Emergent laparoscopic repair of incarcerated incisional and ventral hernia

BACKGROUND

The role of laparoscopy in the repair of incarcerated incisional or ventral hernia is not yet established. This presentation reviews the authors' experience with patients who underwent laparoscopic surgery in presence of incarceration.

METHODS

Patients who had surgery during the years 1997 to 2001 were included in the study. All patients underwent surgery immediately after their admission. In all cases, Gore-Tex Dual Mesh was used.

RESULTS

The review included 25 patients (21 women and 4 men). Ten of these patients (40%) had undergone at least one earlier repair, and one patient (4%) underwent conversion to open repair because of small bowel injury. The mean operation time was 63 min (range, 15-20 min). The median postoperative hospital stay was 3.2 days (range, 2-7 days). There were no noteworthy postoperative complications. During the follow-up period, no patient experienced recurrent hernia.

CONCLUSIONS

The authors' current has experience demonstrated that laparoscopic repair is feasible and can be attempted for patients presenting with incarcerated incisional or ventral hernia.

Laparoscopic repair of poststernotomy subxiphoid epigastric hernia

BACKGROUND

The repair of a subxyphoid hernia is a difficult procedure that nonetheless results in a high rate of recurrence. The laparoscopic approach is a promising new technique for more efficacious treatment of this condition. This is the first report in the English-language literature to describe the use of this approach for the correction of poststernotomy subxiphoideal hernia.

METHODS

Information was retrieved from the patients' hospitalization and outpatient clinic files. Of 984 patients who had a median sternotomy, 10 developed a substernal subxiphoid epigastric hernia. These patients had all been treated laparoscopically using Gore-Tex mesh.

RESULTS

Nine patients were admitted electively and one urgently. The fascial defect sizes were 4-15 cm (mean, 8.5) in length. Intraabdominal content was adherent to the hernia in six patients; in the other four cases, the defect was adhesion free. In four patients, an incidental surgical procedure was performed (three cholecystectomies and one inguinal hernia repair using the trans abdominal preperitoneal [TAPP] technique). The operations lasted 25-120 min (average, 55). No death occurred as a result of the operations, and none of the operations was converted to an open procedure. Three patients had minor postoperative complications. During 20-42 months of follow-up, one patient suffered a recurrence.

CONCLUSIONS

Laparoscopic repair of a poststernotomy subxiphoideal epigastric hernia is feasible and has a low rate of minor complications. Our review of the literature indicates that this technique produces a better outcome than the conventional open repair.

Use of adjustable silicone gastric banding for revision of failed gastric bariatric operations

BACKGROUND

Revision of gastric bariatric operations is sometimes technically difficult and may fail to achieve prolonged weight reduction. The use of the adjustable silicone gastric banding (ASGB) offers a new approach for these revisions.

METHODS

ASGB was performed as a revisional procedure on 37 patients whose initial bariatric operations were as follows: silastic ring vertical gastroplasty (21), gastric bypass (12), horizontal gastroplasty (3) and vertical banded gastroplasty (1).

RESULTS

The length of the procedure varied from 55 to 145 minutes (mean 83 minutes). Intraoperative complications included two fundic tears which were sutured without any postoperative sequelae. Five patients needed reoperation during the first postoperative year due to gastric volvulus (1), tubing tear (1) and development of postoperative ventral hernia (3). BMI fell from 44.8+/-SD 8.07 to 33.4+/-6.9 kg/m2 for patients operated with BMI higher than 35 kg/m2 and from 29.2+/-3.32 to 25.4+/-2.8 kg/m2 for patients operated with BMI lower than 35 kg/m2.

CONCLUSIONS

ASBG can be performed with revisions with an acceptable complication rate and postoperative weight reduction.

Silastic ring vertical gastroplasty by minilaparotomy

BACKGROUND

The incision length has significant influence on the postoperative course after silastic ring vertical gastroplasty (SRVG).

METHODS

A technique is described in which SRVG can be performed through a minilaparotomy incision.

RESULTS

110 patients were operated with this technique during 1996. No remarkable intraoperative or postoperative complications were encountered. Postoperative weight loss has been satisfactory.

CONCLUSIONS

Performance of SRVG through a minilaparotomy is feasible. The technique is recommended for surgeons familiar with the operation through the formal incision.

The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture

BACKGROUND

Diaphragmatic rupture is one of the most commonly missed injuries in trauma cases. Traditionally, laparotomy or thoracotomy has been the treatment of choice for this condition.

METHODS

During the last 2 years, we treated three patients laparoscopically to address neglected diaphragmatic ruptures that caused herniation of the intraabdominal contents.

RESULTS

In all three cases, laparoscopy succeeded in identifying the diaphragmatic defect, so that the herniated viscera could be released and the defect repaired primarily or with a prosthesis. The intraoperative and the postoperative courses were uneventful; there were no significant complications.

CONCLUSION

Laparoscopy has an important role in the surgical treatment of missed diaphragmatic ruptures.

Pseudomembranous colitis: report of a severe case with unusual clinical signs in a young nurse

We describe the case of a young and otherwise healthy nurse who developed pseudomembranous colitis ten days after receiving oral clindamycin for dental infection. Her clinical course was particularly stormy and was characterized by severe diarrhea and vomiting, profuse ascites, pleural effusion, abdominal tenderness, peritoneal irritation, and systemic toxicity. The Clostridium difficile assay was negative on two occasions. Features compatible with pseudomembranous colitis were seen at sigmoidoscopy, and the diagnosis was confirmed by biopsies.

