Foreign bodies in the alimentary tract. Surgical treatment

Gastro-intestinal foreign bodies are a by no means rare event in surgery and in the USA mortality is about 1500 people per annum. The surgical treatment of foreign bodies in the alimentary tract is reported here. Certain cases of voluntary ingestion in mental patients are reported, comparing personal experience with the data reported in the literature.     

Octreotide for treatment of postoperative alimentary tract fistulas

Eighteen patients with postoperative fistulas of the gastrointestinal tract were treated with the somatostatin analog octreotide between November 1989 and November 1992. Fourteen patients had enterocutaneous fistulas: seven from the duodenum and seven from the ileum. Another three patients had pancreatic fistulas, and one patient had a biliary fistula. Within 24 hours of octreotide treatment, a mean reduction of 52% in the intestinal fistulas' output, 40% in the pancreatic fistulas, and 30% in the biliary fistula was noted. In the intestinal fistulas group the closure rate was 72% after a mean of 11 days. Early closure (mean 6 days) was achieved in all three pancreatic fistulas. In the patient with the biliary fistula a 30% reduction was observed twice following the administration of octreotide, and an increase occurred when it was withheld. The reduction rate of the secretions in high-output intestinal fistulas (>500 ml/day) was higher than in the low-output fistulas (63±8% versus 39±4%, p<0.05). Fistula output and the initial response to octreotide treatment had no value in predicting spontaneous healing. In conclusion, octreotide is a valuable tool for the conservative treatment of fistulas of the digestive tract. It is especially valuable for management of high-output enteric fistulas and pancreatic fistulas.

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Resumen Dieciocho pacientes con fistulas postoperatorias del tracto gastrointestinal fueron tratados con el análogo de la somatostatina, el octreótido, entre noviembre de 1989 y noviembre de 1992. Catorce pacientes presentaban fistula enterocutáneas: 7 duodenales y 7 del íleo. Otros 3 pacientes padecían fistulas pancreáticas y 1 presentaba fistula biliar. En las primeras 24 horas de iniciado el tratamiento con octreótido, se registró una reducción promedio de 52% en el drenaje de las fistulas intestinales, de 40% en el de las fistulas pancreáticas y de 30% en el de las fistulas biliares. En el grupo de las fistulas intestinales la tasa de cierre fue 72% luego de un promedio de 11 días. Se logró un cierre temprano (promedio 6 días) en los 3 pacientes con fistulas pancreáticas. En el paciente con fistula biliar se observó reducción de 30% en dos ocasiones luego de la administración del octreótido, en tanto que se observaba incremento cuando el agente no fue administrado. La reducción en el volumen de secreción de las fístulas de alto gasto (>500 ml/d) fue mayor que en las de bajo gasto (63±8% versus 39±4%, p<0.05). Ni el drenaje de la fistula ni la respuesta inicial al tratamiento con octreótido demostraron tener significado en cuanto al cierre espontáneo. En conclusión, el octreótido, análogo de la somatostatina, es un elemento valioso en el tratamiento conservador de las fistulas del tracto digestivo. Es especialmente valioso en el manejo de las fistulas entéricas de alto gasto y de las fistulas pancreáticas.

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Résumé Dix-huit patients ayant une fistule postopératoire du tube digestif ont été traités par un analogue de la somatostatine, l'octréotide, entre Novembre 1989 et Novembre 1992. Quatorze patients avaient une fistule entérocutanée sept intéressant le duodénum, les sept autres, l'intestin grêle. Trois autres patients avait une fistule pancréatique et enfin, un patient avait une fistule biliaire. En moins de 24 heures après l'administration de l'octréotide, des réductions moyennes de 52% du débit de la fistule intestinale, de 40% de la fistule pancréatique, et de 30% de la fistule biliaire ont été enregistrées. On a noté que 72% des fistules intestinales se sont fermés après une moyenne de 11 jours. Une fermeture précoce (moyenne = 6 jours) a été obtenue chez les trois patients ayant une fistule pancréatique. Chez le patient ayant une fistule biliaire, une réduction de 30% a été observée chaque fois que l'octréotide a été administrée et le débit a ensuite augmenté chaque fois que l'octréotide a été retiré. La réduction des sécrétions des fistules à grand débit (>500 ml/j) était plus importante que pour les fistules à bas débit (<500 ml/j) (63±8% vs 39±4%, p<0.05). Le débit de la fistule et la réponse initiale à l'octréotide n'avaient aucune valeur prédictive de la guérison spontanée. En conclusion, l'analogue de la somatostatine, l'octréotide, est utile dans le traitement conservateur des fistules du tube digestif. Elle semble trouver une indication particulière dans le traitement des fistules intestinales et pancréatiques.

