Cholinergic and purinergic contribution to the micturition reflex in conscious rats with long-term bladder outlet obstruction

The urethra of female Wistar rats was partially obstructed for 15 weeks. The effects of atropine (1 mg/kg i.v.), suramin (100 mg/kg i.v.), and a combination of atropine and suramin on the peak micturition pressure (MP) were compared during cystometry in conscious rats controls or subjected to outlet obstruction. On the isolated bladder dome, we studied the inhibitory effect of 1 micromol/L atropine, 1 mmol/L suramin, and the combination of the two drugs on contractions induced by electrical field stimulation (EFS). We studied also the contractile response to 80 mmol/L KCl and the concentration-response curves to noradrenaline, phenylephrine, and carbachol on the bladder dome and bladder neck and alpha, beta-methylene adenosine triphosphate on the bladder dome. In conscious rats, the MP, bladder capacity, and micturition volume were significantly higher in obstructed rats than in controls. Suramin induced the same inhibition in the two groups of animals (-30.7 +/- 13.3% in controls and -29.2 +/- 8.5% in obstructed rats). Atropine decreased the MP, but this effect was twofold greater in obstructed animals (-28.1 +/- 3.1% and -65.1 +/- 6.9% in control and obstructed animals, respectively). However, the combined effect of atropine and suramin was additive in controls but not in obstructed (-56.7 +/- 5.4% and -55.9 +/- 9.4%, respectively). Similar results were obtained in vitro using 1 micromol/L atropine and 1 mmol/L suramin. In the obstructed bladder dome and bladder neck, we found a great reduction in KCl- and carbachol-induced contractility but no difference in the response to EFS. Responses to noradrenaline and phenylephrine were moderately reduced in the bladder neck only, whereas responses to alpha, beta-methylene adenosine triphosphate in the bladder dome were not reduced except at the concentration of 300 micromol/L. We conclude that long-term obstruction in rats could induce cholinergic nerve fiber proliferation as suggested by the decrease in M(3) muscarinic receptor contractility (desensitization) and by a greater sensitivity of the MP to atropine.     

Congenital diaphragmatic hernia: experience without extracoporeal membrane oxygenation

While extracorporeal membrane oxygenation (ECMO) is used in the management of congenital diaphragmatic hernia (CDH), its value is questioned. The charts of all newborn infants who presented in respiratory distress due to CDH over the past 27 years were reviewed. Inborn versus outborn, year of repair, use of ultrasound (US), and the predictive value of various parameters was evaluated. Fisher's exact test and logistic regression tests were used to analyze data. There were 81 patients, 43 males and 38 females. Repair occurred after stabilization without ECMO; 65 patients survived (80%). Apgar scores at 1 min (P=0.03) and 5 min (P=0.005), best postductal PaO₂ (BPDPaO₂) (P=0.02), and type of repair (P=0.01) were predictive of outcome. There was no difference in survival between inborn and outborn patients or over the years of review (P=0.29). Forty-six patients had documented prenatal US scans, with no obvious impact on outcome. Thus, survival of CDH patients without ECMO is comparable to the best results reported with ECMO, suggesting that the costs and associated morbidity of ECMO may not justify its use for such patients. Apgar scores, BPDPaO₂, and type of repair are good predictors of outcome. Accepted: 9 March 2001     

Transient mega-esophagus in a neonate with congenital diaphragmatic hernia

Esophageal dilatation (ED) in neonates is rare. In the present case, ED was detected in a chest radiograph following repair of congenital diaphragmatic hernia (CDH) in a term neonate. A roentgenographic swallow study on the seventh day of life demonstrated ED and a sub-diaphragmatic stomach. The infant thrived adequately on enteral feeding. A swallow study on the twentieth day of life showed a normal-width esophagus with gastroesophageal reflux and small hiatus hernia. The longstanding herniated stomach in the fetus apparently caused kinking, edema, and obstruction of the gastroesophageal junction. This led to a significant ED and concealment of gastroesophageal reflux. We aim to arouse awareness about the occurrence of ED with CDH, and about its benign course under conservative management. Received: 12 May 2000 Revised: 3 August 2000 Accepted: 4 August 2000     

Roux-en-Y jejunostomy button in infants

Establishing enteral feeding in high-risk infants with significant gastroesophageal reflux is a difficult challenge. Some patients are considered at very high risk for fundoplication and gastrostomy due to unstable medical conditions, dense upper-abdominal adhesions due to previous surgical procedures, or unfavorable anatomy. We describe a less invasive operation that provides jejunal feeding in a way that is safe, reliable, and convenient for the family. Accepted: 4 March 1999     

Left diaphragmatic hernia associated with lower esophageal atresia

A case of combined left diaphragmatic hernia and lower esophageal atresia, which is an unusual occurrence, is described. The preoperative diagnosis was difficult because of the presence of an abnormal air bubble, thought to be the stomach, in the chest. The surgical management is discussed. Correspondence to: N. Komi     

Diaphragmatic Endometriosis: Multidisciplinary Treatment

Study Objective

To demonstrate a safe laparoscopic procedure for diaphragmatic infiltrative endometriosis.

Transdiaphragmatic Liver Hernia in Adults

Right sided transdiaphragmatic liver herniation is a rare type of diaphragmatic hernia. Three such cases in adults are reported. A localized hepatic herniation (type III) masquerading as pulmonary neoplasm was revealed in one, while in the other two cases liver herniation was accompanied by herniation of bowel (type III). A history of trauma was present in all three patients with a latent period between injury and discovery of diaphragmatic hernia ranging from 10–20 years. The role of current imaging modalities in arriving at the correct diagnosis is emphasized.     