Laparoscopic repair of postoperation ventral hernia. Early postoperation results

BACKGROUND

Laparoscopic repair is a new alternative approach to postoperation ventral hernia (POVH). Whether this procedure is accompanied with acceptable operation risk and recurrence rate is not yet established.

METHODS

During 1996, we performed laparoscopic repair of POVH in 53 patients. Twenty-nine (55%) of these patients had a history of at least one failed hernia repair. The size of the abdominal wall defect varied from 4 x 5 cm to 15 x 20 cm (median, 13 x 9 cm). All operations were performed with the patient under general anesthesia. In all cases, the Gore-Tex(R) Dual Mesh (W. L. Gore & Associates, Flagstaff, AZ, USA) was used in sizes varying from 5 x 7 cm to 20 x 30 cm (median, 15 x 12 cm).

RESULTS

No deaths occurred as a result of the operations. Intraoperative small bowel injury occurred in two patients (3.6%), which necessitated conversion to laparotomy and performance of small bowel resection in one case and simple suture in the other. Small bowel obstruction developed during the immediate postoperation period in two patients (3.6%). In one of these patients, laparoscopic lysis of adhesions had to be performed. Graft infection with subsequent graft removal occurred in one patient (1.8%), and abdominal wall hematoma developed in another patient (1.8%). Length of hospital stay varied from 2 to 8 days (median, 3.3 days). Follow-up period ranged from 10 to 22 months (median, 17 months). During this period, recurrence of hernia occurred only in one patient in which the mesh had been removed.

CONCLUSIONS

Laparoscopic repair of POVH is technically feasible. According to our experience, it is the preferred method for patients who have had an earlier failed open repair and patients in whom it is the first repair. Cases with a high likelihood for small bowel injury must be recognized and converted to routine open repair.

The effect of surgically induced weight reduction on the serum levels of the cytokines: interleukin-3 and tumor necrosis factor

BACKGROUND

Morbid obesity and malnutrition have both been demonstrated to have deleterious effects on the immune function. Cytokines are immunomodulatory peptides that have profound effects on immune function. To the authors' knowledge, the effect of surgically induced weight reduction on the cytokine levels has yet not been studied. In the present study, the authors determined the effect of surgically induced weight reduction on the levels of the cytokines interleukin-3 (IL-3) and tumor necrosis factor-alpha (TNF-alpha).

METHODS

14 patients undergoing silicone ring vertical gastroplasty were included in the study (mean BMI 48.85 kg/m2; range 38.1-52.0 kg/m2). Determination of the IL-3 and TNF-alpha levels was performed preoperatively and 14 days and 6 months postoperatively, when all patients had lost 25% to 30% of their preoperative weight.

RESULTS

The IL-3 values before the procedure, and 14 days and 6 months after, were as follows: 9.69 +/- 1.82, 9.36 +/- 1.28, and 8.42 +/- 1.26 pg/mL, respectively (P < 0.05 preoperative versus 6 months postoperative level). The preoperative TNF-alpha levels showed a wide distribution. For this reason, the patients were divided into two groups: Group A with preoperative values >10 pg/mL and Group B with values <10 pg/mL. In Group A, a significant decrease from the preoperative level of 24.46 +/- 6.83 to 7.59 +/- 4.56, and 6.69 +/- 5.46 pg/mL was measured at 14 days and 6 months postoperatively, respectively (P < 0.05). In Group B, the TNF-alpha levels were not significantly changed and were 5.45 +/- 2.26, 7.59 +/- 4.56, and 8.82 < or = 6.27 pg/mL, respectively.

CONCLUSION

The present study demonstrates a significant decrease in the levels of the cytokines, IL-3 and TNF-alpha. These changes can be responsible for alteration of the immune function after surgically induced weight reduction.

[Laparoscopic treatment of small bowel obstruction caused by adhesions]

We describe our experience in 14 patients operated on for small bowel obstruction, who underwent laparoscopic adhesiolysis. In 13 (93%) the obstruction was relieved and only 1 case required conversion to open operation. Bowel activity usually resumed within 24-48 hours, and there were no remarkable intraoperative and postoperative complications. During follow-up none developed recurrent obstruction. Our experience demonstrates that laparoscopic adhesiolysis is a valid therapeutic option. Additional experience is needed to determine which types of cases are suitable for the procedure.

[Laparoscopic repair of inguinal hernia--experience in 54 consecutive cases]

We describe our experience in 54 consecutive patients who underwent laparoscopic repair of 86 inguinal hernias. Laparoscopic repair of inguinal hernia is technically feasible, does not prolong the length of the procedure nor of hospitalization and is not accompanied by increased morbidity. Although there is not yet general agreement, in our experience and that of others, it appears that laparoscopic repair will be the preferred approach to the treatment of inguinal hernia.

Obstructive sleep apnea in the obese

Obstructive sleep apnea (OSA) syndrome occurs in 4% to 9% of middle-aged men and in 1% to 2% of middle-aged women. The incidence of OSA among morbidly obese patients is 12- to 30-fold higher. The pathophysiology of OSA is complex and incompletely understood. The important clinical symptoms of OSA include snoring, daytime sleepiness, restless sleep, morning fatigue, and headaches. The diagnosis is made by polysomnography. The possible sequelae of OSA are hypertension, left and right ventricular hypertrophy, sudden cardiovascular death, and increased risk for brain infarction. Nasal continuous positive airway pressure (nCPAP) appears to be the recommended treatment for OSA. Morbidly obese patients may also benefit from weight reduction gastric surgery.

