Diagnostic laparoscopy for chronic abdominal pain after gastric bypass.

BACKGROUND: To evaluate, in an observational study, the utility of diagnostic laparoscopy as a tool to evaluate patients with abdominal pain of unknown etiology after gastric bypass surgery. METHODS: A retrospective analysis was performed of data from patients who had undergone laparoscopy for diagnosis or treatment of abdominal pain. This study included 13 patients with negative preoperative radiographic and/or endoscopic findings. RESULTS: A total of 13 patients who had undergone Roux-en-Y gastric bypass underwent diagnostic laparoscopy for abdominal pain. The findings included internal hernia (4), adhesions (3), ventral hernia (2), partial small bowel obstruction (1), and chronic cholecystitis (1). There were 2 negative laparoscopies, while a diagnosis was made in 85%. After an average follow-up of 3.2 months, 7 of 11 patients had unresolved abdominal pain and 4 patients experienced pain resolution (2 patients were lost to follow-up). CONCLUSION: The results from this small retrospective study suggest that significant pathologic findings can be identified in most patients who have negative preoperative evaluation findings; however, the efficacy of diagnostic laparoscopy to eliminate pain in this patient population requires additional study. Despite the potential complications, we believe that diagnostic laparoscopy has a role in the diagnosis and treatment of chronic abdominal pain after gastric bypass.     

联合门静脉／肠系膜上静脉切除的胰头癌根治术

目的探讨胰头癌侵犯门静脉（portalvein，PV）和（／或）肠系膜上静脉（superior mesentericvein，SMV）时根治切除的可行性。方法回顾分析11例PV／SMV受侵的胰头癌患者临床资料，均行扩大胰十二指肠切除术。其中7例行血管壁部分切除，3例行血管节段性切除及对端吻合，1例行受侵血管切除＋人工血管移植。脾静脉与SMV端侧吻合4例，脾静脉结扎3例。消化道重建采用Child术式。结果本组PV阻断时间平均为18．1（9～32）min。全组患者术后均未发生血管栓塞、肠坏死、肝衰竭等并发症，均康复出院。11例均获随访，时间6～20个月，3例术后1年内死亡，4例术后1—2年死亡，患者平均生存时间15（7～20）个月。结论对单纯侵犯PV／SMV的胰头癌施行联合PV／SMV切除的胰头癌扩大根治术是安全可行的。     

Retrograde (reverse) jejunal intussusception might not be such a rare problem: a single group’s experience of 23 cases

BACKGROUND: Retrograde (reverse) intussusception of the jejunum is thought to be a very rare occurrence, having been reported approximately 15 times (21 patients) in medical studies. A review of our own experience of >15,000 Roux-en-Y gastric bypass patients found 23 cases treated since 1996. This is the largest single-center report to date. METHODS: A chart review dating back to 1996 revealed 23 patients with retrograde intussusception involving the jejunum. Their charts were reviewed. A variety of data was reviewed to identify the risk factors for developing intussusception, as well as the presentation, findings, and treatment. RESULTS: We identified 23 patients with retrograde intussusception involving the jejunum. Of these 23 patients, 22 had undergone Roux-en-Y gastric bypass. One patient had undergone Roux-en-Y choledochojejunostomy. Of the 23 patients, 1 (4%) had a gastrojejunal intussusception and 22 (96%) jejunojejunal intussusceptions. All patients were women, with a median age of 32 years (range 20-50). The mean body mass index at gastric bypass was 45.2 kg/m2 (range 39.4-55). Of the 23 patients, 19 (83%) had undergone open and 4 (17%) laparoscopic gastric bypass. The median duration from gastric bypass to the diagnosis of intussusception was 51 months (range 6-288). Of the 23 patients, 8 (35%) presented with gangrene, perforation, or nonreducable obstruction, 9 (39%) had a spontaneous reduction, and in 6 (26%), the obstruction was successfully reduced at surgery. The treatment was surgical resection in 16 (70%) with 2 recurrences (12.5%), simple reduction in 2 (9%) with 100% recurrence, and plication in 5 patients (22%) with 2 recurrences (40%). CONCLUSION: Retrograde intussusception of the jejunum after gastric bypass is probably more common than previously believed. Although resection and revision of the area of intussusception appears to be effective, more information is needed about the treatment and possible prevention of this disorder.     

