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PubMed2001

The effects of mesenteric ischemia on ileal colonization, intestinal integrity, and bacterial translocation in newborn piglets.

The effects of mesenteric ischemia on ileal colonization, intestinal integrity, and bacterial translocation (BT) in newborn piglets were investigated in 362-day-old Pietrain piglets. Group I, controls were not operated upon; group II underwent a sham laparotomy; and group III underwent ligation of the mesenteric vessels in the distal ileum. After 3 days, the kidneys, spleens, livers, and ileal segments were harvested for microbial and histologic analyses. Two piglets in the ischemic group died; microscopic examination showed severe histologic lesions of the ischemic area. Escherichia coli counts were increased in the ischemic segment compared to the upper loop (P < 0.05). Ischemia favoured staphylococcal colonization, whereas in the sham group a drastic reduction of these organisms was observed (P < 0.005). BT to the kidneys, spleen, and liver occurred normally in the control group. Ischemia significantly increased the total microflora in the spleen and liver (P < 0.05) and furthered dissemination of Clostridium perfringens in the kidneys (P < 0.05); 50% of ischemic animals had proteolytic clostridia in this organ (P < 0.05). Moreover, the incidence of E. coli in the kidneys, spleen, and liver was significantly higher in the sham and ischemic groups than in the controls (P < 0.05). Ileal ischemia thus induced significant histologic lesions, and surgery rather than gut microflora controls translocation.

Animals↗

PubMed2002

Laparoscopic harvesting of small bowel graft for small bowel transplantation.

BACKGROUND: Small bowel transplantation represents a valid therapeutic option for patients with intestinal failure, obviating the need for long-term total parenteral nutrition. Recently, reports have shown the feasibility of performing living related intestinal transplantation using segmental small bowel grafts. The limitations of this technique include inadequate harvested small bowel lengths, as compared with the lengths obtained in cadaveric small bowel harvests, and large incisions for the donor. In this pilot study, we evaluated the feasibility of laparoscopically harvesting long segments of proximal jejunum for small bowel transplantation using a porcine model. The results can be used to evaluate the potential for applying this technique in human cases. METHODS: For this study 10 yorkshire pigs were used. Under general anesthesia, each pig underwent laparoscopic segmental resection of 200 cm of proximal jejunum on a vascular pedicle. The harvested graft then was autoreimplanted using an open technique by anastomosing the vascular pedicle to the superior mesenteric vessels. Success was determined 2 hours after anastomosis by visually identifying a pink graft with viable-appearing mucosa, an artery with a strong thrill, and palpable venous flow. The animals were then sacrificed. RESULTS: The mean operation time required to laparoscopically harvest the small bowel graft was 80 min (range, 35-120 min), and the mean length of harvested graft was 220 cm (range, 200-260 cm). The mean length of the graft's vascular pedicle was 4.5 cm (range, 4-5 cm). All 10 grafts were successfully harvested laparoscopically and then reimplanted using an open technique. All the grafts maintained good vascular flow, and showed no evidence of mucosal necrosis at necropsy. Obviously, further studies would be required to examine the long-term results of reimplanting a laparoscopically harvested small bowel graft, but proposals for such studies is beyond the scope of this report. CONCLUSION: Minimally invasive techniques can be used to harvest proximal small bowel grafts for living related small bowel transplantation.

Animals↗

PubMed2003

Laparoscopic repair of a right paraduodenal hernia.

BACKGROUND: Laparoscopic repair of a right paraduodenal hernia has never been described in the literature. A 24-year-old woman was admitted after 2 weeks of intermittent abdominal pain associated with nausea and vomiting. Physical examination was normal. Laboratory studies and upper endoscopy were normal. Computed tomography revealed that the small bowel was on the right side of the abdomen and the colon on the left, suspicious for malrotation. Subsequent upper gastrointestinal series with small bowel follow-through revealed the ligament of Treitz on the right with the small bowel encased within a probable hernia sac. A presumptive diagnosis of a right paraduodenal hernia was made. METHODS AND RESULTS: Initial access was obtained with a 10-mm infraumbilical port followed by placement of 5-mm ports in the right and left upper and lower quadrants. The duodenum was identified and the small bowel was found encased within a hernia sac, which was opened widely from the duodenum to the pelvis. The hernia sac was opened laterally to avoid injury to the superior mesenteric vessels. The small bowel was then released from the sac into the peritoneal cavity. The entire bowel was inspected and no other abnormalities were noted. The patient had resolution of her abdominal pain and her postoperative course was uncomplicated. She was discharged home on postoperative day 3 and has since done exceptionally well. CONCLUSIONS: Paraduodenal hernia, a rare cause of small bowel obstruction, can present a diagnostic challenge. However, when the diagnosis is made preoperatively, a laparoscopic repair is a feasible and practical option.

