Early short segment left colon interposition for esophageal atresia

Colon Interposition is frequently used for correction of esophageal atresia. The use of both retrosternal right colon^1–5 and transthoracic left or transverse colon^2,6–10 has been recommended. Retrosternal right colon interposition may be complicated by break downs and/or stricture of the anastomosis between cervical pharyngo-esophagus and the proximal interposed colon;^3–5,9 by vascular compromise and ischemia of the colon segment;^2,5 and by peptic ulceration of the distal interposed colon where it is anastomosed to the stomach.¹¹ Long-segment transthoracic left colon interposition may be attended by the first two complications as well;¹⁰ utilization of the esophageal stump for the distal colo-esophageal anastomosis in this technique may prevent gastroesophgeal reflux.^8–10,12Because of these problems, other methods of treatment have been suggested. The use of a gastric tube as esophageal replacement has been recommended;^13–15 however, peptic ulceration of the gastric esophagus may result.¹⁶ Elongation of the upper and, sometimes, the lower esophageal pouch with delayed primary anastomosis has been advocated.^17–19 Anastomotic leaks and/or stricture frequently accompany this procedure.Short-segment transthoracic left colon interpositions for esophageal stricture or varices have been attended by relatively fewer complications.^6–8 Therefore, a modified procedure was adopted for wide-gap esophageal atresia in 1968. A short segment of left colon was interposed transthoracically between the distal esophageal stump and proximal esophageal pouch in two infants after several weeks of bougienage had stretched the proximal pouch well below the aortic arch, so that a colo-esophageal anastomosis could be accomplished within the thorax without difficulty.     

The adult ergonomic face mask concept: historical and theoretical perspectives

The fundamental skill required of the anesthesiologist and rescuer is to treat upper airway obstruction and maintain adequate ventilation. Adult one-hand face mask ventilation is a complex technique, often applied with suboptimal results. The adult face mask in use today was not designed for one-handed ventilation but inherited its features from the 19^th century face piece. The airway maneuver used with one-handed ventilation is not standardized. An ergonomic face mask has an asymmetrical dome that accommodates the hand grip required for chin lift and may be better for one-hand ventilation. The historical and theoretical considerations patent to the design and technique of the ergonomic face mask are reviewed.     

Enterocutaneous Fistula: A Complication of Posterior Iliac Bone Graft Harvesting not Previously Described

Summary  A case of enterocutaneous fistula at the donor site is presented. A patient underwent posterior C₅–C₆ wire fusion with autologous bone graft taken from the posterior superior iliac crest for degenerative C₅–C₆ spondylolisthesis. The tip of the osteotome slipped anteriorly during the procurement but neither neurovascular nor peritoneal injury were observed. Spillage of formed faecal material was observed from the donor site on the 12^th postoperative day. Fistulogram showed an enterocutaneous fistula to descending colon. The fistula closed spontaneously in a week.  Enterocutaneous fistula after bone harvesting has never been reported in the literature as far as we know. Congenital malformations and acquired causes may create a vulnerable peritoneal area. Small bowel or descending colon may show a close relationship or even an adhesion to peritoneum in the presence of local peritonitis. A small lesion in this area may play a role in the occurrence of a fistula, and a low flow pseudofistulous tract may appear. The thermal injury and possible ischaemic necrosis due to cauterisation may be predisposing factors in the aetiology of this kind of fistula. The lack of foreign material and spontaneous closure were against an infectious origin. The aims of this report are to present and analyse the reasons of this complication, not previously described.     

