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PubMed2005

Laparoscopic transabdominal preperitoneal approach to place a polypropylene mesh on the abdominal wall: an experimental swine model of a technique that can be used for incisional hernia repair.

BACKGROUND: The placement of intraabdominal polypropylene mesh entails risks of adhesions and fistulas that can be avoided by preperitoneal placement. METHODS: This comparative, open, experimental, prospective, randomized, and transversal study randomized pigs into two groups of 11 each for intraperitoneal (IPOM) or preperitoneal (TAPP) polypropylene mesh placement by laparoscopy. Diagnostic laparoscopy and tissue en-bloc resection was performed 28 days postoperatively for histopathologic analysis. RESULTS: The following data were observed for the two study groups: surgical time (IPOM: 35.73 +/- 4.22 min; TAPP: 58.09 +/- 6.28 min; p = or < 0.0001); adhesions (IPOM: 81.81%; TAPP: 27.27%; p = 0.032), grade III for IPOM and grade II for TAPP (p = 0.001); and interloop adhesions (IPOM: 81.81%; TAPP: 9.09%; p = 0.003). No fistulas were found in either group. The TAPP procedure showed better integration of mesh, without lesion to abdominal organs. Two complications, occurred with IPOM, and one with TAPP (p = 1.0, not significant). CONCLUSIONS: The perperitoneal technique requires more time, but has fewer adhesions and less intraabdominal inflammatory response. It is a feasible technique that may diminish risks in the laparoscopic treatment of incisional hernias with polypropylene mesh.

Abdominal Wall↗

PubMed2005

Direct percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts.

BACKGROUND: Clinical utilization of direct percutaneous endoscopic jejunostomy (DPEJ) is increasing. However, little data exist regarding important clinical outcomes with DPEJ. OBJECTIVE: To describe the indications, success, and complications of DPEJ in a large cohort of >300 consecutive attempted DPEJ cases at our institution. METHODS: Institutional databases identified 316 consecutive attempted DPEJ placements between January 1996 and August 2004. The medical records of consenting patients were abstracted for demographics, indication, success, complications, and follow-up. A scheme for classifying complication severity was designed. RESULTS: Three hundred and seven attempts at DPEJ were made on 286 patients. Of these, 209 succeeded (68%). The most common indications for DPEJ included resectable distal esophageal cancer, other malignancies causing obstruction, gastroparesis, prior esophageal or gastric resection, and high aspiration risk. Overall, 81 adverse events (AEs) were associated with DPEJ placement or removal in 69 (22.5%) cases. There were 14 serious AEs, 20 moderate AEs, and 47 mild AEs. Serious AEs included 7 bowel perforations, 3 jejunal volvuli, 3 major bleeds, and 1 aspiration. The only death was due to profound jejunal mesenteric bleeding after an unsuccessful trocar pass. Moderate AEs included 9 chronic enterocutaneous fistulae. Many of the 47 mild AEs were site infections requiring oral antibiotics (23) or persistent site pain (14). CONCLUSIONS: DPEJ was associated with a moderate or severe complication in approximately 10% of cases. While DPEJ is a useful technique to gain enteral access that obviates the need for surgery and is more reliable than percutaneous gastrostomy with jejunal extension, patients and physicians should be aware of the risks involved.

Adult↗

PubMed1979

[Variations in electrolytes in the smooth muscle tissue of the alimentary canal (author's transl)].

Electrolytes in the smooth muscle tissue of the alimentary canal were measured and their behavior under various conditions were studied on the basis of values measured. The results are summarized as follows: 1. Organic changes due to edema and the like are more prominent in the region near the wound in cases of damaged intestine. Utmost care should therefore be exercised when surgical treatment including resection of the intestine is given. 2. Variations in electrolytes are slight in cases of mesenteric hematoma, and surgical treatment is not necessary. 3. Variations in electrolytes are rather prominent in cases of intestinal fistula, and full consideration should be given to the balance of electrolytes, particularly supplement of K. 4. In casees of intestinal anastomosis, the rate of variation is the highest near the site of anastomosis and on the third day after surgery. Therapeutically, therefore, attention should be given to prevention of complications such as incomplete suture. 5. In cases of intestinal obstruction, variations are more marked and rapid. It brings about a high degree of disequilibrium of intra-tissue electrolytes in the upper intestinal tract; hence the early and adequate treatments are needed.