Abdominal Pain↗

PubMed2006

Multimedia article. Laparoscopic abdominoperineal resection for lower rectal cancers: how do we do it?

BACKGROUND: The appropriateness of the laparoscopic approach for the resection of rectal cancer has been controversial, although it is well established in colon cancer. This is a phase II study of laparoscopic abdominoperineal resection (APR) in the treatment of lower rectal cancers. METHODS: Patients with lower rectal adenocarcinoma located within 6 cm above the anal verge were recruited and subjected to laparoscopic APR. The surgical principle included en bloc resection with high ligation of inferior mesenteric vessels by no-touch isolation and total mesorectal excision. Details of the surgical procedures are presented in the video. The technical efficiency and outcome of this surgical approach were evaluated prospectively. This study was approved by the institutional review board of National Taiwan University Hospital (NTUH). RESULTS: A total of 22 patients were enrolled in the study from January 2003 to December 2004 under the ethical guidelines of clinical trials in NTUH. There were 12 females and 10 males, with an age distribution of 62.5 +/- 10.4 years. The body mass index was 24.8 +/- 4.0 kg/m2. Physical status (American Society of Anesthesiology classification) was class I in 12, class II in eight, and class III in two patients. Tumor size was 44.0 +/- 12.0 mm in diameter. Two patients were in pathologic TNM stage I, 14 in stage II, and six in stage III. The operation time was 214.0 +/- 28.4 min. Blood loss was 54.0 +/- 14.0 ml. Because the tumor specimen was retrieved from a perineal wound, the five 5 to 12 mm working ports constituted the abdominal wound. There were no major complications. However, wound infection of port sites was detected in one patient. The patients had a quick convalescence, as evaluated by the length of postoperative ileus (48.0 +/- 12.0 h), length of hospitalization (8.0 +/- 2.0 days), and degree of postoperative pain (3.5 +/- 0.5 visual analogue scale). Return to partial activity, full activity, and work was 2.0 +/- 0.5, 4.0 +/- 0.8, and 6.0 +/- 0.5 weeks, respectively. The number of cleared lymph nodes was 14.0 +/- 2.0. During follow-up (median, 18 months; range, 6-30), lung metastasis and local pelvic recurrence developed in one and two patients, respectively. Besides the expenses covered by the National Bureau of Health Insurance of Taiwan, the additional payment by patients undergoing laparoscopic procedures was NTD 24,000 +/- 3000 (1 U.S. dollar = 32 NTD). CONCLUSIONS: In our clinical setting, laparoscopic APR can be performed with good technical efficiency, quick functional recovery, and mild disability. The short-term oncologic results of laparoscopic APR seem to be acceptable, but further long-term follow-up for these patients is mandatory to define the oncologic outcomes of this approach.

Abdomen↗

PubMed2001

Laparoscopic pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy.