     

Smooth muscle tumours of the alimentary tract.

Neoplasms arising from smooth muscle of the gastrointestinal (GI) tract are uncommon, comprising only 1% of gastrointestinal tumours. A total of 51 cases of smooth muscle tumour of the GI tract were analysed; 44 leiomyomas and 7 leiomyosarcomas. Lesions occurred in all areas from the oesophagus to the rectum, the stomach being the commonest site. Thirty-six patients had clinical features referable to the tumour. The tumour was detected during investigation or management of an unrelated disease process in 15 patients. The clinical presentation varied depending on tumour location, but abdominal pain and GI bleeding were the commonest presenting symptoms. The lesion was demonstrated preoperatively, mainly by endoscopy and barium studies, in 27 patients. Surgical excision was the treatment of choice, where possible. There was no recurrence in the leiomyoma group but four patients died in the leiomyosarcoma group. Although rare, smooth muscle tumours should be considered in situations where clinical presentation and investigations are not suggestive of any common GI disorder. The preoperative assessment and diagnosis is difficult because of the variability in clinical features and their inaccessibility to routine GI investigation. It is recommended that, where possible, the lesion, whether symptomatic or discovered incidentally, should be excised completely to achieve a cure and prevent future complications.     

The treatment of associated intracranial aneurysms and arteriovenous malformations.

Cerebral arterial aneurysm associated with arteriovenous malformation (AVM) has been described with a variable incidence, averaging 10% of AVM cases. The present series includes 39 patients with this association, derived from a total of 400 patients with AVM's evaluated and treated since 1970. The aneurysms are classified into four major groups, each carrying particular therapeutic implications. Optimum treatment of these lesions is based in part on a knowledge of the hemodynamic alterations associated with the AVM's. In most of these cases, the symptomatic lesion was treated first; occasionally, when feasible, both lesions were treated during the same operation. All patients had some form of treatment, either surgical or endovascular, directed to at least one of the two types of lesions. All symptomatic lesions were treated and all ruptured aneurysms were obliterated. There were no deaths in this series.     

Surgical management of alimentary tract duplications.

Alimentary tract duplications are unusual anomalies that may require surgical intervention in the neonate, infant, and occasionally in the older child. The clinical presentation of patients with alimentary tract duplications includes bleeding, abdominal pain, intussusception, and respiratory distress, or it may be an incidental finding on either abdominal examination or chest x-ray. A review of 96 patients with 101 duplications seen over the last 37 years is reported herein. Twenty-one duplications were confined to the thorax; three were thoracoabdominal, and 77 were abdominal. Seventy-four patients presented as infants less than 2 years of age, and 22 patients were older. Ectopic gastric mucosa was found in 21 duplications, and pancreatic tissue was found in five. Seventy-five duplications were cystic and 26 were tubular. Ultrasonography, computed tomography (CT), and myelography are helpful diagnostic tools. Ninety-four of the 96 patients underwent surgical management for their duplications. One duplication was found at necropsy, and one patient was asymptomatic and did not undergo operation. A single death occurred in a 2-day-old infant who had intrauterine volvulus and meconium peritonitis. Management was based on the age and condition of the patient, the location of the lesion, whether it was cystic or tubular and communicating with the true intestinal lumen, and whether it involved one or more anatomic locations. Generally, total excision was preferred, but staged approaches were sometimes necessary.     

Vascular malformations of the gastrointestinal tract.