Giant splenomegaly caused by splenic metastases of melanoma

Splenic metastases are rare and usually occur in the setting of widespread visceral metastases. Splenomegaly as manifestation of metastatic spread is extremely rare. A patient with melanoma and metastases to the skin and lung is described. He developed a giant painful splenomegaly. The splenectomy specimen demonstrated that the spleen was occupied by metastases from the melanoma. Metastases of melanoma may cause extreme enlargement of the spleen. If the patient's general condition is good, splenectomy is indicated in order to prevent spontaneous rupture of the spleen.

Lymph node revealing solution: a new method for lymph node sampling: results in gastric adenocarcinoma

Staging of gastric carcinoma depends on exact lymph node status. However, very small nodes are not easily found as they are obscured by the surrounding adipose tissue. The purpose of the present study was to demonstrate the usefulness of a Olymph node revealing solutionO (LNRS) in gastric cancer. The perigastric adipose tissue of ten OproblematicO cases of gastric carcinoma, in which <10 lymph nodes were found using the traditional method, was immersed in LNRS for 6-12 h. Subsequently, the lymph nodes stood out as white chalky nodules. They were excised and processed routinely. The traditional method yielded a total of 30 lymph nodes with a mean size of 6.69 +/- 3.43 mm. The LNRS revealed 89 additional nodes with a mean size of 3.03 +/- 3.43 mm, which was significantly smaller. The Node (N) stage was changed in four cases from Nx to N0, in one case from N1 to N2, and in one case from N0 to N2. LNRS seems to be the technique of choice for staging of patients with gastric adenocarcinoma in whom <10 lymph nodes were found with the traditional method and accurate staging was not possible.

Splenectomy for haematological diseases--a single institution experience

OBJECTIVES

To evaluate our experience with splenectomy for haematological disease over 15 years, focusing on the diseases and indications requiring surgery, the complications and the haematological results.

DESIGN

A single institution retrospective analysis.

SETTING

Departments of Surgery, Internal Medicine and Haematology, Rabin Medical Center, Hasharon Hospital, Petah-Tikva, Israel.

PATIENTS

Sixty-nine patients undergoing splenectomy for haematological diseases between 1980 and 1994. PARAMETERS STUDIED: (1) the patient characteristics; (2) the haematological disorders and the indications for splenectomy; (3) the splenic size; (4) perioperative complications; (5) the haematological and other results of surgery.

RESULTS

The common disease requiring splenectomy in our patient population was immune thrombocytopenic purpura (ITP). Eighteen patients (26%) suffered from ITP, 12 (17.4%) had lymphoproliferative (LP) disorders, including 11 patients with non-Hodgkin's lymphoma (NHL), 9 (13%) immune haemolytic anaemia (IHA), 8 (11.6%) Hodgkin's disease (HD), and 8 patients with myeloproliferative diseases (MPD). Fifty-two patients (75.4%) underwent surgery for therapeutic purposes while 25 patients (36.2%) underwent diagnostic surgery. Eight patients were operated on for both indications. Patients with HD and ITP were younger (mean age in the 30th year) as opposed to patients with congestive splenomegaly and LP (mean age in the 60th year). Most patients with ITP, NHL and IHA were female. Patients with HD and ITP had a small spleen (< 300 g), in contrast with HCL and MPD (> 2400 g). No perioperative mortality was observed. Twenty-one patients (30.4%) experienced perioperative complications, including bleeding in 9 patients (13%) and infection in 10 patients (14.5%). Of the 34 patients evaluable for platelet response to splenectomy, 26 (76.5%) achieved complete response (CR), including 15 of 18 patients with ITP. Eleven of the 17 (64.7%) anaemic patients evaluable for haemoglobin (Hb) response achieved CR. Eight of the 9 leucopenic patients obtained CR. In 15 patients, splenectomy established the diagnosis, including 8 patients with NHL. In 2 others, surgery confirmed the tentative diagnosis. In 2 of the 8 HD patients the spleen was found to be involved.

CONCLUSIONS

From both therapeutic and diagnostic standpoints splenectomy is a relatively safe and effective procedure. However, no long-term follow-up data are provided to allow conclusions regarding the long-term prognosis of diseases such as myelo- or lymphoproliferative disorders.

Lymph node revealing solution: a new method for detection of minute axillary lymph nodes in breast cancer specimens

The staging and prognosis of patients with breast cancer is related to the presence or absence of axillary lymph node involvement. However, in some cases no lymph nodes or too small a number of lymph nodes are revealed by the traditional method of palpating and sectioning the axillary fat. In the present study we demonstrate the usefulness of the lymph node revealing solution (LNRS) in breast cancer. Specimens from 13 patients, in whom <10 lymph nodes were identified in the axilla by the traditional method, were included in the study. After excising the lymph nodes by the traditional method, axillary tissue was immersed in LNRS for 6-12 hours. Additional lymph nodes, which stood out as white chalky nodules, were excised and processed as usual. The LNRS increased the mean number of nodes per case from 6.0+/-2.5 found by the traditional method to 12.54+/-4.61 nodes per case (p < 0.01). The size of the nodes identified by the LNRS was significantly smaller (p < 0.01) than those detected by the traditional method. The LNRS changed the lymph node stage of the disease in four of the studied cases (30%). LNRS seems to be the technique of choice for detection of axillary lymph nodes in cases where the number of detected lymph nodes by the traditional method is too small for accurate staging.

