The ileoanal J pouch: radiographic evaluation

Endorectal ileoanal pull-through offers an attractive alternative to proctocolectomy and ileostomy for patients with ulcerative colitis, Gardner syndrome, and familial polyposis. To our knowledge, a careful radiographic analysis of the ileum, ileal pouch, and ileoanal anastomosis after ileoanal pull-through has not been reported. Thirty-two patients with ulcerative colitis, Gardner syndrome, and familial polyposis underwent colectomy, mucosal proctectomy, and endorectal ileoanal pull-through of a 15-cm ileal "J" pouch and loop ileostomy. Twenty-five (78%) of 32 of all the pouches radiographically demonstrated spiral folds extending from the middle of the pouch to the pectinate line. Other radiographic features included a mesenteric mass effect, pseudopolyps, and a central lucency that indicated intrapouch sutures. Radiographs provide useful information in the postoperative management of the ileal pull-through.     

Detection of Met-enkephalin in the pars intermedia of the lampreys, Ichthyomyzon castaneus and Petromyzon marinus.

Acid extracts of the brain and pars intermedia of the chestnut lamprey, Ichthyomyzon castaneus, were fractionated by a combination of gel filtration chromatography and reversed-phase HPLC, and screened with RIAs specific for Met-enkephalin and Leu-enkephalin, respectively. In the brain extract, both Met-enkephalin and Leu-enkephalin were detected in a molar ratio of approximately 4:1. These results would suggest that these two enkephalins were derived from a lamprey Proenkephalin precursor. However, reversed-phase HPLC analysis of the pars intermedia of this species revealed the presence of Met-enkephalin, but not Leu-enkephalin. Analysis of the pars intermedia of the marine lamprey, Petromyzon marinus, also indicated the presence of Met-enkephalin but not Leu-enkephalin. These results would suggest that the Met-enkephalin present in the pars intermedia of lampreys may not be derived from Proenkephalin, but may originate from another opioid precursor. This possibility and alternative hypotheses to explain these observations are discussed.     

Isolation of alpha-melanotropin from the pars intermedia of the larval amphibian, Ambystoma tigrinum

The effect of background adaptation on the steady-state levels of alpha-melanotropin in the pars intermedia of the larval amphibian. Ambystoma tigrinum, was investigated. Acid extracts of pars intermedia obtained from light-adapted and dark-adapted animals were analyzed by radioimmunoassay following Sephadex gel filtration chromatography, reverse-phase HPLC, and Sulfopropyl Sephadex cation-ion-exchange chromatography. For both background adaptation conditions similar results were obtained. The major form of alpha-melanotropin present in the pars intermedia has the following properties: (1) an apparent molecular mass of 1.5 kDa; (2) a net charge at pH 3.5 of +4; and (3) a retention time following reverse-phase HPLC similar to that of synthetic ACTH(1-13)amide. In dark-adapted animals a minor form of alpha-melanotropin which has a net charge of +3 at pH 3.5 was also detected. The latter form represented approximately 10% of the total alpha-melanotropin immunoreactivity in the pars intermedia of dark-adapted animals. These results strongly suggest that the predominant form of alpha-melanotropin in the pars intermedia of larval A. tigrinum is a nonacetylated ACTH(1-13)amide-like polypeptide.     

Hemostatic plug formation in normal and von Willebrand pigs: the effect of the administration of cryoprecipitate and a monoclonal antibody to Willebrand factor

Hemostatic plug (HP) formation was investigated in the ear bleeding time incision in normal and von Willebrand pigs. HP volume was calculated by integrating the areas of serial sections. In normal pigs (n = 11), platelets immediately formed a layer on the surface of the cut channel. Platelet aggregates formed at the ends of transected vessels and gradually enlarged. Finally, all transected vessels were occluded by HP and bleeding stopped. In contrast, large HPs were formed in the incision in von Willebrand's disease (vWD) pigs (n = 4); these HPs did not cover the ends of the transected vessels, which continued to bleed, allowing the formation of large hemostatically ineffective platelet aggregates in the incision. Canals traversed these HPs, and bleeding from the open vessels may have continued through them. After infusion of cryoprecipitate into a vWD pig, the bleeding time shortened, and the morphological findings of the HPs were similar to those of normal pigs. In normal pigs (n = 3) infused with an anti- Willebrand factor monoclonal antibody, which prolonged the bleeding time, a large HP formed in the incision, similar to that observed in the vWD pig. The volume of the normal and vWD HPs increased with time. These in vivo findings suggest that Willebrand factor is involved in the localization of the HP to the damaged vessel and may also play a role in platelet-platelet interaction. A computerized morphometric technique was used for measuring the volume of the hemostatic plugs and the distance of sequential points on the perimeter of the HP from the center of selected bleeding vessels.     

Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages

Introduction

The high mortality and morbidity associated with resection for oesophagogastric malignancy has resulted in a conservative approach to the postoperative management of this patient group. In August 2009 we introduced an enhanced recovery after surgery (ERAS) pathway tailored to patients undergoing resection for oesophagogastric malignancy. We aimed to assess the impact of this change in practice on standard clinical outcomes.

Methods

Two cohorts were studied of patients undergoing resection for oesophagogastric malignancy before (August 2008 – July 2009) and after (August 2009 – July 2010) the implementation of the ERAS pathway. Data were collected on demographics, interventions, length of stay, morbidity and in-hospital mortality.

Results

There were 53 and 55 oesophagogastric resections undertaken respectively for malignant disease in each of the study periods. The median length of stay for both gastric and oesophageal resection decreased from 15 to 11 days (Mann– Whitney U, p<0.001) following implementation of the ERAS pathway. There was no significant increase in morbidity (gastric resection 23.1% vs 5.3% and oesophageal resection 25.9% vs 16.7%) or mortality (gastric resection no deaths and oesophageal resection 1.8% vs 3.6%) associated with the changes. There was a significant decrease in the number of oral contrast studies used following oesophageal resection, with a reduction from 21 (77.8%) in 2008–2009 to 6 (16.7%) in 2009–2010 (chi-squared test, p<0.0001).

Conclusions

The introduction of an enhanced recovery programme following oesophagogastric surgery resulted in a significant decrease in length of median patient stay in hospital without a significant increase in associated morbidity and mortality.