Animals↗

PubMed2006

Palliative surgery for recurrent bowel obstruction due to advanced ovarian cancer.

AIM: Intestinal obstruction is a frequent event in patients affected by ovarian carcinoma. Little data on repeat palliative surgery for recurrent bowel obstruction are available. The aim of this study was to analyze postoperative and long term outcomes of ovarian cancer patients who underwent reoperation for recurrent intestinal obstruction. METHODS: We retrospectively evaluated the records of these patients treated at our Department between 1992 and 2002. RESULTS: Nine women with a mean age of 56 years (range 37-72) were identified. All patients had undergone previous abdominal surgery for bowel obstruction from ovarian cancer. All patients underwent exploratory laparotomy. In 4 patients (Group A) because of advanced disease, only exploratory surgery was carried out. A surgical correction was achieved in the other 5 patients (Group B), but only 3 patients had a successful palliation, defined as the ability to tolerate an oral intake for at least 60 days postoperatively. Postoperative mortality was nil, morbidity was 44.4%; particularly 2 patients developed an enterocutaneous fistula. Mean survival of Group A and B patients were 36.7 and 96.2 days respectively. The 3 successful palliated patients died of disease after 3.5, 4 and 5 months, in 2 cases for recurrent bowel obstruction. CONCLUSIONS: Repeat surgery for recurrent bowel obstruction in advanced ovarian carcinoma may achieve successful palliation in few cases and is associated with high postoperative morbidity and limited survival. In these patients non surgical approaches based on medical treatment, percutaneous endoscopic gastrostomy and stent placement should be considered.

Adult↗

PubMed1986

[Value of absorbable stapling in digestive surgery? Experimental study comparing TA metallic stapling, TA absorbable stapling and manual sutures].

Absorbable staples, recently available for TA 55 instrument, has not been yet evaluated in gastro-intestinal surgery. This experimental work was designed to determine the feasibility and the reality of the advantages of the new material: the wound healing process of 3 techniques of intestinal closure (metal staples, Lactomer absorbable staples and polyglactin sutures) were compared. A double Roux en Y loop was performed on 9 dogs: each end was closed by one of these techniques, and recuperated at regular intervals (3 samples by dog). Twelve sutures were examined at 10 post-operative days, 14 at 25 days, and 10 at 130 days. Macroscopic examination showed major inflammatory adhesions around absorbable staples. Two fistulae have complicated absorbable stapling versus 0 with the 2 others techniques. Histologic review showed greater tissue trauma with Lactomer staples than metal staples; intense and prolonged inflammatory reaction was seen around absorbable staples, while metal staples were well tolerated. The difference in design of the 2 staples can explain the differences in the healing process. In spite of the interest for absorbable material, our experimental study shows the present superiority of the metal stapling and prompts improvements of absorbable staples for reliable use in gastro-intestinal surgery.

Animals↗

PubMed1992

Retroperitoneal laparostomy: a surgical treatment of pancreatic abscesses after an acute necrotizing pancreatitis.

BACKGROUND: From 1982 to 1988, 20 patients with pancreatic abscesses after an acute necrotizing pancreatitis underwent a retroperitoneal laparostomy (RPL). METHODS: The severity of the disease was assessed by Ranson's bioclinical and Hill's computed tomographic scoring systems. The RPL, guided by the results of repeated computed tomographic scans (high frequency of peripancreatic necrotic extension through the anterior pararenal space) consists of a left or right lateral incision under the twelfth rib, allowing direct access to the pancreas and peripancreatic spaces. RESULTS: Four patients (20%) had local complications: colonic fistula (one patient), gastric and colonic fistula (one patient), jejunal fistula (one patient), and local hemorrhage (one patient). Only one complication was lethal (gastric and colonic fistula). Four patients died (mortality rate 20%). In two of the cases death was related directly to a persistent sepsis after the RPL, whereas the two other patients died despite a complete surgical drainage. CONCLUSIONS: RPL (left or right, sometimes bilateral) allows a total exploration of the pancreas and peripancreatic spaces in most cases, as well as a complete manual removal of the necrotic infected masses. Furthermore, several second-look removals of newly formed necrotic masses can be performed without the risk of peritoneal contamination and with a low rate of digestive fistula.

