True clinical entity of vascular compression of the duodenum in adolescence

Thirteen pediatric patients were diagnosed with superior mesenteric artery syndrome (SMAS) at our institution between 1974 and 1986. Four were successfully treated with nasojejunal feedings only, and nine underwent a derotation procedure designed to alleviate the problem of compression of the duodenum by the superior mesenteric artery. Of the nine patients who were operated upon, only one required a gastrojejunostomy to bypass a persistent obstruction. Therapy was aimed specifically toward the problem of duodenal occlusion at the mesenteric root. Because this therapy was successful in all of the patients, we conclude that SMAS exists as a treatable entity and must be considered in any adolescent patient who presents with symptoms of obstruction of the upper part of the gastrointestinal tract and failure to thrive.     

Comparative study of Sperm Motility Analysis System and conventional microscopic semen analysis

Background and Aim:  Conventional manual sperm analysis still shows variations in structure, process and outcome although World Health Organization (WHO) guidelines present an appropriate method for sperm analysis. In the present study a new system for sperm analysis, Sperm Motility Analysis System (SMAS), was compared with manual semen analysis based on WHO guidelines.
Materials and methods:  Samples from 30 infertility patients and 21 healthy volunteers were subjected to manual microscopic analysis and SMAS analysis, simultaneously. We compared these two methods with respect to sperm concentration and percent motility.
Results:  Sperm concentrations obtained by SMAS (Csmas) and manual microscopic analyses on WHO guidelines (Cwho) were strongly correlated (Cwho = 1.325 × Csmas; r  = 0.95, P  < 0.001). If we excluded subjects with Csmas values >30 × 10⁶ sperm/mL, the results were more similar (Cwho = 1.022 × Csmas; r  = 0.81, P  < 0.001). Percent motility obtained by SMAS (Msmas) and manual analysis on WHO guidelines (Mwho) were strongly correlated (Mwho = 1.214 × Msmas; r  = 0.89, P  < 0.001).
Conclusions:  The data indicate that the results of SMAS and those of manual microscopic sperm analyses based on WHO guidelines are strongly correlated. SMAS is therefore a promising system for sperm analysis. (Reprod Med Biol 2006; 5 : 195–200)     

Danazol in the management of ureteral obstruction secondary to endometriosis

Ureteral obstruction caused by endometriosis is uncommon. It is, however, an important complication that imposes a 25% chance for permanent loss of renal function on the affected side. The standard management is surgical; however, three cases have been reported in which regression of obstruction followed medical therapy. This case report concerns a patient with long-standing partial ureteric obstruction due to endometriosis who was treated for 2 months with danazol. Clinical response of the endometriosis was excellent, but the obstruction persisted, a retroperitoneal ureteroneocystotomy was therefore performed. The ureter was found to be obstructed by dense fibrous tissue that contained endometrial glands. It seems therefore that a trial of danazol may be attempted in selected cases, but that the drug is unlikely to relieve endometriotic ureteric obstruction once dense fibrosis has occurred.     

Endometriosis causing extensive intestinal obstruction simulating carcinoma of the sigmoid colon: a case report and review of the literature

Endometriosis with intestinal serosal involvement is not uncommon in women of childbearing age, however, presentation as colon obstruction is rare. Lack of pathognomonic symptoms makes diagnosis difficult, the main problem being differential diagnosis with neoplasm, even intraoperatively. Reported here is a case of extensive bowel obstruction due to sigmoid colon endometriosis in a 43-year-old woman who presented with signs and symptoms of bowel obstruction. Barium enema showed sigmoid obstruction; subsequent exploratory laparotomy showed the sigmoid colon surrounded by fibrous tissue, leading to its angulation and extensive lumen obstruction. Left oophorectomy and radical resection of descending and sigmoid colon as for bowel carcinoma were successfully employed. Pathological examination revealed endometriosis in the bowel wall with preservation of the mucosa. Aetiology, clinical presentation, differential diagnosis and therapeutic options for intestinal obstruction due to endometriosis are discussed.     