Assessment of Effect of Intraperitoneal Tacrolimus on Liver Regeneration in Major (70%) Hepatectomy Model After Experimental Pringle Maneuver in Rats

AimSmall-for-size grafts have become more important, especially in living donor liver transplants. The Pringle maneuver, used to reduce blood loss, and the immunosuppressive medications used to prevent graft rejection in liver transplants have different side effects on liver regeneration. We researched the effect of situations where tacrolimus and the Pringle maneuver were applied or not on liver regeneration in rats with partial hepatectomy.Material and MethodsThis study was completed with 35 Wistar Albino rats. The subjects were randomly divided into 5 groups: Group 1 had the abdomen opened and no other procedure was performed; Group 2 underwent a 70% hepatectomy; Group 3 underwent a 15-minute Pringle maneuver + 70% hepatectomy; Group 4 underwent a 70% hepatectomy + 5 days of 1 mg/kg/day intraperitoneal tacrolimus; and Group 5 underwent a 150 minute Pringle maneuver + 0% hepatectomy + 5 days of 1 mg/kg/day intraperitoneal tacrolimus. All rats were sacrificed on the seventh postoperative day, remaining liver tissue was weighed, and weight indices created. The remaining liver tissue was stained with phosphohistone H3 and the mitotic index calculated.ResultsThe groups that underwent the Pringle maneuver, 70% hepatectomy, and tacrolimus administration were compared with the control group in terms of mitotic index and weight index, but no statistically significant differences were identified.ConclusionSuppression of regeneration forms a risk after liver transplantation with small-volume grafts. As a result, research on the effect of tacrolimus combined with the Pringle maneuver is important, especially for transplantations using segmented liver grafts. In our study, we showed that the use of tacrolimus had no negative effect on liver regeneration.     

Bleeding hemangioma of the colon diagnosed by coloscopy.

Hemangioma of the colon is a rare cause of rectal bleeding and the disease can be most difficult to diagnose.¹ The purpose of this paper is to stress the value of coloscopy when the source of rectal bleeding is not evident.     

Membrane antigens detected on human lung carcinoma cells by hybridoma monoclonal antibody

Hybridoma monoclonal antibodies were used to identify tumor cell membrane antigens on a new human lung carcinoma cell line. Hybridomas were constructed by fusing S194 mouse myeloma cells with lymphocytes from Balb/C mice immunized by the human carcinoma cell line UCLA-SO-P3. Of 768 hybridoma cultures tested 40 secreted antibody reacting with these P3 tumor cells by an indirect ¹²⁵I-protein A binding assay. Three produced antibody binding selectively to the P3 tumor cells, but not with a lymphoblastoid cell line from this same cancer patient. These 3 hybridomas were cloned by limiting dilution and antibody subclass was determined. The first monoclonal antibody reacted only with the P3 lung carcinoma and with one colon carcinoma line. The second cross-reacted with most human carcinomas tested including lung, colon, and breast carcinoma, but not with sarcomas, melanomas, embryonic cells, lymphoblastoid cells, or normal lymphocytes. The third reacted strongly with all the tumor cell lines tested except for sarcoma and with embryonic cells but not with lymphoblastoid cells or lymphocytes. These results show that monoclonal antibodies can be produced against a variety of different membrane antigens on this lung carcinoma cell line including several that may prove useful in diagnosis or treatment of human cancer.     

Sympathetic neurotransmitter metabolism in Hirschsprung's disease.

Tyrosine hydroxylase activity was measured in high speed supernatants obtained from full thickness segments of aganglionic and ganglionic colon of three children with Hirschsprung's disease. Tyrosine hydroxylase activity expressed as pmole DOPA/mg protein/min was 0.93 +/- 0.16 in ganglionic and 2.67 +/- 0.21 in aganglionic colon. Tyrosine hydroxylase activity in ganglionic colon rose to 2.29 +/- 0.11 following calcium stimulation (100 muM) but could not be further increased in aganglionic colon. Addition of norepinephrine (2 X 10(-4) M) to tissue homogenates inhibited tyrosine hydroxylase activity in ganglionic colon by 57 +/- 8% but only by 14 +/- 3% in aganglionic colon, suggesting that the enzyme present in aganglionic colon is insensitive to feedback inhibition by endogenous norepinephrine. The elevation of tyrosine hydroxylase activity in aganglionic colon and its insensitivity to calcium stimulation and norepinephrine inhibition is further evidence of sympathetic overactivity in the aganglionic colon and suggests a basic enzymatic abnormality in the pathogenesis of Hirschsprung's disease.     

