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PubMed1987

Peripheral opioid receptors mediate gastrointestinal secretory and motor effects of dermorphin N-terminal tetrapeptide (NTT) in the dog.

Dermorphin N-terminal-tetrapeptide-amide (NTT) increased both basal and pentagastrin- or histamine-induced secretion in conscious dogs chronically implanted with both gastric fistulae and Heidenhain pouches. These excitatory effects were significantly prevented by the opioid receptor antagonists naloxone and N-methyl-levallorphan-methanesulphonate. In conscious dogs fitted with electrodes and strain-gauges in different parts of gastrointestinal tract, a premature phase III of the migrating myoelectric complex (MMC) in the duodeno-jejunum was triggered by NTT, while the activity of the antrum was not significantly modified. Further, the peptide enhanced the contractile activity of both proximal and distal portions of the colon, including a long-lasting period of increased muscle tone on the distal colon. Either naloxone or N-methyl-levallorphan-methanesulphonate completely prevented motor effects of NTT on gastrointestinal tract. It is concluded that NTT displays significant opiate-like activity on gastric acid secretion and intestinal motility of the dog by activating peripheral mu opioid receptors.

Animals↗

PubMed2005

Pitfalls in the diagnosis of intestinal tuberculosis: a case report.

An 18-year-old long-term Norwegian resident of Somali origin was submitted to hospital with bloody diarrhoea, fever, weight loss and abdominal pain. On initial colonoscopy, colitis with segmental appearance was seen. Apart from a single polymerase chain reaction (PCR) from gastric aspirate staining, PCR and culture for acid-fast bacilli revealed negative results from the multiple samples taken including sputum, gastric fluid, stool, urine and intestinal mucosa. On physical examination and CT scan, there was no evidence of ascites, lymph node enlargement or pathologic pulmonary findings. Although the diagnosis was uncertain, tuberculostatic therapy was initiated. As the conformational testing of the PCR and the microbiological work-up remained negative and the patient's condition did not improve, tuberculostatic treatment was stopped and Crohn's disease was stated as the most likely diagnosis. Although the patient improved clinically under therapy with prednisolone, newly appearing fistulas deriving from the ascending colon were noted on follow-up. Thus tuberculostatic treatment was restarted. However, signs of an acute abdomen appeared and laparotomy was performed, thereby revealing a peritoneal spread of nodules. Resection of the ileum and ascending colon was performed. Diagnosis of intestinal tuberculosis with peritoneal spread was made by histology from resected bowel specimens showing caseating granulomas and a positive PCR result. The patient's condition improved after resection of the highly inflamed bowel segments and tuberculostatic therapy. Our case report shows the difficulty of proving intestinal tuberculosis by microbiological testing, macroscopic features on colonoscopy, histology, imaging such as CT scan and by empirical therapy. Therefore, in cases of colonic inflammation, where intestinal tuberculosis is an important differential diagnosis, a more aggressive diagnostic approach such as explorative laparoscopy should be considered.

Adolescent↗

PubMed1978

Human aeromonas infections: a review of the literature and a case report of endocarditis.

Our patient, with cirrhosis and chronic renal failure, represents an example of the susceptibility of a compromised host to Aeromonas infections. This patient, however, differs from previously reported cases in at least two important aspects. First, it is possible that her portal of entry was a fresh A-V fistula puncture site rather than an intestinal site. The temporal relationship of exposure to flood water prior to the onset of sepsis lends support to this possibility. Epidemiologic investigation of the dialysis center failed to reveal Aeromonas isolates from cultures of the water supply, machinery, or other patients. Second, this case is unique in that our patient developed a destructive aortic valve endocarditis resulting in valvular perforations and acute aortic insufficiency. Furthermore, this infection was initiated on what appears to have been a previously normal valve. Based on a review of the literature and the virulence demonstrated by A. hydrophila in our patient, we conclude that organisms of the genus Aeromonas are capable of inducing serious human infection. Such infections are more likely to occur in compromised hosts. A. hydrophila has accounted for the majority of reported infections.

