Laparoscopic Duodenal-Jejunal Bypass for the Treatment of Duodenal Obstruction Caused by Annular Pancreas: Description of a Surgical Technique

Annular pancreas is a rare congenital anomaly, which is only surgically treated in symptomatic cases. Surgical treatment consists of bypassing the duodenal transit by gastrojejunal or duodenal-jejunal anastomosis. In the absolute majority of published cases, laparotomy is the most widely used access technique. The aim of this article is to report a case of an annular pancreas and describe the technical steps involved in carrying out a laparoscopic duodenal-jejunal anastomosis, for correction of the duodenal obstruction. The patient`s recovery was uneventful; she was discharged on the fourth postoperative day and remained asymptomatic for the 2-year, outpatient follow-up period. Laparoscopic duodenal-jejunal bypass is shown to be feasible and safe, and produce less surgical trauma, when carried out by an experienced surgeon who is duly trained and familiar with the laparoscopic technique.

Colorectal cancer in familial adenomatous polyposis: Are there clinical predictive factors?

Background: Familial Adenomatous Polyposis (FAP) is a hereditary disorder with multiple colorectal polyps that exhibit an almost inevitable risk of colorectal cancer (CRC) in untreated patients. Goals: To evaluate clinical features related to CRC risk at diagnosis. Material and methods: Charts from 88 patients were reviewed to collect information regarding age, family history, symptoms, polyposis severity and association with CRC. Results: 41 men (46.6%) and 47 women (53.4%) were assisted. CRC was detected in 53 patients (60.2%), with a frequency of 9.1% under 20 years, 58% between 21-40 and 85% over 41 years of age. Average age of patients without CRC was lower at treatment (29.5 vs. 40.0 years; p=0.001). Family history was reported by 58 patients (65.9%), whose average age did not differ from those who didn`t report it (33.4 vs. 34.4; p=0.17). Asymptomatic patients comprised 10.2% of the total; in this group, CRC incidence was much lower when compared to those presenting symptoms (1.1% vs. 65.8%; p=0.001). Patients without CRC presented a shorter length of symptoms (15.2 vs. 26.4 months; p=0.03) and less frequent weight loss (11.4% vs. 33.9%; p=0.01). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%), who presented greater average age (48.2 vs. 33.3 years; p=0.02) and equal CRC incidence (58.3% vs. 58.3%; p=0.6) when compared to those with classic polyposis. Conclusions: The risk of CRC in FAP patients 1) increases significantly after the second decade; 2) is associated with higher age, weight loss, presence and duration of simptomatology; 3) is similar in patients with attenuated or classic phenotype. (C) 2010 AEC. Published by Elsevier Espana, S.L. All rights reserved.

Evaluating Causes of Death in Familial Adenomatous Polyposis

Background Familial adenomatous polyposis is a genetic syndrome associated with an increased risk of colorectal cancer (CRC) and different extracolonic manifestations Goals The goal of this study is to evaluate the frequency of death causes Material and Methods Charts from 97 patients treated from 1977 to 2008 were reviewed Retrieved data and family information allowed us to classify causes of death in those related to CCR to other malignancies or other causes Results There were analyzed data from 46 men (47 4%) and 51 women (52 6%) with an average age of 35 1 years (14 to 82) At diagnosis, 57 patients (58 7%) already had CRC-associated polyposis There were performed 93 colectomies, one internal diversion, and one partial resection Two patients were not operated on Results from 19 deceased patients (19 5%) were analyzed CRC, other tumors (desmoid tumors, lymphoma, and gastric cancer), and other causes (complication of duodenal cancer surgery, complication after ileorectal anastomosis (IRA), and coronary disease) were responsible for 12 (63 1%), four (21 1%), and three (15 8%) of all deaths, respectively Death from CRC occurred in the context of either systemic, rectal, or pouch recurrence Desmoid disease was the second cause of death (10 5% of all causes), leading to a fatal outcome 22% of all patients who developed DT during the study period Upper digestive carcinomas were responsible for other two death cases Conclusions (1) CRC is still the most prevalent cause of death, (2) even after curative resections, CRC can cause death through rectal or pouch malignization, (3) long-term survival was also strongly related to the development of extracolonic neoplasia, especially desmoid tumors and gastroduodenal carcinoma, (4) our results raise the need for local improvement in familiar screening and help us to define follow-up strategies and patient-information standards

