Resection Of Tract Research Articles

Disappearance of stress-induced hyperthermia following a low dose of X-irradiation: involvement of the vomeronasal system in the modulation of the radiation-induced effects.

When the rectal temperatures of group-housed mice are measured sequentially, the temperature of the last mouse to be measured is higher than that of the first mouse. The hyperthermia effect observed in the last animal to be measured forms the basis of an experimental paradigm for studying the neurobiology of anticipatory anxiety. Stress-induced hyperthermia (SIH) was calculated as the difference (delta T) between the basal temperature (the averages of the first three mice) and the final temperature (the averages of the last three mice) when the temperatures of the 15 mice were measured sequentially, with a 2 min interval between each temperature measurement. The hyperthermia observed in the last animals measured was abolished by prior treatment with X-irradiation at the relatively low dose of 5-15 cGy. Prevention of the SIH response could be found when the irradiation was confined to the head region only, suggesting the importance of the brain in the radiation-induced effect. Relatively higher doses of 25 or 35 cGy failed to reduce the hyperthermia stress effect. Furthermore, the effect of X-irradiation was not observed following olfactory bulbectomy or resection of the vomeronasal tract. These results indicate that the disappearance of SIH response may only be found following irradiation at low dose levels. Furthermore, the results implicate the olfactory system in the radiation-induced anti-stress effect.

A persistent sinus tract from the vagina to the sacrum after treatment of mesh erosion by partial removal of a GORE-TEX Soft Tissue Patch

Mesh erosion is an unfortunate complication of abdominal sacral colpopexy. A sinus tract from the vagina to the sacrum developed in a patient after partial removal of a GORE-TEX Soft Tissue Patch because of mesh erosion. Successful management eventually required complete removal of all GORE-TEX material and resection of the sinus tract. (Am J Obstet Gynecol 1999;181:762-3.)

Changes in fecal fat excretion from allo-intestine transplanted rats after discontinuance of immunosuppressive agents.

We have previously shown in a rat model of segmental small bowel transplantation, that an ileal graft was more favorable for lipid absorption than a jejunal graft. In the present study, we investigated changes in the lipid absorption of allo-ileal grafts after the withdrawal of an immunosuppressant (methyldeoxyspergualin; given for 1 or 2 weeks at 2.5mg/kg per day) and compared the findings with the results of histological examinations. Heterotopic segmental small bowel transplantation (SBT) was performed using cuff anastomoses in the inbred rat strain combination DA (RT1a) and LEW (RT1). Orthotopic SBT was performed as reconstruction SBT. Reconstruction after resection of the original intestinal tract of the recipient was performed on the seventh day after heterotopic segmental ileal grafting. For the histological evaluation of graft rejection, we performed biopsies in the heterotopic model and autopsies in the orthotopic model. Fecal fat excretion from the orthotopically reconstructed recipients was measured by Folch's method. One- and 2-week use of methyldeoxyspergualin allowed the heterotopic allografts to remain intact histologically for 16.8+/-5.6 and 25.3+/-3.3 (mean+/-SD) days, respectively, whereas the grafts were rejected at 7.3+/-1.1 days when the immunosuppressive drug was not used. All the recipients in the orthotopic group had died by 19 days after reconstruction. After discontinuance of the immunosuppressive agent, fat excretion in feces in the surviving orthotopic grafted rats had increased markedly prior to histologically assessed heterotopic graft rejection. Evaluation of fecal lipid excretion may be a useful parameter for detecting graft rejection in rats.