The effect of octreotide on wound healing: an in vitro and in vivo experimental study

OBJECTIVE

To investigate the effect of octreotide on wound healing.

DESIGN

Experimental studies in vitro and in rats.

SETTING

Teaching hospital, Israel.

MATERIAL

Cultured human diploid fetal fibroblasts, and 36 male Wistar rats.

INTERVENTIONS

Octreotide was added to cultures of fibroblasts in doses of 2, 10, 30, 60 and 120 ng/ml and fibroblasts were counted after 2, 4, and 6 days. Intestinal anastomoses were made in 36 rats. Rats in the octreotide group (n = 18) were given subcutaneous injections of 0.25 microg/kg twice daily and 6 rats were killed at 3, 7, and 14 days. The control group were given injections of saline. Anastomotic bursting pressures and hydroxyproline content were measured at each of the three times.

MAIN OUTCOME MEASURES

Fibroblast counts, anastomotic bursting pressures, and hydroxyproline concentrations.

RESULTS

Octreotide did not inhibit fibroblast proliferation in any of the doses at any of the time periods. The anastomotic bursting pressure was slightly higher in the octreotide group at each of the time points, but not significantly so, and there was no difference in hydroxyproline content between the octreotide and control groups. Octreotide did not inhibit wound healing either in vitro or in vivo.

Comparative study of the early postoperative course and complications in patients undergoing Billroth I and Billroth II gastrectomy

Distal gastric resection can be followed by reconstruction according to the Billroth I (BI) or Billroth II (BII) techniques. The aim of this study was to compare the early postoperative results and complications of patients undergoing BI and those undergoing BII resection. Eighty-eight patients operated during the years 1991 to 1994 underwent distal gastric resection (41 had BI, and 43 had BII resections). The indications for BI resections were gastric tumors in 39 patients (95%) and duodenal ulcer in 2 (5%). The indications for BII resection were malignancy in 28 patients (65%) and duodenal ulcer disease in 15 (35%). The average duration of the procedure was 147 +/- 28 minutes for the BI resection and 175 +/- 38 minutes for the BII resection (p < 0.05). No patient in the BI group developed anastomic leakage. Two patients who underwent BII resection developed duodenal stump leakage (4.7%). Relaparotomy was indicated in five patients, two from the BI group (malignant cells in the resection margins) and three from the BII group (one due to duodenal stump leakage and two for bleeding). There was no postoperative mortality in the BI group. The postoperative mortality in the BII group was 7.1% (p < 0.05). The average proximal gastric resection margins were significantly smaller in the BI group than in the BII group (3.65 +/- 2.83 cm and 5.18 +/- 2.57 cm, respectively; p < 0. 05). The number of lymph nodes found in the resected specimen did not differ significantly between the two groups. Recurrent tumor at the gastric remnant developed in two patients in the BI group but not in the BII group. The results of our study revealed that the BI procedure is accompanied by significantly lower postoperative complication and mortality rates than the BII procedure in cases of gastric malignancy. BI resection performed for malignancy seems to achieve smaller proximal gastric resection margins, which may influence the recurrence rate.

Lymph-node revealing solution: a new method for detecting minute lymph nodes in cystectomy specimens

OBJECTIVE

To describe the use of a new lymph-node revealing solution (LNRS) for detecting lymph node involvement in total cystectomy specimens from patients with locally confined invasive transitional cell carcinoma (TCC) of the bladder, and to compare the results obtained with those using the conventional method (palpation and sectioning perivesical fat) that may fail to detect very small lymph nodes.

MATERIALS AND METHODS

Of 12 cystectomy specimens obtained from patients with TCC, six in which 0-3 metastatic nodes were identified by the conventional method were further investigated using LNRS. The revealing solution comprised 95% ethanol, diethyl ether, glacial acetic acid and buffered formalin (65:20:5:10 v/v) prepared under a fume-hood. After evaluation using the conventional method, the specimens were immersed for 6-12 h in the solution, washed under running tap water and the adipose tissue sectioned at intervals of 2-3 mm. Lymph nodes were identified as white, chalky nodules against the background of yellow fat. The number of the lymph nodes identified by conventional and the LNRS methods was recorded and classified according the TNM system.

RESULT

Twenty-two lymph nodes were detected by the conventional method, of which four were positive for tumour metastasis. Using the LNRS, an additional 21 nodes were identified among which 12 were positive. The mean size of the lymph nodes detected by the conventional and LNRS methods was 7.96 mm and 3.81 mm, respectively. The stage of three patients was increased (Nx to N2, N0 to N2 and N1 to N2) and therefore two of these patients received adjuvant chemotherapy.

CONCLUSIONS

LNRS significantly enhanced the yield of normal and metastatic nodes of cystectomy specimens and may identify smaller nodes. The LNRS method allows a more accurate staging with better assessment of the prognosis and need for adjuvant therapy.

Massively bleeding gastric pouch ulcer after silastic ring vertical gastroplasty successfully treated endoscopically: a report of two cases

Two patients who developed massive bleeding from a gastric pouch ulcer are described. This rare complication occurred during the early postoperative course after silicone ring vertical gastroplasty (SRVG). In both cases the bleeding stopped after the ulcers were injected with epinephrine and alcohol. Both ulcers healed after 1 month of treatment with omeprazole (Losec). The probable etiology of this rare complication is discussed.