Abdomen↗

PubMed2002

Perianal Crohn disease: a new scoring system to evaluate and predict outcome of surgical intervention.

BACKGROUND: Conventional Crohn disease activity indices do not reflect perianal disease activity or allow prognostic implications from surgery. HYPOTHESIS: A new scoring system, based on the patient's disease history and physical examination findings, will allow more accurate use of surgical intervention for perianal Crohn disease. METHODS: A standardized scoring questionnaire was developed and applied to a consecutive group of patients before surgical treatment of perianal Crohn disease. The scoring system included abscess, fistula, ulcer and fissure, stenosis, incontinence, and concomitant disease. Weighted factors included acuity vs chronicity, de novo vs recurrent disease, and concomitant intestinal disease. The scoring system was validated against the surgical outcome, which was classified as poor, satisfactory, or good. RESULTS: Twenty-eight patients with Crohn disease who underwent 33 surgical procedures had a mean score of 16.5 (range, 3-37; possible range, 0-55). Using the Spearman nonparametric correlation test, the scoring system was accurate in predicting the outcome of surgical intervention (correlation coefficient, 0.78, 95% confidence interval, 0.57-0.89; P<.001) at mean follow-up of 20.8 months (range, 6-40 months). Correlation was further validated using a linear regression model (r = 0.75, slope best-fit value, 3.8; 95% confidence interval, 2.46-5.14; P<.001). All patients with a score of 10 or less had a good outcome, whereas all those with a score of 20 or greater had a poor outcome. CONCLUSIONS: The proposed scoring system correlated well with the short-term outcome of surgical intervention in patients with perianal Crohn disease and allowed prediction of surgical success. Ultimately, it may be possible to alter therapy based on preoperative prediction of the expected postoperative outcome.

Adult↗

PubMed1985

[Torsades de pointes and hypomagnesemia].

The authors report a case of "Torsades de pointe" occurring in a patient subjected to intensive surgical care and presenting several causes of magnesium loss: mutilating abdominal surgery, exteriorized gastric fistula, administration of Henle's loop diuretics, electrolytic disorders and exclusive parenteral nutrition without any magnesium Mg supplement. The arrhythmia appeared in the third week and the usual treatment was ineffective. The level of plasma magnesium was below the measurable values on three separate occasions. The administration of magnesium sulphate corrected the dysrhythmia which did not recur. Experimental and clinical data demonstrating the antiarrhythmic effect of magnesium are recalled. The electrophysiological explanation is based on the inhibition of potassium and calcium flow across the cell membrane; magnesium ion has a stabilizing membrane effect and an antagonistic effect on ectopic automaticity. They are particularly important on slowly depolarizing tissue (nodal cells) or partially depolarized cells (ischaemic or digitalis treated cardiac tissue). In intensive care, circumstances for magnesium depletion by digestive or renal losses and by lack of parenteral magnesium supplement are frequently combined. Systematic intravenous administration of magnesium is necessary when such conditions are found and whenever ventricular or auricular dysrhythmias occur.

Calcium↗

PubMed2000

Multiple spontaneous small bowel anastomosis in premature infants with multisegmental necrotizing enterocolitis.

BACKGROUND/PURPOSE: Fulminant necrotizing enterocolitis (NEC) may result in extensive bowel necrosis. Resection of involved segments may result in short bowel syndrome. Multiple stomas result in complications and further loss of intestinal length with closure. METHODS: Two patients with extensive multisegmental NEC were treated with an intraluminal stent without anastomosis. All necrotic intestine was resected and the remaining viable intestine was lined up over a feeding tube without anastomosis of the intestinal segments. One patient had a diverting jejunostomy and mucous fistula with the tube used to orient the defunctionalized intervening intestinal segments. The second patient had the bowel left in continuity with the tube brought into the jejunem proximal to the first area of resection and distally brought out through the tip of the appendix. Both tubes were brought through the abdominal wall and secured in a loop. RESULTS: Contrast study findings showed that the intestinal segments had auto-anastomosed. In the first case the tube was left in place and intestinal continuity was restored. The patient is now 4 years old and takes full enteral feeds. The latter patient had the enterostomy tube removed at the time of the contrast study, but only tolerated partial feedings and died at 1 year of total parenteral nutrition-related liver failure. CONCLUSION: The technique eliminates nonviable bowel, maximizes length, avoids multiple stomas, and may help avoid reoperation.