Endoscopic features in a model of multivisceral xenotransplantation

Introduction: Xenotransplantation and multivisceral transplantation are advanced therapeutic methods that still require a scientific basis. There are no experimental models of multivisceral transplantation available, particularly not the monitoring by endoscopy. Here, we describe the endoscopic features in a model of multivisceral xenotransplantation. Methods: The distal esophagus, stomach, intestine, colon, liver, pancreas, and the kidneys with a common vascular pedicle were harvested from rabbits and implanted in swine (group I, n = 9) or in rabbits (group II, n = 4). Endoscopy was performed in the stomach, jejunum, and ascending colon at four consecutive time points (immediate after surgery and 10, 90, and 180 min after reperfusion). Lesions were macroscopically graded as mild, moderate, and severe. Biopsies were taken following sacrifice at 180 min after reperfusion. Results: In group I, the stomach, jejunum, and colon manifested a progression of lesions with predominance of mild lesions after 10 min, mild to moderate lesions after 90 min, and moderate to severe lesions after 180 min. In animals from group II, endoscopy showed normal features at all time points after reperfusion. Histopathologic analysis confirmed the diagnosis of hyperacute rejection in group I. Grafts from group II animals presented normal or mild ischemic/reperfusion injury. Conclusion: All animals subjected to multivisceral xenotransplantation showed a progression of endoscopic lesions with time after transplantation, while animals subjected to allotransplantation showed no aberrations in endoscopy. We conclude that endoscopy is a useful tool in the assessment of hyperacute rejection of a xenograft.

Rectal and Pouch Recurrences After Surgical Treatment for Familial Adenomatous Polyposis

Familial adenomatous polyposis (FAP) is a genetic disease characterized by multiple adenomatous colorectal polyps and different extracolonic manifestations (ECM). The present work is aimed to analyze the outcome after surgical treatment regarding complications and cancer recurrence. Charts from patients treated between 1977 and 2006 were retrospectively analyzed. Clinical and endoscopic data, results of treatment, pathological reports and information about recurrence were collected. Eighty-eight patients (41 men [46.6%] and 47 women [53.4%]) were assisted. At diagnosis, associated colorectal cancer (CRC) was detected in 53 patients (60.2%), whose average age was higher than those without CRC (40.0 vs. 29.5 years). At colonoscopy, polyposis was classified as attenuated in 12 patients (14.3%). Surgical treatment consisted in total proctocolectomy with ileostomy (PCI, 15 [17.4%]), restorative proctocolectomy (RPC, 27 [31.4%]), total colectomy with ileal-rectum anastomosis (IRA, 42 [48.8%]), palliative segmental resection (1 [1.2%]) and internal bypass (1 [1.2%]). Two patients were not operated on due to religious reasons and advanced disease. Complications occurred in 25 patients (29.0%), more commonly after RPC (48.1%). There was no operative mortality. Local or distant metastases were detected in six (11.3%) patients with CRC treated to cure. During the follow-up of 36 IRA, cancer developed in the rectal cuff in six patients (16.6%), whose average age was higher than in patients without rectal recurrence (45.8 vs. 36.6 years). Five of them have had colonic cancer in the resected specimen. Among the 26 patients followed after RPC, cancer in the ileal pouch developed in 1 (3.8%). (1) Within the present series, FAP patients presented a high incidence of associated CRC and diagnosis was generally established after the third decade of life; (2) operative complications occurred in about one third of the patients, being more frequent after the confection of an ileal reservoir; (3) rectal cancer after IRA was detected in 16.6% of patients and it was associated with greater age and previous colonic carcinoma; (4) both continuous and long-term surveillance of the rectal stump and ileal pouch are necessary during follow-up.