Lymph node-revealing solution: simple new method for detecting minute lymph nodes in colon carcinoma

PURPOSE

Detection of metastatic lymph nodes in colon cancer is essential for determining stage and, thus, therapeutic modalities. However, very small lymph nodes can easily be missed during routine examination. The aim of this study is to describe a new and easy technique for detecting tiny nodes in colonic specimens.

METHODS

Thirty problematic cases, in which an unsatisfactory number of lymph nodes was found by the traditional method, were investigated. The entire mesocolonic fat was immersed for six hours in a lymph node-revealing solution (LNRS) composed of various traditional fixatives and fatty solvents. After six hours, the lymph nodes stood out as white, chalky nodules on the background of yellow fat. They were then excised, processed. and stained.

RESULTS

Total number of lymph nodes found by the traditional method in the 30 cases was 88. After LNRS, 258 additional lymph nodes, measuring from 0.5 to 7 mm in largest diameter, were found. Of the 12 cases in which no lymph nodes were found by the traditional method, 8 became N0 and 4 became N1. Of the 14 cases first classified as N0, 4 became N1; of the 4 classified at first as N1, 2 became N2 after LNRS. Upstaging from Dukes B to C occurred in eight cases. Quality of the sections and histochemical and immunohistochemical stains after LNRS was similar to that of formalin-fixed tissues.

CONCLUSIONS

LNRS is an easy, rapid, and inexpensive technique for detecting very small lymph nodes. These may contain metastases, a fact that changes the stage of disease and influences the mode of therapy.

Determination of proliferative activity in colorectal carcinoma using monoclonal antibody Ki67

PURPOSE

In the search for a prognostic discriminant, Ki67 immunoreactivity of colorectal carcinoma was used to see whether this marker correlated with clinical and pathologic parameters and the ultimate prognosis of the patient.

METHODS

Fresh specimens from 30 surgically resected adenocarcinomas were obtained and frozen in liquid nitrogen. Slides were immunohistochemically stained with Ki67. Ten randomly chosen fields were examined, and 1,000 nuclei per specimen were counted. The percent positive stained nuclei determined the Ki67 score. Correlation was made with the parameters of Dukes stage, location within the colon, size of malignancy, gender, age, and survival.

RESULTS

There was a positive correlation of the Ki67 score for patients with metastatic disease, but no correlation was found to Dukes B and C cases. There was no correlation between Ki67 immunoreactivity and size or location of lesion, patient's age, patient's gender, or whether patient died of disease or developed a recurrence compared with those who survived five years disease-free.

CONCLUSION

Ki67 immunoreactivity could not be correlated with clinical and pathologic parameters except for metastatic disease in this study and was of limited use as a prognostic discriminant.

Repair of fascia with polyglycolic acid mesh cultured with fibroblasts--experimental study

In the present study polyglycolic acid (PGA) mesh was used for repair of fascial defects experimentally made in rats. In the experimental group fibroblasts were cultured on the mesh before implantation and in the control group the mesh alone was used. Rats were sacrificed 7, 14, 28 and 60 days after the implantation of the mesh. Tissues were examined microscopically and for hydroxyproline content. Microscopically good incorporation of the mesh was noted in both the control and experimental groups. However, it seems that in the experimental group earlier dissolution of the mesh occurred. The hydroxyproline content was higher in the experimental group after 7 (statistically not significant) and 14 days (p < 0.05) and in the control group after 28 (p < 0.025) and 60 days (p < 0.05). These results suggest that the use of PGA mesh with cultured fibroblasts might have a beneficial effect on wound healing.

Healing of the esophageal suture line: does it differ from the rest of the alimentary tract?

We investigated the healing pattern of the esophageal suture line in rats. Fifty male wistar rats were divided into experimental (n = 40) and control (n = 10) groups. The rats in the experimental group underwent esophogostomy at the abdominal esophagus, which was immediately sutured, and sacrificed 2, 4, 7 and 14 days later. Esophageal bursting pressure and hydroxyproline content were determined in both groups. The measured bursting pressures in the experimental group on days 2, 4, 7 and 14 were (mean +/- SD) 78 +/- 35, 95 +/- 12, 1,163 +/- 98 and 1,224 +/- 22 cm H2O, respectively, and 1,308 +/- 87 cm H2O in the control group (P <0.05 vs. all the experimental group values). The hydroxyproline content in the experimental group on days 2, 4, 7 and 14 were 13.9 +/- 2.1, 12.53 +/- 2.68, 15.6 +/- 0.85 and 17.75 +/- 5.65 microg/mg, respectively, and 27.88 +/- 2.5 microg/mg in the control group (P <0.05 vs. all the experimental group values). We conclude that the esophagus demonstrates the same healing pattern as the rest of the alimentary tract, but its healing seems to occur at a slower pace.

Outcome of Silicone Ring Vertical Gastroplasty in Patients Aged 50 Years and Older

BACKGROUND: The authors studied the results Of silicone ring vertical gastroplasty (SRVG) in Patients aged 50 years and older. METHODS: The early and late Postoperative results in 28 patients aged.50 Years or older undergoing SRVG were reviewed retrospectively, The results were compared to those of 370 Patients Younger than 50 years operated during the same period. RESULTS: There was no Postoperative mortality among patients aged 50 years and older. There was a significantly higher incidence Of Pulmonary embolus and wound infection among patients aged 50 years and older (P < 0.05). The weight loss did not differ significantly between the two studied age groups. CONCLUSION: SRVG may performed on patients aged 50 years or older with acceptable complication rate and favorable postoperative results.