BACKGROUND: A 4-week-old male infant (4.9 kg) with persistent hyperinsulinemic hypoglycemia of infancy (PHHI) underwent a laparoscopic pancreatectomy to evaluate its feasibility. Preoperative medications included diazoxide and glucagon to maintain adequate blood glucose levels. METHODS: Laparoscopic pancreatectomy was performed using a 5-mm cannula at the umbilicus, external fixation, transcutaneous suture-assisted gastric retraction to expose the lesser sac, and three additional 3.5-mm cannula sites. The pancreas was resected from the splenic hilum to the mesenteric vessels. The splenic vein was dissected from the under surface of the pancreas using electrocautery, and the spleen was easily preserved. Surgery time was 75 min, and minimal blood loss occurred. RESULTS: The child required no narcotic medication and tolerated a regular diet immediately after surgery. Serum glucose levels did decrease postoperatively, and the child required diazoxide, dextrose infusion, glucagon, and octreotide. On postoperative day 7, the child underwent an open near-total pancreatectomy, after which he remained asymptomatic. Essentially no scarring was found in the lesser sac, and the remaining pancreatic remnant was resected without difficulty. CONCLUSIONS: Laparoscopic pancreatectomy can be performed safely, even in a newborn patient, without prolonged operative time or unnecessary risk. The technique using external fixation and transcutaneous suture-assisted gastric retraction provides excellent exposure to the pancreas and lesser sac. In patients with PHHI, in whom reoperative additional pancreatectomy is very likely, this technique is the ideal initial surgical approach.

Humans↗

PubMed2001

Laparoscopically assisted subtotal colectomy for slow-transit constipation.

BACKGROUND: When medical therapy fails, slow-transit constipation (STC), a condition seen almost exclusively in women, can be treated surgically. The aim of this study was to describe our results with laparoscopically assisted subtotal colectomy (LASC) for STC. METHODS: Over a 22-month period, four female patients underwent LASC with ileorectal anastomosis for STC at our hospital. The preoperative workup included clinical assessment, evacuation proctography, rectoanal manometry, and colonic transit measurement. Mobilization of the whole colon and ligation and division of colonic mesenteric vessels with preservation of the omentum were achieved laparoscopically. Through a small Pfannenstiel incision, the colon was removed from the abdomen, leaving a 15-cm rectal stump in situ. The rectal stump was fully mobilized posteriorly, a side-to-end ileorectal anastomosis was fashioned, and the rectal stump was fixed onto the presacral fascia with sutures. RESULTS: The operating time ranged from 150 to 260 min and blood loss was minimal. There were no conversions to open surgery. The postoperative course was uneventful in all patients but one, a 47-year old woman who had transient severe abdominal distension, pain, and frequent small-volume bowel movements. All patients were discharged by the 4th to 10th postoperative day. At 9-month follow-up, all of our patients had normal anorectal function with two to four solid bowel movements per day. CONCLUSION: Although it is a technically demanding procedure, laparoscopically assisted colectomy for slow-transit constipation, can be achieved safely.

Adult↗

PubMed1999

Experimental study on heat production by a 23.5-kHz ultrasonically activated device for endoscopic surgery.

An experimental study was carried out to evaluate heat production by an ultrasonically activated device (USAD) using an animal model. In an anesthetized living pig, the gastroepiploic and mesenteric vessels were coagulated and cut by an USAD at a power level of 70% (n = 8) or 100% (n = 8). During the division, the time-discrete temperature change on the surface of the animal tissue adjacent to the blade was measured by thermography. To compare the USAD with conventional electrocautery (EC), a full-thickness incision of the gastric wall was performed by each device, and the temperature change was measured. With the USAD, the temperature increased gradually and remained below 150 degrees C during the entire activating time at both power levels. By contrast, with EC at 30 W, the temperature increased rapidly and exceeded 350 degrees C within only a few seconds. The area above 60 degrees C reached a final width of 10 mm for the USAD, as compared with 22 mm for EC. Microscopically, thermal alterations such as carbonization and vaporization were much more severe and extensive in the adjacent tissue when using EC rather than the USAD. With the USAD, heat production is much slower and more limited than with conventional EC; thus, the USAD causes fewer thermal alterations in adjacent tissue. USAD should be preferred for tissue coagulation and cutting during endscopic surgery.

Animals↗

PubMed1999

Elective laparoscopic sigmoid colectomy for diverticulitis. Results of a prospective study.