Abscess↗

PubMed1994

Upper gastrointestinal tract ablation for patients with extensive injury after ingestion of strong acid.

OBJECTIVE: Extensive corrosive injury involving the structures beyond the pylorus caused by ingestion of strong acid has a poor prognosis. We reviewed six cases of patients who underwent total upper gastrointestinal tract ablation to see the effect of this extensive procedure for such an injury. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Six patients who ingested more than 250 mL of 20N hydrochloric acid were treated in the Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China, from 1986 to 1992. RESULTS: Three patients with preoperative metabolic acidosis and renal failure died of multiple organ failure within the first postoperative month. The other three patients survived the acute stage. While being readied for a late reconstructive procedure, sepsis developed in one patient due to cholecystostomy leakage about 1 year postoperatively. Another patient died of respiratory failure after development of aspiration pneumonia due to poor drainage of a spit fistula, after surviving for 6 months. Only one patient had a good recovery following a full reconstruction procedure and restoration of the continuity of the gastrointestinal tract. CONCLUSIONS: Three of six patients died in the hospital. The risk factors were preoperative metabolic acidosis, renal failure, and an upper jejunal resection greater than 100 cm in length. Early and aggressive approaches to resect all the necrotic tissue certainly provide good chances to survive the acute stage and later reconstruction.

Adult↗

PubMed2001

Primary tuberculosis of the pancreas mimicking a pancreatic tumor.

BACKGROUND: Diagnosis of tuberculosis of the pancreas is often missed, and may present to the clinician as a difficult diagnostic problem. METHODS: We report an extremely rare case of a 35-year-old woman who admitted for acute pain in the right upper quadrant, jaundice, fever 38 degrees C and chills. During the last 8 mo, she developed increasing fatigue and a weight loss of approx 10 kg. RESULTS: Computed tomography (CT) of the abdomen showed a mass in the head of the pancreas, and upper gastrointestinal endoscopy revealed a stenosis of the second part of duodenum and a pancreatico-duodenum fistula. Frozen sections by direct trucut needle biopsy raised suspicions of a malignancy, and a Whipple procedure was performed as a radical procedure. The final histopathology revealed a chronic granulomatous lesion with caseating necrosis. Mycobacterium of tuberculosis was detected using the polymerase chain reaction-based assay. CONCLUSION: This unusual case emphasizes that in suspected cases of pancreatic carcinoma with an atypical presentation, an attempt should be made to confirm the diagnosis by CT-guided needle biopsy, or by ultrasound endoscopic fine-needle aspiration.

Adult↗

PubMed2005

[The surgical treatment of hemorrhoids].

Surgery is the most effective treatment in patients with symptomatic grade III-IV hemorrhoids who have not responded to outpatient treatment, when there is associated abnormalities (anal fissure, anal fistula, skin tags) and in thrombosed hemorrhoids. Hemorrhoidectomy is currently the "gold standard" treatment. Randomized controlled trials comparing open with closed hemorrhoidectomy show no significant differences in pain scores. Stapled hemorrhoidectomy produces less postoperative pain than hemorrhoidectomy but is less effective in terms of symptom control. No treatment is superior to others in reducing postoperative pain except the use of drugs and anesthetic techniques. In patients with prolapsed internal hemorrhoids and thrombosed hemorrhoids, treatment may initially consist of an urgent hemorrhoidectomy with the same results as those obtained with elective surgery.

Digestive System Surgical Procedures↗

PubMed1981

Pancreatic abscess: importance of conventional radiology.

