Laparoscopic partial posterior (Toupet) fundoplication improves esophageal bolus propagation on scintigraphy

BACKGROUND: Impaired esophageal clearance is important in the pathogenesis of gastroesophageal reflux disease (GERD). It is unknown whether esophageal clearance improves following antireflux surgery. The aim of this study was to investigate the effect of laparoscopic Nissen fundoplication (NF), laparoscopic partial posterior (Toupet) fundoplication (PPF) or medical therapy on esophageal clearance. METHODS: This was a prospective nonrandomized crossover study. Sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying, and assessment of symptoms prior to surgery or medical therapy and 6 months after treatment. In 20 GERD patients with normal esophageal peristalsis an NF was performed, in 20 patients with impaired esophageal peristalsis a PPF was chosen, and 20 patients received proton-pump inhibitor (PPI) treatment. RESULTS: On endoscopy, esophagitis had resolved in all patients after surgery; two patients with medical therapy still had esophagitis. On manometry, a significant improvement of lower esophageal sphincter competence was seen in both surgical groups. LES relaxation was complete after PPF, but incomplete after NF. Esophageal peristalsis did not improve after medical therapy, was significantly improved after PPF, but had worsened after NF. On scintigraphic esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after PPF. A significant deterioration of esophageal emptying was observed after NF. There was a strong correlation between scintigraphic and manometric evaluation of peristalsis preoperatively (r(s) = -0.87, p < 0.05) and postoperatively (r(s) = -0.82, p < 0.05). There was no change in dysphagia after medical therapy and after NF but a significant improvement after PPF. Globus sensation was significantly improved after PPF but did not change after medical therapy or NF. Postprandial bloating and inability to belch were significantly more common after NF than after PPF. CONCLUSION: Laparoscopic partial posterior (Toupet) fundoplication can restore a preoperatively defective esophageal bolus propagation on scintigraphy with the same antireflux effect as the laparoscopic Nissen fundoplication, but with lower side-effects.     

Permanent 125I-seed brachytherapy or radical prostatectomy: a prospective comparison considering oncological and quality of life results

OBJECTIVE: To assess the quality of life in patients with prostate cancer after permanent brachytherapy (BT) or radical perineal prostatectomy (RP). PATIENTS AND METHODS: The American Brachytherapy Society recommends the permanent implantation of radioactive seeds as a monotherapy for patients with T1-T2aN0M0 prostate cancer and a prostate-specific antigen (PSA) level of < or = 10 ng/mL, a Gleason score of <7 and a prostate volume of <60 mL. Using these criteria, 132 patients with low-risk prostate cancer were selected; 52 had BT with 125I-seed implantation, 38 had RP with unilateral nerve-sparing (RP + NS) and 42 extended RP (RP group). Only patients with unilateral tumour on biopsy were considered. Before therapy and 6, 12 and 24 months afterward, patients completed questionnaires to assess perceived health and function. PSA relapse was diagnosed with a PSA of >0.1 ng/mL for patients in the RP groups, and three consecutive PSA increases for those after BT. RESULTS: Extraprostatic tumours were found in 18% of specimens taken during RP, and bilateral tumours in 63% of patients. After a mean follow-up of 27 months, there was PSA relapse in two of the 80 patients in the RP and RP + NS groups, and six of the 52 patients in the BT group; a significant difference, with a hazard ratio of 5.2. The acute morbidity was low in all groups. At 1 year, more than two incontinence pads were used by 5% of patients after RP and by 4% after BT. Similarly, at 1 year 15% of patients after RP and 13% after BT were bothered by urinary incontinence. Newly-developed fecal soiling was reported by 4%, 5% and 11% of the RP, RP + NS and BT groups respectively; none of the patients after RP and 4% after BT were bothered by this symptom. The duration and stiffness of erection was assessed after 1 year and reported to be equal or slightly decreased by a third after RP + NS and 38% after BT. Taking a 5-10 point difference as clinically relevant, role, emotional and social functioning were improved considerably after RP + NS than after BT, but sexual activity was impaired significantly after RP + NS than after BT. CONCLUSIONS: Both therapies showed typical acute and late morbidity; the most bothersome late symptoms were urinary incontinence for patients after RP and fecal soiling after BT. Sexual function was impaired significantly in patients who were potent before RP + NS, whereas after BT men reported only a minor change in sexual performance at 1 year. Tumour control after a median follow-up of 27 months was better after RP but biochemical recurrence may still occur after > or = 5 years; therefore the present results are not mature enough and there were too few patients to provide a more definitive statement. As approximately 18% of patients considered to be appropriate candidates for BT had tumours extending beyond the prostate capsule or invading the seminal vesicles, nomograms are needed for more accurate information before therapy.     