BACKGROUND: We undertook a prospective evaluation of elective laparoscopic sigmoid colectomy for diverticulitis in order to assess the risks and benefits of this approach. METHODS: Between November 1992 and November 1996, 54 consecutive patients were included in this study. Their mean age was 59 +/- 13 years (range, 36-81). The number of attacks of diverticulitis before colectomy ranged from one to four (mean, 2.2 +/- 0.7). The operative technique consisted of elective division of the inferior mesenteric vessels, left colonic flexure mobilization, and colorectal anastomosis using the cross-stapling technique. RESULTS: Five procedures (9.2%) were converted. The primary cause for conversion was obesity. These patients had a simple postoperative course. There were no postoperative deaths. Three patients (6.1%) developed abdominal complications, and four patients (8.2%) had abdominal wall complications. Postoperative paralytic ileus lasted only 2.3 +/- 0.7 days (range, 1-6), allowing for a rapid reintroduction of regular diet. The mean postoperative hospital stay was 6.4 +/- 2.7 days (range, 4-15). CONCLUSIONS: Elective laparoscopic colectomy for diverticulitis is feasible in most cases. In most cases, the operative risk is low and the postoperative course is uneventful. Elective sigmoid laparoscopic colectomy should be considered a good therapeutic option for symptomatic diverticulitis.

Adult↗

PubMed2006

Left-sided paraduodenal hernia: report of a case.

Paraduodenal hernias are rare congenital malformations consisting of incomplete rotation of the midgut, which may lead to intestinal obstruction or simply be detected as an incidental finding at autopsy or laparotomy. We report a case of left paraduodenal hernia diagnosed preoperatively by computed tomography and operated on in an emergency setting for signs of peritoneal irritation. A misdiagnosis had been made when the patient suffered his first attack 6 months earlier and he had been treated for familial Mediterranean fever. We reduced the small bowel loops from the left paraduodenal hernia sac with ligation and transection of the inferior mesenteric vessels. The patient was discharged from hospital on postoperative day 4 after an uneventful recovery.

Adult↗

PubMed2003

CT presentation of ruptured appendicitis in an adult with incomplete intestinal malrotation.

Intestinal malrotation is defined anatomically as a developmental anomaly. It may cause atypical clinical symptoms in relatively common intestinal disorders because of the altered anatomy. A 64-year-old man presented with acute mid-abdominal pain. Underlying incomplete malrotation prevented the correct clinical diagnosis of ruptured appendicitis. Computer tomography demonstrated typical signs of malrotation, i.e., right-sided duodenojejunal junction, left position of cecum, inverted position of the superior mesenteric vessels, and pathology revealed a ruptured appendix with an abscess and a coincident mucinous cystadenoma.

Abdominal Abscess↗

PubMed2007

Mesenteric desmoid tumors in Singapore familial adenomatous polyposis patients: clinical course and genetic profile in a predominantly Chinese population.

PURPOSE: This study examined the mutational profile of the adenomatous polyposis coli gene in relation to the development of desmoid tumors in familial adenomatous polyposis patients from a predominantly Chinese population. METHODS: This is a retrospective review of all patients with familial adenomatous polyposis coli from the Singapore Polyposis Registry. Identification of specific adenomatous polyposis coli gene mutation was performed and clinical course of associated desmoid disease obtained from case records and a computerized database. RESULTS: Two hundred five patients from 75 families afflicted with familial adenomatous polyposis coli were reviewed, with gene mutations identified in 107 patients. Of these, 23 (11.2 percent) developed desmoids. The male-to-female ratio was 1:1.3 and the ethnic distribution was Chinese (n=17) and Malay (n=6). Of the 92 patients with mutations 5' to codon 1444, 11 patients (12 percent) developed desmoids compared with 6 of 15 (40 percent) patients with adenomatous polyposis coli gene mutations 3' to codon 1444 (P<0.01). The clinical course of desmoid tumors can be divided into stable (n=11), variable (n=3), progressive (n=6), and aggressive growth (n=3). Only 3 (13 percent) patients with aggressive tumor growth required chemotherapy. There was no correlation between the site of mutation and the clinical progression of the desmoids. Seventy-four percent of these desmoids (17/23) developed at a mean interval of 2.98 years after restorative proctocolectomy, while only 30 percent (7/23) were diagnosed preoperatively or discovered during the initial surgery. The most common complications related to the mesenteric desmoids were intestinal obstruction (21.7 percent), ureteric obstruction (17.4 percent), and encasement of superior mesenteric vessels (13 percent). CONCLUSION: The clinical course of desmoids in an individual familial adenomatous polyposis patient remains unpredictable and no reliable genetic marker is available for prognostication in desmoid disease.