Neonatal thoracoscopic repair of congenital diaphragmatic hernia: selection criteria for successful outcome

Background/Purpose

Complications of open conversion, hypercarbia, and intestinal injury have plagued minimally invasive approaches to congenital diaphragmatic hernia (CDH) repair in neonates. To safely begin using minimally invasive techniques for neonatal CDH repair, we formulated preoperative selection criteria and operative techniques that would enhance chances for successful thoracoscopic primary diaphragm repair and uncomplicated outcome.

Methods

During the period from January 2003 to October 2004, neonates were selected for thoracoscopic CDH repair using anatomic and physiologic criteria. Anatomically, all patients were required to have stomach in the abdomen by radiography. Physiologically, all patients were required to be on minimal ventilator support with preoperative ventilator peak inspiratory pressures in the low 20s mm Hg. No patient could have clinical evidence of pulmonary hypertension at the time of surgery. Thoracoscopic CDH repair was performed using 3 trocars (3 and 5 mm). The hernia contents were reduced into the abdomen using 5-mm Hg insufflation, and the diaphragms were repaired primarily using interrupted 3-0 Ethibond simple sutures (Ethicon, Inc, Piscataway, NJ). Posterolateral diaphragm stitches were passed around the posterolateral ribs and tied extracorporeally.

Results

Thirty neonates with CDH were admitted to Children's Hospital Boston and Vanderbilt Children's Hospital during the study period. Eight patients (27%) met selection criteria and 7 underwent thoracoscopic CDH repair. Primary diaphragmatic repair was successfully accomplished thoracoscopically in all neonates without perioperative complication. Preoperative anatomic criteria correlated accurately with intact esophageal hiatus and primary diaphragm repair. Physiologically, each patient tolerated intrathoracic insufflation and CDH repair without clinical pulmonary hypertension or blood pressure lability. Three patients had intraoperative respiratory acidosis that was reversed with ventilator changes. Operative times averaged 152 minutes and ranged from 212 to 106 minutes. Postoperative mechanical ventilation ranged from 0 to 7 days, and the length of hospitalization ranged from 5 to 32 days. Longest follow-up has been 17 months. One patient required reoperation for recurrent CDH at 10 months after repair, but there have been no other long-term complications.

Conclusions

Neonatal thoracoscopic CDH repair is safe in selected patients who have good preoperative pulmonary function and anatomy amenable to primary diaphragmatic repair. A wider range of neonates may be acceptable for thoracoscopic CDH repair with increasing surgical experience.     

Health-related quality of life in adults after repair of congenital diaphragmatic defects--a questionnaire study

Background and Aim

Long-term respiratory, gastrointestinal, and vertebral sequelae are common after repair of congenital diaphragmatic defects (CDDs). The aim of this study was to assess the effect of these sequelae on the health-related quality of life (HRQoL) of adult survivors after CDD repair.

Materials and Methods

A questionnaire, including 36-Item Health Survey Form (SF-36), 36-item Gastrointestinal Quality of Life Index (GIQLI), 55-item Psychosocial Survey, 9-item survey for Respiratory Symptoms-Related Quality of Life Index, and a symptoms query, was sent to 94 adult survivors of CDD and to 400 healthy control subjects. One SD lower than the age-adjusted national average in the 36-Item Health Survey Form score for physical or mental health was considered as low HRQoL.

Results

Sixty-nine patients with CDD (72%) and 162 (41%) control subjects returned the questionnaire. The initial presentation was critical in less than 10% of patients with CDD. Forty-five patients with diaphragmatic hernia had primary closure; in 1 patient with diaphragmatic hernia, a patch was used. Twenty-four patients had plication of diaphragmatic eventration. The incidence of gastroesophageal reflux (20% vs 2%), recurrent intestinal obstruction (7% vs 0%), and recurrent abdominal pain (12% vs 2%) was significantly higher in patients with CDD than in control subjects, whereas no difference in the incidence of respiratory, musculoskeletal, or other health problems not associated with CDD was found. Scores in GIQLI, Psychosocial Survey, and Respiratory Symptoms-Related Quality of Life Index did not differ between patients with CDD and control subjects. Health-related quality of life was low in 17 (25%) of 69 patients with CDD, which exceeded 1.5 times the expected value. There was no correlation between the type or severity of the primary defect and HRQoL at the time of the study.

Conclusion

Most adults with repaired CDD have good or satisfactory HRQoL. Congenital diaphragmatic defect-associated symptoms with or without acquired diseases significantly impair HRQoL in one fourth of the patients.     

Para-aortal lymph nodes dissection in 20 cases of primary epithelial ovary carcinoma stage I (Figo): Influence on staging

In this study 20 cases of primary epithelial ovary carcinoma stage I (Figo) were presented.In 5 cases (25%) para-aortic lymph nodes were positive, because of which their stage changed into Stage III. This shows that for correct staging of ovary carcinoma stage I, extirpation of the para-aortal glands is obligatory. It was observed that tumors on the external surface of the ovary and tumor cells in the peritoneum fluid were not related to positive para-aortal glands. The para-aortic metastases were found in the tumors with a histologic grading according to Broders' classification III and IV.