Perioperative artificial nutrition in elective surgery: an impact study of French guidelines

Objective: In France, the consensus conference, held on 16 December 1994, produced guidelineson perioperative artificial nutrition (AN) use in patients undergoing elective surgery. The aim of this study was to assess the impact of these guidelines on practice patterns. Methods: The study was a practice pattern study with a ‘before-after’ design and a control group inEngland. A retrospective cross-sectional sample of adult patients undergoing elective resection of the digestive tract was collected in France and England before and after the consensus conference. Results: Malnourished patients received postoperative AN in 94% of ‘before’ cases and 82% ‘after’ butinadequate preoperative AN (40% ‘before’ and 26% ‘after’). Postoperative AN appeared to be over-prescribed in non-malnourished patients without prolonged postoperative fasting (70% ‘before’ and 65% ‘after’). In the English sample there was no significant variation in AN use between ‘before’ and ‘after’ periods. Conclusion: This study shows that clinical guidelines disseminated by consensus conference had a low impact on practice patterns in France and thus confirms the need to enforce the dissemination of the guidelines.

Partial or total resection of the biliary tract — Surgical strategies for hilar cholangiocarcinoma

Background: Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Although appropriate procedures are not agreed upon, an increase in radicality has been observed during the past 20 years.

Comprehensive Modified Diet Simplifies Nutrition Management of Adults with Short-Bowel Syndrome

Short-bowel syndrome (SBS) is a complex condition resulting from massive surgical resection of the intestinal tract. Nutrient malabsorption and metabolic alterations occur as a function of the portions of bowel removed and the length of remaining bowel segment. The nutrition management of SBS is challenging; many dietary restrictions are described, but inconsistently, throughout the literature. We compiled the restrictions and developed a comprehensive diet to reestablish adult patients with SBS on oral intake after surgery. Our purpose was to simplify the task of instructing patients with SBS in a diet that restricts all categories of food substances that may be poorly absorbed: fat, lactose, insoluble fiber, oxalates, and concentrated sweets. Suggestions to increase the transit time of ingested foods are included with the diet. Patients are taught the SBS diet after surgery and have bimonthly contact with the dietitian after leaving the hospital. Categories of restricted food substances, such as lactose, may be attempted and added back to the diet if they are tolerated. Bowel adaptation enhances tolerance to various dietary components over time. If sufficient bowel adaptation occurs, some patients are eventually able to return to an unrestricted diet. J Am Diet Assoc. 1998;98:309–315.

Reverse flap of distal latissimus dorsi for diaphragm reconstruction in the adult: Specification of the technical procedure and report on six cases

autograft rather than other valve prostheses in children, some specific reasons were present in this special situation. Resection of the aneurysmal aortic root was necessary and the relatively difficult access to the aortic root made the choice of a homograft less preferable in view of the inevitable reoperation. The operation turned out to be straightforward. The anterior placement of the pulmonary trunk made its harvesting easy. Coronary artery problems were not encountered. Transposition may, however, be combined with coronary artery patterns that make harvesting of the pulmonary trunk more difficult, especially a right coronary artery crossing the right ventricular outflow tract. No important mismatch between the diameters of the pulmonary trunk and aortic anulus existed, which further encouraged us to choose the pulmonary autograft for aortic root replacement. In conclusion, the Ross procedure is technically feasible after an arterial switch operation and may be a particularly attractive alternative for this special population. This may be even more true because it is the original aortic valve that is used to replace the insufficient neoaortic valve. R E F E R E N C E S 1. Gittenberger-de Groot AC, Sauer U, Oppenheimer-Dekker A, Quaegebeur JM. Coronary arterial anatomy in transposition of the great arteries: a morphological study. Pediatr Cardiol 1983;4(suppl 1):15-24. 2. Klautz RIM, Ottenkamp J, Quaegebeur JM, Buis-Liem TN, Rohmer J. Anatomic correction for transposition of the great arteries: first follow-up (38 patients). Pediatr Cardiol 1989;10: 1-9. 3. Yamaguchi M, Hosokawa Y, Imai Y, Kurosawa H, Yasui H, Yagihari T, et al. Early and midterm results of the arterial switch operation for transposition of the great arteries in Japan. J Thorac Cardiovasc Surg 1990;100:261-9. 4. Ungerleider RM, Gaynor JW, Israel P, Kanter RJ, Armstrong BE. Report of neoaortic valve replacement in a ten-year-old girl after an arterial switch procedure for transposition. J Thorac Cardiovasc Surg 1992;104:213-5. 5. Serraf A, Roux D, Lacour-Gayet F, Touchot A, Bruniaux J, Sousa-Uva M, et al. Reoperation after arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;110:892-9.