The response of colonic muscle to drugs: an in vitro study of Hirschsprung's disease

An in vitro pharmacologic study was conducted with muscle from 14 cases of Hirschsprung's disease and eight normal controls. The circular muscle from an aganglionic segment was less sensitive to ACh and physostigmine than from segments of proximal ganglionic bowel or normal controls. The degree of insensitivity to ACh had a significant correlation with the clinical severity of obstruction. It appeared that variably increased cholinesterase activity in the aganglionic colon might be responsible for the insensitivity to ACh. These findings suggest the hypothesis that, in addition to the absence of intramural ganglia, there is an imbalance between release of ACh and hydrolysis by ChE which produces the variable clinical symptoms.     

Healing of experimental colonic anastomoses: III. Collagen metabolism in the colon after left colon resection

In a previous study it was shown that resection and anastomosis of the left colon is accompanied by a marked reduction of collagen concentration in the colon. These changes were not confined to the immediate vicinity of the anastomosis but extended a considerable distance along the bowel and were more marked proximally than distally. Whether the decrease in collagen concentration is due to decreased synthesis or increased breakdown of collagen was studied in the present work by measuring the rate of collagen synthesis and comparing the observations with changes in net amounts of collagen.Synthesis of collagen was studied using pulse labeling with ³H-proline. Studies on the time course of incorporation showed a biphasic pattern with maximal specific activities of collagen 4 and 24 hours after injection of the precursor. The maximal labeling occurred after 24 hours. At that time 75 to 90 percent of the label was present in insoluble collagen, indicating a high rate of turnover. Comparison of net amounts with the rate of synthesis indicates an increased breakdown of collagen. The reaction was clearly most pronounced proximal to the anastomosis. During the first 4 postoperative days breakdown (lysis) dominated. On the 7th day increased net amounts of collagen indicate that synthesis had begun to outbalance processes that break down collagen. The results indicate that the entire colon reacts to the trauma of resection and anastomosis and that in healing of the colon a delicate balance exists between the synthesis and breakdown of collagen.     

Sigmoid colon rupture secondary to Credé's method in a patient with spinal cord injury

Credé's method is a manual suprapubic pressure exerted with a clenched fist or fingers, used to initiate micturition, in patients with spinal cord injury (SCI) who have neurovesical dysfunction. It is usually a benign maneuver unassociated with any major complications. This paper will illustrate a case report involving a sigmoid colon rupture secondary to Credé's method in a patient with SCI. Various techniques of Credé's method are briefly described. It is recommended that patients with quadriplegia avoid forceful use of Credé's method, as it may cause contusion of the abdominal wall and injuries to internal viscera, possibly leading to colonic rupture. It is believed that this is the first reported case of such an unusual complication of Credé's method in patients with SCI.     

Esophageal atresia treated by electromagnetic bougienage and subsequent repair

There are some infants with esophageal atresia with or without tracheoesophageal fistula in whom the esophageal segments are too far apart to allow safe primary anastomosis without tension. During the past 20 yr the most widely used approach in these cases has been temporary marsupialization of the blindly ending upper esophagus to the neck, followed later by interposition of a segment of colon.¹ Howard and Myers² introduced manual bougienage for the upper pouch to elongate it and accomplish a delayed primary anastomosis. This technique was later used with some success in other institutions.³ Rehbein⁴ placed bougies in both esophageal segments and applied traction sutures threaded through the ends of the pouches that were pulled together slowly.This paper describes another method used in four infants with esophageal atresia. Metal bougies (“bullets”) were placed into the two ends of the esophagus. An electromagnetic field was then used to pull the bullets together to elongate the esophageal ends in order to allow esophageal anastomosis, which had been impossible previously. Cases 1 and 2 were discussed in a previous report⁵ and therefore will not be described in as much detail as Cases 3 and 4. Certain refinements in the method were developed in treating Cases 3 and 4. For example: (1) The sump suction tube attached to the upper-pouch bullet was brought out through a lateral pharyngotomy instead of the nose. (2) The stem of the lower-pouch bullet was brought through a small separate stab incision in the midline to direct it straight upward. Leakage around the gastrostomy site proved troublesome when it was brought through the same opening as the gastrostomy tube. (3) The lower-pouch bullet was placed “by feel” into the distal esophagus, not requiring anesthesia. Initially this was done under direct endoscopic visualization using anesthesia. (4) Placing of the lower-pouch bullet, which has a flexible steel stem, was accomplished by sliding a rigid metal tube over the flexible cable, using this as a handle to direct the bullet into the distal esophagus.     

Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence

The aim of the study was to determine the immediate effect of timing a pelvic muscle contraction with the moment of expected leakage (the Knack maneuver) to preempt cough-related stress incontinence. Women performed a standing stress test using three hard coughs without and then with the Knack maneuver. Volume of urine loss under both conditions was quantified with paper-towel test. Two groups of women were tested: nonpregnant women (n = 64) and pregnant women (n = 29). In nonpregnant women, wetted area decreased from a median (range) of 43.2 (0.2–183.7) cm² without the Knack maneuver to 6.9 (range of 0 to 183.7 cm²) with it (p < 0.0001); while in pregnant women it decreased from 14.8 (0–169.7) cm² to 0 (0–96.5) cm², respectively (p = 0.001). This study confirms the effect from the Knack maneuver as immediate and provides a partial explanation for early response to widely applied pelvic muscle training regimens in women with stress incontinence.     

Sigmoid Colon Rupture Secondary to Crede’s Method in a Patient with Spinal Cord Injury

Abstract

Crede’s method is a manual suprapubic pressure exerted with a clenched fist or fingers, used to initiate micturition, in patients with spinal cord injury (SCI) who have neurovesical dysfunction. It is usually a benign maneuver unassociated with any major complications. This paper will illustrate a case report involving a sigmoid colon rupture secondary to Crede’s method in a patient with SCI. Various techniques of Crede’s method are briefly described. It is recommended that patients with quadriplegia avoid forceful use of Crede’s method, as it may cause contusion of the abdominal wall and injuries to internal viscera, possibly leading to colonic rupture. It is believed that this is the first reported case of such an unusual complication of Crede’s method in patients with SCI.     

Oesophagusersatz durch Interposition des an der A. mesenterica inferior gestielten Colon ascendens

OBJECTIVE: Colon interposition for esophageal replacement is indicated in patients with benign esophageal disease, in patients who require an esophago gastrectomy for a potential cure and in patients in whom the stomach is no longer available for replacement because of preceding surgery. METHODS: In 30 patients we performed colon interposition grafts for esophageal replacement using a modified technique. This technique includes ligation of the middle and right colic artery, thereby creating an interposition graft of the whole ascending colon which receives blood exclusively from the left colic artery. The main advantage of this procedure is the length of the interposition graft. Preparation of the left colic flexure is no longer required. Nineteen patients had an esophagectomy, 11 patients an esophago-gastrectomy. RESULTS: Minor complications in this unselected patient group occurred six times (20%), and major complications were observed in seven patients (23.3%). Frequency of anastomotic leakage amounted to 13.3%, hospital mortality to 10%. CONCLUSION: Frequency of postoperative complications and hospital mortality of patients in whom a modified colon interposition was done is comparable with published data of unselected patient groups, which had either a standard colon interposition graft for esophageal replacement or a gastric pull-through procedure.     