龋源性前牙复合树脂多层美学修复的临床研究

目的:探讨龋源性前牙的复合树脂多层美学修复临床效果。方法:随机选择80例前牙龋坏病例,以普通树脂材料充填为对照,在患者的美容修复要求下,采用复合树脂多层色美学修复,观察治疗后即刻、治疗后6个月和12个月的充填效果和美观效果。结果:复合树脂多层美学修复的充填效果在治疗后即刻和治疗后6个月成功率为100%,治疗后12个月时成功率为97.5%,普通树脂材料的充填效果在治疗后即刻成功率为100%,和治疗后6个月成功率为95%,治疗后12个月时成功率为65%。复合树脂多层美学修复的美学效果在治疗后即刻和治疗后6个月成功率为100%,治疗后12个月时成功率为97.5%,普通树脂材料的美学效果在治疗后即刻和治疗后6个月成功率为72.5%,治疗后12个月时成功率为65%。结论:通过多色系的树脂材料和多层充填技术,可以更好地实现患者的龋源性前牙美容需求。     

Comparative studies of plasma secretin response after reconstructive surgery of the stomach and pancreas.

The postprandial plasma secretin response was examined in ten normal persons, seven patients with a Billroth I and seven with a Billroth II anastomosis after subtotal gastrectomy, seven with a Roux-en-Y anastomosis, two with an interposed jejunal anastomosis, and five with a modified Child's anastomosis after pancreatoduodenectomy. The postprandial plasma secretin response in patients with Billroth I anastomosis was better than that in patients with a Billroth II anastomosis but was less than that of normal subjects. Although no postprandial secretin response was noted in Roux-en-Y anastomosis after total gastrectomy, a response was seen in patients with the interposed jejunal anastomosis because the digested food passed through the duodenum, but it was less than that for Billroth I and II patients and normal controls. After a modified Child's reconstruction, the postprandial secretin response was similar to that of patients with the Billroth II, which preserved the duodenum. A patient with a modified Child's reconstruction was examined 12 years after surgery and had the same response as other patients with the modified Child's reconstruction and those with a Billroth II anastomosis within 2 months after surgery. After ingestion of hydrochloride solution, the plasma secretin release in patients with a Billroth I and II anastomosis after subtotal gastrectomy and Roux-en-Y anastomosis after total gastrectomy had a better response than after a meal, but this was less than in normal subjects. The authors suggest that careful selection of intestine for the gastrointestinal anastomosis, which contains many secretin secretory cells, is important to obtain endogenous secretin release. For gastrojejunostomy after pancreatoduodenectomy, a method preserving the pylorus is better than the usual gastrojejunostomy because it maintains gastric acid. The ingestion of secretin stimulants, such as hydrochloride, may help to prevent pancreatic dysfunction after gastrectomy and other surgical reconstructions.     

Effects of corticosteroids on bronchodilator action in chronic obstructive lung disease.