Urinary tract obstruction and infection in the neonate.

Congenital urinary tract obstruction is a common cause of renal failure accounting for up to 20% of end-stage renal disease cases. Intrauterine obstruction often results in parenchymal loss and renal dysfunction. The pathophysiology of obstructive nephropathy and its further depression of renal function is related to severe renal vasoconstriction, which is in large part angiotensin mediated. Signs suggestive of urinary obstruction in the newborn may include an abdominal mass, hypertension, oligoanuria/polyuria, urosepsis, and hyperchloremic acidosis. The combination of renal ultrasound, diuretic renal scans, and voiding cystourethrogram are the main diagnostic modalities in infants with hydronephrosis. Nonsurgical management of ureteropelvic junction obstruction has become more popular, particularly in mild to moderate cases. Early fulguration or bypassing the obstruction of urethral valves is essential and a decrease in serum creatinine to below 1 mg/dL within 1 month of relief of obstruction is a favorable prognostic sign. Obstruction complicated by infection is dangerous and requires prompt intervention. Any newborn with a urinary tract infection, regardless of sex, should be presumed to have urinary obstruction or reflux until proven otherwise.     

Antenatal diagnosis of renal anomalies with ultrasound: I. Obstructive uropathy

During a 5-year period, a diagnosis of obstructive uropathy was made in 25 fetuses. Eight of them had unilateral obstruction and 17 were affected bilaterally. The most common condition encountered was urethral obstruction by posterior valves. The site and nature of the obstruction were correctly identified in 22 of the 25 fetuses. Among the 17 who had bilateral obstruction, only three survived. In contrast, only one infant with unilateral obstruction died (of unrelated causes). Oligohydramnios in low-level (urethral) obstruction was a uniformly lethal finding. Relief of urethral obstruction in two fetuses after 20 weeks of gestation did not result in survival of the infant, whereas shunting prior to 20 weeks in one fetus seemed to have a beneficial effect. On the basis of this experience, we suggest that unilateral obstruction would be treated best by conservative management, while in bilateral obstruction invasive treatment may be effective if initiated early in gestation, before significant oligohydramnios occurs.     

Nasal obstruction in pregnancy

Nasal obstruction is a common complaint during pregnancy. It can be either physiologic or pathologic. Physiologic obstruction occurs as a result of the hormonal and vascular changes that evolve during the 9 months of pregnancy. Pathologic obstruction commonly occurs as a result of rhinitis medicamentosa, allergic rhinitis, or sinusitis and requires medical intervention by the physician. Because many women with nasal obstruction seek medical advice from their physicians, it is worthwhile to have an organized approach to their care. This review will discuss the pathophysiology of nasal obstruction as it applies to the pregnant patient and will present an effective management plan for this problem.     

Biliary obstruction after gastrectomy for carcinoma of the stomach.

Extrahepatic biliary obstruction occurred in 34 patients after 1,300 gastrectomies performed for carcinoma of the stomach. Metastasis to the portal nodes caused mainly by distal gastric neoplasms is the most common cause of extrahepatic biliary obstruction. The syndrome of severe unrelenting bilirubinemia with abdominal aches and a palpable liver signifies extrahepatic biliary obstruction until proved otherwise and calls for early exploration. Palliative operation can prolong survival if properly performed. Selection of the proper procedure requires operative cholangiograms. Pancreatoduodenectomy is the most successful palliative procedure. Prevention of extrahepatic biliary obstruction requires a meticulous dissection of the portal pedicle during radical gastrectomy.     

Progestin reversal of ureteral endometriosis

Successful medical therapy of ureteral obstruction secondary to pelvic endometriosis has not previously been documented by roentgenography. Reversal of ureteral obstruction by progestin therapy is reported in a patient with laparotomy-proved pelvic endometriosis.     