Splenectomy, suppressor cell activity, and survival in tumor bearing rats

Young female rats of the Fischer strain were subjected to splenectomy at 10 weeks of age. Three weeks later, these animals and a comparable group of intact animals were inoculated subcutaneously with 3 × 10⁶ cells of the syngeneic Ward colon carcinoma. Tumor growth was recorded by serial measurement. Lymph node cells from control, intact tumor-bearing, and asplenic tumor-bearing animals were tested for reactivity in mixed lymphocyte culture (MLC) and for ability to suppress the allogeneic mixed lymphocyte reaction. At 3 weeks after tumor inoculation, lymphocyte reactivity in MLC was somewhat depressed in asplenic tumor-bearing hosts but severely depressed in intact hosts (P < 0.001); suppressor activity was demonstrable in intact hosts but not in asplenic hosts (P < 0.001). At 5 weeks, lymphocyte reactivity in MLC was severely depressed in both groups; suppressor cell activity was present in both groups and differences were no longer significant. Median survival of intact tumor-bearing animals was 97 days after inoculation (P < 0.0001 by the log-rank test), and 120 days in asplenic animals (P < 0.001). We conclude that both depression of lymphocyte reactivity and onset of suppressor activity are delayed in asplenic tumor-bearing animals. Host survival was significantly prolonged.     

SUBCUTANEOUS METASTASES AFTER LAPAROSCOPIC RESECTION OF MALIGNANCY

Following the introduction and widespread acceptance of laparoscopic cholecystectomy, laparoscopic techniques have been applied to an increasing variety of general surgical procedures. Recently, laparoscopic procedures for resection of malignancy have begun to emerge, in particular laparoscopic assisted colectomy for carcinoma of the colon.^1,2 In the cases reported here, metastatic tumour in the laparoscopy port sites is described as a potentially serious complication of laparoscopic procedures for resection of malignancy.     

On the Chemical Characterization of Colloid Cyst Contents

Summary Colloid cysts of the third ventricle have been investigated by chemical characterization of the cyst contents using ELISA with monoclonal antibodies for certain carbohydrate epitopes as well as a polyclonal antiserum against peptide domains, and immunohistochemistry on the cyst wall using the same antibodies. Furthermore, the carbohydrate composition of one sample has been determined after gel filtration. The cyst contents reacted strongly with the monoclonal antibody for the sulfo-Lewis^a epitope, and with the anti-mucin polyclonal antiserum. In one case the cyst fluid exhibited a blood group A antigen. A sample of cyst wall obtained by biopsy showed strong immunoreactivity against sulfo-Lewis^a antigen, and the sialo-Lewis^a antigen. The presence of the S atom with its high atomic number relative to that of C, H, and O atoms, may contribute to the high density appearance of colloid cysts on CT-scans. The sulfo-Lewis^a and sialo-Lewis^a carbohydrate epitopes are known as ligands for selectins, involved in inflammatory processes, and may well account for the aseptic meningeal reaction that may follow spilling of cyst contents during operative evacuation. The carbohydrate epitopes exhibited by colloid cysts and their contents, have also been reported for the mucins of salivary glands, uterine cervix, gall bladder and colon, and therefore, are not inconsistent with the assumption of an endodermal origin of colloid cysts.     

Preventing wound infection from distant endogenous sources in the rat.

Surgical wound infection results not so much from exogenous bacterial sources as from endogenous sources. Endogenous bacteria produce wound infection by two mechanisms: by direct implantation of bacteria (primary lodgement) and by the wound serving as a locus minoris resistentiae. The efficacy of prophylactic antibiotics in preventing infection in wounds contaminated by primary lodgement, such as occurs during a colon resection, is well known. No study has shown the role or the timing of antibiotics in protecting a clean incision from infection when a known sustained source of bacteria is present distant from the wound.Abscesses containing 5 × 10⁸ cephalosporin-sensitive Escherichia coli organisms/g of tissue were created in the hind leg of 101 Sprague-Dawley rats. Incisions were created on the rats' backs 24 hr after abscess formation. Serial relationships of quantitative bacterial counts were plotted between abscess, blood, and wound tissue. Three different antibiotic timing regimen groups were employed, and a final group of animals served as controls.Quantitative bacterial analyses of the abscesses, blood, and wounds indicate that wounds in the control group consistently became infected with 3 × 10⁸E. coli organisms/g of tissue within 6 hr of operation. The group with antibiotic prophylaxis begun 2 hr prior to wounding and continued for 2 hr postoperatively showed complete protection to the wound with average bacterial levels reaching only 3.6 × 10². A single dose of antibiotic at the time of wounding protected 75% of the wounds, with mean bacterial levels at 3.6 × 10³.These data will help one determine antibiotic prophylaxis in wounds with known sustained distant sources of bacteria.     