BACKGROUND: Short term treatment with corticosteroids does not usually reduce airflow limitation and airway responsiveness in patients with chronic obstructive lung disease. We investigated whether corticosteroids modulate the effects of inhaled salbutamol and ipratropium bromide. METHODS: Ten non-allergic subjects with stable disease were investigated; eight completed the randomised, double blind, three period cross over study. Treatment regimens consisted of 1.6 mg inhaled budesonide a day for three weeks, 40 mg oral prednisone a day for eight days, and placebo. After each period cumulative doubling doses of salbutamol, ipratropium, a combination of salbutamol and ipratropium, and placebo were administered on separate days until a plateau in FEV1 was reached. A histamine challenge was then performed. RESULTS: At the end of placebo treatment mean FEV1 was 55.5% predicted after inhaled placebo, 67.9% predicted after salbutamol and 64.0% predicted after ipratropium. Compared with the results after the placebo period the FEV1 with salbutamol increased by 0.7% predicted after treatment with budesonide and by 0.7% predicted after treatment with prednisone; the FEV1 with ipratropium increased by 0.7% predicted after budesonide and by 4.8% predicted after prednisone; none of these changes was significant. After placebo treatment the geometric mean PC20 was 0.55 mg/ml after placebo, 1.71 mg/ml after salbutamol and 0.97 mg/ml after ipratropium. Compared with the placebo period the PC20 with salbutamol was increased by 0.86 doubling concentrations after treatment with budesonide, and by 0.67 doubling concentrations after prednisone; the PC20 with ipratropium increased by 0.03 and 0.34 doubling concentrations after budesonide and after prednisone respectively compared with placebo; none of these changes was significant. CONCLUSIONS: In non-allergic subjects with chronic obstructive lung disease short term treatment with high doses of inhaled or oral corticosteroids does not modify the bronchodilator response to salbutamol or ipratropium or the protection provided by either drug against histamine. Salbutamol produces greater protection from histamine induced bronchoconstriction than ipratropium.     

Stellenwert der Metastasenchirurgie beim metastasierten Nierenzellkarzinom

Metastasectomy in patients with renal cell carcinoma has to be considered as a palliative approach for symptomatic metastases (e.g., pathologic fracture) or as a curative approach in patients with the option for radical resection of all metastases. By modern perioperative management, even extended resections can be performed with limited morbidity and mortality. The survival rate is significantly higher after resection of pulmonary metastases than after resection of extrapulmonary metastases. Solitary metastases show a better prognosis than multiple metastases. Metachronous metastases that develop after a tumor-free interval of at least 12 months after tumor nephrectomy have a better prognosis than earlier metastases. For metastases that are resected with a curative intent, the best long-term results can be achieved after complete or radical resection.     

Acute Postoperative Herpes Zoster With a Sciatic Nerve Distribution After Total Joint Arthroplasty of the Ipsilateral Hip and Contralateral Knee

The differential diagnosis of a patient with acute onset of hip pain during the postoperative recovery period after total hip arthroplasty includes sciatic nerve injury, infection, incisional pain, hardware, or simply muscular issues related to overactivity. Moreover, because the rash of herpes zoster develops after 4 or 5 days of pain, it is difficult to diagnose herpes zoster during the early period. A number of reports have been issued on herpes zoster after surgery or trauma, but no report is available on herpes zoster development with a sciatic nerve distribution after ipsilateral total hip arthroplasty. The authors report the case of 75-year-old woman with herpes zoster with a sciatic nerve distribution after 2 primary total joint arthroplasties of a hip and knee.     

Improvement after treatment of hydrocephalus in aneurysmal subarachnoid haemorrhage: implications for grading and prognosis

Summary Two patients with aneurysmal subarachnoid haemorrhage and hydrocephalus are presented. On admission they scored E1M4V1 and E1M3Vtube on the Glasgow Coma Scale. The first patient recovered to E3M5Vtube after treatment of hydrocpehalus by extraventricular drainage. The second recovered to E2M5Vtube and later E4M6V4 after treatment of hydrocephalus with lumbar drainage. Based on the literature it is argued that these cases are no exception as to the improvement after treatment of hydrocephalus. The prognosis of patients with hydrocephalus after a subarachnoid haemorrhage, improves in parallel with the Glasgow Coma Scale after treatment of hydrocephalus. Therefore decision making on whether or not to treat a patient with a subarachnoid haemorrhage should be postponed until after treatment of hydrocephalus, if present.     

