A simple snare for polypectomy through the fiberoptic colonoscope

A new snare for polypectomy through the fiberoptic colonoscope is described. It is safe, simple to manipulate, and economical. To insure longevity of the wire a detailed knowledge of the mechanism and technic is necessary.     

The true incidence of synchronous cancer of the large bowel: A prospective study

The reported incidence of synchronous primary cancers and polyps associated with single cancers of the large bowel is varied. In a prospective study over a 5 year period, 166 patients with primary colorectal cancer had either total colonoscopy preoperatively or total colonoscopy within 6 months of surgical resection. One hundred seventy-eight cancers were detected. Synchronous cancers were found in eight patients (5 percent), and benign neoplastic polyps were demonstrated in 46 patients with single cancers (28 percent) and in 112 patients with synchronous primary cancers (38 percent). Of significance is that seven of eight (88 percent) synchronous cancers would not have been included in the standard resection for the index primary cancer. Similarly 31 of 46 neoplastic polyps (67 percent) were not in the same surgical segment as the primary cancer. Total large bowel evaluation, preferably using colonoscopy, is essential in all patients with cancer of the large bowel.     

Liver biopsy findings in seventy-seven consecutive patients undergoing jejunoileal bypass for morbid obesity

To clarify the status of hepatic morphology existent at the time of jejunoileal bypass in morbidly obese patients (those more than 100 pounds overweight) and the subsequent changes in liver architecture after jejunoileal bypass, we are performing intraoperative and yearly postoperative liver biopsies in all of our patients managed in this manner. This is the first report of our liver studies and this paper is an analysis of the histologic aspects of the liver at the time of bypass in seventy-seven consecutive patients.This study clearly demonstrates that the majority of markedly obese patients undergoing jejunoileal bypass have fatty metamorphosis of the liver at the time of their operative procedure. Previous similar reports from the literature are reviewed, and theories for the origin of hepatic fatty infiltration in obesity per se and after jejunoileal bypass are discussed.     

An improved technique of rubber band ligation of hemorrhoids

Based on the new concept that a hemorrhoid is caused by downward displacement of the anal cushion, rubber band ligation is applied on the redundant rectal mucosa above the hemorrhoid to prevent prolapse. The Hinkel-James anoscope is an ideal instrument for this purpose. It gives excellent exposure of the rectal mucosa and prevents the anal cushion from incorporating into the banding.     

Renal transplantation for the nail patella syndrome

A patient with the nail patella syndrome (Fong's disease) with end stage renal failure received a renal transplant from his mother. There has been no recurrence of the disease in the year since transplantation. Such patients are apparently good candidates for transplantation, although careful selection of the donor from among the potentially affected family members should be conducted. In addition, the orthopedic and metabolic disabilities that characterize this disease may render these patients more susceptible to aseptic necrosis of the hips.     

Double renal transplants from pediatric donors to adult recipients

Ten pairs of kidneys from pediatric cadaver donors have been transplanted in patients with renal failure. Preservation by perfusion and transplantation are carried out by way of the distal aorta after the proximal aorta and vena cava are closed. Seven of the ten pairs of kidneys have normal function sixteen to twenty-four months later. Since pediatric donors appear to be unusually frequent, this technic permits transplantation of pediatric kidneys into adults and provides adequate renal mass for normal function.     

Orthotopic renal homotransplantation in a patient with thrombosis of the inferior vena cava

Complete thrombosis of the infrarenal vena cava and the entire iliac venous system is a unique circumstance in a candidate for renal allotransplantation. This condition was created in a patient by the previous use of an inferior vena caval clip. The patient received a kidney transplant in the orthotopic intra-abdominal position, using his own renal vein for renovenous anastomosis. The usual method of urinary drainage was also modified. This approach to transplantation should be considered in the presence of partial clotting or occlusion in the distal vena cava or iliac venous system.     

"Paratransplant" hernia. Three patients with a new variant of internal hernia.

Three cases of bowel obstruction due to internal hernia caused by entrapment of bowel or omentum through a defect in the peritoneum covering the transplanted kidney are described. All three patients survived due to early surgical intervention and reduction of the hernia and/or resection of necrotic bowel or omentum. In view of the high mortality of peritonitis in transplant patients, early surgical treatment is indicated in all cases of intestinal obstruction to avoid the sequelae of bowel infarction. This "paratransplant" hernia represents the newest type of internal hernia described.     

Rapid long tube intubation of the jejunum by a new endoscopic device.

Despite the advantages of aseptic nonoperative intubation of the small intestine for decompression of obstructed loops, 48% of the attempts lead to failure to pass the tube through the pylorus. The difficulty and inconvenience of passage beyond the stomach have been overcome by the development of a special tube attachment adapted to a fiberoptic duodenoscope (Olympus Model GIF-K). Under direct endoscopic vision the tube can be carried into the second and third portion of the duodenum, released from the scope, and then further prodded into the jejunum. The entire procedure takes less than 15 minutes. Rapid intubation has now been easily carried out in five patients. Three patients had mechanical bowel obstruction. Rapid and effective decompression allowed adequate time for stabilization of concomitant serious problems such as (1) marked cardiopulmonary dysfunction secondary to a near fatal pulmonary embolus, (2) severe peritonitis post appendectomy, and (3) acidosis and dehydration. Surgical correction of the obstructing lesions was safely deferred for up to one week until the concomitant problems improved. The fourth patient, who was a renal transplant recipient, had chronic gastric ileus secondary to duodenal ulcer. Rapid passage of the long tube into the jejunum allowed restoration of nutrition and avoidance of gastrostomy. The fifth patient, with an ileus secondary to an infected abdominal aortic graft, underwent successful decompression but died of sepsis. He represents the only mortality. We propose that jejunal intubation using our technic is not only rapid but relatively easy and should encourage the wider acceptance of aseptic long tube intestinal decompression.     