To determine the clinical usefulness of conventional radiographic methods in pancreatic abscess, studies from 35 patients were retrospectively evaluated. Plain films of the abdomen were obtained in 31 and showed the diagnostic finding of extraluminal gas in the pancreatic area in 18 (58%). Gastrointestinal contrast studies were done in 28 patients and confirmed the extraluminal location of abscess gas in 17 (61%). These contrast studies provided important preoperative evidence of perforation or fistula in six (21%) patients. Because of the risk of extravasation in complicated pancreatic abscesses, water soluble contrast media are recommended instead of barium. Abscess gas was shown by computed tomography (CT) in four (50%) of eight patients and sonography suggested a diagnosis in five (31%) of 16. In aggregate all radiographic methods demonstrated evidence of a pancreatic abscess in 69%. While sonography and CT are being used with increasing frequency, this experience reaffirms the value of plain film and gastrointestinal contrast studies in patients with suspected pancreatic abscess.

Abscess↗

PubMed2005

Complications with reconstruction procedures in pylorus-preserving pancreaticoduodenectomy.

This study was conducted retrospectively to examine the efficacy of Traverso reconstruction compared with Billroth I reconstruction after pylorus-preserving pancreaticoduodenectomy, in the prevention of several complications. Pylorus-preserving pancreaticoduodenectomy is an aggressive surgery, and insufficiency of the pancreaticoenterostomy plays an important role in the postoperative progression. However, reports examining the correlation between pancreatic fistula and the type of reconstruction after pylorus-preserving pancreaticoduodenectomy have been limited. Sixty-four patients who underwent pylorus-preserving pancreaticoduodenectomy (33 reconstructed by the Traverso technique and 31 reconstructed by the Billroth I technique) were entered into this study to investigate whether the complications were related to the type of reconstruction procedure employed. Insufficiency of the pancreaticojejunostomy, including major leakage and pancreatic fistula, occurred in 18.2% of the reconstructions by Billroth I and 0% of the reconstructions by Traverso (p < 0.05). In addition, jejunal obstruction by recurrent tumor in the remnant pancreas was observed in 3 patients reconstructed by Billroth I, and required palliative bypass surgery. Reconstruction by the Traverso procedure after pylorus-preserving pancreaticoduodenectomy is a safe surgical method and has an advantage for advanced pancreatic cancer, which has high risk of jejunal obstruction by recurrent tumor in the remnant pancreas.

Aged↗

PubMed2004

Inhibition of ampicillin-induced emergence of resistance in intestinal coliforms by targeted recombinant beta-lactamase.

The aim of the present study was to determine whether oral targeted recombinant beta-lactamase (TRBL) administration could overcome the development of ampicillin-induced resistance in the gut microbiota. Eighteen laboratory beagles with permanent jejunal fistula were randomised to receive ampicillin + placebo, ampicillin + TRBL or placebo. A total of 982 coliform isolates, collected from jejunal and faecal samples before, during and after the treatment were tested against nine antimicrobials. The proportion of ampicillin resistance (multi-resistance) among coliform isolates increased from 20 to 36% in the ampicillin + placebo group but far less, 20-36%, in the ampicillin + TRBL group. These results indicate that TRBL may prevent the emergence of beta-lactam-associated resistance in coliforms in the gut.

Administration, Oral↗

PubMed1999

The role of octreotide and somatostatin in acute and chronic pancreatitis.

Acute pancreatitis may follow a mild or a severe course. Whereas mild or edematous pancreatitis is a self-limiting disease with a low complication rate and low death rate, morbidity and mortality in severe or necrotizing pancreatitis are still unacceptably high. The major problem is the lack of a specific drug, especially in the early phase of the disease, to interfere with the systemic inflammatory response syndrome and to limit or prevent complications of the disease. Although the initiating pathophysiological process is not known, the destruction of the gland ('autodigestion') by digestive enzymes may be responsible for disease progression. Inhibition of pancreatic activity, which reduces exocrine secretion and further prevents the release and activation of enzymes, was therefore suggested as a specific treatment concept. The results of clinical investigations using somatostatin or its analogue are controversial, since all these trials had low statistical power. In a recent multicenter randomized controlled study with a large number of patients (n = 302) (and an adequate level of disease severity), no benefit of octreotide on progression or outcome was found. Chronic pancreatitis is characterized by an irreversible destruction of the exocrine and endocrine pancreatic parenchyma leading to maldigestion and diabetes. Pain, which may be caused by increased ductal pressure, is one of the most dominant symptoms in chronic pancreatitis. However, no beneficial effects on pain with pancreatic exocrine secretion-inhibiting drugs have been demonstrated. Treatment of other complications of the disease (pseudocyst formation, fistula and pancreatic ascites), with somatostatin or octreotide has given conflicting results. However, in a prophylactic clinical setting (e.g. elective pancreatic surgery) the inhibition of exocrine pancreatic secretion reduces complications.

