Luminal hydrochloric acid stimulates rapid transepithelial ion fluxes in rodent esophageal stratified squamous epithelium.

It remains unclear whether enhanced ion fluxes occur in the esophageal stratified squamous epithelium upon acid exposure. Rat esophageal tissues devoid of submucosal glands displayed basal short-circuit current (Isc) of 5.03 +/- 1.93 microA/cm(2) and lumen-negative potential difference (PD) in association with net absorption of Na+ and Cl-, and secretion of HCO3(-). Luminal hydrochloric acid (HCl) challenge (pH = 1.6) triggered an acute rise of the Isc and increment of negative PD to seven-fold of baseline, which was diminished in HCO3(-)-free, but not Na+- free buffer. The rise of Isc was inhibited by pretreatment with di-isothiocyanatostilbene-2, 2'-disulphonic acid (DIDS) and 5-(N-ethyl-N-isopropyl)-amiloride (EIPA). Topical carbachol, capsaicin, forskolin or CFTR(inh)-172 had no effect on basal Isc.CFTR(inh)-172 did not reduce the acid-increased Isc. Functional ablation of capsaicin-sensitive nerves had no effect on the acid-induced Isc. The phenomenon of enhanced ion fluxes upon acid stimulation was confirmed in human esophageal specimens. Our results demonstrated that the mechanism of acid-induced rapid transepithelial ion fluxes is dependent on the presence of bicarbonate ions as well as functional anion transporters and Na+/H+ exchanger, but independent of cystic fibrosis transmembrane conductance regulator (CFTR). The capsaicin-sensitive and muscarinic-dependent nerve pathways did not play roles in the mechanism.

Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases.

BACKGROUND: The safety and feasibility of minilaparoscopic cholecystectomy has not been documented with a large patient sample. This study reports the results of 1,011 minilaparoscopic cholecystectomies performed in a single institution. METHODS: From November 1997 to May 2002, 1,023 consecutive patients underwent minilaparoscopic cholecystectomy at National Taiwan University Hospital, Taipei, Taiwan. Patients with clinical evidence of common bile duct stones (1 patient) and combined surgery for other purposes (11 patients) were excluded. The operative indication, total operative time, conversion rate, hospital stay, morbidity and mortality of 1,011 patients were reviewed and statistically analyzed. RESULTS: Minilaparoscopic cholecystectomy was performed in 1,009 of 1,011 patients (375 males and 636 female; mean age, 54.8 years; range 13-92 years). The total operative time was 68.8 +/- 31.9 min. The total hospital stay was 2.5 +/- 2 days. One patient (0.10%) underwent conversion to open cholecystectomy because of common hepatic duct laceration. One patient (0.10%) underwent conversion to standard laparoscopic cholecystectomy for control of cystic artery bleeding. Ten patients (0.99%) experienced major complications including intraabdominal abscess (1 patient), bile leakage (5 patients), major bile duct injury (2 patients), bowel injury (1 patient), and postoperative hemorrhage (1 patient). Eleven patients (1.09%) had minor complications including wound infection, incisional herniation, postoperative ileus, and acute urine retention. One patient (0.10%) with bleeding tendency succumbed to postoperative hemorrhage. CONCLUSIONS: Minilaparoscopic cholecystectomy is a technically demanding approach. Our results indicate that this procedure could be performed successfully and safely by experienced surgical teams.

Randomized clinical trial of Ligasure versus conventional surgery for extended gastric cancer resection.

BACKGROUND: The Ligasure Vessel Sealing System is a haemostatic device designed primarily for use in abdominal surgery. Randomized trials have demonstrated that it is safe and quick for haemorrhoidectomy, but there is no evidence that it confers any advantage in complicated gastrointestinal surgery. The aim of the present study was to examine the value of the Ligasure system in extended lymph node dissection (D2) during gastrectomy for cancer in a randomized clinical trial. METHODS: D2 gastric resection performed with the Ligasure system was compared with resection using conventional haemostatic methods in a prospective randomized trial. Central randomization (40 patients in each group) was performed after a staging laparotomy. The main outcome measures were operating time, intraoperative blood loss, postoperative course and complications. RESULTS: Ligasure was associated with less intraoperative blood loss (mean(s.d.) 142(73) versus 239(124) ml; P = 0.001) and a shorter operating time (mean(s.d.) 169(25) versus 222(28) min; P = 0.001) than conventional operation. Postoperative drainage fluid volumes were greater in the Ligasure group (mean(s.d.) 1577(940) versus 886(542) ml; P = 0.020). There were no differences in postoperative complications or hospital stay. CONCLUSION: The Ligasure Vessel Sealing System is safe for use in extended lymph node dissection for gastric cancer, and is associated with a shorter operating time and decreased blood loss compared with conventional haemostatic techniques.