Digestive System Surgical Procedures↗

PubMed2005

Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study.

BACKGROUND: The role of laparoscopic resection (LR) in the management of extraperitoneal rectal cancer still is unclear. This study aimed to compare perioperative and long-term results of laparoscopic and open resection (OR) for low and midrectal cancer. METHODS: A prospective nonrandomized trial comparing patients submitted to OR or LR for low and midrectal cancer at a single institution was conducted. RESULTS: The study included 191 consecutive patients: 98 patients who underwent LR and 93 who underwent OR. The mean follow-up period was 46.3 months for LR and 49.7 months for OR. The conversion rate for LR was 18.4%. With the use of LR, the mean time for complete patient mobilization was shorter (1.7 vs 3.3 days; p < 0.001) and patients were earlier in passing flatus (2.6 vs 3.9 days; p < 0.001) and stools (3.8 vs 4.7 days; p < 0.01), and in resuming oral intake (3.4 vs 4.8 days; p < 0.001). The mean hospital stay was shorter for LR, but the difference did not reach significance (11.4 vs 13 days). Morbidity and mortality rates were similar: LR (24.4% and 1%) and OR (23.6% and 2.2%). Laparoscopic patients presented a higher rate of anastomotic fistulas (13.5% vs 5.1%) and reoperations (6.1% vs 3.2%) but the difference was statistically nonsignificant. Laparoscopic resection presented a significantly lower local recurrence rate (3.2% vs 12.6%; p < 0.05). The cumulative survival and disease-free rates at 5 years were, respectively, 80% and 65.4% after LR and 68.9% and 58.9% after OR (nonsignificant difference). Stage-by-stage comparison showed prolonged cumulative survival for stages III and IV cancer in LR (82.5% vs 40.5%; p = 0.006 and 15.8% vs 0%; p = 0.013, respectively) and a reduced rate of cancer-related death for stage III in LR (11.4% vs 51.9%; p = 0.001). CONCLUSIONS: As compared with conventional open surgery, LR for low and midrectal cancer is characterized by a faster recovery and similar overall morbidity (but a higher rate of anastomotic leakages), and does not present any adverse oncologic effect.

Adult↗

PubMed2003

Anal sphincter reconstruction for incontinence due to non-obstetric sphincter damage.

OBJECTIVE: To assess the outcome after anal sphincteroplasty in patients with anal incontinence following non-obstetric anal sphincter damage. DESIGN: A prospective study carried out in an urban teaching hospital over five years (1994-1998). PATIENTS AND METHODS: Fourteen patients, median age of 30 years, all undergoing anal sphincter reconstruction. The procedure was performed under general or regional anaesthesia. Operative management was (i) excision of the scar tissue and apposition of the cut ends of the sphincter or (ii) a reefing technique. RESULTS: Sphincter damage was as a result of trauma in nine cases, haemorrhoidectomy in two cases, sepsis in two and failed recto-vaginal fistula repair in one case. In six patients with traumatic sphincter damage a colostomy was performed at original operation. The other eight presented with incontinence, four of whom required a diverting colostomy prior to repair. The median delay between sphincter injury and repair was six months (range 4-120). The posterior approach was used in eight patients, an anterior approach in five and both approaches in one. Non-absorbable suture material was used in six and absorbable material was used in eight patients. Twelve of the 14 patients had scar tissue at the site of damage requiring excision. Two post-haemorrhoidectomy patients underwent the reefing technique. Eleven patients (79%) were completely continent after initial repair. Two required further repair resulting in complete continence. One patient remained with mild incontinence. CONCLUSION: Anal sphincter reconstruction for non-obstetric anal incontinence produced good short-term results.