Chylous ascites after liver transplantation with mesentero-portal jump graft

Chylous effusions and lymphatic leaks occur after trauma, malignant disease, primary lymphatic disorders, and parasitosis, and rarely after abdominal surgery. Chylous ascites after orthotopic liver transplantation is a rare complication. We report a case of chylous ascites occurring after hepatic transplantation with a mesentero-portal venous jump graft, successfully treated with conservative management. Received: November 13, 2000 / Accepted: September 26, 2001     

Natural history of positive urinary cytology after radical cystectomy

PURPOSE: The natural history and risk of disease progression in patients with positive urine cytology after radical cystectomy for urothelial carcinoma has not been adequately elucidated. MATERIALS AND METHODS: An institutional review board approved, retrospective review in patients undergoing radical cystectomy was performed to identify those with positive urinary cytology after radical cystectomy. Cox proportional hazards regression was used to determine factors associated with positive cytology after radical cystectomy and upper tract recurrence after positive cytology. Survival curves and probabilities were examined by Kaplan-Meier analysis. RESULTS: A total of 101 patients with at least a single positive urinary cytology result after radical cystectomy were identified. Ureteral involvement in the radical cystectomy specimen was significantly associated with subsequent positive cytology. At the first positive urinary cytology only 9 of 101 patients (9%) had documented urothelial recurrence but eventually 57 of 101 had radiographic evidence of urothelial recurrence. Median freedom from radiological evidence of urothelial recurrence after positive cytology was 2.1 years and ureteral involvement was associated with a higher likelihood of urothelial recurrence. Despite surgical and chemotherapeutic interventions median survival after urothelial recurrence was 2.1 years. CONCLUSIONS: Urine cytology may have a valuable role for detecting upper tract recurrence after radical cystectomy. Most patients with positive cytology after radical cystectomy eventually have radiological evidence of urothelial recurrence. These data may help clarify natural history in patients with positive cytology after radical cystectomy. Additionally, these data indicate the need for diligent evaluation for recurrent disease and potentially the role of early adjuvant therapy in patients with positive cytology after radical cystectomy.     

Monoclonal gammopathy after liver transplantation: a risk factor for long-term medical complications other than malignancies

The aims of the study were to evaluate (i) the prevalence of MGUS in patients after liver transplantation (LT), (ii) the role of MGUS as a risk factor for malignancy and other medical complications after LT. One hundred and fifty consecutive patients were included in the study and followed prospectively after LT for more than 18 months. Eighteen patients had MGUS before LT, whereas 49 patients developed MGUS after LT ('de novo' MGUS). Thirty-six of these patients showed a MGUS along all the follow up after LT ('permanent' MGUS). In 31 patients, MGUS disappeared after LT ('transient' MGUS). No patient with MGUS developed B-malignant lymphoproliferative disorder and only one patient developed a myeloma after LT. Comparing patients with 'permanent' MGUS to patients with 'transient' MGUS or without MGUS after LT, the former group showed a higher rate of serious infections (30% versus 13%, P = 0.01), chronic kidney disease (CKD) (75% versus 44%, P = 0.001) and mortality (33% versus 17%, P = 0.04). Permanent MGUS was confirmed as an independent risk factor for serious infections and CKD by multivariate analysis. Permanent MGUS after LT does not entail a significant risk of malignancy, but it is associated with a higher risk of serious infections and CKD.     

Bowel-Associated Dermatosis-Arthritis Syndrome after Biliopancreatic Diversion

The bowel-associated dermatosis-arthritis syndrome (BADAS), originally called the bowel bypass syndrome, and described after jejuno-ileal bypass, has subsequently been reported in association with inflammatory bowel disease and after gastric resection. BADAS has not been reported after biliopancreatic diversion (BPD). This case report describes a 47-year-old female who presented with recurrent skin rashes and arthralgia after a BPD, consistent with a clinical diagnosis of BADAS which was confirmed by skin biopsy. To date, she has been managed with cyclical courses of antibiotics without reversal of her surgery.This syndrome may be under-diagnosed and is a condition with which bariatric surgeons should be familiar.     

