Hirschsprung's disease in adults: the Duhamel procedure

Hirschprung's disease is a rare condition in the adult. We present three patients with Hirschsprung's disease who successfully underwent the modified Duhamel procedure. The diagnosis was suspected on the basis of the typical medical history of lifelong constipation. The diagnosis was confirmed by anorectal manometric studies and/or full thickness rectal biopsy. The relief of the marked preoperative abdominal distention was complete and the bowel movements were active and smooth. Two out of three had perfect faecal control and continence. The Duhamel-Martin procedure seems a safe and reliable technique in the treatment of Hirschsprung's disease.

Prolonged hyperlipasemia attributable to a novel type of macrolipase

BACKGROUND

We present the case of an 80-year-old woman who was admitted to hospital with an intermittent volvulus of the right colon. A total colectomy was performed. Initially, serum amylase and lipase increased concordantly, but after a few weeks amylase normalized (85 U/L), whereas lipase increased to 3764 U/L. This discrepancy and persistence of hyperlipasemia suggested a macromolecular form of lipase.

METHODS

The nature of the macromolecular complex was studied using high-pressure liquid gel-permeation chromatography, affinity chromatography, (immuno)electrophoresis, and immunodiffusion.

RESULTS

Gel-permeation chromatography revealed a macrolipase, with a molecular mass >900 kDa, that contributed up to 56% of total serum lipase activity. Butanol extraction of the specimen did not alter the elution profile. The thermostabilities of pancreatic lipase and the macroform were similar, whereas activation energy (E:(a)) was lower in the macromolecular lipase (28 +/- 4 kJ. mol(-1). K(-1) vs 48 +/- 7 kJ. mol(-1). K(-1) (P: = 0.02). Agarose electrophoresis showed a broad band of lipase activity at the application site. Protein A-Sepharose affinity gel chromatography excluded IgG-linked lipase. Agarose electrophoresis and immunofixation excluded linkage to other immunoglobulins. Radial immunodiffusion did not show lipase activity in the immunoglobulin precipitation bands. Radial immunodiffusion with alpha(2)-macroglobulin (alpha(2)-MG) antibodies showed a diffuse spot of lipase activity within the precipitation band, suggesting a macromolecular association between lipase and alpha(2)-MG. Affinity gel chromatography against alpha(2)-MG showed lipase activity in the alpha(2)-MG-bound fractions.

CONCLUSION

This is the first report of a macrolipase in which an association between alpha(2)-MG and lipase is described.

Laparoscopic repair of perforated duodenal ulcer. A prospective multicenter clinical trial

BACKGROUND

A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated.

METHODS

All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%.

RESULTS

The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study.

CONCLUSIONS

Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery.

Paraoesophageal hernia with acute intrathoracic volvulus of the stomach after laparoscopic Nissen fundoplication

In experienced hands, the value of the laparoscopic Nissen fundoplication as antireflux correction is established. The case report concerns a woman who underwent an emergency laparotomy for acute intrathoracic stomach volvulus with incarceration, one year after a laparoscopic Nissen fundoplication was carried out without closure of the diaphragmatic hiatus. In literature acute postoperative paraoesophageal hernia with intrathoracic migration of the stomach as an early and late complication of the laparoscopic fundoplication has already been reported. The authors advocate the closure of the diaphragmatic crura as a routine manoeuvre during the laparoscopic fundoplication.

Pitfalls in laparoscopic cholecystectomy

On the basis of literature and of 475 laparoscopic cholecystectomies of the authors, some pitfalls are reviewed. The circumstances, the mechanism and the prevention of injuries were detailed together with the connected problem of postoperative bile leakage. Among the cholangiographic pitfalls the importance of detection of congenital and acquired anomalies of the biliary tree by means of preoperative ERCP or intraoperative trans-cystic cholangiograms was emphasized. A particular study was made of 3 pictures: Mirizzi syndrome; stone impaction in Vater's papilla; no retrograde flow of the common hepatic duct on intraoperative cholangiograms. Biliodigestive fistulas were briefly commented. The problems with cystic duct stones, particularly the treatment of stones in a long, low inserted cystic duct with retroduodenal course and the closing of thick-walled or wide cystic stumps, were explained. In patients with intraoperative residual common bile duct stones and with failed preoperative catheterization of the papilla, the authors advocate their double approach technique. This combined intraoperative laparoscopic and postoperative endoscopic procedure is carried out via the same transcystic polythene catheters as used for cholangiography and external biliary drainage of the common bile duct.

Pancreatic-duct reflux and acute gallstone pancreatitis

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Pancreas divisum: a teenager with calculi in the duct of Santorini. Report of a case treated by double drainage procedure

Since the age of sixteen, a teenager suffers from acute recurrent pancreatitis with a weight loss of 17 kg, without evident etiologic factor. At laparotomy the duct of Wirsung is absent; calculi are found in a grossly dilated duct of Santorini and the minor papilla is stenosed with periductal fibrosis and a large retention pseudocyst. Recurrent pancreatitis is cured by sphincteroplasty of the minor papilla and side-to-side pancreatico-jejunostomy. After a follow-up of 17 months the recurrent pancreatitis seems cured by sphincteroplasty of the minor papilla and side-to-side pancreatico-jejunostomy.

[Resection of a voluminous malignant tumor of the adrenal cortex by a combined thoraco-abdominal approach. Excellent survival over 5 years (author's transl)]

The case of a 41 year-old female presenting a voluminous (2 kg) non-functioning tumor of the adrenal cortex with excellent survival at 5 years and 3 months is reported. The tumor extended mainly cephalad and occupied the cerebral right hepatic space. The importance of preoperative inferior cavogram as well as a large thoraco-abdominal approach is stressed. The key to success is exposure and control of the entire segment of the inferior vena cava between renal vein and diaphragm. Particular attention must be paid to the middle (principal) suprarenal vein, a very short vessel (less than or equal to 1 cm) on the right side, which may enter either the inferior vena cava on the right suprahepatic vein.

Benign stenosis of the papilla of Vater. Diagnosis of 119 cases with conventional and selective low radiomanometry

Intra-operative radiomanometry with serial conventional films (panoramic cholangiography) and intra-abdominally placed large dental films (selective low cholangiography) produce a dynamic and static, millimetric study of the lower part of the common duct. It revealed in 2,095 patients with benign biliary pathology 119 cases of stenosis of the papilla of which 34 are detected during secondary operations of 85 patients. With the procedure of the authors a clear definition of the benign stenosis of the papilla is obtained radiomanometrically: 1. moderate hypertony; 2. disappearance of the normal rhythmical sphincter activity; 3. the biliary infundibulum, no longer conical, is wider than the intrapancreatic part of the common bile duct above it; 4. the biliary pancreatic reflux more rarely appears and, if it is discernible, pancreatic reflux is shorter than expected and the pancreatic duct obviously enlarged. These signs are quite characteristic of chronic stasis in both common bile duct and pancreatic duct, from infundibulum to intrahepatic ducts above the stenosic papilla (Acta chir. belg., 1977,76,523-532).