Multiple Abdominal Surgeries Research Articles

INTESTINAL TRANSPLANTATION FOR END STAGE CROHN'S DISEASE

387 Intractable Crohn's disease is a common cause of chronic intestinal failure among adult patients. Intestinal transplantation has recently evolved to be the only life saving therapy for patients who cannot be maintained on TPN. Materials and Methods: Crohn's disease was the cause of irreversible intestinal failure in 11 (23%) out of 48 adult patients who received intestinal transplantation at our institution during the period from May 1990 to December 1998. Six patients were male and 5 were female with a mean age of 38 ± 10 years. Two of the 11 patients received combined liver-intestine because of hepatointestinal failure and the remaining 9 received isolated intestine. The indications for isolated intestinal transplantation were vanishing central venous access (n=4), frequent line sepsis (n=8), persistent fluid and electrolyte disturbances (n=5), and impending liver failure (n=2). All recipients had multiple abdominal surgery with a median of 10 operations (range: 2-19) and received TPN therapy for a median of 80 months (range: 15-156). All donors were cadaveric and primary immunosuppression was with tacrolimus and steroids. Results: The median operative time of transplantation was 11.9 hours (range: 15-22.5). Defective abdominal wall with contracture of the abdominal cavity that required major plastic reconstruction was observed in 3 patients. With a mean follow-up of 26 months (range:0.4-82), 5 (45%) patients (4 isolated intestine, 1 liver-intestine) are currently alive with fully functioning grafts. The causes of patient/graft loss were respiratory failure (n=3), rejection (n=1), technical (n=1), and narcotic overdose (n=1). None of the grafts have developed recurrent disease. The incidence, frequency, and severity of rejection were similar to that of a well matched historical control group. Cytomegaloviral disease developed in 5 (45%) of the patients and was intractable in 3. None of the recipients had PTLD or graft versus host disease. Conclusions: 1) Intestinal transplantation is a life saving therapy for Crohn's disease patients with intestinal failure who can no longer be maintained on TPN. 2) Crohn's disease does not increase the risk of intestinal allograft rejection. 3) The potential risk of disease recurrence has yet to be demonstrated in our series.

Ovarielles Implantations-Syndrom mit Mesenterialzyste

Fragestellung: Der unbeabsichtigte Verbleib von Ovarialresten in situ nach operativen Eingriffen oder das Vorkommen ovarieller Überschußtehlbildungen (überzähliges/akzessorisches Ovarialgewebe) kann lokale und/oder systemische Folgeverändealgewebe im Mesenterium ist eine extrem seltene Variante. Wir berichten über einen einschlägigen Fall und diskutieren die klinischen Syndrome, die aus dem unerwarteten Vorkommen von Ovarialgewebe resultieren können.

C1 esterase inhibitor deficiency, airway compromise, and anesthesia.

C1 esterase inhibitor deficiency, airway compromise, and anesthesia.

Laparoscopically assisted vaginal hysterectomy: report of 190 cases.

We report 190 cases where laparoscopy assisted vaginal hysterectomy (LAVH) was used as a primary procedure when the patients were not suitable candidates for a vaginal hysterectomy (VH) either because of lack of prolapse or multiple abdominal surgeries. All the surgeries were done by the same gynecologist. A total of 209 cases were performed, but 8 cases (3.8%) have been converted to TAH because of intraoperative bleeding or severe adhesions. The remaining 201 (96.2%) cases have been completed as LAVH. In this study we have evaluated only 190 cases as 19 cases had additional associated surgeries or incomplete records. The average operating time was 117+/-25.9 min, the intraoperative blood loss was 242.3+/-213.3 mL, and the average hospitalization was 0.7+/-0.7 days. Although the operating time and intraoperative blood loss over a span of time showed significant reduction, the hospitalization did not show any significant change. The complication rate was 6.6%. The average hospitalization cost excluding the surgeons and anesthesiologist charges was $3936.00. With these findings we have concluded that regardless of preoperative diagnosis and findings when vaginal hysterectomy is not suitable, LAVH is a viable alternative to TAH. To the best of our knowledge this is the first article discussing this particular approach.

The effect of antithrombin III substitution therapy on components of the plasma protease systems in surgical patients

Objective: To evaluate the possible effects of antithrombin III (AT III) concentrate therapy on components of the plasma protease systems in surgical intensive care patients. Design: Open randomised, prospective study. Setting: General intensive care units in secondary and tertiary care hospitals. Subjects: Eighty-three surgical patients with functional plasma activity of AT III below 80% of normal plasma pool value the day after multiple trauma or major abdominal surgery. Interventions: Intravenous infusion of AT III concentrate. Endpoints: To maintain plasma AT III activity above 90% of normal plasma pool value in the therapy group. Measurements and main results: AT III, prothrombin, prekallikrein, kallikrein inhibition, kallikrein-like activity, plasminogen, antiplasmin activity and plasmin-like activity were measured with chromogenic peptide substrate assays. AT III, prothrombin, prekallikrein and plasminogen were reduced on the inclusion day in all patients. The other variables were in the normal ran...

