Long-Term Outcomes of Simultaneous Skin and Bowel Flaps for Esophageal Reconstruction.

Esophageal reconstruction can be performed with skin or bowel flaps. The choice of flap remains controversial, as the long-term outcomes of skin flaps cannot always be assessed in patients with limited life expectancies due to advanced malignancy, unlike the pediatric and benign cases which have had esophageal reconstruction using bowel flaps. We report the long-term clinical and histopathological outcomes in a series of 45 cases repaired with combined skin and bowel flaps.Four patients developed symptomatic strictures after corrosive esophageal injuries were repaired with a combination of a tubed free radial forearm fasciocutaneous flap and a pedicled bowel flap. On average, 24 years had passed since uneventful initial esophageal reconstructions. Barium esophagograms were obtained in all cases and pathological examination was performed upon all surgical specimens.The cutaneous portions of the reconstructed esophagus exhibited a variety of findings on barium examination. Each of the 4 cases developed an esophagocutaneous fistula after revision; an average of 4 surgeries was required to close these fistulae. The inner surfaces of the portion of esophagus repaired with skin flaps showed extensive ulceration, polypoid lesions, and fibrosis. Pathology specimens from skin flaps showed extensive acute and chronic inflammation, microabscesses, fibrosis, and acanthosis, with depletion and degeneration of the pilosebaceous units. By contrast, adjacent parts of the esophagus repaired with bowel were widely patent with normal appearing mucosa.Our findings indicate that a bowel flap is durable with good tolerance to gastrointestinal content over long periods, whereas skin flaps often developed morphological changes and could not maintain long-term esophageal function without eventual stricture and dysphagia. We therefore recommend use of bowel flaps for esophageal reconstruction in patients with long life expectancy.

A comparison of surgical outcomes between laparoscopic and open myomectomy in Southern Taiwan.

OBJECTIVE: To compare operative data and operative and clinical outcomes of laparoscopic myomectomy (LM) with those of open myomectomy (OM). METHODS: In a retrospective study, the records of 81 women who underwent LM and 74 women who underwent at E-DA Hospital, Yan-Chau Shiang, Taiwan, from June 2004 to October 2007 were reviewed. Patient demographic, intraoperative, and postoperative data were compared between the 2 surgical groups. RESULTS: The mean ± SD age of patients in the OM and LM groups was 40.08 ± 6.49 years and 41.14 ± 6.46 years, respectively. Median (range) surgical time and blood loss were both significantly less in the LM group than in the OM group (100 min [73-120 min] versus 120 min [90-146 min], and 100mL [100-200 mL] versus 150 mL [100-305 mL], respectively). Thirteen patients in the OM group required a blood transfusion, compared with 1 in the LM group. There was no difference in complications or recurrences between the 2 groups. CONCLUSION: Compared with OM, LM was found to be associated with shorter surgical time and less blood loss, but there was no difference in the rate of complications or recurrence between the 2 groups.

Opiate-induced constipation related to activation of small intestine opioid µ2-receptors.

AIM: To investigate the role of opioid µ-receptor subtype in opiate-induced constipation (OIC). METHODS: The effect of loperamide on intestinal transit was investigated in mice. Ileum strips were isolated from 12-wk-old male BALB/c mice for identification of isometric tension. The ileum strips were precontracted with 1 µmol/L acetylcholine (ACh). Then, decrease in muscle tone (relaxation) was characterized after cumulative administration of 0.1-10 µmol/L loperamide into the organ bath, for a concentration-dependent study. Specific blockers or antagonists were used for pretreatment to compare the changes in loperamide-induced relaxation. RESULTS: In addition to the delay in intestinal transit, loperamide produced a marked relaxation in isolated ileum precontracted with ACh, in a dose-dependent manner. This relaxation was abolished by cyprodime, a selective opioid µ-receptor antagonist, but not modified by naloxonazine at a dose sufficient to block opioid µ-1 receptors. Also, treatment with opioid µ-1 receptor agonist failed to modify the muscle tone. Moreover, the relaxation by loperamide was attenuated by glibenclamide at a dose sufficient to block ATP-sensitive K+ (K(ATP)) channels, and by protein kinase A (PKA) inhibitor, but was enhanced by an inhibitor of phosphodiesterase for cyclic adenosine monophosphate (cAMP). CONCLUSION: Loperamide induces intestinal relaxation by activation of opioid µ-2 receptors via the cAMP-PKA pathway to open K(ATP) channels, relates to OIC.

Oleic acid activates peroxisome proliferator-activated receptor δ to compensate insulin resistance in steatotic cells.