Adenomatous Polyposis Coli↗

PubMed2006

Laparoscopic assisted percutaneous nephrolithotomy (PCNL) in ectopic kidneys: two different techniques.

Two patients presented with calculi in ectopic kidneys. Complete clearance of calculi was achieved by laparoscopic assisted percutaneous nephrolithotomy (PCNL), by different but related techniques. In one patient with prior history of open pyelolithotomy, the anterior surface of the kidney was exposed by mobilizing the overlying sigmoid colon laparoscopically and the percutaneous tract was established into the desired calyx under combined laparoscopic and fluoroscopic control. In the second patient, the tract was established between the major mesenteric vessels without any mobilization of the bowel. Herein, we outline the nuances of these two related techniques, and the indications and contraindications for their use for laparoscopic assisted PCNL in ectopic kidneys.

Adult↗

PubMed1982

Peritoneal lavage and angiography in the management of patients with pelvic fractures.

One hundred consecutive patients with pelvic fractures who had undergone peritoneal lavage and abdominal and pelvic angiography were retrospectively analyzed. Sixty-four patients with negative lavages were treated successfully without laparotomy despite a 20 percent incidence of subcapsular or intraparenchymal hematomas of the liver or spleen. Thirty percent of the patients with positive peritoneal lavages were successfully managed without laparotomy when abdominal angiography failed to identify a source of active bleeding. Abdominal angiography was 92 percent accurate in predicting the presence or absence of hemorrhage in 25 patients who underwent laparotomy. There were no false-positive angiograms. The overall false-negative rate was 2.12 percent. These occurred in two patients with torn mesenteric vessels. Pelvic angiography identified arterial pelvic bleeding in 18 percent of the patients. Eighty-four percent of patients with major pelvic bleeding had successful embolization with prompt cessation of arterial bleeding. We conclude that abdominal and pelvic angiography can be a useful adjunct to peritoneal lavage in detecting intraperitoneal hemorrhage and can be of therapeutic value for arterial pelvic bleeding.

Adolescent↗

PubMed1986

Colonic vascular ectasias and aortic stenosis: coincidence or causal relationship?

Eleven patients with vascular ectasias of the colon and associated gastrointestinal hemorrhage were evaluated. All had the clinical features associated with aortic stenosis. In two patients, the configuration of the pulse wave in the mesenteric vessel was studied. In both, the abnormal peripheral pulse wave pattern associated with aortic stenosis was also transmitted to the ileocolic artery, where it differed quite clearly from the pattern in control patients. In a parallel study, the computer records of 3,623 patients with aortic or mitral stenosis admitted to the Mount Sinai Hospital over a 10 year period were reviewed for the presence of cryptogenic gastrointestinal hemorrhage. Twenty-one of 1,811 patients with aortic stenosis but only 1 of 1,812 patients with mitral stenosis had concomitant gastrointestinal hemorrhage (chi-square = 18, p less than 0.001). These data suggest that the cause of colonic vascular ectasias should be attributed to pathologic abnormalities of the arterial inflow pulse wave, rather than to chronic intermittent submucosal venous outflow obstruction.

Aged↗

PubMed1984

Antagonism by ketanserin of 5-HT-induced vasoconstriction unmasks a 5-HT-induced vasodilation.

The effect of ketanserin on the action of 5-hydroxytryptamine (5-HT) and noradrenaline has been studied using the rat isolated perfused mesentery preparation. Both 5-HT and noradrenaline produced constriction in the mesenteric vessels. The responses to 5-HT and noradrenaline were greater in tissues from hypertensive animals. Responses to 5-HT were abolished by 1 nM ketanserin. Ketanserin was found to be a competitive antagonist of the noradrenaline-induced constrictions (pA2 = 7.5). In partially constricted tissues, 5-HT induced vasoconstriction and vasodilation. In the presence of ketanserin the vasoconstriction was reduced and the 5-HT-induced vasodilation was potentiated. The amount of potentiation of the 5-HT-induced vasodilation by ketanserin was similar in tissues from normotensive and hypertensive rats. It is suggested that the 5-HT-induced vasoconstriction is mediated by activation of 5-HT2 receptors. In the presence of ketanserin, the 5-HT2 receptor mediated vasoconstriction is antagonized, unmasking a 5-HT-induced vasodilation.