Acute Disease↗

PubMed1985

Analysis of pancreatoduodenectomy.

Between 1956 and 1982, there were 55 pancreatoduodenectomies performed at the Medical University of South Carolina by 19 different surgeons. There were 26 resections for adenocarcinoma of the head of the pancreas and 16 resections for carcinoma of the ampulla of vater, carcinoma of the extrahepatic biliary ducts, and carcinoma of the duodenum. There were seven resections for chronic pancreatitis. There were two resections for trauma and three resections in the (1960s) for carcinoma of the stomach. There was one resection for cystadenocarcinoma of the pancreas. In the patients with carcinoma of the pancreas, resection was only performed when there was no gross evidence of extension beyond the parenchyma of the pancreas. Analysis of the resected specimen revealed 44% of the pancreatic carcinomas subsequently had positive lymph nodes. None of these patients became long-term survivors. Failure of the pancreato-jejunostomy was the most serious complication, occurring in 7 of 55 resections. There were no fistulas where a mucosal to mucosal anastomosis was performed to join the pancreas with the jejunum. The five-year survival for all patients with carcinoma of the pancreas was 11.6%. The 3 five-year survivors were from resections performed between 1956 and 1970. During these years, the mortality rate for the procedure was 21%. From 1970 to 1982 there were no five-year survivors from carcinoma of the pancreas. However, the mortality rate was 10.6%. The history and current controversies over this surgical procedure are reviewed.

Abdominal Injuries↗

PubMed2001

Effect of monensin on the performance and nitrogen utilization of lactating dairy cows consuming fresh forage.

We conducted a lactation trial with a fresh forage diet in order to evaluate 1) the effects of monensin on nitrogen metabolism, and 2) the Cornell Net Carbohydrate and Protein System (CNCPS). Thirty Holstein cows in midlactation (eight fitted with ruminal fistulas) were gradually introduced to a fresh forage diet. A concentrate mix based on corn meal was fed before the a.m. and p.m. milking times 0730 and 1730 h, then the fresh forage was fed at 0830 and 1830 h. Fifteen cows each were allocated to a control (no monensin) and a treatment group receiving 350 mg/cow per day of monensin in the p.m. concentrate feeding. A 7-d fecal and urine collection period and a 3-d rumen sampling period were conducted with the fistulated cows. After the lactation study was concluded, the fistulated cows were fed forage regrowth and a 3-d rumen sampling period was repeated. Monensin increased milk production by 1.85 kg. Milk fat and protein concentrations decreased and milk fat and protein yields increased, but the effects were nonsignificant. Monensin did not significantly affect DMI. Ruminal ammonia and the acetate-to-propionate ratio decreased with the addition of monensin in both fed forages. Monensin decreased fecal N output, and increased apparent N digestibility by 5.4%. Because of the decrease in ruminal ammonia and increase in apparent N digestibility, we concluded monensin was sparing amino acids from wasteful rumen degradation with a fresh forage diet. The precision of the CNCPS in predicting performance was high (r2 = 0.76), and the bias was low (overprediction of 3.6%). These results indicate that the CNCPS can be used for dairy cows consuming fresh forage and gives realistic predictions of performance.

Acetates↗

PubMed2006

New applications for endoscopy: the emerging field of endoluminal and transgastric bariatric surgery.