Needlescopic, laparoscopic, and open appendectomy: a comparative study.

SUMMARY: The benefits of laparoscopic appendectomy appear to be controversial. Since 1994, several abdominal procedures have been completed by using the needlescopic technique, but there appear to be no prospective studies to demonstrate the perceived benefits of needlescopic appendectomy. The authors compared open, laparoscopic, and needlescopic appendectomy in a randomized fashion with regard to duration of surgery, length of hospitalization, analgesic dosage, and surgery-associated complications. From March to July 1998, 75 patients admitted at the emergency station of the authors' hospital with a final diagnosis of acute appendicitis without tumor formation were randomized to receive one of the three treatment categories: open (OA), laparoscopic (LA), and needlescopic (nLA) appendectomy. Laparoscopic and needlescopic appendectomy were performed by using a three-port technique, although the size of the trocar used varied. There were 26 patients in the OA group, 23 in the LA group, and 26 in the nLA group. The mean operation durations for the OA, LA, and nLA groups were 55.4 +/- 28.0 minutes, 69.1 +/- 48.8 minutes, and 62.3 +/- 26.3 minutes, respectively, and these were not significantly different from one another. The mean number of the analgesic doses (Pethidine 1 mg/kg) required was 1.3 +/- 1.2 mg/kg, 0.5 +/- 0.8 mg/kg, and 0.2 +/- 0.6 mg/kg, respectively. Significant differences were noted when comparing the OA with the LA or nLA groups (OA vs. LA, P = 0.02; OA vs. nLA, P = 0.0002; LA vs. nLA, P = 0.06). The mean oral intake durations were 32.2 +/- 16.9 hours, 21.0 +/- 14.6 hours, and 20.8 +/- 16.4 hours, respectively, after surgery for the OA, LA, and nLA groups, and the between-group differences were statistically significant for the OA versus LA group ( P = 0.004) and for the OA versus nLA group ( P = 0.003). The mean durations of hospitalization for the OA, LA, and nLA groups were 3.6 +/-1.8 days, 2.8 +/- 1.4 days, and 2.4 +/- 0.9 days, and difference was detected between the OA and the nLA groups ( P = 0.02). The OA group rendered a greater wound-complication rate and ileus than did the other two groups, but the differences were not detected between the three categories ( P = 0.065, 0.6935). The result of the current study confirmed that the nLA procedure is a feasible and safe one. The nLA procedure provided substantial advantages over the OA procedure in the contexts of diminished postoperative pain and shorter hospital stay without significant increases in postoperative complication rate or surgical time.

Laparoscopic versus open vertical banded gastroplasty for the treatment of morbid obesity.

Vertical banded gastroplasty (VBG) is an effective treatment for morbid obesity. Recent advancement in laparoscopic surgery has made laparoscopic VBG possible. The authors compared retrospectively the outcomes of laparoscopic VBG versus open VBG in patients with morbid obesity. From June 1998 to April 1999, 100 patients (18 men, 82 women; average age, 32.6 years) underwent laparoscopic VBG, and 40 patients (7 men, 33 women; average age, 28.8 years) underwent conventional open VBG. The two groups were similar regarding sex, age, and body mass index distribution. Mean surgical time, blood loss estimate, duration of postoperative recovery, analgesic usage, complications, and weight reduction were compared among the two groups. Laparoscopic VBG was successful in 99 (99%) of the 100 patients. Mean surgical time was longer in duration for the laparoscopic VBG group than it was for the open VBG group (173 vs. 101 minutes, P < 0.01). The laparoscopic VBG group had earlier flatus passage (1.9 vs. 2.6 days; P < 0.01), less usage of analgesics (meperidine 50 mg/unit; 0.9 vs. 2.3 units; P < 0.01), and a shorter postoperative hospital stay (3.7 vs. 6.0 days; P < 0.01). Estimated blood loss, surgical complication rate, and weight reduction were similar among the two groups. Although laparoscopic VBG required a longer surgical time and was technically more demanding, it resulted in shorter recovery time, less analgesic use, and less severe physical discomfort. The authors' findings show that the two methods were approached safely equally.