Amidines↗

PubMed1991

Mucosal morphology in experimental intestinal atresia: studies in the chick embryo.

Lesions identical to those observed in human intestinal atresia (IA) have been experimentally reproduced in several mammal models by either mesenteric vessels or intestinal wall injury. The recent availability of an avian model led us to investigate whether the same lesions could be studied at less expense. An intestinal loop within the body stalk hernia was coagulated on the 12th incubation day in 427 chick embryos (group 3), the lesions were studied in survivors 4 days later under light and scanning electronmicroscopy (EM), and the findings were compared with those in 12 control embryos (group 1) and 14 sham-operated ones (group 2). Types I or II atresias were obtained in 61 (73.4%) of the 83 survivors in group 3. Seromuscular layers were normal at both ends of the lesion; there was some flattening of villi at the proximal, dilated end, and hyperplasia with apparently lengthened, branched villi at the distal, unused one. Mucosal pattern under light microscopy was strikingly close to that observed in human IA and in the fetal lamb experimental model. On the other hand, scanning EM showed that in this model there were no villi as such, but rather prominent mucosal folds that were regularly arranged in a tire-rubber pattern in the normal intestine, flattened and distended in the dilated one, and again roughly normal in the distal unused gut. High-power magnification scanning EM showed that enterocytes were normal at all levels but, in agreement with previous findings in the fetal lamb model, that intercellular spaces were widened in the dilated portion adjacent to the obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

PubMed1993

Pancreatic anatomy in children: emphasis on its importance to pancreatectomy.

The literature is riddled with misconceptions concerning the landmarks and the actual amount of pancreatic tissue resected in "subtotal" 60% to 90% pancreatectomies. In order to clarify the surgical anatomy of the pancreas, 13 autopsy specimens from children aged 2 days to 15 years were carefully examined. Pancreata were serially removed from the in situ position in four sections and weighed. Section 1 included pancreatic tissue from the tail to the left of the superior mesenteric vessels (SMV); section 2 included all tissue from the tail to the right of the SMV; section 3 contained tissue up to the left of the pancreaticoduodenal vessels in the head of the pancreas; and section 4 included the remainder of the pancreatic head within the duodenal sweep and the uncinate process. Results showed that section 1 weighed 47.5% +/- 9.7% (mean +/- SD) of the total pancreatic weight with a wide range of 32.3% to 67.3%; section 2 weighed 53.5% +/- 9.0% (range, 38.7% to 72.2%); section 3 weighed 69.1% +/- 15.6% (range, 43.5% to 95.8%); and section 4 weighed 31.6% +/- 14.6% (range, 4.2% to 56.5%). As noted, pancreatic anatomy was extremely variable in relation to the percent of tissue to either side of the SMV and the proportion of tissue contained within the uncinate process. Resections historically reported to result in a "75%" pancreatectomy (section 2) were demonstrated to contain a mean of only 53.5% +/- 9.0% of the pancreas. Less tissue than expected would be resected by using the SMV as landmarks for a 75% resection. The wide variation in anatomy also has important clinical implications in performing "subtotal" pancreatectomies in infants with nesidioblastosis in whom the amount of tissue resected is critical to the patient's postoperative clinical course. This study demonstrates that a subtotal pancreatectomy should not be based upon the presumed relation of the pancreatic substance to the SMV. The entire gland including the uncinate process should be visualized at operation in order that a proper pancreatectomy is performed.

Adolescent↗

PubMed1994

The proximal mesenteric flap: a method for closing large mesenteric defects in jejunal atresia.

In selected patients with jejunal atresia, closure of the associated large mesenteric defect remains a technical problem. A case of jejunal atresia is reported in which a segment of dysfunctional proximal jejunum was resected and its mesentery retained, creating a flap of mesenteric tissue that was used to close a large defect. This technique allowed the closure of the mesenteric defect with a decreased chance of injury or kinking of the tenuous distal mesenteric vessels, improved orientation and stabilization of the distal bowel, and, theoretically, improved blood flow to the distal segment.

Female↗