papillary transitional cell carcinoma of the right renal pelvis resected in 1981 and papillary transitional cell carcinoma of the left renal pelvis removed surgically in 1983. Recurrent transitional cell carcinoma necessitated further resection of tumor in the right renal pelvis in 1983, right nephrectomy and partial ureterectomy in 1984, and removal of the right ureteral stump in 1985. History included multiple seborrheic keratoses, a keratoacanthoma and 4 sebaceous carcinomas between 1968 and 1985. In 1971 partial colectomy and jejunectomy were performed for stage D (Duke classification) adenocarcinoma of the transverse colon. Despite this the patient remains alive and well with no evidence of residual or metastatic disease. The Muir-Torre syndrome is a subtype of the cancer family syndrome, with gastrointestinal tract tumors being the most frequent visceral malignancies. Urinary tract carcinomas are present in just more than 10 per cent of the cases. This entity is discussed and the literature is reviewed with emphasis on the urological associations.

Aged↗
PubMed1982

Management of urinary and bowel complications after ileal conduit diversion.

Serious urinary and bowel complications after ileal conduit diversion are associated with significant morbidity and mortality rates. We reviewed 9 patients treated at our institution during the last 5 years for sequelae after ileal conduit diversion for bladder cancer. Of these patients 8 are well and 1 died postoperatively of a myocardial infarction. In all, 33 operations were required to treat complications after initial diversion. A variety of surgical procedures, including anastomotic revision, ileal ureter, stomal revision, transverse colon conduit and nephrectomy, was used to treat urinary complications. A treatment outline emphasizing an initial conservative approach, the importance of nutritional support and the appropriate options for reconstruction is presented.

Abscess↗
PubMed2001

Effects of internal biliary bypass on the regulation of hepatic cholesterol 7alpha-hydroxylase activity in rats.

In order to re-evaluate the importance of the enterohepatic circulation of bile acid in the regulation of the activities of hepatic cholesterol 7alpha-hydroxylase, bile acid metabolism was examined in internal biliary bypass models of rats. A polyethylene tube was inserted into the common bile duct and another side of the tube was placed in the duodenum (DD), lower jejunum (JD), cecum (CeD), or transverse colon (CoD) as internal biliary bypass models and in the urinary bladder as an external biliary drainage (ED). After bile diversion for 7 days in each group, hepatic cholesterol 7alpha-hydroxylase activities, bile acid concentrations in bile, serum, and portal vein, biliary bile acid compositions, and intestinal absorption rates of infused labeled taurocholic acid were analyzed. Hepatic cholesterol 7alpha-hydroxylase activity was similar in the JD group compared with the DD group, however, it was significantly up-regulated in the CeD (227% of the DD group), CoD (312%), and ED groups (316%). Biliary, serum, and portal bile acid concentrations were not significantly changed in the DD, JD, and CeD groups but those were significantly lower in the CoD and ED groups compared with the DD group. The proportion of the secondary bile acids was significantly increased in the CeD group and was decreased in the CoD and ED groups. The absorption rate of taurocholic acid was almost 100%, 56%, and 23% in the JD, CeD, and the CoD group, respectively. As the cholesterol 7alpha-hydroxylase activity was not significantly changed in the JD group and the predominance of secondary bile acids did not suppress the enzyme activity in the CeD group, the luminal factor, which is absorbed in the presence of bile acids, and the bile acid metabolites are not likely the regulatory factor. The cholesterol 7alpha-hydroxylase activity seems to be primarily regulated by the intestinal absorption of bile acids and partly by the intestinal mucosal factor which is linked to the intestinal bile acid absorption.

Animals↗
PubMed2001

Urinary diversion in gynecologic oncology.

Urinary diversion in gynecology is performed primarily in conjunction with cancer surgery, but at times, it is required for women with intractable urinary fistulas or other urologic disorders. After 1950, ileal conduits replaced ureterosigmoidostomies as the most widely used form of urinary diversion. Transverse colon conduits have gained popularity because these nonirradiated bowel segments offer less risk for postoperative urinary leaks and small bowel complications associated with bowel and ureteral anastomoses. In 1978, Kock et al described the use of detubularized segments of ileum and the intussuscepted nipple valves to create a continent pouch that is still advocated by urologists in some centers. Ileocolonic continent pouches, originally suggested in 1908, have received considerable attention in the past 10 to 15 years because of ease of construction, lower revision rates, and higher continence rates compared with the Kock ileal pouches. At the Division of Gynecologic Oncology at the University of Miami, the authors have been using the Miami pouch as the preferred form of continent urinary diversion since 1988, with acceptable results. Women who need urinary diversion can be offered at least two major choices: (1) the traditional bowel (ileum or colon) conduit, which requires an external ostomy appliance, or (2) a continent pouch, such as the Miami ileocolonic reservoir. In choosing between non-continent and continent conduits, the patients must be made aware that the continent pouches are available in only a few centers in the United States and carry a slightly higher risk for complications because of the relatively higher complexity. Nonetheless, data strongly suggest that most of these complications can be managed noninvasively and that these patients retain a closer to normal quality of life. The age, disease status, and general health of the woman and the likelihood of her long-term survival after diversion weigh heavily in the final decision.

Female↗
PubMed1989

Use of the omentum in chest-wall reconstruction.

Increased use of the omentum in chest-wall reconstruction has paralleled the refinement of anatomic knowledge and the development of safe mobilization techniques. Important anatomic points are the omental attachments to surrounding structures, the major blood supply from the left and right gastroepiploic vessels, and the collateral circulation via the gastroepiploic arch and Barkow's marginal artery. Mobilization of the omentum to the thorax involves division of its attachments to the transverse colon and separation from the greater curvature to fabricate a bipedicled flap. Most anterior chest wounds and virtually all mediastinal wounds can be covered with the omentum based on both sets of gastroepiploic vessels. The arc of transposition is increased when the omentum is based on a single pedicle, allowing coverage of virtually all chest-wall defects. The final method of increasing flap length involves division of the gastroepiploic arch and reliance on Barkow's marginal artery as collateral circulation to maintain flap viability. With regard to chest-wall reconstruction, we have included the omentum in the armamentarium of flaps used to cover mediastinal wounds. The omentum is our flap of choice for the reconstruction of most radiation injuries of the chest wall. The omentum may also be used to provide protection to visceral anastomoses, vascular conduits, and damaged structures in the chest, as well as to cover defects secondary to tumor excision or trauma. In brief, the omentum has proved to be a most dependable and versatile flap, particularly applicable to chest-wall reconstruction.

Humans↗