Mini-laparoscopic reduction of intussusception for children.

The success of mini-laparoscopic cholecystectomy and splenectomy has encouraged the application of this new technique in children with non-complicated intussusception. Here, we report on the use of this technique in two children, aged 21 and 24 months, respectively, who had failed saline enema reduction of ileocolic intussusception. Under a 2-mm videoscopic visualization, the intussuscepted bowel was identified and reduced with the assistance of a 2-mm working port placed at the right lower abdominal area and a 5- to 10-mm working port placed at the supraumbilical area. An intussuscepted lymph node at the ileocecal area, as the lead point, was removed at the time of the procedure in one child. Both patients experienced relief of symptoms the day after operation and resumed a regular diet on the first post-operative day. No recurrence or complications, including abscess and wound infection, occurred. These findings suggest that mini-laparoscopic reduction is a safe procedure for children with uncomplicated intussusception. Moreover, the procedure provides better cosmesis than conventional laparoscopic techniques.

Laparoscopic wedge resection of benign gastric tumor.

BACKGROUND/AIMS: In the past 2 years, 9 patients diagnosed as benign gastric tumor pre-operatively underwent laparoscopic wedge resection of stomach at National Taiwan University Hospital. Among them, 6 were females and 3 were males. METHODOLOGY: Histopathologically, 7 of 9 cases were of gastrointestinal stromal tumor (GIST). The clinical characteristics of this group were retrospectively reviewed and compared with another 12 cases of benign gastric tumor receiving open wedge resection in the same period. RESULTS: There were no differences in sex, age, and pre-operative diagnosis in these two groups. It took a significantly longer operation time in the laparoscopic group than it did in the open group (205.71 vs. 97.5 min, p<0.05). However, the patients of the laparoscopic group started post-operative oral intake earlier (4.0 vs. 5.58 days, p<0.05), had shorter hospital stays (6.67 vs. 10.77 days, p<0.05), and lower analgesic usage rate (55% vs. 100%). There were no differences in operative complication rates. CONCLUSIONS: Laparoscopic resection of benign-gastric tumor is recommended as a minimally invasive procedure.

Preoperative localization procedures for initial surgery in primary hyperparathyroidism.

The experience of the surgeon and precise localization of abnormal parathyroid glands determine the success of surgery for primary hyperparathyroidism (HPT). In HPT patients undergoing repeat surgery, the use of localization studies improved the ability to identify the remaining abnormal parathyroid tissue. This study investigated the roles of preoperative localization techniques for initial surgery for primary HPT. From 1985 through 1997, two noninvasive localization procedures, ultrasonography (US) and 201thallium chloride-99mtechnetium pertechnetate subtraction scanning (Tl-Tc), were used prior to initial exploration for primary HPT in 76 patients. Their accuracy was determined on the basis of surgical and pathologic results. The surgical success rate was 96% (73/76). The sensitivities of US and Tl-Tc were 71% and 49%, respectively. The sensitivity of Tl-Tc was higher for the lower parathyroid glands. In 21 of 26 patients who underwent fine-needle aspiration (FNA) of the suspected enlarged parathyroid gland, the diagnosis of parathyroid adenoma was confirmed preoperatively. We conclude that the concomitant use of US and FNA is a safe and convenient method for preoperative localization of the parathyroid glands prior to initial surgical exploration in patients with primary HPT. Bilateral neck exploration by an experienced surgeon should be the routine procedure. US and Tl-Tc alone offer limited localization information, and unilateral exploration should be reserved for selected cases in which the results of these two imaging studies are consistent with one another.

Gastric cancer in the young.