Nonalcoholic fatty liver disease is frequently associated with type 2 diabetes; however, this idea is challenged by recent studies because hepatic steatosis is not always associated with insulin resistance (IR). Oleic acid (OA) is known to induce hepatic steatosis with normal insulin sensitivity; however, the mechanism is still unknown. Previous studies depict that activation of peroxisome proliferator-activated receptor δ (PPARδ) improves hepatic steatosis and IR, whereas the role of PPARδ in the improvement of insulin sensitivity by OA is unknown. Here we induced steatosis in HepG2 cells by incubation with OA and OA significantly increased the expression of PPARδ through a calcium-dependent pathway. OA also induced the expression of G protein-coupled receptor 40 (GPR40), and deletion of GPR40 by small interfering ribonucleic acid transfection partially reversed the effect of OA on PPARδ. Inhibition of phospholipase C (PLC) by U73122 also reversed OA-induced PPARδ expression. Otherwise, deletion of PPARδ augmented the OA-induced steatosis in HepG2 cells. Furthermore, IR was developed in OA-treated HepG2 cells with PPARδ deletion, while insulin-related signals and insulin-stimulated glycogen synthesis were reduced through increase of phosphatase and tensin homolog (PTEN) expression. In conclusion, OA activates GPR40-PLC-calcium pathway to increase the expression of PPARδ and PPARδ further decreased the expression of PTEN to regulate insulin sensitivity in hepatic steatosis.

Use of individual surgeon versus surgical team approach: surgical outcomes of laparoscopic Roux-en-Y gastric bypass in an Asian Medical Center.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been shown to improve both the health and the quality of life of morbidly obese patients. We compared the efficacy and safety of using a team approach to LRYGB versus an individual surgeon at a medical center. METHODS: Data were collected from 200 consecutive patients undergoing LRYGB for morbid obesity from August 2005 to February 2008. Groups 1 and 2 included 50 patients each who underwent surgery and were cared for by the same surgeon. Group 3 included the next 100 consecutive patients, who underwent LRYGB by the same surgeon but who were cared for by a dedicated bariatric team. RESULTS: For the 76 men (38%) and 124 women (62%) in the study, the excess weight loss at 1 and 3 months of follow-up did not differ; however, it was significantly different at 6 and 12 months. At the mean follow-up period, 30% of group 1, 6% of group 2, and 8% of group 3 had experienced complications. Most complications in group 1 occurred early and were related to the surgical technique; however, in groups 2 and 3, the complications related to the technique were markedly reduced. Men were 4.57 times as likely as women to experience complications related to bariatric surgery. CONCLUSION: A team-based approach is a better option for patients undergoing LRYGB than care by a single surgeon. With an experienced bariatric surgeon, the team approach resulted in shorter operative times and shorter hospital stays, with the same rate of complications.

Combination of a free jejunal flap and a Roux-en-Y colojejunostomy for reconstruction of esophageal stricture secondary to a distant blast injury: a case report.

Pneumatic perforation of the esophagus caused by blast injury is very rare. Our patient presented with esophageal stricture in the context of a previous reconstruction of an esophageal rupture secondary to a distant air-blast injury. The ruptured esophagus was initially reconstructed with a left pedicled colon interposition in an antiperistaltic pattern. However, dysphagia developed 4 years later because of severe reflux-induced stenosis at the junction of the cervical esophagus and the left pedicled colon segment. A free isoperistaltic jejunal flap was performed to replace the cervical esophagus, with an anti-reflux Roux-en-Y colojejunostomy between the caudal segment of the left pedicled colon and the jejunum. The patient was discharged uneventfully 29 days later with smooth esophageal transit and no further reflux, as shown by scintigraphic scan. Esophageal reconstruction in an isoperistaltic pattern using a free isoperistaltic jejunal flap combined with an anti-reflux Roux-en-Y colojejunostomy has never been reported in the literature and appears to be an effective method to provide smooth passage of food and prevent restenosis of the esophagus.

The effect of surgeon empathy and emotional intelligence on patient satisfaction.

We investigated the associations of surgeons' emotional intelligence and surgeons' empathy with patient-surgeon relationships, patient perceptions of their health, and patient satisfaction before and after surgical procedures. We used multi-source approaches to survey 50 surgeons and their 549 outpatients during initial and follow-up visits. Surgeons' emotional intelligence had a positive effect (r = .45; p < .001) on patient-rated patient-surgeon relationships. Patient-surgeon relationships had a positive impact on patient satisfaction before surgery (r = .95; p < .001). Surgeon empathy did not have an effect on patient-surgeon relationships or patient satisfaction prior to surgery. But after surgery, surgeon empathy appeared to have a significantly positive and indirect effect on patient satisfaction through the mediating effect of patients' self-reported health status (r = .21; p < .001). Our study showed that long-term patient satisfaction with their surgeons is affected less by emotional intelligence than by empathy. Furthermore, empathy indirectly affects patient satisfaction through its positive effect on health outcomes, which have a direct effect on patients' satisfaction with their surgeons.

Decrease of plasma glucose by allantoin, an active principle of yam ( Dioscorea spp.), in streptozotocin-induced diabetic rats.

The effect of allantoin, an active component of yam, on plasma glucose of streptozotocin-induced diabetic rats (STZ-diabetic rats) is investigated. Allantoin decreased plasma glucose levels in a dose-related manner, which was reduced by pretreatment with naloxone or naloxonazine. A concomitant increase in plasma ß-endorphin, detected by enzyme-linked immunosorbent assay, was observed. Moreover, allantoin enhanced ß-endorphin release from the isolated adrenal medulla of STZ-diabetic rat in a dose-related manner. However, its plasma glucose lowering action was reduced but not totally abolished by bilateral adrenalectomy. Furthermore, allantoin directly increased radioactive glucose uptake in isolated skeletal muscle, and repeated administration for 3 days increased GLUT4 mRNA and protein levels in muscle. This effect was markedly reduced in STZ-diabetic rats with bilateral adrenalectomy. This study suggests that allantoin increases GLUT4 gene expression in muscle by increasing ß-endorphin secretion from the adrenal gland in STZ-diabetic rats.