Laparoscopic Nephrectomy Via the Reproperitoneal Approach

Purpose We evaluated efficacy of the retroperitoneal approach for laparoscopic nephrectomy of kidneys with benign disease. Materials and Methods Eight men and 12 women (mean age 55 years) with severely damaged kidneys underwent laparoscopic retroperitoneal nephrectomy. One patient had a history of multiple open abdominal and gynecological operations. Kidneys were removed laparoscopically from the working space, which was created by finger and balloon dissection, and maintained by carbon dioxide insufflation in the retroperitoneal cavity. Results All kidneys were removed successfully via this procedure. Mean operative time was 3.3 hours and mean estimated blood loss was 135 ml. One patient experienced bleeding from the injured capsular artery just after removal of the kidney. Conclusions The retroperitoneal approach is recommended for laparoscopic nephrectomy.

Gasless Laparoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in the nutritional management of patients requiring gastrostomies. Laparoscopic gastrostomy is usually performed when PEG is contraindicated, for example, in patients with esophageal strictures, large gastric tumors, or a history of multiple abdominal surgery. We report herein a case of gasless laparoscopic gastrostomy performed for carcinoma associated with a severe respiratory distress syndrome in a malnourished patient with a tight esophageal stricture. The gasless technique uses the Laparolift System (Laparolift, Origin Medsystem, Inc.), a device composed of a fan-shaped retractor and a mechanical lifting arm that produces an abdominal wall distention resembling a truncated pyramid. Gasless laparoscopy was a safe alternative approach to CO2 pneumoperitoneum in this patient.

Laparoscopic placement of ventriculoperitoneal shunts: preliminary report.

We used a laparoscopic technique for the percutaneous placement of the peritoneal end of cerebrospinal fluid shunts in adult patients with obstructive or normal-pressure hydrocephalus. Concurrent with the initial cranial part of the procedure, pneumoperitoneum is established in a routine fashion, and a video-laparoscope and grasping forceps are inserted into the peritoneal cavity. With use of a pacemaker introducer kit, the peritoneal catheter is placed percutaneously under direct laparoscopic vision through a small upper abdominal incision into the peritoneal cavity. At the completion of the procedure, the patency of the assembled shunt system can be verified by observing free flow of cerebrospinal fluid from the catheter tip as the valve is being pumped. We found that this technique is particularly useful in technically challenging cases--for example, those involving obese patients and those who have undergone multiple abdominal operations. No complications associated with the technique were encountered.

Lithotripsy of an impacted calcified stone in the cystic duct accompanied by cholecystitis in severe Crohn's disease.

A 35 year old women patient with Crohn's disease and previous multiple abdominal operations presented with a calcified stone of 12 mm diameter in the cystic duct giving rise to cholecystitis. The surgeons declined to operate because of extensive intra-abdominal adhesions caused by multiple intestinal resections and chronic enterocutaneous fistulas. It was possible to fragment the stone in three lithotripsy sessions. The fragments were excreted spontaneously through the ductus choledochus and the cholecystitis was cured by antibiotic treatment. The patient remained symptom free after 12 months.

Abdominal Wall Considerations and Complications in Reoperative Surgery

The abdominal wall is the source of significant problems for patients undergoing multiple abdominal operations. The orientation of sequential incisions must be carefully considered to avoid compromise of the abdominal wall blood supply, which may result in either acute (dehiscence) or delayed (ventral hernia) complications. Infections are the most serious problems of the multiply operated on abdominal wall. These complications may range from simple wound infection to necrotizing fasciitis. Management may require only simple drainage of the infection or may entail extensive debridement for the necrotizing processes. Regardless of the cause, the multiply operated on abdominal wall may require reconstruction because of lost fascia. Polypropylene mesh can be employed safely and effectively for this purpose.

Laparoscopic Enterolysis for Chronic Abdominal Pain

Many patients who have undergone multiple abdominal operations have significant pain related to abdominal or bowel adhesions. Laparoscopic attempts at treatment of these patients is risky and should be undertaken only after proper consultation and preparation for immediate bowel surgery. In a series of 42 patients (38 females, 4 males) treated laparoscopically between 1984 and 1988, only 2 required immediate laparotomy during laparoscopic attempts. At 3 months follow-up, 67% of the patients were improved, and 33% were not. Ten patients underwent later laparotomy because of persistence of symptoms. (J GYNECOL SURG 5:61, 1989)

Descending thoracic aorta-to-femoral artery bypass.

Descending thoracic aorta-to-femoral artery grafts were placed in 13 patients who had abdominal aortas deemed undesirable for surgical treatment. These included seven patients in whom an infected aortic graft had been removed for primary graft infection (three) or aortoduodenal fistula (four). These patients had been treated initially with axillary-femoral grafts. In five other patients, this approach was used following failure of at least two previous aortofemoral grafts. The remaining patient was so treated following multiple complex abdominal operations. The surgical technique involves a posterolateral, seventh interspace thoracoabdominal incision with a transdiaphragmatic retroperitoneal tunnel to the left groin. There was no operative mortality. The mean follow-up of all patients was 22 months (range, one to 44 months). All grafts remained patent except one, which was removed because of ascending groin infection. Three patients died, at 24, 29, and 44 months postoperatively, respectively. Reasonable perioperative morbidity and reliable patency make this an attractive technique for the conversion of axillofemoral bypasses and, when reentry of the abdominal cavity is undesirable, laparotomy is avoided.