Reconstruction of the sellar dura in transsphenoidal surgery using an expanded polytetrafluoroethylene dural substitute

BACKGROUND: The transsphenoidal approach for resecting pituitary tumors has classically included reconstruction of the anterior wall of the sella turcica. A variety of materials have been used in this process for the purpose of both recreating the original anatomy and preventing postoperative cerebrospinal fluid (CSF) leaks. We studied the use of an ePTFE dural substitute (GORE Preclude MVP, W.L. Gore & Associates, Flagstaff, Arizona, USA), as a method for obtaining reliable reconstruction of the sellar dura. METHODS: A prospective alternate case trial was designed to assess this new dural substitute wherein 60 patients who underwent transsphenoidal surgical resection of intrasellar lesions larger than 1 cm were included. Thirty patients had the sellar dura closed with ePTFE dural substitute, whereas 30 patients underwent anterior wall reconstruction as ordinarily performed in our institution. RESULTS: Each patient was reassessed at closure, and the operative site and sphenoid sinus were evaluated with 3-months-postoperative magnetic resonance imaging. Three patients experienced postoperative CSF leaks: 1 with ePTFE dural substitute and 2 without. All 3 patients underwent a second operation to repair the CSF leak, without further complications. No other postoperative complications were noted in the series. CONCLUSION: Expanded polytetrafluoroethylene dural substitute provides a safe and effective adjunctive method for reconstruction of the sellar dura.     

The natural history and significance of ultrasonographically defined polypoid lesions of the gallbladder in children

Background/Purpose

Gallbladder polyps are relatively common in adults and may increase the risk of gallbladder cancer. The increased use of high-quality abdominal ultrasonography has likely led to the increase detection of these lesions in the pediatric population. The aim of the present study was to address the significance of the ultrasonographic finding of a gallbladder polyp in children.

Methods

This prospective case series of 4 children with ultrasonographically defined gallbladder polyps outlines their presentation and clinical course. A detailed review of the literature and a management approach has been provided.

Results

In the 4 cases, polyps were followed for 2, 5, 72, and 84 months with a clinical follow-up of 7 to 11 years. Three underwent cholecystectomy and only 1 of 3 had a polypoid gallbladder lesion. One child, followed for 7 years, had no change in size, shape, or location of the polyp. This case series adds to the small group of children in the literature with polypoid gallbladder lesions and, to our knowledge, none have developed malignant transformation.

Conclusions

Clearly more studies on such children are required to further add to our knowledge on the natural history and the appropriate management of these lesions.     

Vitamin A therapy in patients with Crohn's disease

Vitamin A therapy has been claimed in isolated reports to be of benefit to patients with Crohn's disease. To investigate this further, 86 patients were entered into a long-term double-blind study of vitamin A, 50,000 U twice daily, as compared with placebo. After a mean of 14.1 mo of treatment there was no significant difference between the groups as measured by a variety of activity indices (including the National Cooperative Crohn's Disease Activity Index), the number of acute attacks, and the surgical rate. No toxic effects of vitamin A were observed during the study. In this study vitamin A has not been shown to be of benefit to patients with Crohn's disease who are in remission.     

Organization of pigment proteins in the photosystem II complex of the cyanobacterium Anacystis nidulans R2.

Two chlorophyll-protein complexes associated with photosystem II (PSII) of the cyanobacterium Anacystis nidulans R2 have been detected. The larger of the two complexes, CPVI-1, contained a 71-kDa and a 42-kDa protein. The 71-kDa protein was determined to be the anchor protein of the phycobilisomes (the light-harvesting complex of A. nidulans PSII), since it was recognized by an antibody raised against a similar protein from another cyanobacterium. The second complex, CPVI-4, contained a previously unobserved 36-kDa chlorophyll-binding protein. Additionally, two other PSII chlorophyll-protein bands were characterized. CPVI-2 contained a 52-kDa band that was recognized by an antibody raised against the presumptive PSII reaction center protein of Chlamydomonas reinhardtii. It gave rise to a fluorescence emission peak (77K) at 695 nm, indicating that this chlorophyll-protein complex may harbor the reaction center of PSII. Finally, CPVI-3 was found to have a 45-kDa protein and to be immunologically related to the presumptive immediate-antenna protein of the C. reinhardtii PSII.     