Needle tract recurrences after closed biopsy for sarcoma: Three cases and review of the literature

Percutaneous closed needle biopsy of musculoskeletal neoplasms has gained in popularity. However, it remains controversial whether or not to resect the needle tract for fear of a local recurrence. A single published case report exists, noting the lone tract recurrence of an extremity skeletal osteosarcoma. We report on three additional individuals who demonstrated that tract local recurrences may occur after a closed needle biopsy for nonosteosarcoma, nonextremity sarcomas. For perspective, the world literature is reviewed to identify tract recurrences for other malignancies and the results of needle biopsy in musculoskeletal neoplasms. Eighty-nine percent of needle tract local recurrences occur when carcinomas are subjected to biopsy, as reported in the literature. Forty-seven cases since 1950 are described representing essentially all tumor types. The nature of musculoskeletal neoplasms makes closed biopsy more difficult than for softer, more homogeneous, and easier to access neoplasms. Local recurrences of sarcoma may occur in closed needle biopsy tracts. Strong consideration should be given to open biopsy and tract resection.

Intensive care unit stay is prolonged in chronic alcoholic men following tumor resection of the upper digestive tract.

The prevalence of chronic alcohol misuse in patients with oral, pharyngeal, laryngeal or esophageal carcinomas exceeds 60%. No data is available, to our knowledge, on the morbidity and mortality of chronic alcoholics in surgical intensive care units (ICU) following tumor resection. We investigated whether the subsequent ICU stay in chronic alcoholics following tumor resection was prolonged and whether the incidence of pneumonia and sepsis was increased. 213 patients with carcinomas of the upper digestive tract were evaluated regarding their drinking habits. Chronic alcoholics met either the DSM-III-R criteria for alcohol abuse or dependence. Conventional laboratory markers and serum carbohydrate-deficient transferrin were determined preoperatively. Major intercurrent complications during ICU stay such as an alcohol withdrawal syndrome, pneumonia and sepsis as well as the frequency of death were documented. Patients did not differ significantly between groups regarding age or APACHE score on admission to the ICU.121 patients were diagnosed as being chronic alcoholics, 39 as being social drinkers and 61 as being non-alcoholics. In chronic alcoholics the frequency of death was significantly increased. Due to the increased incidence of pneumonia and sepsis the ICU stay was significantly prolonged in chronic alcoholics by approximately 8 days. The increased mortality and morbidity rate demonstrates that chronic alcoholics undergoing major tumor surgery have to be considered as high-risk patients during their postoperative ICU stay. Further studies are required with respect to the immuno-competence of chronic alcoholics and the prevention of alcohol withdrawal syndrome, pneumonia and sepsis in these patients.

A New Treatment for Patients with Short-Bowel Syndrome Growth Hormone, Glutamine, and a Modified Diet