Adolescent↗

PubMedDate not supplied

A clinical case of duodenal gastrointestinal stromal tumor with a peculiarity in the surgical approach.

We describe a case of duodenal, third portion, segmental resection for gastrointestinal stromal tumor. A 76-year-old man was referred for gastrointestinal bleeding, dyspnea and asthenia. Esophagogastroduodenoscopy showed a duodenal bleeding fistula. Computerized tomography demonstrated a retroperitoneal mass that compressed and displaced forward the third duodenal tract. Segmental resection of the third portion of the duodenum with a subtotal gastrectomy was performed. The patient was reconstructed with a termino-terminal duodenal anastomosis of the second and the fourth tract and with a Roux-en-Y gastrojejunum anastomosis. There were no postoperative complications. This duodenectomy procedure could be useful as a less extensive resection for duodenal gastrointestinal stromal tumor located in the third portion of the duodenum when the tumor is well capsulated, when the surrounding structures are not infiltrated and when there are no vascular difficulties. The technique reduces the morbidity and mortality correlated with duodenocefalopancreasectomy and improves postsurgical quality of life without worsening the risk of recurrence.

Aged↗

PubMed1984

Diagnostic significance of bile cytology in obstructive jaundice.

Cytological examination of exfoliated cells in the bile or irrigated fluid from a percutaneous transhepatic choledochal drainage (PTCD) tube and other jaundice-reducing fistula was performed in 59 patients with obstructive jaundice. Malignant cells were found in 22 of 27 patients with choledochal cancer, 50 of 17 patients with pancreatic cancer, 3 of 6 patients with gallbladder cancer, and one of 5 patients with other malignancies. Exfoliated malignant cells were found at a higher rate in the washed fluid of the PTCD tube than in the pure bile aspirated from the PTCD tube. Half of the positive cases were diagnosed as such upon the first cytological examination, and the remaining in second or subsequent cytological examinations. The cytological appearance of cells in the washed fluid or bile reflected the type of cancer cells found by touch-smear of the lesion and also the histological type. This method requires no special technique and facilitates accurate diagnosis in patients with malignant lesion of the choledochal duct.

Adult↗

PubMed2001

Surgical treatment of constipation and fecal incontinence.

Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.

Constipation↗

PubMed1998

Effects of keratinocyte growth factor (KGF) on gut growth and repair.

Keratinocyte growth factor (KGF) is a mitogen found throughout the gastrointestinal tract, but its role in gastrointestinal pathophysiology is unclear. The effect of recombinant KGF on gut growth and repair has been examined using a variety of in vivo models. Rats receiving total parenteral nutrition had co-infusions of KGF or control for 6 days. Changes in gut growth (wet weight and vincristine-induced metaphase arrest) were then assessed. The effects of KGF on gastric repair and acid secretion in rats were determined using an indomethacin (20 mg/kg)/restraint model and animals fitted with chronic gastric fistulae. KGF at 0.1, 1, and 3 mg/kg increased gut growth as assessed by wet weight throughout the gastrointestinal tract and increased vincristine-induced accumulation of metaphases in the stomach and small intestine but not in the colon. Plasma gastrin, peptide YY, enteroglucagon, and glucagon-like peptide-1 were all increased, whereas insulin was lowered by KGF (all P < 0.01). KGF was ineffective in reducing indomethacin-induced gastric damage but caused a reduction in basal acid secretion of about 35 and 50 per cent when administered at 0.2 or 5 mg/kg (P < 0.05). These studies support the idea that KGF is involved in the control of proliferation of the gastrointestinal tract. They do not provide evidence, however, for a role in the early reparative process invoked during short-term models of gastrointestinal injury.