Barrett`s esophagus (BE) and carcinoma in the esophageal stump (ES) after esophagectomy with gastric pull-up in achalasia patients: A study based on 10 years follow-up

Background: Subtotal esophagectomy and gastric pull-up with cervical anastomosis is the main treatment for advanced achalasia. This surgical technique has been associated to esophagitis and also Barrett`s epithelium following esophagectomy. Aim: To analyze late clinical, endoscopic, and pathologic findings in the esophageal stump (ES) mucosa after subtotal esophagectomy in patients treated for advanced chagasic achalasia. Methods: 101 patients submitted to esophagectomy and cervical gastroplasty were followed-up prospectively for a mean of 10.5 +/- 8.8 years. All patients underwent clinical, endoscopic and histopathological evaluation every 2 years. Gastric acid secretion was also assessed. Results: The incidence of esophagitis in the esophageal stump (45.9% at 1 year; 71.9% at 5 years, and 70.0% at 10 years follow-up); gastritis in the transposed stomach (20.4% at 1 year, 31.0% at 5 years, and 40.0% at 10 or more years follow-up), and the occurrence of ectopic columnar metaplasia and Barrett`s Esophagus in the ES (none until 1 year; 10.9% between 1 and 5 years; 29.5% between 5 and 10 years; and 57.5% at 10 or more years follow-up), all rose over time. Gastric acid secretion returns to its preoperative values 4 years postoperatively. Esophageal stump cancer was detected in the setting of chronic esophagitis in five patients: three squamous cell carcinomas and two adenocarcinomas. Conclusion: (1) Esophagitis and Barrett`s esophagus in the esophageal stump rose over time. (2) These mucosal alterations and the development of squamous cell carcinoma and adenocarcinoma are probably due to exposure to duodenogastric reflux, and progressively higher acid output in the transposed stomach.

Notopronocephalus peekayi gen. et sp. n. (Digenea: Pronocephalidae) from Australian freshwater turtles

Notopronocephalus peekayi gen, et sp, n. is described from the intestine of Elseya latisternum Gray, 1867, E. dentata (Gray, 1863) and Emydura signata Ahl, 1932 from rivers in Queensland. The new genus is distinguished by the absence of ventral glands, simple (neither diverticulate nor sinuous) caeca terminating at the anterior margin of the testes, excretory arms not uniting in forebody, single ovary, two opposite testes close to the posterior end of the body, intracaecal genital pore, vitelline follicles anterior to the testes, cirrus-sac orientated obliquely and not divided into two portions, and the uterus intracaecal. This is the first pronocephalid to be described from an Australian freshwater turtle and the first from the family Chelidae.

Partial lesions of the intratemporal segment of the facial nerve: Graft versus partial reconstruction

Objectives: In cases of partial lesions of the intratemporal segment of the facial nerve, should the surgeon perform an intraoperative partial reconstruction, or partially remove the injured segment and place a graft? We present results from partial lesion reconstruction on the intratemporal segment of the facial nerve. Methods: A retrospective study on 42 patients who presented partial lesions on the intratemporal segment of the facial nerve was performed between 1988 and 2005. The patients were divided into 3 groups based on the procedure used: interposition of the partial graft on the injured area of the nerve (group 1; 12 patients); keeping the preserved part and performing tubulization (group 2; 8 patients); and dividing the parts of the injured nerve (proximal and distal) and placing a total graft of the sural nerve (group 3; 22 patients). Results: Fracture of the temporal bone was the most frequent cause of the lesion in all groups, followed by iatrogenic causes (p < 0.005). Those who obtained results lower than or equal to III on the House-Brackmann scale were 1 (8.3%) of the patients in group 1, none (0.0%) of the patients in group 2, and 15 (68.2%) of the patients in group 3 (p < 0.001). Conclusions: The best surgical technique for therapy of a partial lesion of the facial nerve is still questionable. Among these 42 patients, the best results were those from the total graft of the facial nerve.

Application of fibrin glue in microvascular anastomoses: Comparative analysis with the conventional suture technique using a free flap model

Background: Several studies have already reported the utilization of fibrin glue in microvascular anastomoses to minimize the number of sutures and to decrease the operative time. Despite the good results obtained in most of these experiments, its clinical application has not launched. The aim of this study was to clarify the controversies around the safeness of fibrin glue application in microvascular anastomoses, and also to demonstrate the potential benefits of fibrin glue application in a realistic free flap model. Methods: Twenty-seven rabbits were used in this study The experimental model consisted of a free groin flap transfer to the anterior cervical region. The flap`s circulation was restored by means of an end-to-side anastomosis between the femoral and carotid arteries, and an end-to-end anastomosis between the femoral and external jugular veins. The animals were divided into two groups (n = 10) according to the anastomosis technique: Group I (conventional suture) and group 11 (fibrin glue). Results: The number of sutures required to complete the arterial and venous anastomoses was reduced in 39 and 37% in group 11, respectively. Despite this reduction, the anastomoses maintained adequate patency rates and mechanical strength. Both arterial and venous anastomoses benefited from fibrin glue application, which made them easier and faster to perform. The flaps` ischemic time and the total operative time were also significantly shortened. Conclusions: In this study, the application of fibrin glue in microvascular anastomoses was safe and reliable. The risk-benefit ratio of fibrin glue application in microvascular anastomoses is favorable for its use. (c) 2008 Wiley-Liss, Inc.

