Short-segment jejunoplasty: the option treatment in the management of benign esophageal stricture

A non-dilatable benign stricture of the esophagus is a problem for the patient and always a challenge for the surgeon. The present study is intended to provide some details of surgical technique and the physiological concept that constitutes the basis for patient selection for short-segment jejunoplasty. In this study, out of 98 patients, 91 had complex stricture of the lower, and seven of the cervical esophagus. The main cause of stenosis in 60 patients (61.2%) was gastroesophageal reflux, in 34 (34.7%) post-corrosive damage, and in three (3.0%) it was other causes. All patients were treated by three methods of jejunoplasty: group I (n=54 patients) short-segment of the jejunum; group II (n=37 pts) Roux-en-Y double tract; and group III (n=7 patients) short jejunal segment on the long vascular pedicle. Intraoperative complications occurred in 17 (17.34%) of the patients. An anastomotic leak occurred only in three (3.29%) in group I and II, and 1/98 patients (1.02%) died from mediastinitis. Follow-up of functional results for up to 36 months (average 18 months) was available in 77/97 (79.3%) hospital survivors. Fifty-seven (74%) patients are satisfied with their ability to take food, postoperative reflux was completely denied by 72 (93.5%) patients. Postvagotomy diarrhea was transient and gradually subsided over the course of the first 6 months.     

Mechanical restitution curves: a possible load independent assessment of contractile function.

OBJECTIVE: The time constant of mechanical restitution (T((MRC))), proposed to reflect changes in calcium release and uptake, has been shown to increase in left ventricular (LV) failure, and might have a potential as an index of contractile function. However, in vivo studies of the effect on T((MRC)) of changing loading conditions in the normal and failing heart have not been reported. Consequently, in this study, we tested the hypothesis that the increase in T((MRC)) in vivo is independent of preload and afterload. METHODS: Left ventricular pressure-volume loops were assessed at baseline in eight open chest pigs using the combined pressure-volume conductance catheter technique during right atrial pacing at 120b/min. Mechanical restitution curves (MRC) were constructed during four different loading conditions in all eight animals: uninfluenced load, reduced preload (balloon catheter in v. cava inferior), increased afterload (balloon catheter in descending aorta), and increased preload combined with reduced afterload (aortocaval shunting). Acute LV failure was then induced by microembolization through the left main coronary artery, and the experimental protocol was repeated. Contractile response was defined as the maximal first derivative of pressure (dP/dt(max)), and T((MRC)) was calculated using a least square approximation algorithm. RESULTS: Hemodynamic data 30min after microembolization showed decreased mean arterial pressure (98+/-14-67+/-10mmHg, (mean+/-SD) P<0.0001) and dP/dt(max) (1482+/-193-1001+/-125mmHg/s, P=0.001). Stroke volume decreased from 30+/-5 to 20+/-5ml (P<0.0001) compared to baseline, and preload recruitable stroke work decreased from 52+/-7 to 31+/-10mmHg (P=0.002). T((MRC)) increased in all eight animals after induction of LV failure at all loading conditions. There was no difference between the different loading conditions at baseline, nor at LV heart failure, but T((MRC)) increased significantly after the induction of heart failure (ANOVA, two ways). CONCLUSIONS: We have shown that the left ventricular T((MRC)) increases after developed heart failure. The increase in T((MRC)) was independent on loading conditions and thus have a potential for a contractility index.     

The high prevalence of colorectal neoplasms in preoperative patients with abdominal aortic aneurysm or peripheral artery disease.

OBJECTIVE: In Japan, the incidence of both colorectal carcinoma and vascular disease is increasing. We screened preoperative patients with abdominal aortic aneurysm (AAA) or peripheral artery disease (PAD) for colorectal cancer. DESIGN OF STUDY: This study was retrospective and cross-sectional. MATERIALS: The subjects were 492 patients admitted for elective surgery of AAA or PAD. METHODS: The patients underwent immunochemical faecal occult blood tests (FOBT) before operation, and those with positive results underwent investigations for colorectal neoplasm. We compared the results with that of screening programmes performed on the general population. RESULTS: Of the 408 patients that underwent FOBT, 104 (25.5%) were positive. After colonoscopy, six (1.5%) had colorectal carcinoma and 16 (3.9%) had advanced adenoma. These values were several folds higher than that for the general population in Japan. CONCLUSIONS: Patients with AAA or PAD carry a high risk for colorectal neoplasm.     

Carotid sinus nerve blockade to reduce blood pressure instability following carotid endarterectomy: a systematic review and meta-analysis.

OBJECTIVES: Local anaesthetic infiltration into the carotid sinus during carotid endarterectomy (CEA) has been recommended to minimise blood pressure fluctuations but its use remains controversial. The aim of this meta-analysis was to determine whether intra-operative administration of local anaesthetic reduces the incidence of haemodynamic instability following CEA. MATERIALS AND METHODS: A search of the Medline, Pubmed and Embase databases and the Current Controlled Trials register identified four trials, which met the pre-defined inclusion criteria for data extraction. Pooled odds ratios with 95 per cent confidence intervals (c.i.) for the development of post-operative hypotension and hypertension were calculated using a random-effects model. RESULTS: Outcomes of 432 patients were studied. Local anaesthetic blockade of the carotid sinus was associated with a pooled odds ratio of 1.25 (95 per cent c.i. 0.496 to 3.15); p=0.216) and 1.28 (95 per cent c.i. 0.699 to 2.33; p=0.428) for the development of post-operative hypotension and hypertension respectively. Although none reach significance there was a trend towards increased risk of developing a complication in those patients who received local anaesthetic. CONCLUSIONS: There are insufficient data to determine the role of intra-operative local anaesthetic administration in reducing post-operative blood pressure lability following CEA. Conversely, the possibility of harm cannot be excluded on the basis of the currently available data.     

Reactive arthritis and internal derangement of the temporomandibular joint.

OBJECTIVE: The objective of this study was to determine if temporomandibular joint (TMJ) samples positive for Chlamydia trachomatis have a greater presence of tumor necrosis factor-alpha (TNFalpha) or interleukin-6 (IL-6) when compared with Chlamydia-negative samples. STUDY DESIGN: Posterior bilaminar tissue samples removed during TMJ surgery from 70 patients were evaluated. Cryosections were stained using monoclonal antibody that identifies C. trachomatis. The presence of IL-6 and TNFalpha were evaluated by immunostaining in 15 samples positive and in 25 samples negative for the presence of C. trachomatis. RESULTS: Of the 70 TMJ samples, 32 (46%) were positive for C. trachomatis. In 15 samples positive for C. trachomatis, 10 (67%) were positive for TNFalpha and 7 (47%) for IL-6. In 25 samples negative for C. trachomatis, only 4 (16%) were positive for TNFalpha and only 2 (8%) for IL-6. Differences in C. trachomatis-positive samples versus negative were significant for both TNFalpha (P < .002) and IL-6 (P < .008). CONCLUSION: The presence of C. trachomatis in the TMJ is associated with a significantly increased presence of TNFalpha and IL-6.