Performed On Postoperative Day Research Articles

Pure natural orifice transluminal endoscopic surgery (NOTES) with ultrasonography-guided transgastric access and over-the-scope-clip closure: a porcine feasibility and survival study

Most natural orifice transluminal endoscopic surgery (NOTES) procedures to date rely on the hybrid technique with simultaneous laparoscopic access to protect against access-related complications and to achieve adequate triangulation for dissection. This is done at the cost of the potential benefits of this new minimally invasive technique. This study aimed to evaluate the feasibility and safety of a transgastric (TG) pure-NOTES procedure in a diagnostic setting. A TG pure-NOTES procedure with endoscopic ultrasonograpy (EUS)-guided access and over-the-scope-clip (OTSC) closure was performed for 10 pigs in a survival and feasibility study. A full macroscopic necropsy with subsequent histologic evaluation was performed on postoperative day (POD) 14. The outcome parameters were uncomplicated follow-up assessment, survival, intraoperative complications, intraabdominal pathology, macroscopic full-thickness closure, and histology-proven full-thickness healing of the gastrotomy. An uncomplicated postoperative course was reported for 9 of the 10 pigs, and survival was reported for all 10 pigs. For all the pigs, EUS-guided access was performed successfully with a median duration of 25 min (range, 12-62 min) and without intraoperative complications or access-related lesions at necropsy. An OTSC closure was achieved with a median duration of 11 min (range, 3-28 min). The OTSC provided immediate closure, but according to the authors' definition of a full-thickness healing evaluated by histologic examination, this was not achieved in any of the cases. Although all the animals survived until POD 14, intraabdominal chronic abscesses were present in 3 of the 10 pigs at necropsy. The EUS-guided TG access proved to be feasible without access-related complications. Although OTSC provided an immediate closure, the histopathology raised concerns regarding the risk of perforation. Together with the high risk of intraabdominal infection, TG pure-NOTES is not yet ready for routine clinical practice.

Simultaneous resection of Barrett's esophageal cancer and severe stenosis caused by reflux esophagitis

A 60-year-old woman presented with dysphagia. Upper endoscopy revealed severe stenosis in Barrett’s esophagus with the internal diameter narrowed to 8 mm (Fig. 1). Contrast-enhanced CT ruled out metastasis. Tongueshaped brownish areas, where adenocarcinoma had been diagnosed, were approximately 5 to 7 mm in diameter. ESD extending 5 cm in the longitudinal direction was performed to resect the adenocarcinoma and the nearcircumferential stenosis site. Considering the severe fibrosis present, surgical entry was made 3 cm from the proximal end. At the stenosis site, EUS (20 MHz) revealed an intact submucosal layer around 0.5 mm of the circumference. In a retroflexed view from the stomach, we made an incision on the distal side of the stenosis. By advancing the endoscope into the submucosal layer by using the tunnel technique, we observed the most severe scarring (Fig. 2). Circumferential resection was completed (Fig. 3). Postoperative pathology revealed high-grade dysplasia and Barrett’s well-differentiated adenocarcinoma (Fig. 4). Kenacort was applied, and balloon dilation was performed on postoperative day (POD) 5 to prevent stenosis. The muscularis was exposed over the ulcer surface, and it was possible to permeate the gel into the remaining muscularis by expanding the balloon. Granulation tissue accompanied by extensive microvasculature was observed by magnified narrow-band imaging endoscopy on POD 12. By POD 15, granulation tissue was replaced by regenerating epithelium, with no post-ESD stricture formation apparent. On POD 60, Gastrografin contrast imaging confirmed smooth passage past the post-ESD lesion, and additional balloon dilation (to 18 mm) was performed. No stenosis or clinical symptoms were apparent at POD 90. n

Acute renal failure due to obstructive uric acid stones associated with acute gastroenteritis

Sirs, The development of acute renal failure (ARF) in young children with acute gastroenteritis can lead to a presumptive diagnosis of pre-renal azotemia resulting from diarrheal dehydration. Recently, however, several cases of children with acute post-renal failure due to bilateral obstructive uric acid stones associated with acute gastroenteritis have been reported in Japan [1]. We have also encountered three similar cases in which the serum uric acid concentration was in the lower end of the normal range and fractional excretion of uric acid (FEUA) increased after the patients had recovered. Case 1 was a 3-year-old boy with a 1-week history of rotavirus gastroenteritis and a 2-day history of oligouria. He was referred to our hospital for further examination of the oligouria. He had been healthy prior to the presentation of the gastroenteritis and had no familial history of urolithiasis. On admission, physical examination showed peripheral oxygen saturation (SpO2) of between 80 and 90% for a maximum of 2 l/min supplemental O2. Clinical and laboratory data are summarized in Table 1. Ultrasound scan of the kidney disclosed bilateral dilated pelvises containing debris. Despite adequate fluid control and diuretic therapy, his condition worsened rapidly, desaturating to SpO2 60% for a maximum of 10 l/min supplemental O2, so that he required mechanical ventilation. Emergent computed tomography (CT) disclosed pulmonary edema and bilateral urolithiasis located at the pelviureteric junction (PUJ). Based on these findings, he was diagnosed with severe overhydration resulting from post-renal ARF due to bilateral urolithiasis. Since the anuria continued after 15 h of emergent continuous venovenous hemodiafiltration, percutaneous nephrostomy tubes were inserted bilaterally under ultrasound guidance. Sandy stones excreted through the nephrostomy tubes together with the urine consisted mainly of ammonium acid urate (AAU) (>98%). An antegrade nephrostogram performed on postoperative day (POD) 6 showed residual stones in the left PUJ. The patient therefore underwent left-sided extracorporeal shockwave lithotripsy (ESWL). He was discharged on POD 17. Follow-up ultrasound performed 6 months postoperatively indicated bilateral mild hydronephrosis, but no evidence of stones. Case 2 was a 16-month-old boy with a 3-day history of vomiting and diarrhea. He was initially admitted to a local hospital because of dehydration but was referred to our hospital the following day as he demonstrated prolonged oligouria despite sufficient fluid replacement therapy. He had been previously healthy and had no familial history of urolithiasis. On admission, physical examination revealed mild dehydration. Ultrasound scan of the kidney disclosed bilateral dilated pelvises containing debris, and the abdominal CT scan revealed bilateral urolithiasis at the PUJ. Percutaneous nephrostomy tubes were inserted bilaterally on his second day of hospitalization, and after 48 h of Pediatr Nephrol (2009) 24:2467–2469 DOI 10.1007/s00467-009-1222-x