Liver disease activity and hepatitis B virus replication in chronic delta antigen-positive hepatitis B virus carriers

Delta antigen is currently thought to reflect superinfection of the liver with a defective RNA virus (delta agent), requiring helper function from hepatitis B virus for its replication. To assess the influence of delta agent on hepatitis B virus replication in patients persistently infected with both viruses and showing chronic liver disease, we measured serum and liver hepatitis B virus DNA in HBsAg-positive chronic liver disease patients who were either positive or negative for delta antigen in the liver. Hepatitis B virus DNA was assayed in the serum of 21 patients with delta antigen-positive/HBsAg-positive chronic liver disease and in 21 patients with delta antigen-negative/HBsAg-positive chronic liver disease matched for HBeAg/anti-HBe status and underlying liver histology. HBcAg and delta antigen in liver was determined by immunofluorescence or immunoperoxidase staining. In delta antigen-positive/HBsAg-positive chronic liver disease, serum hepatitis B virus DNA was detected transiently in 4 of 21 cases (19%) and was present in these patients at low levels (trace to 2+). In contrast, 9 of 21 (43%) delta antigen-negative/HBsAg-positive chronic liver disease patients were serum hepatitis B virus DNA positive, and five of these had high serum hepatitis B virus DNA levels (3+ to 4+). Serum HBsAg and anti-HBc titers were significantly lower in delta antigen-positive cases and correlated with reduced amount of HBcAg in the liver.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical outcomes of revision biceps tenodesis

Purpose:

Biceps tenotomy and tenodesis are effective treatment options for biceps pathology, but outcomes of revision surgery are not known. This study examines the clinical outcomes of patients who have undergone a revision biceps tenodesis.

Materials and Methods:

A retrospective review of all patients since 2004 (N = 21) who had undergone a revision biceps tenodesis with greater than 6-month follow-up was completed. A follow-up survey was carried out, and the visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and University of California – Los Angeles (UCLA) scores were obtained, along with SF-12 Mental (MCS-12) and Physical Component Summaries (PCS-12).

Results:

Indications for revision surgery were continued pain (14) and ruptured biceps (7). Complete follow-up examinations were performed in 15 of 21 patients (71.4%). Average follow-up was 33.4 ± 23.5 months. The mean postoperative scores were 1.9 out of 10, VAS; 79 out of 100, SANE; 10.2 out of 12, SST; 83 out of 100, ASES; 29 out of 35, UCLA; 44, PCS- 12; and 47.1, MCS- 12. Five patients were considered failures with a UCLA score below 27. Seventeen of twenty-one patient underwent concomitant procedures. Complete preoperative and postoperative data were collected for 14 patients. All scores demonstrated highly significant improvement from preoperative levels (P < 0.005), except for the MCS-12. There was no statistically significant difference in the outcomes of revision due to rupture and revision due to persistent pain.

Conclusions:

The results suggest that revision subpectoral biceps tenodesis provides significant pain relief and improvement in functional outcomes at a mean follow-up of 33.4 months.

Level of Evidence:

Case Series, Level 4.     

The predictive value of diagnostic imaging for histological lesions of the upper poles in duplex systems with ureteroceles

OBJECTIVE: To compare the diagnostic imaging findings with the histological lesions in upper pole nephrectomy (UPN) specimens of duplex system ureteroceles, using renal ultrasonography (US) and nuclear renal scintigraphy. PATIENTS AND METHODS: Between 1992 and 2000, 86 patients with a ureterocele in a duplex system underwent surgery. The results from US were reviewed in 84 patients by a radiologist, for echogenicity, parenchymal thinning and hydronephrosis; 77 nuclear renal scans describing the differential function of the upper poles were also reviewed. Fifty-five patients underwent UPN (25 antenatal, 30 postnatal; 18 intravesical, 37 extravesical) and the specimens were available for independent review by a pathologist, describing five histological categories, i.e. chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Histological lesions were categorized as severe (> 25%) or minimal (相似文献