Preoperative diagnosis of intestinal intussusception in pregnancy. A case report

BACKGROUND: Intestinal intussusception is a rare event during pregnancy. The diagnosis of intestinal obstruction from any cause in pregnancy is made more difficult by the common overlapping complaints of nausea, vomiting and abdominal pain, which may persist during the second trimester. CASE: Intestinal obstruction occurred at 17 weeks' gestation. A preoperative diagnosis of intussusception was made by ultrasound by demonstrating multiple ecodense and ecolucent rings in the right lower quadrant of the abdomen. CONCLUSION: Ultrasonography may support the diagnosis of intussusception in pregnant women with intestinal obstruction.     

Obstructive renal failure and pleural effusion caused by the gravid uterus

Acute renal failure due to ureteral obstruction by the gravid uterus is considered to be a rare complication of late pregnancy. Pleural effusion caused by urinary tract obstruction is also extremely uncommon. This presentation reports what is believed to be the first case in which both these complications appeared at the same time in a pregnant patient.     

Patient rotation and resolution of unilateral cornual obstruction during hysterosalpingography

OBJECTIVE: Unilateral obstruction of the proximal fallopian tube is identified in 10-24% of patients undergoing hysterosalpingography for evaluation of infertility. Upon further testing, this obstruction spontaneously resolves 16-80% of the time. We hypothesized that patient rotation during hysterosalpingography might resolve proximal tubal obstruction in some cases by altering either the location of intrauterine air bubbles or the spatial relationship of the tube to the uterine fundus. METHODS: In patients in whom unilateral proximal tubal obstruction was detected during hysterosalpingography performed for standard clinical indications, the patient was rotated on her hip approximately 45 degrees such that the obstructed tube was first superior (ventral) to the patent tube, and dye was reinjected. If obstruction did not resolve, the patient was rotated in the opposite direction so that the obstructed tube was inferior (dorsal) to the patent tube and dye reinjected. RESULTS: Unilateral tubal obstruction was found in 15% of cases (24 of 156). Rotating the patient with obstructed tube superior to the patent tube never resulted in tubal patency, whereas rotating the patient with the obstructed tube inferior resulted in resolution of tubal patency in 63% of cases (15 of 24) CONCLUSION: .Unilateral cornual obstruction during hysterosalpingography is often resolved by rotating the patient such that the obstructed tube is more inferior. Although this observation may be the result of dislodging smaller air bubbles, from a fluid dynamics perspective a more likely explanation is unkinking of the more inferior tube.     

Endometriosis as a cause of ileal obstruction

This paper presents the first analysis of clinical data of a series of cases in which ileal obstruction was caused by endometriosis. The subject is of particular significance because the obstructive involvement of the distal part of the ileum by this highly invasive nonmalignant tissue often has been confused clinically with appendicitis accompanied by ileus, with malignant lesions causing obstruction of the intestine, and with intestinal obstruction caused by the adhesions of pelvic inflammatory disease. The importance of endometriosis as a cause of ileal obstruction has not been sufficiently stressed. The clinical picture of this condition, as revealed by a detailed analysis of the clinical data of sixteen cases, will be presented, as will also (1) certain facts higly pertinent to the differential diagnosis, (2) pathologic lesions and (3) surgical treatment.The term “endometriosis” indicates the existence of endometrial tissue in any extrauterine location.     

Reoperation for palliation of recurrent malignant bowel obstruction in ovarian carcinoma