BACKGROUND/AIMS: Gastric cancer in the young is relatively uncommon, but it carries important clinical significance. This study was designed to determine the clinicopathological characteristics of young patients who underwent a gastrectomy for gastric cancer in order to improve clinical management. METHODOLOGY: From January 1977 to December 1994, 997 patients underwent surgical treatment for gastric cancer in the Department of Surgery of the National Taiwan University Hospital. All of these patients were classified into 6 groups based on their age at the time of surgery. Of these, 52 patients (5.2%) were 35 years of age or younger. The clinicopathological data of these patients were reviewed and compared to the data of the other age groups. RESULTS: There was a female predominance, with a male:female ratio of 1:1.36. In the majority of patients, the time period from the onset of symptoms to the time of diagnosis was less than one year (76.9%). Epigastralgia was the most common complaint (65.4%). Six patients (11%) were diagnosed as having a benign peptic ulcer during the first endoscopy. Histologically, there were more diffuse (65.4%) and scirrhous types of gastric cancer in the young group. Half of the patients (49.9%) were at TNM stage III or IV at the time of surgery. Curative resections were performed on 49 patients. The cumulative 5-year survival rate was 36.1% among the young patients, which was no different from the survival rates of the other age groups. While the 5-year survival rate of patients with stage I gastric cancer was 90% in the young age group, of the 26 patients with stage III or IV, only one survived more than 5 years. Four female patients (13.3%) were found to have metastases to the ovaries during follow-up. CONCLUSION: The clinicopathological characteristics of young patients with gastric cancer are as follows: 1) female dominance; 2) more diffuse and scirrhous types of gastric carcinoma; 3) the prognosis after surgery depends on the stage rather than the age; 4) free use of endoscopy and clinical alertness are important for the early diagnosis of malignancy in young patients.

Colorectal surgery using a biofragmentable anastomotic ring.

To compare the efficacy of the biofragmentable anastomotic ring (Valtrac-BAR, Davis and Geck, Medical Device Division, Danbury, CT, USA) with conventional anastomotic techniques, 30 patients who underwent colorectal surgery from August 1993 to March 1995 were retrospectively studied. The use of the BAR was also compared with conventional techniques including hand-sewn sutures in 30 patients and an end-to-end anastomosis (EEA) stapler in 24 patients. There were 17 men and 13 women in the BAR group with ages ranging from 37 to 80 years, 18 men and 12 women in the hand-sewn group with ages ranging from 41 to 82 years and 14 men and 10 women in the EEA group with ages ranging from 38 to 72 years. Surgical indications included: 25 colon cancers and five rectal cancers in the BAR group; 27 colon cancers and three rectal cancers in the hand-sewn group; and six colon cancers and 18 rectal cancers in the EEA group. There was no conversion to other anastomotic methods. Most of the patients tolerated a low-residual diet from the fifth post-operative day. No clinical leakage or stricture was noted. Only seven patients were aware of the passage of BAR fragments. The mean hospital stay was 14.1 days. There were no significant differences among these techniques in the return of bowel function, the incidence of surgical complications, including anastomotic leakage, or the length of hospitalization. BAR anastomosis was more time efficient than conventional techniques. Our results confirmed that BAR was an ideal sutureless alternative for anastomosis in colorectal surgery.

Cytomegalovirus enteritis causing massive bleeding in a patient with AIDS.

An emergency operation was performed on a 58 year-old heterosexual male patient for massive lower gastrointestinal bleeding, which was caused by cytomegalovirus (CMV) related ulceration at the terminal ileum. Pre-operative endoscopic evaluation revealed multiple esophageal and gastric ulcerations in upper gastrointestinal tract and much fresh blood in distal colon. Angiography showed vascular tufts and extravasation of contrast medium in the cecal area. Angiodysplasia of cecum with massive bleeding was initially impressed. However, CMV enteritis was identified in the resected ileum, the diagnosis of Acquired Immunodeficiency Syndrome (AIDS) was confirmed by subsequent serological tests. AIDS was unknown to treating physicians until diagnosed by pathological specimen. Massive lower gastrointestinal bleeding related to CMV ulceration in small bowel is rare, we report this unusual presentation and highlight the the suspicion of immunocompromised state of patients with unusual, multiple gastro-intestinal ulcers.