Proliferative activity at rectal anastomoses performed with various suture materials. An experimental study

BACKGROUND

Suture line recurrence continues to be an important cause of failure following curative resection for colorectal carcinoma. Our aim was to determine whether the nature of the suture material used affected the proliferative activity of colonic crypt cells at the anastomosis.

METHODS AND MATERIALS

Sprague-Dawley rats were randomized into one control and three experimental groups. In each experimental group the proximal 2 cm of rectum were resected and anastomoses constructed with titanium clips, interrupted 6-0 Vicryl (Ethicon, Inc., Somerville, NJ), and interrupted 6-0 silk. Control animals had a sham operation. One-quarter of each group of rats were killed at 14, 30, 60, and 90 days. Each animal received intraperitoneal tritiated thymidine 30 minutes before death. Each anastomosis was harvested, and longitudinally oriented crypts were analyzed for the total number and position of labeled cells at five equal distances from the anastomosis. Random crypts were studied in the control group.

RESULTS

Labeling indices were increased in almost all experimental groups at days 14, 30, 60, and 90. There were no persistent, statistically significant differences in labeling indices among the various suture materials.

CONCLUSION

The type of suture material used did not significantly affect the proliferative rate in this animal model.

Adenocarcinoma at ureterosigmoidostomy junction in a renal transplant recipient 15 years after conversion to ileal conduit

In recent years, adenocarcinoma of the colon mucosa has become a recognized complication of ureterosigmoidostomy and in most cases the tumor arises at the site of ureterocolonic anastomosis. We report a case of a 29-year-old renal transplant recipient who developed two colonic carcinomas at the site of ureterosigmoidostomy 25 years after the urinary diversion and 15 years after conversion to an ileal conduit. This case emphasizes the need for a careful life-long follow-up of all patients who undergo ureterosigmoidostomy.

Patient-Controlled Analgesia Following Vertical Gastroplasty: a Comparison with Intramuscular Narcotics

BACKGROUND: patient-controlled analgesia PCA is a rapidly spreading approach to the management of post-operative pain. The suitability of this method for the morbidly obese patient undergoing bariatric surgery has not yet been determined. METHODS: in the present study we randomly compared two groups of patients undergoing silastic ring vertical gastroplasty. One group received PCA (12 patients) and the other (11 patients) received intermittent doses of pethidine intramuscularly. RESULTS: the cumulative morphine use during the first post-operative day was 52.71 +/- 1.83 mg by the PCA group and an equivalent of 24.55 +/- 3.42 mg morphine by the IM pethidine group (p = 0.0002). The analgesic and sedative effects by the PCA were found to be superior. There were no significant differences between the groups in the incidence of side-effects or complications, except a higher, unexplained incidence of wound infection in the PCA group. CONCLUSION: use of PCA in patients undergoing bariatric surgery has obvious advantages and appears to be a safe procedure.

Erroneous diagnosis of left ureteric injury leading to insertion of double J catheter to the left spermatic vein

A case of erroneous diagnosis of left ureteric injury and its results is reported. An 86-year-old man was operated on for perforated diverticulitis. A tubular structure was injured at the left paracolic gutter and repaired over double J catheter. Six months later the proximal side of the catheter was found in the right ventricle, because it has been introduced into the spermatic vein and not into the left ureter.

Peritoneal band containing talc: rare cause of small bowel obstruction in a previously unoperated child

The authors report on a 10-year-old boy who was operated on for small bowel obstruction. The obstruction was caused by a peritoneal band that was found to contain talc of an unknown source. The possible explanation for this rare pathology is discussed.

Proliferative activity at colonic anastomoses as determined by statin. A nonproliferation-specific nuclear protein

PURPOSE

One theory of anastomotic recurrence in large bowel carcinoma is that epithelial hyperplasia at the suture line causes metachronous carcinoma.

METHODS

S44, a monoclonal antibody directed against statin, a nuclear protein expressed in quiescent cells, was used to determine whether the anastomosis represents an area with a high proliferation rate. During follow-up colonoscopic examination of patients who had undergone previous resection for colorectal carcinoma, biopsies were taken from the anastomotic site and from the mucosa 10 to 15 cm from the anastomosis. One side of 10 well-oriented crypts was counted for each patient with the number of nuclei positive for statin being determined by the presence of dark brown reaction product.

RESULTS

The average percentages of statin-positive cells varied between 19.4 and 44.4 (average, 31.3 +/- 6.5) for the normal mucosa and 22.8 to 35.1 (average, 29.98 +/- 3.67) for the anastomotic mucosa. The differences were not significant. There were no differences between those patients in whom the postoperative time elapsed was two years or less and those greater than two years.

CONCLUSION

This study is unique in that the proliferative activity at the site of colonic anastomosis was determined in a clinical setting, and patients in which the anastomoses were created anywhere from 1 to 14 years earlier were included. Using S44 as a marker, this study does not support the theory that suture line recurrence is a result of an enhanced proliferation rate.

The prophylactic use of ureteral catheters during colorectal operations

The necessity for preoperative ureteral catheter insertion for colorectal operations continues to be controversial. To determine our experience and what complications might be associated with ureteral catheter use, the charts of all patients in our department undergoing ureteral catheterization in combination with colorectal procedures between the years 1978 and 1989 were reviewed. The indications for operation, the presence or absence of urinary tract symptoms, and intravenous pyelogram findings (if performed) were recorded. Time for the procedure, size and number of catheters, and complications were noted. From the operative report, a retrospective grading of necessity for ureteral catheterization was assessed according to a scale from A to D. There were 120 ureteral catheterizations performed, bilaterally in 60 per cent of cases. Complications included renal colic (1), oliguria (1), and anuria (2). Intraoperatively, one ureter was cut and one ureter tied but recognized by palpation and ligature removed. Retrospective grading deemed ureteral catheterization necessary in 27.5 per cent of cases. We conclude that catheters are helpful in selected cases. For patients with bilateral catheter insertion, complications can be reduced by ensuring urine output prior to removal of the second catheter.