OBJECTIVE: While initial surgical treatment for palliation of malignant bowel obstruction is well described, data on reoperation for palliation of recurrent obstruction in ovarian carcinoma are limited. The purpose of this study was to analyze the outcome of patients undergoing reoperation for repeat bowel obstruction. METHODS: We reviewed the records of all patients with ovarian cancer who underwent repeat surgery for recurrent, malignant bowel obstruction at our institution between 1994 and 2002. RESULTS: Ten patients were identified. All patients had bowel obstruction caused by recurrent ovarian carcinoma and had a previous corrective surgical procedure for malignant bowel obstruction. The mean age at diagnosis of repeat obstruction was 54.1 years (range, 34-74 years). All patients had initial stage III or IV disease with moderately to poorly differentiated cancers. No patient received prior radiation therapy. The sites of obstruction in patients were as follows: small bowel, 3; large bowel, 3; both small and large bowel, 4. The mean number of prior laparotomies was 2.7 (range, 2-5). The mean interval from previous surgery for bowel obstruction to recurrent bowel obstruction was 8.3 months (range, 1-22 months). Surgical correction was possible in 5 (50%) of 10 patients, with 3 (60%) of these 5 patients obtaining successful palliation. Successful palliation is defined as the ability to tolerate a regular or low-residue diet at least 60 days postoperatively. Complications included enterocutaneous fistulas in three patients (two had enterotomies at time of surgery) and wound infection in one patient. There were no postoperative mortalities. The mean postoperative stay was 15.8 days (range, 8-29 days). Two of the three patients successfully palliated presented with a subsequent obstruction at 3 and 5 months postoperatively and were treated with gastrostomy tubes. The median length of survival for the entire cohort from the date of surgery for repeat obstruction was 4.5 months (range, 3-17 months). CONCLUSIONS: Patients undergoing repeat surgery for recurrent bowel obstruction have a low likelihood of successful palliation (30%). The surgery is associated with significant complications after surgery, rapid development of subsequent bowel obstructions, and limited survival rates. Alternative management approaches such as percutaneous endoscopic gastrostomy (PEG) tube placement should be considered in this group of patients.     

Mechanical intestinal obstruction in patients with gynecologic disease: a review of 368 patients

To review the management of intestinal obstruction associated with gynecologic disease, the authors studied the records of 368 patients with acute intestinal obstruction. Most patients (83%) had gynecologic malignancies. Obstruction of the small intestines was more common than obstruction of the large intestines (77% versus 23%). Major causes of mechanical small bowel obstruction included extrinsic neoplasms (62%, mostly ovarian carcinomas), radiation therapy-associated strictures and adhesions (17%), postoperative adhesions (14%), and inflammatory strictures and adhesions (3%). Obstruction of the colon was caused mainly by extrinsic neoplasms (45%), strictures and adhesions associated with radiation therapy (26%), fecal impaction (9%), and intrinsic neoplasms (8%). Gastrointestinal intubation successfully relieved 81% of small bowel obstructions caused by postoperative adhesions. Tube suction alone was rarely successful when the obstruction was caused by malignant neoplasms. The prognosis was dependent on the cause of the underlying disease. The cases studied in this report were compared with a large number of cases of bowel obstruction in general surgery. It is concluded that bowel obstruction associated with gynecologic disease has unique features deserving wider recognition.     

卵巢上皮性癌合并肠梗阻22例临床分析

目的 探讨卵巢癌合并肠梗阻的治疗方法及其对预后的影响。方法 1989年1月～2007年12月,北京大学人民医院收治的22例原发性卵巢上皮性癌患者,在治疗或随访中合并肠梗阻。依据肠梗阻处理方式,分为肠梗阻保守治疗组（15例）和手术组（7例）。保守组10例不全小肠梗阻,5例不全结肠梗阻;手术组完全结肠和完全小肠梗阻各2例,不全小肠及结肠、不全小肠、不全结肠梗阻各1例,术后病理均证实卵巢癌肠转移。回顾性分析肠梗阻的诊断与治疗,肠梗阻不同治疗方法与预后的关系。结果 保守组除1例直肠癌性梗阻未缓解2个月内死亡外,14例肠梗阻缓解,1例2个月后死于严重感染,4例于肠梗阻后12～44个月死于晚期癌,9例肠梗阻治疗后随访1～120个月至今生存,生存期超过两年6例。手术组1例术后13d死于脑卒中;4例术后3个月内死于癌;术后再次辅助化疗2例,分别于肠梗阻后8个月和21个月死于癌。结论 卵巢上皮性癌合并肠梗阻的治疗应兼顾生存期和生活质量,慎重把握手术指征和手术方式,建议应首选保守治疗,并在肠梗阻缓解后予以化疗,可适当延长生命。     

