Repair of bile duct defect with full-thickness vascularized jejunal patch

The use of a vascularized jejunal patch for the reconstruction of bile duct injuries is presented. The method has been used in 1 patient with a common bile duct stricture and in 1 patient with a noncircumferential bile duct defect. The procedure has the advantages of technical simplicity, primary mucosal coverage, lasting elasticity, and minimal risk for stricture formation.

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Resumen Se presenta el uso de un parche vascularizado de yeyuno para la reconstrucción de lesiones del canal colédoco. Se reseca un segmento móvil del yeyuno lo suficientemente amplio para cubrir el defecto, asegurándose de que existe buena irrigación para el segmento, visualizando los vasos por transiluminación con luz ordinaria. La continuidad del intestino es restablecida mediante anastomosis término-terminal. Se utiliza la parte mesentérica del segmento intestinal, el cual es ascendido por vía retrocólica. Se sutura mucosa con mucosa con una sola capa de puntos separados de ácido poliglicólico 5-0. Se coloca un tubo-en-T para drenaje, el cual es retirado a las 6 semanas. El método ha sido utilizado en un caso de estenosis del colédoco y en un caso con un defecto circunferencial del mismo canal biliar. El procedimiento tiene la ventaja de la simplicidad técnica, la cobertura primaria de la mucosa, la elasticidad permanente y un mínimo riesgo de que se produzca estenosis.

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Résumé L'emploi d'un patch jéjunal bien vascularisé pour traiter les blessures de la voie biliaire fait l'objet de l'article. La méthode a été utilisée pour un cas de sténose de la voie biliaire principale et un cas de plaie n'intéressant pas la totalité de la circonférence du canal biliaire. Elle a pour avantages sa simplicité technique et le fait qu'elle assure une couverture muqueuse, sa persistante élasticité et le fait qu'elle présente un risque réduit de sténose.

     

Dysaccommodation of the stomach: therapeutic nirvana?

Functional dyspepsia (FD) is a highly prevalent gastrointestinal disorder and has a complex pathophysiology. Impaired fundic relaxation in response to a meal is present in 40% of patients with FD. This review focuses on impaired gastric accommodation of the stomach as a pathophysiological mechanism and the possible therapeutic targets that can be derived from the current knowledge of the neuroregulation of the accommodation reflex. First the different means of gastric accommodation assessment are described and the relationship between symptoms and impaired gastric accommodation. The different therapeutic options are subsequently discussed in view of their molecular target, based on the different receptor subtypes involved in the accommodation reflex. Although impaired gastric accommodation is highly prevalent in dyspeptic patients and basic knowledge about the accommodation reflex enables to develop pathophysiologically targeted therapies, it is unlikely that therapies aimed at dysaccommodation of the stomach will lead to symptom relief in all dyspeptic patients. A major challenge is the development of methods that readily identify impaired accommodation in clinical practice.     

Sildenafil relieves symptoms and normalizes motility in patients with oesophageal spasm: a report of two cases

Oesophageal spasm presents with dysphagia and chest pain. Current treatments are limited by poor efficacy and side effects. Studies in health and oesophageal dysmotility show that sildenafil reduces peristaltic pressure and velocity; however the clinical efficacy and tolerability in symptomatic oesophageal spasm remains uncertain. We provided open-label sildenafil treatment to two patients with severe, treatment resistant symptoms associated with oesophageal spasm. The effects of sildenafil on oesophageal function and symptoms were documented by high resolution manometry (HRM). Patients were followed up to assess the efficacy of maintenance treatment with sildenafil b.i.d. HRM revealed focal and diffuse spasm in the smooth muscle oesophagus that were associated with symptoms in both cases, especially on swallowing solids. Lower oesophageal sphincter function was normal. A therapeutic trial of 25-50 mg sildenafil suppressed oesophageal contraction almost completely for water swallows; however effective, coordinated peristalsis returned with reduced frequency of spasm for solid swallows. Dysphagia and chest pain resolved during the therapeutic trial and efficacy was maintained on maintenance treatment with 25-50 mg sildenafil b.i.d. without troublesome side effects. This report shows that sildenafil can improve oesophageal function and relieve dysphagia and chest pain in patients with oesophageal spasm in whom other treatments have failed.     

The influence of the helmet respirator on peak flow rate in aluminum potroom

The efficiency of the Racal Airstream helmet respirator in improving peak expiratory flow rates (PEFR) and symptoms (dyspnea, wheezing, and cough) in aluminum potroom workers with respiratory complaints was assessed in 19 workers. Peak expiratory flow readings and symptom recording from a 2-week working period with use of the respirator were compared with a period when the 3M 9906 disposable mask was used. The study was designed as a randomized, parallel, cross-over study with five or six daily measurements of PEFR and daily symptom recording. A significant number of workers (15) had a higher mean peak flow in the helmet period than in the nonhelmet period (p less than 0.01); symptoms did not improve significantly in the helmet period. Objective evidence of respiratory protection was observed for the group of workers as a whole, but the effect on symptoms as well as individual effect on peak flow was minor in the majority of the workers.