The ontogeny of the expression of K+ channel-like gene (CHIF) in the rat kidney papilla

Recently, an IsK-like potassium (K⁺) channel corticosteroid-induced gene (CHIF) was cloned. A high-K⁺ diet enhances, while a low-K⁺ diet decreases the expression of this gene. The major expression of CHIF in the adult rat kidney is in the papilla, where it is constitutive, in contrast to its inducibility by corticosteroids and a low-salt diet in the rat colon. In order to further understand the ontogeny of K⁺ clearance, we studied the presence of CHIF in the kidney papilla in different stages of rat development. Total RNA from rat kidney papillae of 1- to 3-day pre-labor unborn offspring, 2- to 3-day-old newborns, 10-day-old, 6-week-old, and 43-week-old rats underwent northern hybridization for CHIF and the α-subunit of the Na⁺-K⁺-ATPase mRNA. Minor expression of CHIF mRNA was found in fetal and newborn rat papillae, while older rats showed an age-related increase in gene expression¹.The expression of the α-sub unit of the Na⁺-K⁺-ATPase was not age related. We conclude that CHIF is present in the rat kidney papilla and the expression is related to age. The relative deficiency of CHIF in the newborn may be one of the factors responsible for the reduced K⁺ clearance in is period. Received July 23, 1997; received in revised form December 31, 1997; accepted January 2, 1998     

Preliminary Report of Photodynamic Therapy for Intraperitoneal Sarcomatosis

Introduction: Sarcomatosis is the disseminated intraperitoneal spread of sarcoma. It is a condition for which there is no effective treatment. Photodynamic therapy (PDT) is a cancer treatment modality that uses a photosensitizing agent and laser light to kill cells. We report our preliminary Phase II clinical trial experience using PDT for the treatment of intraperitoneal sarcomatosis.Methods: From May 1997 to December 1998 eleven patients received twelve PDT treatments for intraperitoneal sarcomatosis. Photofrin® (PF) 2.5 mg/kg was administered intravenously 48 hours before surgical debulking to a maximum residual tumor size of less than 5 mm. Light therapy was administered at a fluence of 2.5 J/cm² of 532 nm green light to the mesentery and serosa of the small bowel and colon; 5 J/cm² of 630 nm red light to the stomach and duodenum; 7.5 J/cm² of red light to the surface of the liver, spleen, and diaphragms; and 10 J/cm² of red light to the retroperitoneal gutters and pelvis. Light fluence was measured with an on-line light dosimetry system. Response to treatment was evaluated by abdominal CT scan at 3 and 6 months, diagnostic laparoscopy at 3 to 6 months, and clinical examination every 3 months.Results: Adequate tumor debulking required an omentectomy in eight patients (73%), small bowel resection in seven patients (64%), colon resection in four patients (36%), splenectomy in one patient (9%), and a left spermatic cord resection in one patient. Five patients (45%) have no evidence of disease at follow-up (range, 1.7–17.3 months), including patients at 13.8 and 17.3 months examined by CT. Two patients (18%) died from disease progression. Four patients (36%) are alive with disease progression. Toxicities related to PDT included substantial postoperative fluid shifts with volume overload, transient thrombocytopenia, and elevated liver function tests. One patient suffered a postoperative pulmonary embolism complicated by adult respiratory distress syndrome (ARDS).Conclusions: Debulking surgery with intraperitoneal PDT for sarcomatosis is feasible. Preliminary response data suggest prolonged relapse-free survival in some patients. Additional follow-up with more patients will be necessary for full evaluation of the added benefit of PDT and aggressive surgical debulking in these patients.