Endoluminal and transgastric procedures are evolving concepts that combine the skills and techniques of flexible endoscopy with minimally invasive surgery. Precisely how this technology and skill set will be applied in the field of general surgery is not yet known, but the treatment of obesity with an endoluminal or transgastric procedure holds great promise. As the demand for bariatric surgery increases, efforts will be directed toward developing less morbid and less costly treatment options that can provide substantial weight loss and resolution of comorbid conditions. Natural orifice bariatric procedures may include short-term weight loss in preparation for a definitive laparoscopic procedure, revisional procedures to reduce stoma or pouch size or repair fistulas, or primary therapy that provides durable weight loss. The latter application will undoubtedly appeal to patients and referring physicians if it can be performed as an outpatient procedure with significantly less morbidity than a laparoscopic procedure. Early preclinical and clinical work has been published in this area, but many technical obstacles must be overcome before a primary endoluminal or transgastric bariatric procedure can be offered. This article reviews the endoluminal and transgastric technology currently available, the endoluminal procedures currently performed, and the future of these technologies with respect to bariatric surgery.

Bariatric Surgery↗

PubMed2005

A flexible approach to achieve a true primary repair for all infants with esophageal atresia.

Our purpose is to present our results using a flexible surgical approach to achieve a true primary repair for all infants with esophageal atresia (EA). The proposed methods are designed to reach this goal, even when most of the intrathoracic esophagus is missing. What has made this goal attainable is the ability to rapidly induce esophageal growth. We reviewed the results of 63 consecutive patients who presented between 1984 and 2004 with an esophageal gap of greater than 2.5 cm, a distance where increasingly difficult repairs begin. Gaps of 4 cm or longer (46), 6.0 cm or longer (14), and over 10 cm (3) were included. Repairs begun elsewhere (20) included 17 spit fistulas. We present 3 surgical stages, designed to overcome tension and, for longer gaps, induce esophageal growth. For 25 infants, traction in the operating room was sufficient to dissipate tension and allow a primary repair. For the longest gaps, successful esophageal growth was induced over days in 38 patients by internal (5), external (23), and mixed internal/external traction (10). Growth quickly produced adequate esophagus for a primary repair. We conclude that adequate esophageal growth can be induced within days, even early in infancy, and this flexible approach allows the entire EA spectrum to be repaired primarily.

Digestive System Surgical Procedures↗

PubMed2005

Complications and reoperations in stapled anopexy: learning by doing.

Although stapled anopexy for second and third degree hemorrhoids has been widely used since 1998, there are limited long-term data available. We performed an analysis of a prospectively accrued data set of all patients undergoing stapled anopexy in our practice from 1998 through August 2003. Patients were specifically assessed for early and late complications and long-term reoperation rates for anorectal pathology. We performed stapled anopexy in 654 patients (296 females) during the study period. Mean operation time was 21 min (5-70 min), and the postoperative stay was 3.6 days (1-13 days). Early postoperative complications: urinary retention, 42 patients (6.4%); fecal impaction, 18 (2.8%); postoperative hemorrhage, 26 (4.0%); thrombosed external hemorrhoid, four (0.6%); and fistula/abscess, nine (1.4%). Late postoperative complications: anastomotic dehiscence, 21 patients (3.2%); persistence of prolapse in three (0.5%); submucosal anastomotic cysts in four (0.6%); thrombosed external hemorrhoid in two (0.3%); skin tags in ten (1.5%); fissure in six (0.9%); proctitis in two (0.3%); and fecal incontinence in ten (1.5%). Reoperation was required in 50 patients (7.6%). Reoperation for complications within 30 days occurred in 42 patients (6.4%) for the following reasons: bleeding (23), dehiscence (five), thrombosed external hemorrhoid (three), fecal retention (two), fistula (three), fissure (five), and anal papilla (one). Reoperation for anorectal pathology after 30 days was required in 54 patients (8.3%) and was performed for the following: dehiscence/reprolapse (17), stenosis (two), submucous cyst (two), fistula (four), fissure (six), anal papilla (four), skin tags (five), persistent anal itching (five), and miscellaneous (seven). These data represent the largest series of patients with long-term follow-up following stapled anopexy and confirm that the operation is safe in experienced hands using appropriate patient selection. The early complication rate is low and similar to rates reported for excisional hemorrhoidectomy. Importantly, the procedure is associated with a low 3.4% rate of reoperation for persistence or recurrence of hemorrhoidal prolapse with good patient selection.

Adult↗