The purpose of this study was to initially determine if growth hormone or nutrients, given alone or together, could enhance absorption from the remnant small bowel after massive intestinal resection. If clinical improvement were observed, this therapy would then be used to treat patients with the short-bowel syndrome over the long term. Patients who undergo extensive resection of the gastrointestinal tract frequently develop malabsorption and require long-term parenteral nutrition. The authors hypothesized that the administration of growth factors and/or nutrients could enhance further compensation of the remnant intestine and thereby improve absorption. Specifically, animal studies have shown that there is enhanced cellularity with the administration of growth hormone (GH) or glutamine (GLN), or a fiber-containing diet. Initially, 17 studies were performed in 15 total parenteral nutrition (TPN)-dependent short-bowel patients over 3 to 4 weeks in the clinical research center; the first week served as a control period, and during the next 1 to 3 weeks, the specific treatment was administered and evaluated. Throughout the study, food of known composition was provided and all stool was collected and analyzed to determine absorption across the remaining bowel. The effect of a high-carbohydrate, low-fat diet (DIET), the amino acid glutamine (GLN) and growth hormone (GH) administered alone or in combination with the other therapies (GH + GLN + DIET) was evaluated. The treatment was expanded to 47 adults (25 men, 22 women) with the short-bowel syndrome, dependent on TPN for 6 +/- 1 years. The average age was 46 +/- 2 years, and the average jejunal-ileal length was 50 +/- 7 cm (median 35 cm) in those with all or a portion of colon and 102 +/- 24 cm (median 102 cm) in those with no colon. After 28 days of therapy, the patients were discharged on only GLN + DIET. The initial balance studies indicated improvement in absorption of protein by 39% accompanied by a 33% decrease in stool output with the GH + GLN + DIET. In the long-term study, 40% of the group remain off TPN and an additional 40% have reduced their TPN requirements, with follow-up averaging a year and the longest being over 5 years. GH + GLN + DIET offers a potential method for providing cost-effective rehabilitation of surgical patients who have the short-bowel syndrome or other complex problems of the gastrointestinal tract. This therapeutic combination also may be useful to enhance bowel function in patients with other gastrointestinal diseases and those requiring extensive intestinal operations, including transplantation.

Dermoids and Dermal Sinus Tracts of the Spine

The evaluation of a child with a midline dimple or pit is one of the most common referrals to a pediatric neurosurgeon. Regardless of their depth, those below the top of the intergluteal crease end blindly and never extend intraspinally. Families can be reassured there is no infection or mechanical risk to the developing nervous system. A high index of suspicion must be maintained for all dimples above the intergluteal fold despite a normal examination or neuroradiologic studies. The midline must be carefully inspected when a child of any age suffers meningitis, especially when an unusual organism is cultured. Conservative management of dermal sinuses is not justified, and these lesions should be electively resected at the time of diagnosis. Dermal sinuses and inclusion tumors may lead to spinal cord tethering and progressive neurologic deterioration. Surgery in advance of deficits maintains normal neurologic function, and children can develop unencumbered by infection, motor, or bladder paralysis.

Complete duodenum-preserving resection of the head of the pancreas with preservation of the biliary tract

A complete resection of the head of the pancreas, with preservation of the duodenum and biliary tract was performed for 14 patients: 8 with chronic pancreatitis, 3 with mucin-producing cancer of the head of the pancreas, 2 with pancreas divisum, and 1 with cystadenoma of the head of the pancreas. With our technique, duodenal blood flow is maintained, and no pancreatic parenchyma is left on the duodenal side. For these patients, a pancreaticoduodenostomy without resection of the digestive tract was provided; however, for those in whom an anastomosis between the caudal side of the pancreas and the duodenum was too difficult, due to distance, a pancreaticojejunostomy, using a Roux-en-Y jejunal loop, was performed as an alternative method. The digestive tract was reconstructed by a pancreaticoduodenostomy in 8 patients and by a pancreaticojejunostomy in the remaining 6. The operation time for the former procedure was 5h, and for the latter, 5h and 40 min; the mean blood loss in both groups was similar, being 926 and 940 ml, respectively. The successful results in all cases indicate that maintenance of the duodenal blood flow is significantly related to complete resection of the head of the pancreas. Thus, it appears that the use of Kocher's maneuver should be avoided and that the preservation of the posterior superior pancreaticoduodenal artery is important.

Serum drug concentrations after oral administration of paracetamol to patients with surgical resection of the gastrointestinal tract.