Kidney transplantation from living related donors with multiple vessels. A problem revisited

Thirty-one renal transplantations were performed using kidneys from living donors with known bilateral double renal arteries. In twenty-one patients both vessels were anastomosed but in ten patients a tiny polar vessel was sacrificed resulting in a small infarct in the grafted kidney. Results of transplantation in these patients were compared with those in recipients of related and cadaver kidneys matched for time of transplant, sex, and age of recipient. There is an increased incidence of acute tubular necrosis in recipients of transplants from living donors with double renal arteries. By several weeks after transplantation, however, renal function is identical to that in recipients of related donor organs with single arteries. Hypertension that is more common in patients with double renal arterial anastomoses is relatively easy to control with increased antihypertensive medications. Two patients had loss of the kidney transplants because of stenosis of one or both renal arterial anastomoses. Despite these losses, the results of renal transplantation from living related donors with double renal arteries are almost as successful as those from a related donor with single renal arteries.In contrast, recipients of kidneys with polar infarcts appear to undergo more episodes of rejection, infection, or both, than do recipients of related transplants with single renal arteries. In one patient with a polar infarct, delayed total ureteral necrosis developed.Living related donors with bilateral double renal arteries should be accepted as donors in preference to cadaver donors if both vessels can easily be anastomosed. If, however, a polar vessel must be sacrificed, it is suggested that a cadaver donor be utilized in preference to a related donor.     

Successful transplantation of ectopic kidneys from living related donors

Two ectopic pelvic kidneys were transplanted from living donors into well matched recipients. Both kidneys have good function at two and four years post transplantation and there has been no evidence of infection post transplantation. Such kidneys can be utilized when there is no evidence of obstruction or infection in the donor and when the contralateral kidney is normal.     

Methionine-induced hepatic coma in dogs.

Oral methionine is noncomatogenic in normal dogs, but it is consistently comatogenic in dogs with portacaval shunts in the presence of elevated ammonia levels. Such action appears to be enhanced by the ammonia itself, since relatively small doses of oral methionine can induce coma when baseline levels of ammonia are above 1,000 mug/100 ml; much higher doses are nesessary for near normal ammonemia. The methionine-induced coma closely reproduces the clinical and electroencephalographic picture of coma in other canine models. Oral methionine does not significantly increase the ammonia levels, but its action is probably mediated by the release of methanethiol (and other less active compounds) from the bowel. Methanethiol levels tend to increase in proportion to the amount of methionine administered, and its comatogenic action may be amplified, up to one hundredfold, by high ammonia levels. Methanethiol levels in comatose patients and the concept of the synergistic effect with ammonia may lead to a clearer understanding of certain enterogenous and dietetic forms of hepatic encephalopathy in cirrhotic patients. The lowering of ammonia levels by hemodialysis or methanethiol levels by activated charcoal hemoperfusion, as attempts to reverse such forms of coma, warrants further investigation.     

Diagnostic and surgical aspects of insulinoma. A review of twenty-seven cases

The clinical features of twenty-seven patients with insulinoma are discussed. The best diagnostic test is a seventy-two hour fast with multiple determinations of blood glucose and insulin. Preoperative arteriography and intraoperative blood glucose monitoring are recommended in all patients. In the present series there was no operative mortality, and all patients were rendered asymptomatic.     

Tuberculous joint disease in transplant patients.

Three patients with tuberculosis, all manifesting monarticular joint involvement, among 845 renal allograft recipients at the University of Minnesota are reported on. Clinical symptoms, methods of diagnosis, and optimal antibiotic regimes are discussed. The physician must suspect tuberculous joint disease when confronted with monarticular swelling and pain in the transplant recipient.     

Aneurysms of the gastroduodenal and pancreaticoduodenal arteries

The operative management of an aneurysm of the gastroduodenal artery and an aneurysm of the pancreaticoduodenal artery is discussed. There are only eight cases of gastroduodenal artery aneurysms and eighteen cases of pancreaticoduodenal artery aneurysms in the literature. Because of the difficulty in making a clinical diagnosis, even after exploratory laparotomy, we stress the importance of the use of angiography in the final diagnosis. We also emphasize the necessity of aggressive operative management after a diagnosis of aneurysm of the splanchnic artery has been made, because of the high incidence of rupture and possible death.     

Plasma activities of lysosomal enzymes after hepatic dearterialization in man.

Six patients with liver metastases from carcinoid or colon carcinoma underwent hepatic derterialization. This operation, known to cause both tumor necrosis and liver cell damage, caused considerable increases of several lysosomal acid hydrolases in the circulation. Thus, beta-glucosidase showed a small temporary increase during the operation, followed by a slower but higher reaction reaching a maximum 12 to 36 hours postoperatively. Similar reactions were noted for beta-glucuronidase, acid phosphatase, beta-galactosidase, arylsuphatase A, and N-acetyl-beta-glucosaminidase while no reactions were found for cathepsin D. Very high enzyme levels occurred in a patient dying from bleeding complications in the postoperative period.     

Protection of the ischemic liver by donor pretreatment before transplantation

Canine livers ischemically damaged for thirty minutes prior to auxiliary transplantation did not survive for long periods of time unless a combination of isoproterenol, allopurinol, and heparin was administered intravenously to the donor animal before the ischemic damage. These drugs had no protective effect when given individually. Ischemic livers treated with adenosine prior to transplantation also showed no improved recovery of function.