Animals↗

PubMed2005

Artificial sphincter with colonic reservoir for severe anal incontinence because of imperforate anus and short-bowel syndrome: report of a case.

Anal sphincter replacement is a treatment option for severe anal incontinence that is not amenable to direct repair. We describe the unusual case of a 25-year-old male who has been successfully treated by implantable artificial sphincter for severe anal incontinence caused by imperforate anus and concomitant short-bowel syndrome. In early life, the patient underwent several surgical procedures, including a perineal colostomy for a high imperforate anus associated with a rectourethral fistula. At aged 21 years, he underwent a subtotal small-bowel resection and a restorative jejunotransverse anastomosis for acute intestinal necrosis related to intestinal malrotation with volvulus. The length of remnant jejunum was 90 cm. Consequently. the patient became permanently incontinent and required nutritional therapy. An artificial sphincter, after the creation of colonic reservoir, was implanted around the pulled-through colon. At two-year follow-up after implantation, despite short remnant bowel, the patient was fully continent without medication. Normal nutritional status was maintained under 100 percent oral nutrition. The patient's quality of life improved dramatically. He has returned to work and had no major restriction in his level of social functioning. Our case illustrates for the first time the original concept of artificial anal artificial sphincter implantation around a pulled-through colon, which constitutes a different situation from disease with rectum in place.

Adult↗

PubMed2005

Laparoscopically assisted anorectoplasty using perineal ultrasonographic guide: a preliminary report.

BACKGROUND/PURPOSE: As minimal invasive surgery, laparoscopically assisted anorectal pull-through has been reported with new devices. However, it is not easy to create an accurate pull-through canal (PTC) because of the narrow space between the urethra and puborectal sling. The authors describe a new method using perineal ultrasonography. METHODS: The rectourethral prostatic fistula was dissected laparoscopically. Externally, electrostimulation identified the center of the muscle contraction, over which a 1.2-cm skin incision was made, and the lower part of PTC was created by hemostat forceps guided by electrostimulation. An ultrasonographic probe applied to the perineum demonstrated the urethra, and the forceps was advanced behind the urethra into the pelvic cavity using the ultrasonographic guide. Anorectal pull-through was performed after dilatation of the PTC with dilators. RESULTS: The authors applied this procedure in 5 cases of male high and intermediate anomalies. Surgical damages to the urethra and the levator and vertical muscles were not encountered. Postoperative fluoroscopic study demonstrated good anterior angulation and intact contraction and relaxation of those muscles. CONCLUSION: The combination of laparoscopic dissection, pinpointing the center of anal sphincter by electrostimulation, and identification of the urethra by ultrasonographic images from the perineum facilitated creation of appropriate PTC in the muscle complex.

Anal Canal↗

PubMed2000

Study populations and casemix: influence on analysis of postoperative outcomes.