Computerized Tomographic Scanning with Intraperitoneal Contrast Enhancement in a CAPD Patient with Localized EDEMA

In a patient on continuous ambulatory peritoneal dialysis with localized abdominal and genital edema, the site of extraperitoneal dialysate leakage was determined by computerized tomographic scanning with intraperitoneal contrast enhancement. No adverse effects were encountered. The source of fluid leakage should be sought in CAPD patients with localized (i.e. genital) edema, because often they may have an undetected hernia or other peritoneal defect. Removal of the peritoneal dialysis catheter would not solve such a problem. In such cases, intraperitoneal contrast-enhanced CT scanning may represent an effective technique for identifying the site of dialysate leakage. Abdominal and inguinal hernias are well-recognized complications of con tinuous ambulatory peritoneal dialysis (CAPD). Dialysate may escape from the peritoneal space through such hernias; also the development of genital edema in a CAPD patient may indicate the presence of an inguinal hernia, which otherwise may be impossible to detect clinically (I). In CAPD patients who have had multiple abdominal operations, there may be numerous possible sites of hemia development and dialysate leakage, so that it may prove difficult to identify and repair the defect. We describe a patient in whom contrast-enhanced computerized tomographic scanning was used to identify the site of extraperitoneal dialysate leakage.

Extended aortic bypass

At the University of Alberta Hospital, six patients recently underwent placement of Dacron bypass grafts from the ascending aorta to the infrarenal abdominal aorta or femoral arteries for a variety of vascular problems. The operations were performed in patients with (1) multiple aortic coarctations, (2) congenital aortic arch interruption and congenital mitral stenosis, (3) recoarctation of the thoracic aorta after previous coaractation repair (two patients), (4) aortoiliac occlusive disease in a patient with multiple previous abdominal operations including an abdominal-perineal resection and left lower quadrant colostomy, and (5) idiopathic retroperitoneal fibrosis and multiple previous operations on the abdominal aorta. Surgical access was through midline sternotomy and laparotomy incisions, and groin incisions were used as required. Careful attention was paid to placing as much graft as possible in an extraperitoneal position. All patients survived the operation and had essentially uneventful postoperative courses with good results. This technique has previously been described. However, attention is drawn to it once again as an excellent means of bypassing the thoracic and abdominal aorta in selected patients with complex vascular problems.

Vaginal cystectomy

The technique of vaginal cystectomy is described in 2 patients. These patients were particularly suited for vaginal cystectomy because severe lower- abdominal scarring from previous multiple abdominal operations would have made the standard suprapub-ic approac difficult.

Gastrointestinal tube stent plication in infants and children.

Twenty cases of intestinal obstruction in infants and children were managed by gastrointestinal tube stent plication. The mean age was 2.6 years, and ten patients were infants. Previous (often multiple) abdominal operations were performed in 18 patients with a variety of anomalies. Tube plication was used at initial operation in two neonates with malrotation. Following lysis of adhesions, a No. 12 or No. 16 tube (usually a Baker tube) was inserted by gastrostomy and advanced distally into the colon. The tube was kept in place for ten days, with caloric needs supplied by parenteral alimentation. Barium tubogram showed distal patency, and the tube was removed. Eighteen patients survived (90%), and obstruction was relieved in each instance. These observations suggest that gastrointestinal tube stent plication is a useful adjunctive procedure in carefully selected cases or recurrent adhesive intestinal obstruction in infants and children.

The Watson-Schwartz Test

The Watson-Schwartz test for porphobilinogen is an excellent, simple screening procedure for porphyria and certainly its use should be considered in any patient with a history of abdominal pain, constipation, obscure neurological disorder, mental disturbance, multiple abdominal operations, or dark urine. The porphyrias are a group of inherited disorders of porphyrin metabolism (Table) manifested chemically by an increased excretion of the porphyrins and their precursors or both. Porphyrins are normally synthesized from glycine and succinic acid which combine to yield α-amino-β-ketoadiptic acid. Decarboxylation results in δ-aminolevulinic acid. Two molecules of δ-aminolevulinic acid condense, forming the monopyrolle, porphobilinogen. Four molecules of porphobilinogen condense producing the various tetrapyrolle porphyrinogens (copro-, uro-, protoporphyrinogen), the reduced, colorless precursors of the porphyrins. 1 Porphyrins linked to metal and protein constitute the important biological compounds: hemoglobin, myoglobin, cytochrome, and catalase. Varieties of Porphyria.— Porphyria Erythropoietica . —Inherited as an autosomal recessive, it accounts for only 3% of