Vasodilatation induced by sinomenine lowers blood pressure in spontaneously hypertensive rats.

1. Sinomenine is an alkaloid with a wide range of pharmacological actions. In the present study, we investigated the effect of sinomenine on blood pressure and its possible mechanisms of action. 2. Spontaneously hypertensive rats (SHR) and normotensive Wistar-Kyoto (WKY) rats were given intraperitoneal injections of sinomenine. At 30 min, 2.5-10 mg/kg sinomenine decreased systolic blood pressure (SBP) in a dose-dependent manner in SHR, but had no effect on the SBP in WKY rats. 3. The vascular effect of sinomenine was then examined in aortic rings isolated from Wistar rats. Sinomenine (0.1-10 micromol/L) produced concentration-dependent relaxation in aortic rings precontracted with phenylephrine (10 nmol/L) or KCl (40 mmol/L). Glibenclamide (1-100 micromol/L), a specific inhibitor of ATP-sensitive K(+) channels attenuated the sinomenine-induced relaxation, but this effect was not observed when inhibitors of other types of K(+) channels were used. 4. We further investigated the effects of sinomenine on changes in intracellular Ca(2+) concentrations ([Ca(2+)](i)) in cultured aortic smooth muscle (A7r5) cells by using the Ca(2+)-sensitive dye fura-2 as an indicator. Sinomenine, over the concentration range 0.1-10 micromol/L, decreased the increases in [Ca(2+)](i) elicited by phenylephrine (1 micromol/L) or KCl (40 mmol/L) in a concentration-dependent manner. Glibenclamide (1-100 micromol/L) abolished the effects of sinomenine. 5. In conclusion, sinomenine causes vascular relaxation by opening ATP-sensitive K(+) channels, thus decreasing [Ca(2+)](i).

Acute Q fever hepatitis in patients with and without underlying hepatitis B or C virus infection.

BACKGROUND: Although hepatitis is one of the major presentations of acute Q fever, the possible influence of viral hepatitis in Q fever has, to our knowledge, never been investigated. It is an important issue in regions where Q fever hepatitis and viral hepatitis are prevalent, such as Taiwan. We conducted a study to investigate the possible influence of viral hepatitis in cases of acute Q fever hepatitis. METHODS: Cases of acute Q fever confirmed by serologic examination were included in the study. All patients who were found to be positive for Q fever were tested for hepatitis B surface antigen and antibody to hepatitis C virus, and those with positive results had their viral loads determined. Demographic data, clinical manifestations, results of laboratory and imaging examinations, and responses to treatment were recorded retrospectively from charts. RESULTS: A total of 58 patients with acute Q fever hepatitis were studied, of whom 16 (27.6%) had viral hepatitis (hepatitis B virus infection in 12 and hepatitis C virus infection in 4). Patients with and patients without viral hepatitis did not differ with regard to clinical manifestations and responses to treatment, except that chills (100% vs. 73.8%; P=.02) and nausea and/or vomiting (18.8% vs. 2.4%; P=.03) were significantly more common among patients with viral hepatitis. The change in hepatitis B and C virus loads between the acute and convalescent phase was <1.0 log(10). CONCLUSIONS: The clinical manifestations of acute Q fever hepatitis differ little in patients with and patients without underlying viral hepatitis, and replication of hepatitis virus is not influenced by acute Q fever hepatitis.

A prospective, randomized trial of endoscopic hemoclip placement and distilled water injection for treatment of high-risk bleeding ulcers.

BACKGROUND: Although endoscopic hemoclip therapy is widely used in the treatment of GI bleeding, there are few prospective trials that assess its efficacy. This study evaluated the efficacy and safety of hemoclip placement and distilled water injection for the treatment of high-risk bleeding ulcers. METHODS: Seventy-nine patients with major stigmata of ulcer hemorrhage were randomly assigned to either endoscopic hemoclip placement (n = 39) or injection with distilled water (n = 40). RESULTS: Initial hemostasis was achieved in all patients treated with hemoclips and 39 treated by distilled water injection (respectively, 100.0% vs. 97.5%; p = 1.00). Bleeding recurred in 4 and 11 of patients, respectively, in the hemoclip and water injection groups. It occurred significantly more frequently in the injection group (hemoclip, 10.3%; injection, 28.2%; p = 0.04). No major procedure-related complication occurred in either group. Emergency operations were performed in 5.1% of patients treated with hemoclips versus 12.5% of those in the water injection group (p = 0.43). Hospital days and mortality rate were similar in both groups. CONCLUSION: Endoscopic hemoclip placement is a safe and effective hemostatic method that is superior to distilled water injection for treatment of bleeding peptic ulcer.