Management of fetal airway obstruction

Fetal airway obstruction can make it difficult if not impossible to secure the airway at birth, before hypoxia, brain injury, or death results. Fetal airway obstruction can result from an intrinsic defect in the airway, such as the congenital high airway obstruction syndrome or extrinsic compression of the airway caused by a cervical mass, most commonly a cervical teratoma or lymphangioma. As fetuses with fetal airway obstruction reach viability, they should be monitored closely for the development or progression of hydrops in intrinsic obstruction cases or polyhydramnios in extrinsic obstruction cases. The fetus should be delivered by using the ex utero intrapartum treatment procedure, with maintenance of uteroplacental circulation and gas exchange. This approach provides time to perform procedures such as direct laryngoscopy, bronchoscopy, or tracheostomy to secure the fetal airway, thereby converting an emergent airway crisis into a controlled situation.     

Predictive factors of fetal urethral obstruction: a multivariate analysis

OBJECTIVE: The purpose of this study was to identify predictive factors of fetal urethral obstruction. METHODS: One hundred and forty-eight children with fetal hydronephrosis were admitted, submitted to a systematic protocol and prospectively followed. Possible predictive factors of urethral obstruction associated with fetal echography and clinical findings on admission were studied. The analysis was conducted in two steps. In a univariate analysis, variables associated with urethral obstruction were identified by the chi(2) test or by Fisher's exact test. Then, the variables that were significantly associated with urethral obstruction were included in a multiple logistic regression analysis. RESULTS: After final adjustment by multiple logistic regression analysis, only two variables were identified as independent predictors of fetal urethral obstruction: oligohydramnios (odds ratio, OR = 5, 95% confidence interval, CI, = 1.3-15, p = 0.01) and megacystis (OR = 9, 95% CI = 2.0-40, p = 0.004). The sensitivity and specificity of the combination of both variables were 60 and 98.5%, respectively. CONCLUSIONS: The presence of oligohydramnios and megacystis on prenatal ultrasound is highly predictive of fetal urethral obstruction.     

A case of nephrogenic diabetes insipidus caused by partial bilateral ureteral obstruction due to advanced stage ovarian carcinoma

Nephrogenic diabetes insipidus (NDI) secondary to chronic urinary tract obstruction is a rare condition. The exact cause is unknown; it is likely that increased collecting duct pressures cause damage to the tubular epithelium, resulting in insensitivity to the antidiuretic hormone (ADH). We report a case of NDI associated with ureteral obstruction caused by advanced stage ovarian carcioma in a 20-year-old girl. After debulcking surgery, massive polyuria continued. Several administrations of an ADH analog were ineffective in reducing urine output, suggesting a possible relationship of massive polyuria with NDI. Following oral administration of a thiazide diuretic, known to exert antidiuretic action in NDI, the urine output was dramatically reduced. This case suggests that ureteral obstruction due to ovarian mass may cause NDI and after the surgery thiazide diuretics are effective in reducing urine output in NDI with ureteral obstruction.     

Small bowel incarceration in the umbilical artery following total laparoscopic radical hysterectomy

Total laparoscopic radical hysterectomy (TLRH) has demonstrated to be a feasible and safe technique for patients affected of early cervical cancer. Small bowel obstruction resulting from a loop volvulus represents a very uncommon postoperative complication in gynecological laparoscopic surgery. We report a case of a patient who presented an intestinal obstruction following a TLRH for cervical cancer. The obstruction was caused by entrapment of a segment of small bowel under the dissected obliterated umbilical artery resulting in a loop incarceration. Wide radical pelvic dissection in radical hysterectomy usually leaves uncovered many dissected retroperitoneal structures. Postoperative bands and adhesions represent the main cause of bowel obstruction after a surgical procedure. Retroperitoneal vessel dissection is mandatory to achieve safely an adequate radicality, but it may lead to intestinal complications that should be taken into account. To our knowledge, this is the first report of postoperative bowel incarceration through the umbilical artery after a laparoscopic oncological procedure.