Endothelin activation and postoperative renal failure after human liver transplantation.

Renal failure is an established risk factor for impaired patient outcome after orthotopic liver transplantation (OLT). As the endothelin pathway is known to be involved in the development of acute renal failure (ARF), we designed a study to clarify its role in ARF following OLT. Twenty consecutive patients with intact kidney function scheduled for their first OLT were prospectively studied. Plasma big endothelin-1 (ET-1) levels were measured before surgery, after graft reperfusion, and on the first and second postoperative day. According to postoperative glomerular filtration rate (GFR), patients were assigned to the acute renal dysfunction group (ARDF) and the non-ARDF group. Each patient's GFR was estimated according to the 4-variable formula used in the modification of diet in renal disease before surgery, daily within the first postoperative week, and at 1, 3, 12, and 24 months after surgery. Postoperative mean big ET-1 levels correlated significantly with the maximum percent decrease of GFR within 3 days after OLT (P < 0.01). The proportion of patients who developed ARDF was significantly correlated to mean postoperative big ET-1 quartiles (P < 0.01). In the ARDF group, the percent decrease of GFR within 24 months was significantly higher (P < 0.05) as compared to the non-ARDF group. In conclusion, patients who develop ARDF immediately after OLT do not fully recover to baseline regarding long-term kidney function. Short-term GFR was significantly correlated with postoperative big ET-1 plasma levels, suggesting renal dysfunction is mediated by the activated endothelin system.     

Solitary rectal cap polyp: Case report and review of the literature

Rectal bleeding combined with the presence of a rectal mass has been traditionally associated with the presence of malignant disease.Cap polyposis is a relatively young and still undefined rare entity which mainly involves the rectosigmoid.It is characterized by the presence of inflammatory polyps.In this case report,we present a patient who was diagnosed with a solitary cap polyp of the rectum during the investigation of a bleeding rectal mass.The patient’s age and the absence of family history were not in favor of malignancy,despite the strong initial clinical impression.After confirmation of the diagnosis,the patient underwent a snare excision and remains asymptomatic.Cap polyposis,although rare,should be suspected and,when diagnosed,should be treated according to location,number of polyps and severity of symptoms.     

Percutaneous fetoscopic patch closure of human spina bifida aperta: advances in fetal surgical techniques may obviate the need for early postnatal neurosurgical intervention

Background  A percutaneous minimally invasive fetoscopic approach was attempted for closure of a spina bifida aperta in two fetuses with L5 lesions. The goal was to obviate the need for postnatal neurosurgery to manage this condition. Methods and Results  The percutaneous fetoscopic procedures were performed by a two-layer approach at respectively 22 ± 2 and 22 ± 4 weeks of gestation. The fetuses were delivered respectively at 32 ± 6 and 32 + 3 weeks of gestation. Their neural cords were completely covered although in small areas skin closure was incomplete. Postnatally, complete skin closure occurred beneath an occlusive draping within 2 to 3 weeks such that neurosurgical intervention was not required. Both neonates showed reversal of hindbrain herniation, near-normal leg function, and satisfactory bladder and bowel function. For one of the two fetuses, ventriculoperitoneal shunt insertion was not required. Conclusions  Percutaneous minimally invasive fetoscopic patch closure of spina bifida aperta offers a substantially less maternal trauma than open fetal surgical repair and currently may even obviate the need for postnatal neurosurgical repair. With a little further improvement in surgical techniques and a better understanding of incorporating surgical patches into the fetus, complete skin closure seems possible in the near future.     

Prolonged Postoperative Ileus—Definition, Risk Factors, and Predictors after Surgery

BACKGROUND: Postoperative ileus (POI) remains an inevitable consequence of abdominal surgery. Although the pathogenesis of delayed gastrointestinal transit in the postoperative period has been the subject of considerable study, a clinically useful definition of what constitutes a pathologically prolonged ileus has yet to be established. The objectives of this study were to describe a definition for an abnormally prolonged ileus and to identify risk factors and predictors of prolonged ileus in patients undergoing abdominal surgery. MATERIALS AND METHODS: Over a 12-month period 88 patients who had abdominal surgery were retrospectively reviewed. The association of clinical factors with the duration of POI was examined with statistical tests. RESULTS: The mean time to commencing the consumption of unrestricted clear fluids after surgery was 2.3 +/- SD 1.6 days. The median duration of POI was 5 days (median 6 days), with an interquartile range of 3-6 days. Univariate regression analysis demonstrated significant correlations between duration of POI and estimated blood loss (EBL), total surgical time, and total opiate dose (TOD) (p = 0.009, p = 0.045, and p = 0.041, respectively). Multiple regression analysis identified EBL and TOD as independent predictors of duration of POI. CONCLUSIONS: We have identified two risk factors (EBL and TOD) that are independently associated with duration of POI. Our data suggest that with the definition of abnormal prolonged postoperative ileus as the number of days above the 3rd quartile, an ileus greater than 6 days serves as a better clinical definition of prolonged POI than 3 days, the measure that has previously been suggested.     

Sonographic Characteristics of Rectal Sensations in Healthy Females

Purpose This study was designed to characterize rectal sensations by visualizing the internal and external anal sphincter and intra-anal transport of bolus during elicited rectal sensations. Methods The anal canal was visualized with real-time transperineal ultrasonography in 13 healthy female volunteers. Rectal sensations were elicited by injecting water into the rectum. The ultrasound images were recorded on a videotape and analyzed offline. Results The median time between an injection of water and the events studied was calculated in 105 rectal sensations. A relaxation in the internal anal sphincter (4 seconds after the injection of water), an antegrade transport of bolus (4 seconds) into the anal canal, and a contraction in the external anal sphincter (5 seconds) were observed before a sensation (6 seconds) was reported. The antegrade flow continued until the distal internal anal sphincter contracted (18 seconds) and the bolus moved in a retrograde transport direction (17 seconds) thereafter the sensation disappeared (18 seconds) and the external anal sphincter relaxed (22 seconds). A significant correlation in time between the end of the sensation, contraction in the internal anal sphincter, reversed flow of anal contents, and relaxation of the external anal sphincter was found (Pearson, P<0.01). Conclusions The results verified that the internal anal sphincter contributes to the perception of rectal sensations by a relaxation allowing intra-anal bolus to increase the pressure on the anoderm during rectal contraction. A new observation is presented on the time relation between contraction in the distal internal anal sphincter, reversed flow in the anal canal, and the end of rectal sensations. Presented at the meeting of the International Continence Society, Christchurch, New Zealand, November 27 to December 1, 2006. Supported by Hitachi Ultrasound, Supfstrasse 24, 6300 Zug Switzerland provided the sonography system. Reprints are not available.