The advent of fiberoptic endoscopy, which became widespread in the evaluation of gastrointestinal bleeding throughout the late 1970s and 1980s, has dramatically changed both our understanding of the extent to which vascular malformations account for gastrointestinal blood loss and our ability to treat these lesions at the time of diagnosis. Colonic vascular malformations appear to be the single most common cause of acute or recurrent gastrointestinal bleeding episodes in patients over 60 years of age, being responsible for the bleeding in as many as 35% of such patients. Although less common as a cause of upper gastrointestinal bleeding, these lesions still account for 2% to 5% of bleeding lesions in older patients. Diagnosis is accomplished by endoscopy, and the vascular malformations can then be coagulated via the endoscope using one of a number of thermal systems. The argon laser, the heater probe, and the BICAP system are all effective and safe throughout the gastrointestinal tract, especially in the cecum and right colon, where the majority of sporadic vascular malformations occur. Monopolar cautery and the Nd:YAG laser are equally efficacious, but their greater and less predictable depth of coagulation make them much less safe in the cecum and right colon. There are no apparent advantages in terms of efficacy and safety between laser treatment and the other thermal modalities. The laser has the advantage of being quicker, which is especially important when treating large or multiple lesions. The other modalities have the advantages of portability and low relative cost. Endoscopic therapy with lasers or other thermal devices is nonspecific. The effects are achieved by thermally coagulating the mucosal vascular lesions, allowing the coagulated tissue to slough, and leaving a mucosal ulceration that subsequently heals with re-epithelialization. Endoscopic coagulation has thus been reported effective in the treatment of gastrointestinal mucosal vascular lesions regardless of their etiology or characteristics. It has been effective for sporadic vascular malformations, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), radiation proctocolitis, the blue rubber-bleb nevus syndrome, and diffuse gastric antral vascular ectasia (the watermelon stomach). As we move through the 1990s and beyond, these endoscopic modalities offer an effective, relatively safe, and clearly less invasive treatment option for the many patients who experience acute, recurrent, or chronic gastrointestinal bleeding from any of these lesions.     

Duplications of the lower urinary tract in children

Seven cases of bladder duplication are described, and compared with 27 cases of urethral duplication. Bladder duplication was collateral while urethral duplication was usually in the sagittal plane. The conditions may coexist when the duplication of the bladder extends caudally to produce a collateral urethral duplication, but in one boy bladder duplication was associated with 4 urethrae in the sagittal plane. In 5 cases the bladders were united; in 2 cases, one bladder was excised. The results were satisfactory in 6 and in one the bladder failed to empty. The basic defects that lead to duplication are unknown. Several features of the conditons suggest that there are different aetiologies in each type. There are similarities with the exstrophy epispadias complex. Even when there are major abnormalities in other systems the general and urological prognosis is good.     

Arteriovenous malformations of the gastrointestinal tract.

During an eight-year period, 17 patients ranging in age from 7 months to 81 years were found to have arteriovenous malformations (AVMs) of the gastrointestinal tract complicated by major hemorrhage. After review of these cases, a clinical classification of AVMs was developed, based on angiographic characteristics, localization, age of the patient, and family history. Type 1 AVMs were solitary, localized lesions within the right side of the colon. They occurred in seven patients 55 years of age or older. None were palpable or visible at operation. Type 2 AVMs occurred in seven patients. They were larger and occasionally visible, most commonly in the small intestine, and probably of congenital origin. Symptoms all began before 50 years of age. Type 3 AVMs were punctate angiomas causing gastrointestinal hemorrhage. They occurred in three patients with the classical findings of hereditary hemorrhagic telangiectasia. The diagnosis of most AVMs can be determined preoperatively only by selective angiographic studies.     

消化道出血少见病例报告及其经验教训(附9例报告)

目的为了吸取一些少见消化道出血诊治的经验与教训。方法回顾性分析9例疑难消化道大出血,并复习有关文献。结果造成误诊误治的原因为病史询问和分析不仔细,另一原因是手术探查不彻底。结论正确的诊断与治疗依赖于详细的询问与分析病史以及正确的手术选择。     

Islet cell tumors of the pancreas and the alimentary tract.