BACKGROUND: The importance of patient casemix as a determinant of surgical outcome is now being recognized. The present study was undertaken in order to compare the presentation and outcomes in colorectal patients managed surgically by the same surgeon, in the same way, in different settings. METHODS: Colorectal outcome data from the University Department of Surgery in Wellington and the King Faisal Specialist Hospital in Riyadh were analysed in order to determine casemix differences between the two hospitals. Data relating to the type of surgery, the surgeon, the patient's disease, the operation performed and the postoperative complications were compared. Specific colorectal clinical indicators were compared for two commonly performed operations for rectal cancer: anterior resection and abdomino-perineal resection of the rectum. RESULTS: Wellington patients were slightly older and there were more females. Emergency surgery was more frequent in Wellington. Left hemicolectomy, sigmoid colectomy, abscess drainage and pilonidal surgery were more common in Wellington whereas abdomino-perineal resection and anterior resection of the rectum, stoma closure, fistula surgery, seton insertion, restorative proctocolectomy and ileostomy were undertaken more frequently in Riyadh. More complex anal fistulas were managed in Riyadh. Condylomata accuminata, pilonidal abscess, anorectal abscess, rectal prolapse and diverticular disease were rarely seen in Riyadh. There were more postoperative pulmonary and cardiac complications in Wellington. Patients having anterior resection of the rectum were younger in Riyadh and there were proportionally more females. There were some obvious numerical outcome differences in postoperative atelectasis, wound infection, anastomotic leak and deep vein thrombosis rates but none of these reached statistical significance except atelectasis. In Riyadh the usual male-to-female ratio of patients undergoing abdomino-perineal resection was reversed but, again, none of the numerical outcome differences observed reached statistical significance except postoperative atelectasis and intraabdominal abscess. CONCLUSION: Although not statistically significant, the results of the present study suggest that when the same surgeon operates using the same technique in different communities, the outcomes may be different. Care should thus be taken when comparing different populations with different casemixes before definitive conclusions are made in comparative studies.

Adult↗

PubMed2005

The advancing art and science of endoscopy.

Flexible endoscopy continues to advance encompassing treatment of a variety of diseases traditionally managed surgically. This review describes and evaluates many of these new endoscopic approaches with an eye toward the future. Gastroesophageal reflux disease is now treated with several endoscopic, non-operative techniques. A procedure using radiofrequency energy delivered by a peroral catheter with small needles inserted into the wall of the esophagus causes collagen deposition and ablates transient lower esophageal sphincter relaxation, both of which reduce reflux. With this treatment, >80% of patients will reduce or stop their medication for reflux. Trials involving new injectable materials show promise with a 75-80% improvement in heartburn-related quality-of-life scores and reduced medication use. Endoscopic suture and stapling devices restore the antireflux barrier with sutures that create a pleat or plication at the gastroesophageal junction. Early results indicated that 62-74% of patients had significant improvement. Long-term results are not available for any of these new techniques and there seems to be a drop off in effectiveness over time. Gastrointestinal bleeding has been more effectively managed with the recent introduction of small clips and detachable snares to control bleeding vessels. Banding and sclerotherapy for variceal bleeding has all but eliminated urgent operation for that diagnosis. In the biliary-pancreas realm, endoscopic management of pancreatic pseudocysts, stenting of pancreatic or biliary strictures and fistulae have reduced operative indications in those disease processes. Pseudocyst drainage involves creation of a transenteric communication between the pseudocyst and the stomach or duodenum. Complete cyst resolution without recurrence can be expected in 85% of patients. While endoscopic palliation of malignant biliary strictures has been accepted for years, experience with endoscopic management of iatrogenic strictures indicates that it may serve as an alternative option without surgery in many patients. Enteric stenting using metallic self-expanding stents in the esophagus, duodenum, and colon allows alleviation of obstruction without surgery for palliantation and in the colon may relieve obstruction to avoid colostomy prior to an elective resection. On the horizon stands the flexible endoscopic route to the abdominal cavity via the transgastric route and the promise of combined endoscopic-laparoscopic approaches to complex abdominal problems. General surgeons should rekindle their interest in flexible endoscopy or risk losing entire categories of disease to other specialties or to a small specialized group of endoscopic surgeons.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1997

Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes.