Vascularized Bone Grafts for Upper Limb Reconstruction: Defects at the Distal Radius, Wrist, and Hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand. (J Hand Surg 2010;35A:1710-1718. (C) 2010 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)

Intracardiac Cavopulmonary Connection in Patients with Univentricular Heart Using Intra-atrial Lateral Tunnel and Intra-atrial Conduit Techniques

Background: In this study, we analyzed the time course of hemodynamic efficiency and follow-up in Fontan candidates who underwent the bidirectional Glenn procedure for staged intracardiac cavopulmonary connection (ICPC). Methods: Between 1991 and 2008, 52 patients with univentricular heart (mean age, 3.3 years; range, 2-8 years; 27 female patients [51.9%]) underwent ICPC. The cardiac malformations were as follows: tricuspid atresia, 25 cases (48.0%); common ventricle, 16 cases (30.7%); and pulmonary atresia with intact ventricular septum, 11 cases (21.1%). The intracardiac cavopulmonary procedure was indicated for all 52 cases. In 42 patients (80.7%), an intra-atrial lateral tunnel was constructed with a bovine pericardium patch. In the last 10 consecutive cases (19.3%), we performed a modified surgical technique in which we implanted an intra-atrial corrugated bovine pericardium tube sutured around the superior and inferior vena cava ostium. In all cases, a 4-mm fenestration was made to reduce the intratunnel pressure. All 52 patients had previously undergone a Glenn operation. Results: There were 2 hospital deaths (3.8%) and no recorded late deaths. During the follow-up, all patients were medicated with antiplatelet drugs. To evaluate the hemodynamic performance, we used Doppler echocardiography, computed tomography, and magnetic nuclear resonance studies. There were no prosthesis thromboses during this follow-up period. To evaluate cardiac arrhythmias, we conducted a Holter study. The last 10 patients with an intra-atrial conduit (IAC) presented with sinus rhythm and no arrhythmias during the last 4 years. The 50 surviving patients (96.1%) have been followed up for 6 to 204 months; all these patients are free of reoperation. Conclusion: The Glenn operation, which is performed at an early age, prepares the pulmonary bed to receive the ICPC. The midterm results of the intracardiac Fontan procedure seem to be good. The modified surgical procedure (IAC) can be a good alternative technique to the Fontan procedure in suitable patients.

Intravenous glutamine decreases lung and distal organ injury in an experimental model of abdominal sepsis

Introduction The protective effect of glutamine, as a pharmacological agent against lung injury, has been reported in experimental sepsis; however, its efficacy at improving oxygenation and lung mechanics, attenuating diaphragm and distal organ injury has to be better elucidated. In the present study, we tested the hypothesis that a single early intravenous dose of glutamine was associated not only with the improvement of lung morpho-function, but also the reduction of the inflammatory process and epithelial cell apoptosis in kidney, liver, and intestine villi. Methods Seventy-two Wistar rats were randomly assigned into four groups. Sepsis was induced by cecal ligation and puncture surgery (CLP), while a sham operated group was used as control (C). One hour after surgery, C and CLP groups were further randomized into subgroups receiving intravenous saline (1 ml, SAL) or glutamine (0.75 g/kg, Gln). At 48 hours, animals were anesthetized, and the following parameters were measured: arterial oxygenation, pulmonary mechanics, and diaphragm, lung, kidney, liver, and small intestine villi histology. At 18 and 48 hours, Cytokine-Induced Neutrophil Chemoattractant (CINC)-1, interleukin (IL)-6 and 10 were quantified in bronchoalveolar and peritoneal lavage fluids (BALF and PLF, respectively). Results CLP induced: a) deterioration of lung mechanics and gas exchange; b) ultrastructural changes of lung parenchyma and diaphragm; and c) lung and distal organ epithelial cell apoptosis. Glutamine improved survival rate, oxygenation and lung mechanics, minimized pulmonary and diaphragmatic changes, attenuating lung and distal organ epithelial cell apoptosis. Glutamine increased IL-10 in peritoneal lavage fluid at 18 hours and bronchoalveolar lavage fluid at 48 hours, but decreased CINC-1 and IL-6 in BALF and PLF only at 18 hours. Conclusions In an experimental model of abdominal sepsis, a single intravenous dose of glutamine administered after sepsis induction may modulate the inflammatory process reducing not only the risk of lung injury, but also distal organ impairment. These results suggest that intravenous glutamine may be a potentially beneficial therapy for abdominal sepsis.