Hidden colostomy

For the patient with an unresectable carcinoma of the rectum, establishment of a "hidden" colostomy rather than formal colostomy, provides a better interim quality of life. When necessary, the "hidden" colostomy can readily be converted to a formal colostomy without the need for a laparotomy or general anesthetic. We conclude that surgeons should remember this technique when the appropriate situation occurs.

The care of patients with colorectal polyps that contain invasive adenocarcinoma. Endoscopic polypectomy or colectomy?

BACKGROUND

The appropriateness of resection in patients from whom polyps with invasive adenocarcinoma were excised has been questioned.

METHODS

To determine the results of this policy, the authors reviewed the outcome of 42 patients from whom 44 such polyps were removed. Each polyp was categorized for the level of invasion according to the classification of Haggitt.

RESULTS

Level 1 invasion was found in 27%; level 2, in 9%; level 3, in 11%; level 4, in 39%; and uncertain, in 14%. The histologic grade was well differentiated in 48% of patients and moderately differentiated in 52%. No polyps contained poorly differentiated adenocarcinoma; lymphatic and vascular invasion were not encountered. Excision was judged complete in 23 patients; 11 underwent resection, and in none was residual adenocarcinoma identified. In 14 patients, margins could not be evaluated; of 12 patients who underwent resection, residual adenocarcinoma was found in 1. Of the seven patients with positive margins who underwent resection, residual adenocarcinoma was found in only two. In the resected specimens in which residual carcinoma was encountered, all original lesions were designated level 4. None of the patients treated by polypectomy alone has experienced a recurrence at a mean follow-up time of 66 months (range, 12-152 months).

CONCLUSIONS

The authors conclude that only patients with level 4 invasion require resection.

The care of patients with colorectal polyps that contain invasive adenocarcinoma. Endoscopic polypectomy or colectomy?

BACKGROUND

The appropriateness of resection in patients from whom polyps with invasive adenocarcinoma were excised has been questioned.

METHODS

To determine the results of this policy, the authors reviewed the outcome of 42 patients from whom 44 such polyps were removed. Each polyp was categorized for the level of invasion according to the classification of Haggitt.

RESULTS

Level 1 invasion was found in 27%; level 2, in 9%; level 3, in 11%; level 4, in 39%; and uncertain, in 14%. The histologic grade was well differentiated in 48% of patients and moderately differentiated in 52%. No polyps contained poorly differentiated adenocarcinoma; lymphatic and vascular invasion were not encountered. Excision was judged complete in 23 patients; 11 underwent resection, and in none was residual adenocarcinoma identified. In 14 patients, margins could not be evaluated; of 12 patients who underwent resection, residual adenocarcinoma was found in 1. Of the seven patients with positive margins who underwent resection, residual adenocarcinoma was found in only two. In the resected specimens in which residual carcinoma was encountered, all original lesions were designated level 4. None of the patients treated by polypectomy alone has experienced a recurrence at a mean follow-up time of 66 months (range, 12-152 months).

CONCLUSIONS

The authors conclude that only patients with level 4 invasion require resection.

The stapled functional end-to-end anastomosis following colonic resection

To determine the results of our experience with the use of staples for construction of anastomoses following colonic resection, a series of 223 anastomoses performed in 205 patients was reviewed. Indications for operation included malignancy, benign neoplasms, inflammatory bowel disease, and several miscellaneous entities. A functional end-to-end anastomosis using the standard GIA cartridge and the TA 55 instruments was performed. The operative mortality was 1.5% with none of the deaths related to the anastomosis. Intraoperative complications encountered included bleeding (21), leak (1), tissue fracture (1), instrument failure (4), and technical error (3). Early postoperative complications related or potentially related to the anastomosis included bleeding (5), pelvic abscess (1), fistula (1), peritonitis (2), ischemia of anastomosis (1). Late complications included five patients with small bowel obstruction, two of whom required operation. Anastomotic recurrences developed in 5.9% of patients. Our experience gained with stapling instruments has shown them to be a reliable method for performing anastomoses in the colon in a safe and expeditious manner.

The value of nuclear morphometry in the management of patients with colorectal polyps that contain invasive adenocarcinoma

Haggitt's classification is a useful guide in the management of patients with large bowel polyps which contain invasive adenocarcinoma in that patients with levels 1 to 3 require no operation. Nuclear morphometry has been shown to be a useful prognostic discriminant for patients with invasive carcinoma of the large bowel. The nuclear shape factor of 44 polyps with invasive carcinoma was studied to determine whether this parameter was of value to define those patients with Haggitt level 4 who should have a resection. The shape factor of 50 interphase nuclei was obtained through the use of image analysis by tracing the nuclear profiles as digitized on a video screen. The nuclear shape factor was defined as the degree of circularity of the nucleus, a perfect circle recorded as 1.0. Our previous experience showed a nuclear shape factor greater than 0.84 was associated with a poor outcome. The overall mean shape factor was 0.71 (0.59-0.85). There was a tendency for the patients with residual disease to have values in the upper range. Our findings suggest that nuclear morphometry fails to add any predictive information in this clinical situation.