OBJECTIVE: The authors reviewed the pathology, complications, and outcomes in a consecutive group of 650 patients undergoing pancreaticoduodenectomy in the 1990s. SUMMARY BACKGROUND DATA: Pancreaticoduodenectomy has been used increasingly in recent years to resect a variety of malignant and benign diseases of the pancreas and periampullary region. METHODS: Between January 1990 and July 1996, inclusive, 650 patients underwent pancreaticoduodenal resection at The Johns Hopkins Hospital. Data were recorded prospectively on all patients. All pathology specimens were reviewed and categorized. Statistical analyses were performed using both univariate and multivariate models. RESULTS: The patients had a mean age of 63 +/- 12.8 years, with 54% male and 91% white. The number of resections per year rose from 60 in 1990 to 161 in 1995. Pathologic examination results showed pancreatic cancer (n = 282; 43%), ampullary cancer (n = 70; 11%), distal common bile duct cancer (n = 65; 10%), duodenal cancer (n = 26; 4%), chronic pancreatitis (n = 71; 11%), neuroendocrine tumor (n = 31; 5%), periampullary adenoma (n = 21; 3%), cystadenocarcinoma (n = 14; 2%), cystadenoma (n = 25; 4%), and other (n = 45; 7%). The surgical procedure involved pylorus preservation in 82%, partial pancreatectomy in 95%, and portal or superior mesenteric venous resection in 4%. Pancreatic-enteric reconstruction, when appropriate, was via pancreaticojejunostomy in 71% and pancreaticogastrostomy in 29%. The median intraoperative blood loss was 625 mL, median units of red cells transfused was zero, and the median operative time was 7 hours. During this period, 190 consecutive pancreaticoduodenectomies were performed without a mortality. Nine deaths occurred in-hospital or within 30 days of operation (1.4% operative mortality). The postoperative complication rate was 41%, with the most common complications being early delayed gastric emptying (19%), pancreatic fistula (14%), and wound infection (10%). Twenty-three patients required reoperation in the immediate postoperative period (3.5%), most commonly for bleeding, abscess, or dehiscence. The median postoperative length of stay was 13 days. A multivariate analysis of the 443 patients with periampullary adenocarcinoma indicated that the most powerful independent predictors favoring long-term survival included a pathologic diagnosis of duodenal adenocarcinoma, tumor diameter <3 cm, negative resection margins, absence of lymph node metastases, well-differentiated histology, and no reoperation. CONCLUSIONS: This single institution, high-volume experience indicates that pancreaticoduodenectomy can be performed safely for a variety of malignant and benign disorders of the pancreas and periampullary region. Overall survival is determined largely by the pathology within the resection specimen.

Adenocarcinoma↗

PubMed1989

Pediatric upper gastrointestinal endoscopy: a 13-year experience.

This report describes a series of 553 flexible upper gastrointestinal (GI) endoscopies performed on 382 children in two surgical centers between 1975 and 1987. Indications included abdominal pain (180), reassessment of known disease (149), upper GI bleeding (99), foreign body ingestion (77), vomiting (14), dysphagia (10), and miscellaneous (24). Findings were chronic peptic ulcer (47), gastritis/duodenitis (63), healing disease (92), nonhealing disease (22), recurrent disease (32), foreign body impaction (22), stricture (9), esophagitis (7), varices (7), mass (6 [3 polyp, 1 lymphoma, 1 fungus ball, 1 inflammation]), normal (209), and miscellaneous (37). Endoscopic diagnosis was uniformly correct except on two occasions, when the presence of recurrent tracheoesophageal fistula in small infants was missed due to use of an inadequate instrument. A pathologic lesion is likely to be identifiable in GI bleeding (84.8%). Endoscopic surveillance for progress of known disease was found to be valuable, particularly in peptic ulcer management, as both incomplete healing after standard therapy as well as recurrence are frequent. The recent practice of routine antral biopsy in children with severe "nonspecific abdominable pain" enabled four cases of Campylobacter pylori colonization in the stomach to be diagnosed, thus allowing appropriate treatment. Endoscopy was therapeutic on 61 occasions: injection sclerotherapy (32), foreign body removal (20), polypectomy (3), and stricture dilatation (6). Endoscopy-guided bougienage, in particular, represents a recent major advance. There was no morbidity or mortality in the entire series. It is concluded that pediatric upper GI endoscopy performed by experienced surgeons is safe and effective. As a result of better understanding and technological advances, a changing trend of wider and more rational applications of the procedure is now evident.

Adolescent↗