Protective effect of octreotide and infliximab in an experimental model of indomethacin-induced inflammatory bowel disease

Indomethacin administration in animals increases permeability of the small intestine, leading to inflammation that mimics Crohn`s disease. Nonsteroidal anti-inflammatory drugs increase the permeability of the intestinal epithelial barrier and should therefore be used with caution in patients with Crohn`s disease. We analyzed the protective effects of octreotide and the tumor necrosis factor-alpha inhibitor infliximab in a rat model of indomethacin-induced enterocolitis. Male Wistar rats received 20 mg of infliximab or 10 mu g of octreotide 24 h prior to injection with indomethacin. Intestinal permeability was analyzed using Cr-51-ethylenediaminetetraacetic acid clearance. No microscopic or macroscopic alterations were observed in the rats receiving infliximab or octreotide, both of which increased permeability (P < 0.001 versus controls). Our macroscopic and microscopic findings might be related to the low specificity of infliximab and suggest that cytokines affect the intestinal epithelial barrier, as evidenced by the protective effect that infliximab had on the permeability parameters evaluated.

Rex Shunt for Acute Portal Vein Thrombosis After Pediatric Liver Transplantation in Children With Biliary Atresia

Background/Purpose. Posttransplantation portal vein thrombosis (PVT) can have severe health consequences, and portal hypertension and other consequences of the long-term privation of portal inflow to the graft may be hazardous, especially in young children. The Rex shunt has been used successfully to treat PVT patients since 1998. In 2007, we started to perform this surgery in patients with idiopathic PVT and late posttransplantation PVT. Herein we have reported our experience with this technique in acute posttransplantation PVT. Methods. Three patients of ages 12, 15, and 18 months underwent cadaveric (n = 1) or living donor (n = 2) orthotopic liver transplantation (OLT). All patients had biliary atresia with portal vein hypoplasia; they developed acute PVT on the first postoperative day. They underwent a mesenteric-portal surgical shunt (Rex shunt) using a left internal jugular vein autograft (n = 2) or cadaveric iliac vein graft (n = 1) on the first postoperative day. Results. The 8-month follow-up has confirmed shunt patency by postoperative Doppler ultrasound. There have been no biliary complications to date. Conclusions. The mesenteric-portal shunt (Rex shunt) using an autograft of the left internal jugular or a cadaveric vein graft should be considered for children with acute PVT after OLT. These children usually have small portal veins; reanastomosis is often unsuccessful. In addition, this technique has the advantage to avoid manipulation of the hepatic hilum and biliary anastomosis. Although this study was based on a limited experience, we concluded that this technique is feasible, with great benefits to and low risks for these patients.

Transvaginal US after Bowel Preparation for Deeply Infiltrating Endometriosis: Protocol, Imaging Appearances, and Laparoscopic Correlation

Deeply infiltrating endometriosis (DIE) is a common gynecologic disease that is characterized by a difficult and delayed diagnosis. Radiologic mapping of the DIE lesion sites is crucial for case management, patient counseling, and surgical planning. Transvaginal ultrasonography (US) is the initial imaging modality for investigating DIE and has been the focus of several recent studies. DIE typically manifests at imaging as hypoechogenic nodules throughout the affected sites and thickening of the intestinal wall, with some lesions showing a mixed pattern due to cystic areas. Transvaginal US performed after bowel preparation improves the ability to diagnose intestinal lesions and provides invaluable details, including which layers of the intestine are affected and the distance between the lesion and the anal border. It is vital that radiologists be familiar with the technical aspects of this modality and with the US manifestations of DIE lesions. Transvaginal US performed after bowel preparation should be the first-line imaging modality for the evaluation of women with suspected endometriosis. (C) RSNA, 2010 . radiographics.rsna.org