RENAL EFFECTS OF CARDIAC ANGIOGRAPHY WITH DIFFERENT LOW-OSMOLAR CONTRAST MEDIA

The aim of this study was to evaluate the renal effects of cardiac angiography performed with three low-osmolar contrast media (CM): iopromide (IPR), ioversol (IVR) and ioxaglate (IOX). IPR and IVR are non-ionic CM, IOX is an ionic CM. Different parameters of renal function were determined before and 6, 24, 48, 72 hrs after angiography in 45 patients: 15 patients were examined with IPR, 15 with IVR and 15 with IOX. Glomerular effects – Plasma creatinine increased slightly at the 24th hour after IVR and IOX and at 48 hours after IOP. A significant increase in plasma β2-microglobulin was observed, at the same time, only after IOX. A significant decrease in creatinine clearance was found at 6 hours after IOX. No significant variations in glomerular filtration rate (GFR) and in effective renal plasma flow were found at 48 hours after cardiac angiography; while filtration fraction was significantly reduced after IOP and IOX. Tubular effects – A marked decrease in sodium clearance and a relevant increase of urinary activities of different tubular enzymes were found after cardiac angiography with all CM, but were more evident after the ionic CM IOX, than after the two non-ionic agents. These tubular effects reached the maximum between 6 and 24 hours and returned to baseline within 72 hrs after cardiac angiography. In conclusion, slight glomerular effects were observed mainly after IOX. A reversible tubular malfunction was found with the three low-osmolar CM and was more evident after ionic CM IOX, thus suggesting that other mechanisms, besides osmolarity, play a role in tubular toxicity due to CM. In no patient did the glomerular and tubular effects of CM have a clinical relevance.     

Breast augmentation after reduction mammaplasty: getting the size right

Although patients are typically satisfied after reduction mammaplasty, a subgroup later deems the volume of remaining breast tissue inadequate and presents for breast enhancement. Our purpose was to identify patient and procedural risk factors that may contribute to an over-reduced breast and the desire for breast augmentation after initial reduction. Seven patients were identified who had breast augmentation an average of 13 years after breast reduction. Four patients were satisfied with breast size immediately after reduction mammaplasty but lost breast volume subsequent to weight loss or childbearing. Three patients with a body mass index of 18 to 20 were dissatisfied immediately after reduction. Body image improved in 100% of patients after enhancement. Getting the size right depends upon thorough discussion with the patient regarding desired size, insurance requirements, and potential for decreased size after weight loss or childbearing. Breast augmentation may improve body image in patients with small breasts after reduction.     

Late Hematoma After Aesthetic Breast Augmentation with Textured Silicone Prosthesis: A Case Report

Late hematoma is an extremely rare complication after augmentation mammaplasty with silicone prostheses. The authors present a case of late hematoma after breast augmentation with textured gel-filled silicone prostheses, which appeared after intense physical effort 1 year after the implantation of the prosthesis. The hematoma was drained in three subsequent ultrasound-guided percutaneous needle aspirations, with no need for removal of the implant. In a 9-month follow-up period, the patient had no other problems with the implants.     

A comparison of highly selective vagotomy with truncal vagotomy and pyloroplasty--one surgeon's results after 5 years

In a prospective randomized trial highly selective vagotomy (HSV) was compared with truncal vagotomy and pyloroplasty (TVP). One surgeon performed all the operations. Ninety-eight per cent of patients were reviewed by two physicians after 20-97 mth (mean 61 mth). Fifty-nine of 68 patients (87 per cent) had an excellent or very good result after HSV (Visick grades I and II) compared with 48 of 69 (70 per cent) after TVP (P less than 0.05). There was 1 proven recurrence after HSV and 4 after TVP. Diarrhoea, including mild symptoms, occurred in 5 patients (7 per cent) after HSV and in 27 (39 per cent) after TVP (P less than 0.001). Severe diarrhoea did not occur after HSV but was present in 4 patients (6 per cent) after TVP (P less than 0.001). Flatulence, epigastric fullness and weight loss were also significantly more common after TVP. On average HSV took 72 min to perform compared with 44 min for TVP (P less than 0.001). Transient dysphagia occurred in 19 patients after HSV compared with 8 after TVP (P less than 0.05). HSV gave better results than TVP and was associated with a low recurrence rate (1.5 per cent at a mean of 5 yr). Although technically more demanding, HSV in our hands is a better operation than TVP for uncomplicated duodenal ulcer.     