Serum concentrations of paracetamol were measured at 30, 60, 120 and 180 min after oral administration of a solution of 1500 mg paracetamol in normal subjects (n = 32) (Group A) and in patients with total gastrectomy (Roux-en-Y reconstruction) (n = 5) (Group B), distal partial gastrectomy (Billroth I reconstruction) (n = 7) (Group C), pylorus preserving pancreatoduodenectomy (Billroth I type reconstruction) (n = 12) (Group D), and short bowel syndrome (n = 5) (Group E). In Group B, the dose was delivery directly into the jejunum 20 cm distal to the duodenojejunal flexure. The highest serum drug concentrations were observed in the 30 min sample in Groups B and C and in the 120 min sample in Groups A, D, and E. Mean (+/- s.d.) concentrations at these times were 18.90 +/- 1.55 micrograms ml-1 (Group B), 12.89 +/- 2.12 micrograms ml-1 (Group C), 11.12 +/- 3.16 micrograms ml-1 (Group A), 9.78 +/- 2.85 micrograms ml-1 (Group D), and 4.89 +/- 1.96 micrograms ml-1 (Group E), respectively. We conclude that in patients with normal intact gastrointestinal tract, most of a dose of oral paracetamol is absorbed from the jejunum distal to the duodenojejunal flexure.

A one-stage marsupialization procedure for management of infected umbilical vein remnants in calves and foals.

Five Holstein calves and two foals with omphalophlebitis were treated by surgical marsupialization of the umbilical vein remnant because complete resection of the infected tract was not possible. The infected umbilical stalk was resected, and the umbilical vein remnant was marsupialized in a one-stage procedure by suturing it into the abdominal wall lateral to the abdominal incision. Antimicrobial drugs were administered, and the marsupialized tract was irrigated until closure by second intention healing. Cellulitis associated with the marsupialization site occurred in two calves but resolved with antimicrobial therapy. Owners reported that, 9 to 60 months after surgery, there were no complications associated with the procedure.

The left ventricular resectoscopeA new instrument for the comprehensive resection of the left ventricular outflow tract in hypertrophic obstructive cardiomyopathy (HCOM)

After disappointing results with non-surgical measures there is now a move back towards surgical left ventricular outflow tract resection as a treatment of choice for hypertrophic obstructive cardiomyopathy. The traditional operation presents various technical difficulties and occasionally disappointing results. Using a diathermy loop to resect the hypertrophied outflow tract has provided a much more convenient and reliable technique. This paper describes an instrument incorporating all the features of this technique (Left ventricular resectoscope).

Gasless Laparoscopy With Conventional Instruments: The Next Phase in Minimally Invasive Surgery

This interesting treatise begins with a well-done historical review of laparoscopy. The disadvantages of carbon dioxide pneumoperitoneum, some real and some hypothetical, are noted. The authors' analysis of gasless laparoscopy is informative and gives the reader a historical perspective of this evolving technique. The midportion of the text is devoted to the application of the techniques to three areas of general surgery, the biliary tract, herniorrhaphy, and bowel resection. The retractor system used is described in detail and involves an intraabdominal device attached to a hydraulic lifting apparatus. The majority of experience has been in cholecystectomy, with fewer operations done for hernia and colon resection. Of interest is the report of a hernia repair with epidural anesthesia. In cholecystectomy and bowel resection the advantages of being able to use traditional instruments are stressed. This aspect of the technique is particularly attractive, since it may lower instrumentation costs and facilitate procedures

Doppler analysis of hepatic blood flow predicts liver dysfunction after major hepatectomy.

