An exceptional postoperative gastric tube bleeding after esophageal resection for cancer

A case of gastric tube bleeding after an Ivor-Lewis esophagectomy with gastroesophageal anastomosis is reported. During the early postoperative course, the patient had a gastric tube stasis that improved progressively. The subsequent onset of a serious and intermittent hematemesis, which was endoscopically deemed to be the result of a hemorrhagic gastritis, required multiple blood transfusions. The evolution to a severe hemodynamic instability obliged us to reoperate on the patient. During surgery, a band-related obstruction of the first jejunal loop with local signs of vascular hypertension was noted. As soon as the obstruction was solved, the gastric bleeding stopped. The authors discuss the clinical aspects and physiopathology of the gastric tube bleeding and, in particular, they evaluate the influence of the intestinal obstruction with vascular involvement on the development of this exceptional and severe complication.     

Effect of N-acetylcysteine on blood and tissue lipid peroxidation in lipopolysaccharide-induced obstructive jaundice.

In obstructive jaundice, free radical production is increased and antioxidative activity is reduced. N-Acetylcysteine (NAC) has a beneficial effect with anti-inflammatory and antioxidant activity, acting as a free radical scavenger. NAC inhibits inducible nitric oxide synthase, suppresses cytokine expression/release, and inhibits adhesion molecule expression and nuclear factor kappa B. The aim of this study was to investigate the effects of NAC on liver/renal tissue and serum lipid peroxidation in lipopolysaccharide (LPS)-induced obstructive jaundice. We randomized 60 rats into 6 groups: group 1, Sham; group 2, obstructive jaundice (OJ) induced after bile-duct ligation; group 3, OJ + NAC (100 mg kg- 1 subcutaneously); group 4, OJ + LPS (10 mg kg-1); group 5, OJ + NAC + LPS; and group 6, OJ + LPS + NAC. For each group, the biochemical markers of lipid peroxidation and the antioxidant products were measured in serum and liver/renal tissue after sacrifice. Almost all lipid peroxidation products levels were increased and antioxidant products levels were decreased in groups who received LPS (groups 4, 5, and 6), but the effect was less remarkable when NAC was administered before LPS (group 5). The same trend was seen for groups with OJ +/- LPS who did not received NAC or received it after induced toxemia (groups 2, 4, and 6) as compared to groups 1 and 3. Moreover, in the case of OJ + LPS, rats treated with NAC before LPS (group 5) had lower lipid peroxidation products levels and higher antioxidant products levels as compared to those who did not received NAC (group 4). This phenomenon was not reproducible with NAC administered after LPS (group 6). Thus, results of this study showed that NAC prevents the deleterious effects of LPS in obstructive jaundice by reducing lipid peroxidation in serum and liver/renal tissue if administered before LPS. Nonetheless, NAC failed to prevent the lipid peroxidation in the case of established endotoxemia in obstructive jaundice.     

Dependence of Genotoxicity of Benzo[a]pyrene Suspensions in Mutatox Test on Dissolved Concentration and S9 Addition

The Mutatox test is a novel genotoxicity test measuring the ability of a test chemical to restore the luminescent state in dark mutants ofVibrio fischeri.Chemicals can be tested with or without rat hepatic S9 enzymes for metabolic activity, so that promutagenic agents can be detected as well. In theMicrobics Mutatox Manual(1993, Microbics Corp., Carlsbad, CA), benzo[a]pyrene is recommended as positive control for S9 medium at a nominal concentration of 10 mg/liter with 2% DMSO as carrier solvent. The concentration of benzo[a]pyrene dissolved in this test suspension without addition of S9 was determined by GC–MS. It was significantly lower than the nominal concentration and did not reveal a genotoxic effect in the Mutatox test with S9. The analytical concentration of benzo[a]pyrene in the supernatant of the test suspension in S9 medium was significantly higher and induced the luminescence of bacteria. Therefore, S9 microsomes seem, apart from metabolizing benzo[a]pyrene to its genotoxic epoxide, to increase transfer of benzo[a]pyrene intoV. fischeriin such a way that the genotoxic effect is produced. This suggests that sparingly soluble compounds might have different ecotoxicological effects as suspensions than as solutions. Therefore, the possible uptake of suspended particles by organisms without being completely dissolved before should be considered in ecotoxicological tests.     

Complications of laser-assisted angioplasty: definition and classification of perforations

Although laser-assisted angioplasty is becoming increasingly common, there has been no definitive report, drawing its data from a significant patient population, regarding the complications of this technique. To define and enumerate such adverse results, we collected data on 664 peripheral laser procedures performed in 349 patients over a 15-month period (February 1987 through April 1988). The complications proved similar to those of standard angioplasty: hematoma formation, 100 cases (15.0%); perforation/dissection, 38 cases (5.7%); acute thrombosis, 23 cases (3.5%); false aneurysm formation at the puncture site, 7 cases (1.1%); vascular spasm, 5 cases (0.8%); and embolism, 1 case (0.2%). Because perforation was the most significant complication during angioplasty, we devised a system for uniform documentation and reporting of perforations, based on both the arterial condition responsible for the laser probe's deviation and the clinical consequences of the aberration. According to this system, Class-I perforations are dissections that do not penetrate the adventitia; Class-II perforations are adventitial wall ruptures (true perforations) that do not require treatment; and Class-III perforations are adventitial wall ruptures with hemorrhage. In our series, we had no Class-III perforation, but had 21 Class-I (3.1%) and 17 Class-II (2.6%) perforations. Because prudent treatment of an evolving complication often can salvage the procedure, we discuss appropriate therapies, as well as preventive measures.     