Metastatic renal cell carcinoma mimicking a meningioma

We report a patient with renal cell carcinoma metastatic to the left trigone, which mimicked an intraventricular meningioma. The metastasis was recognized 1.3 years after removal of the primary tumor, a longer disease-free interval than any previously reported cases with brain metastases of renal cell carcinoma. The patient is now free of disease of years after resection and 17 years after the discovery of the primary tumor. Metastatic disease should be considered in all patients with prior resection of renal cell carcinoma who experience the onset of neurological disease, even after a prolonged disease-free interval. Long term survival is observed after the resection of solitary metastases, particularly if these appear after a prolonged disease-free interval.     

External fixator in complicated tibial fracture. Effect of various fixation systems on fracture healing and rate of complications]

In a retrospective analysis 93 external fixations with different rigidity after open tibial shaft fractures have been reviewed and compared concerning complications and healing time. Fracture consolidation was attained in fixation with unilateral frame after 14 weeks, with bilateral v-shaped fixator after 19 weeks and with triangular configuration in about 28 weeks. Subsequent internal fixation or extension to v-shaped fixation was necessary in about 33% after initial unilateral half-pin frame, whereas 90% of the two rigid systems could be left in situ until fracture consolidation was achieved. Cancellous bone grafts were performed in 58% after triangular, in 40% after v-shaped, and 28% after unilateral fixation. Pin infections were observed in 36% after triangular, 25% after bilateral v-shaped, and in 15% after unilateral fixation.     

TAPP versus TEP

INTRODUCTION: The 5-year results after laparoscopic repair of inguinal and femoral hernias with the TAPP and TEP techniques were analyzed. METHODS: We examined all patients after inguinal repair with the TAPP or TEP technique for the treatment of inguinal and/or femoral hernias from September 1992 to February 1996 performed by four surgeons at the Lüneburg community hospital (TAPP: 294 patients with 352 hernias, TEP: 278 patients with 324 hernias). The follow-up included a clinical examination, a questionnaire, and an ultrasound examination of the inguinal area. RESULTS: The follow-up rate was 93.5% after TAPP and 91% after TEP with a median follow-up of 5.7 postoperative years. With a total complication rate of almost 10.2% both methods did not differ. The recurrence rate after TAPP was 2.3% ( re-recurrence rate 6.7%) and 1.5% after TEP ( re-recurrence rate 4.8%). Recurrences occurred on average 45 months after TAPP and 36.6 months after TEP. CONCLUSION: TAPP and TEP are both safe and efficient. Because of the late occurrence of recurrence we suggest randomized prospective studies over a period of 5-10 postoperative years.     

Utility of Hydrogen and Methane Breath Tests in Combination with X-Ray Examination after a Barium Meal in the Diagnosis of Small Bowel Bacterial Overgrowth after Jejuno-Ileal Bypass for Morbid Obesity

To study why the symptoms of abdominal bloating occurring in a number of patients after jejuno-ileal bypass for morbid obesity become resistant to antibiotics, we used a method which combined a hydrogen breath test after lactulose with an X-ray examination of the abdomen after barium. Ten operated patients with bloating symptoms resistant to antibiotics, ten operated patients without symptoms or with pre-existing symptoms, that had remitted after antibiotic treatment and ten non-operated obese controls were investigated. There was a significant correlation between post-surgical symptoms persisting after antibiotics and the exhalation of large amounts of hydrogen of colonic origin (> 100 parts per million) after lactulose. Furthermore, symptomatic patients had high prevalence of colonic motility disorders (slow transit). In these patients, treatment with a prokinetic (cisapride 40 mg/kg/day for 10 days) reduced colonic transit time, colonic hydrogen production and bloating symptoms. Abdominal symptoms in these patients may therefore have other causes than small-bowel bacterial overgrowth alone. All operated patients with persistent abdominal bloating should therefore be investigated before starting empirical treatment with antibiotics.