A case of massive kidney graft calcification that developed early in a child recipient with hyperparathyroidism

Abstract: A boy aged six yr and six months with end‐stage renal disease because of focal segmental glomerulosclerosis underwent cadaveric renal transplantation. Ischemic injury during the operation resulted in a severely dysfunctional graft. A renal graft biopsy was performed on post‐operative day (POD) 21. The biopsy specimen showed the presence of many intratubular calcium crystals, patchy tubular injury, and focal aggressive tubulointerstitial rejection. Pelvic computed tomography performed on POD 23 also showed prominent calcification in and around up to two‐thirds of the graft. After the biopsy, the graft function recovered, and hemodialysis was stopped on POD 22. A second graft biopsy was performed on POD 52. This biopsy specimen showed recovery from rejection, although the nephrocalcinosis remained. It was suggested that secondary hyperparathyroidism and hyperphosphatemia provoked nephrocalcinosis in this patient.

Feasibility of thoracoscopic U-clip esophageal anastomosis: an alternative for esophageal atresia reconstruction

Background The authors propose that U-Clips can significantly decrease the technical difficulty of performing thoracoscopic esophageal reconstruction, thus, reducing operating time, the incidence of postoperative leak, and stricture rate. Methods After obtaining Institutional Animal Care and Use Committee approval, 3 4-kg female piglets underwent complete thoracoscopic esophageal transections. The esophagus was reconstructed thoracoscopically using S50 and S60 U-Clips over an 8F transanastomotic tube. Esophagrams were performed on postoperative day (POD) 7, 21, 44, and 77. Results Mean operating time was 57 minutes (45 to 75 min). Two of 3 piglets had no evidence of leak on POD 7 esophagrams. One animal had a small leak that resolved spontaneously on antibiotics. All 3 piglets tolerated a formula diet orally by POD 8. Over a 77-day survival period all 3 piglets had steady weight gain on an oral diet. Conclusions U-Clips are a feasible alternative to sutures for esophageal reconstruction in thoracoscopic surgery. Further study is warranted to investigate the full potential of U-Clips in minimally invasive pediatric surgery.

The effects of convenient vagorrhaphy on the early recovery of gastric secretion and emptying: an experimental study on function-preserving gastric cancer surgery.

An experimental study was conducted using a canine model to elucidate whether the once transected vagal nerve can be conveniently anastomosed, and to determine when and to what degree the vagorrhaphy retains its functions. In the vagorrhaphy group (n = 5), the anterior and posterior vagal trunks were transected 1.5 cm above the diaphragma and the cut ends were anastomosed using two stitches of 8-0 nylon and fibria glue adhesive without microsurgery. In the nonvagorrhaphy group (n = 5), a 1-cm length of the nerve segment was resected to prevent reinnervation. A microscopic study of the anastomotic site performed on postoperative day (POD) 10 indicated the intervention of nerve fibers between the cut ends. No differences were found in the gastric secretory function, as assessed by the Hollander insulin test, or in the emptying function, as assessed by the acetaminophen test, between the vagorrhaphy group and the control preoperative values. However, both of these functions were superior in the vagorrhaphy group compared to the nonvagorrhaphy group. These results indicate that the technique of convenient vagal anastomosis could be put to practical use in gastric cancer operations to avoid postvagotomy syndrome.

Urethral catheter removal prior to hospital discharge following radical prostatectomy

Objectives To investigate the feasibility of early catheter removal following radical prostatectomy. Methods Fifty-eight consecutive patients underwent radical prostatectomy, with intent of early catheter removal. Catheter removal was based on postoperative cystograms performed on postoperative day (POD) 3 or 4. Charts were retrospectively reviewed and patients were contacted by phone and specifically questioned regarding continence and bladder control. Results Fifty-one patients (87.9%) had a cystogram performed on POD 3 or 4. In 43 patients (74.1%), the catheter was successfully removed prior to hospital discharge. Eight patients experienced either early or late complications (excluding incontinence); these included 3 patients with a superficial wound infection, 2 patients with hematuria requiring reinsertion of a urethral catheter, 1 patient with a spontaneous pneumothorax, 1 patient who developed a deep vein thrombosis and lymphocele, and 1 patient with a bladder neck contracture. Urinary continence was reported as excellent to good in 86% of the patients at a mean followup of 17.4 months. Three patients (5%) underwent placement of an artificial urinary sphincter. Conclusions Catheter removal prior to hospital discharge after radical prostatectomy is feasible without any increase in morbidity.