Cholesterol crystals in biliary microlithiasis

A recent study put forward the hypothesis that microlithiasis may represent an early stage in the development of biliary calculi. It is an established fact that cholesterol crystals are the product of an inevitable stage in the sequence leading to gallstone formation. To test the hypothesis stated above ten patients affected by gallbladder cholesterol microlithiasis (CM) were examined in the lipid composition of the bile, the cholesterol saturation index and the presence of cholesterol crystals being calculated. The results were compared with those of 14 patients affected by pigment microliths, 24 with larger stones (LS) and ten control patients. The cholesterol saturation index was above one in all CM patients, whereas in some LS patients the gall-bladder bile was not supersaturated. Cholesterol crystals were observed in the gallbladders of all CM patients and seven LS patients. These results would seem to provide support for the hypothesis of microcalculi as being "young stones", with the bile of CM patients maintaining the conditions leading to gallstone formation.     

Fibroblastic reticular cell tumor of the spleen: report of a case and review of the entity

Fibroblastic reticulum cells (FBRCs) are stromal support cells located in the parafollicular area and deep cortex of lymph nodes and in the extrafollicular areas of the spleen and tonsils. We report a case of malignant FBRC tumor of the spleen occurring in a 61-year-old woman. Two years after splenectomy, multiple hepatic lesions were found, which were resected. Histologically, the tumor showed similar morphological features in the spleen as in the liver metastases. There was a whorled pattern of oval and spindle cells in a collagenized background admixed with an inflammatory cell infiltrate composed of lymphocytes and plasma cells. The tumor cells were positive for common muscle actin, smooth muscle actin, and focally for CD68. In situ hybridization for Epstein Barr virus was negative. To the best of our knowledge, this is the first report of malignant FBRC tumor arising in the spleen. The differential diagnosis of splenic tumors with inflammatory pseudotumor-like features is discussed.     

Five-year Prospective Audit of Routine Intravenous Cholangiography and Selective Endoscopic Retrograde Cholangiography with or without Intraoperative Cholangiography in Patients Undergoing Laparoscopic Cholecystectomy

Consensus has never been reached regarding the need or the imaging technique for evaluating the common bile duct (CBD) in patients considered for cholecystectomy. With the advent of laparoscopic cholecystectomy there has been a resurgence of interest in the role of preoperative intravenous cholangiography (IVC) as an alternative for evaluating the CBD. The purpose of this audit was to assess whether a diagnostic workup based on IVC, which permits selective use of intraoperative cholangiography (IOC) and endoscopic treatment of CBD stones before surgery, could be useful in patients undergoing laparoscopic cholecystectomy (LC). In patients without jaundice, gallstone pancreatitis, a prior diagnosis of CBD stones, a prior history of contrast allergy, or a risk of contrast-associated acute renal failure, IVC was performed routinely. Patients suspected to have CBD stones based on IVC results or with inconclusive IVC and patients with a strong clinical suspicion of CBD stones were referred for endoscopic retrograde cholangiography (ERC). IOC was carried out in patients who had a history of contrast allergy or risk of contrast-associated acute renal failure and whenever the surgeon was in doubt as to the biliary anatomy or CBD clearance. IVC was carried out in 1155 patients, ERC in 225, and IOC in 54. IVC was conclusive in 1132 patients, with a diagnostic accuracy of 99%. Our workup permitted the sequential endoscopic-laparoscopic treatment of cholecystocholedocholithiasis in 162 cases. During the follow-up period residual CBD stones were detected in four patients. Our diagnostic workup showed that routine IVC exposes the population to a large radiation burden, and the cost is high for the small number of patients who benefit. Moreover, it does not seem helpful in reducing the incidence of CBD injuries during LC.     

The effect on the middle-ear cavity of an absorbable gelatine sponge alone and with corticosteroids

The objectives of this study were to establish whether there is an obvious difference between intact mucosa and abraded mucosa of the middle-ear cavity in respect to the potential side effects from the application of absorbable gelatine sponge (Gelfoam) and to investigate if Gelfoam combined with corticosteroid ointment (cortimycine, sterile 1% hydrocortisone acetate) can reduce the occurrence of these effects. Twenty Albino rats were used in the study. These animals were divided into four groups, with ten ears in each group. In group A, the middle-ear mucosa was kept intact, and Gelfoam was inserted into the middle-ear cavity. In group B, the middle-ear mucosa was abraded, and Gelfoam was inserted. In group C, Gelfoam with corticosteroid was implanted over the intact mucosa, and in group D, the mucosa was abraded prior to the insertion of Gelfoam with corticosteroid. The changes were evaluated 8 weeks postoperatively. In group A, there was a minimal increase in fibroblastic activity, vascular proliferation with mild to moderate fibrosis and all but two tympanic membranes were perfectly normal. However, in group B, we encountered a significant increase in fibroblastic activity, vascular proliferation and fibrosis, and we observed that all tympanic membranes were moderately to severely thickened. These histopathologic changes related to Gelfoam were noted to be decreased in group C and especially in group D. As previously reported in the literature, Gelfoam was found to promote the formation of connective tissue in the middle-ear cavity regardless of the status of the mucosa. The unwanted effects of this material may be decreased if it is combined with corticosteroids in the middle-ear cavity.     

Caecal-rectal antiperistaltic anastomosis without torsion of the vascular pedicle

Caecorectal anastomosis by Deloyers' procedure has the disadvantage of creating torsion of the vascular pedicle. The technique reported here is a simple mechanical anti-peristaltic anastomosis without inversion of the caecum. This technique was performed successfully in 26 patients after subtotal colectomy for multiple colonic carcinomas or severe constipation.