Functioning tumors of the pancreatic islets are now recognized as the source of clinical syndromes affecting the gastrointestinal tract which have a wide variety of catastrophic symptoms. Experiences with thirty-six cases suggest at least four separate diagnostic categories in the ulcerogenic tumor syndrome. These include: a typical history, gastric analysis, and roentgenographic findings with boderline fasting serum gastrin levels; ulcerogenic tumor with evidence of hyperparathyroidism; iatrogenic ulcerogenic syndrome associated with failure of a previous operation for duodenal ulcer; and the classic ulcerogenic syndrome associated with a fulminating ulcer diathesis or diarrhea and high serum gastrin levels. The problems presented at operation include: decisions to be make in the presence of a negative exploration; the finding of a solitary tumor in the wall of the duodenum; solitary pancreatic tumors particularly in the body and tail; ulcerogenic tumors in the very young; liver metastases in the elderly; and the wisdom of removing gross metastases in combination with total gastrectomy. The long-term survival in the ulcerogenic tumor syndrome approximated 50 per cent, with 40 per cent of those having proved malignancy living five years. Evidence of hyperparathyroidism is relatively common in association with both the ulcerogenic and the diarrheogenic tumor syndromes. The association may by a result of a congenital abnormality, metabolic alkalosis, or a direct effect of the islet cell tumor. Parathyroidectomy may be indicated when both the serum calcium and parathormone levels are elevated in the presence of borderline fasting gastrin levels. The latter may return to normal after parathyroidectomy. The evidence of hyperparathyroidism closely parallels the episodes of diarrhea in the diarrheogenic syndrome, and hyperparathyroidism may regress spontaneously after total removal of the pancreatic tumor. Just as routine calcium determinations made the diagnosis of hyperparathyroidism more commonplace, it is suggested that the gastrointestinal syndromes associated with islet cell tumor would receive wider recognition if radioimmunoassays for gastrin as well as secretin, and the other secretin-like polypeptides, were carried out routinely.     

Arteriovenous malformations of the posterior fossa. Clinical presentation, diagnostic evaluation, and surgical treatment

Infratentorial arteriovenous malformations (AVM's) represent only 5% to 7% of all AVM's in major series. Since 1977, 32 patients with intracranial intradural malformations of the brain stem or cerebellum have been evaluated at the University of Texas Health Science Center, 30 of whom underwent surgical treatment. Twenty-three patients presented with intracranial hemorrhage, which was recurrent in 11 cases, and nine patients were evaluated for progressive brain-stem or cerebellar deficits. A history of progressive deficits was unusual in the group that presented with hemorrhage, and a prior or subsequent hemorrhage was rare in the patients initially evaluated for progressive deficits. Seventeen of these AVM's were located in the vermis, seven within the cerebellar hemisphere, two in the tonsil, two in the cerebellopontine angle, and four within the brain stem. Operative intervention was directed at primary resection in 15 cases, staged resection in seven, embolization and resection in five, and evacuation of hematoma in three. Operative mortality in this surgical series was 7%, with significant morbidity in 13%. Use of modern microsurgical techniques in removal of posterior fossa AVM's may offer results better than the natural history of the disease process, especially in patients who present with hemorrhage.     

上消化道大出血诊疗分析

目的提高上消化道大出血的诊疗水平。方法回顾分析162例上消化道大出血病人的病因诊断、急症手术指征,剖腹探查原则、术式及治疗结果。结果本组治愈150例,死亡12,治愈率92．6％、死亡率7．4％．主要死于失血性休克、肝功能衰竭。主要并发症为再出血、肝昏迷、肠粘连、腹腔脓肿、切口裂开。结论在积极抗休克非手术止血的同时,尽快初步确定出血的病因和部位,早期掌握急症手术指征,切除出血病灶,合理选择术式是提高治愈率减少死亡率的关键。     

Symptomatic congenital lesions of the alimentary tract in adults.

Congenital anomalies of the alimentary tract can evade detection into adulthood because they cause only moderate symptoms or they escape purview of a prepared observer. In other instances, evolution or copathogenesis may need to occur before the lesions become manifest. We have managed 17 of these patients presenting at ages 23 to 71 years. The median duration of symptoms was 5 years, ranging from 1 months to 23 years. Defects of foregut embryogenesis predominated (71%). We were able to establish the correct diagnosis before operating on nine patients, but three had already had a previous celiotomy for the same problem so a truly preoperative diagnosis was possible in only six (35%). The literature validates the dominance of foregut anomalies in adults. There is no older age limit that would exclude consideration of these lesions. Endoscopy, computerized tomography, and ultrasonography have greatly facilitated recognition, but our experience suggests that the principal obstacle to timely diagnosis is the reluctance to consider a congenital cause for an adult's symptoms.