In 17 consecutive patients who underwent major hepatic resection, 9 of whom with combined resection of the gastrointestinal tract or the pancreatic head (or both), postoperative hepatic blood flow was investigated. In this study, the patients were classified into two groups according to their postoperative serum total bilirubin level: Group A comprised 7 patients with the level higher than 7 mg/dl for more than 1 week postoperatively, and group B comprised 10 patients who did not meet this criterion. For 2 weeks after surgery, the portal blood flow velocity, the hepatic artery resistive index (RI) calculated from the changes in Doppler frequency shifts, and the hepatic venous blood flow velocity were measured intermittently using color Doppler ultrasonography. Liver volume was assessed by computed tomography to provide the restoration. Significant differences in portal blood flow velocity and hepatic artery RI were noted between the two groups from the third postoperative day. In group A the portal blood flow velocity decreased below the preoperative value, and the hepatic artery RI increased above 0.75. In contrast, group B showed high portal blood flow velocity and low hepatic artery RI. In both groups the RI correlated significantly with the total bilirubin level (r = 0.74; p < 0.0001), and the growth rate of the remnant liver was proportional to the mean postoperative portal blood flow velocity (r = 0.70; p = 0.016). We concluded that measurement of the portal blood flow velocity and hepatic artery RI can be useful for predicting postoperative liver dysfunction and liver regeneration after major hepatic resection.

Transitional Cell Carcinoma of the Upper Urinary Tract: Analysis of Morphology and Distribution for Surgical Management

Two series of transitional cell carcinomas (TCC), one including 49 renal pelvic and/or ureteral cancers and the other 29 bladder cancers with concomitant ureteral involvement, were reviewed to establish the criteria for nephron-sparing surgery and for selecting the most appropriate surgical intervention for TCCs at the ureterovesical junction. The following categorization of tumors was made possible by histological mappings of step-sectioned surgical specimens from various surgical modes: 1) low grade papillary superficial tumor, 2) high grade papillary or non-papillary tumor with adjacent or skipped carcinoma in situ (CIS), 3) high grade non-papillary invasive tumor without CIS, 4) high grade papillary superficial tumor without CIS. We can, by comparing postoperative clinical courses, select the mode of surgery in the following manner: 1) nephron-sparing surgery could be indicated in cases of low grade papillary tumor so far as a complete resection is possible; 2) in a case of high grade papillary or non-papillary tumor with adjacent or skipped CIS, extended resection of the urinary tract is required; 3) in a case of high grade non-papillary tumor without CIS, complete en bloc resection of the tumor site, including surrounding organs, will be necessary. The possibility of organ-sparing surgery for early stage cancer without CIS at the ureterovesical junction has been suggested. Preoperative consideration of the above classifications for conservative surgery is also discussed.

AN OPERATED CASE OF MIRIZZI SYNDROME PRESENTING WITH STENOSIS EXTENDING TO THE INTRAHEPATIC DUCTS

An operated case of Mirizzi syndrome presenting with stenosis extending to the intrahepatic ducts is reported.A 63-year-old man presented with a sudden onset of jaundice and fever. Laboratory data revealed a total bilirubin of 12.1 mg/dl. Ultrasonography and CT revealed gallstones within the gallbladder and marked wall thickness of the neck and solid mass continuous with the gallbladder in the liver. ERCP demonstrated the obstruction of the cystic duct and a 5 cm smooth stricture of the common hepatic duct. Administration of antibiotics improved his complaints and total bilirubin decreased to 2.2 mg/dl, however, ERCP performed again after the improvement showed a progression of the stricture and additionally stenosis of the intrahepatic ducts.At surgery, the gallbladder neck and porta hepatis formed a mass. However, intraoperative ultrasonography revealed a gallstone impacted in the neck of the gallbladder and no invasive lesions in the liver, accordingly presumptive intraoperative diagnosis of Mirizzi syndrome was made. Cholecystectomy with partial hepatectomy including the gallbladder bed, and resection of the biliary tract were performed. The postoperative course was uneventful. Pathologic histology revealed chronic cholecystitis and marked fibrosis of the biliary tract and no malignant change was found.

Obstructive Jaundice Due toHepatocarcinoma With IntraductalGrowth. Report of a Successful Resection

We present a patient with hepatocellular carcinoma causing obstructive jaundice due to intraductal growth, diagnosed intraoperatively by cholangiography and histological examination, and radically treated by left lobectomy, extrahepatic biliary tract resection and Roux-en-Y hepaticojejunostomy. Survival after operation was 13 months. Other similar cases reported in the literature are reviewed.