Proliferative activity of colonic mucosa at different distances from primary adenocarcinoma as determined by the presence of statin: a nonproliferation-specific nuclear protein

The field change is one hypothesis concerning the development of colorectal carcinoma. Removal of a carcinoma without its entire surrounding altered mucosa may result in the development of a recurrence. S44, a monoclonal antibody directed against statin, a nuclear protein expressed in nonproliferating cells in either a quiescent or senescent state, was used to determine the rate of cell growth in colorectal mucosa at different distances from carcinomas. The specimens of 18 patients undergoing resection of a colorectal carcinoma were immediately opened after operation, and strips of mucosa were taken at distances of 1 cm, 5 cm, and 10 cm from the carcinoma. For each location, 10 longitudinally oriented crypts were evaluated for statin-positive cells identified by the presence of a dark brown peroxidase-conjugated antibody reaction product. The average percentage of statin-positive cells per crypt was significantly lower at a 1-cm distance from the carcinoma compared with the mucosa located 5 and 10 cm from the carcinoma (20.89 +/- 4.33 at 1 cm, 32.41 +/- 5.27 at 5 cm, and 34.23 +/- 6.45 at 10 cm). None of the calculated parameters showed any significant difference between the 5-cm and 10-cm locations. The fact that the proliferation rate of the mucosal cells returns to the normal level at 5 cm from the margin of the carcinoma suggests that cells located within this distance still retain proliferative potential even though they are morphologically indistinguishable from their normal counterparts. We conclude that failure to remove this transitional, potentially proliferative mucosa may result in subsequent development of anastomotic or perianastomotic recurrences.

Experience with the use of the circular stapler in rectal surgery

This report provides our personal experience along with a general overview of the use of the circular stapler in rectal surgery. To determine the results of our experience with the use of the circular stapler for construction of anastomoses following resection, a series of 215 anastomoses performed in 214 patients was reviewed. The patients ranged in age from 33 to 88 years. There were 116 men and 98 women. Indications for operation included malignancy, diverticular disease, villous adenoma, Crohn's disease, and rectal procidentia. The types of operation performed included removal of varying portions of the large bowel. The anastomosis was performed in a uniform manner with the EEA (United States Surgical Corp., Norwalk, CT) and more recently the CEEA (United States Surgical Corp., Norwalk, CT). The operative mortality was 0.47 percent, with the death being unrelated to the anastomosis. Intraoperative complications encountered included bleeding, difficult extraction, instrument failure, incomplete doughnuts, deficient anastomoses, and miscellaneous problems. Early postoperative complications included one leak and a number of complications unrelated to the anastomoses. Anastomotic stenosis developed in 27 patients, but only 8 were permanent and only 3 of these were symptomatic. Two of these patients were treated with balloon dilatation. Anastomotic recurrences developed in 13.1 percent of patients. Our experience gained with the circular stapling device and that reported in the literature have shown it to be a reliable method of performing anastomoses to the rectum in a safe and expeditious manner.

[Unusual presentation of malignant melanoma of the small intestine]

2 patients with unusual presentations of malignant melanoma involving the small intestine, a 75-year-old woman and a 78-year-old man, are described. One underwent laparotomy for diagnosis and removal of a retroperitoneal mass, with no preoperative evidence of the primary disease. The other underwent emergency laparotomy for small bowel obstruction due to intussusception, which was found to result from a metastatic melanoma. A melanoma had been completely resected from the patient's thigh a month previously, but full investigation before the operation for intussusception failed to establish the diagnosis. Malignant melanoma tends to spread to the small intestine, but tumors of this organ are very rare. Preoperative diagnosis is important since it may improve the outcome of surgical intervention, as well as the prognosis in general.

[Complications of laparoscopic cholecystectomy]

92% of our first 60 laparoscopic cholecystectomies were successful. Postoperative complications included fever in 10 cases (17%), urinary retention in 5 (8%), intraabdominal abscess in 2 (3%), biliary leakage in 1 (2%) and unexplained abdominal pain in 10 (17%). Although laparoscopic cholecystectomy has obvious advantages, it also has major as well as minor complications.

Cyclophosphamide, doxorubicin, dexamethasone and procarbazine: effect on seminal plasma sialyltransferase activity

The influence of chemotherapy agents, doxorubicin (adriamycin), cyclophosphamide, procarbazine, and dexamethasone on the activity of sialyltransferase in human semen has been examined. Aliquots of 25 mcL semen were incubated for 2 hours with the above substances at concentrations ranging from 10 to 800 mcg/incubation mixture. The measurement of sialyltransferase activity was based on the incorporation of radioactive sialic acid from CMP (14) C sialic acid) into asialofetuin. Doxorubicin and cyclophosphamide, at the maximal concentration of 800 mcg/incubation mixture exhibited an inhibiting effect on sialyltransferase activity which accounted for 15.7 +or- 16% and 12.2 +or- 16%, respectively. The rate of inhibition following incubation with maximal doses of dexamethasone (400 mcg) was 25.3 +or- 13%, respectively. The rate of inhibition following incubation with maximal doses of dexamethasone (400 mcg) was 25.3 +or- 12%. Inhibition caused by procarbazine did not exceed 5%. Inhibition of sialyltransferase in human semen by the materials examined in this study can diminish the transfer of sialic acid, thus interfering with normal glycoprotein's and glycolipid's syntheses in semen and possibly also in other fluids and tissues.