Life-threatening hemorrhage from abdominal aorta following a percutaneous renal biopsy.

We report on a case of life-threatening abdominal aorta hemorrhage following percutaneous renal biopsy. A 42-year-old woman with chronic kidney disease stage 2 and microscopic hematuria underwent a percutaneous renal biopsy to evaluate renal insufficiency. One hour following the biopsy procedure, she complained of an abdominal pain and developed signs ofoligemic shock. In despite of 4 blood units transfusion, the patient continued to be in shock. She was transmitted urgently to the operating room without any other examinations (such as abdominal computer tomography) and underwent an emergency laparotomy. A transverse tear in the abdominal aorta was identified as the bleeding site, and after occlusion, the hemorrhage was stopped. The patient gradually recovered and she was discharged in good clinical condition after a few days.

Long-term effects of myotomy and partial fundoplication for esophageal achalasia.

Controversy persists in the surgical approach to treat esophageal achalasia. This investigation reports the long-term effects of esophageal myotomy and partial fundoplication in treating this disorder. From 1984 to 1998, 32 patients with achalasia underwent myotomy and partial fundoplication (Belsey Mark IV) using a left thoracotomy. The median follow up is 7.2 years. Assessments include clinical evaluation, esophagogram, radionuclide transit, manometry, 24-h pH, and endoscopy. There is no complication and no mortality. Preoperative assessment was compared with that in 0-3, 3-7, and 7-16 postoperative years. Clinically, the prevalence of dysphagia was decreased from 100% to 6%, 12%, and 13%, respectively (P < 0.001). Heartburn remains unchanged (P > 0.25). On radiology, the prevalence of barium stasis was decreased from 97% to 44%, 48%, and 47%, respectively (P=0.001), whereas a pseudo-diverticulum was observed in two-thirds of patients after operation (P=0.001). Percent radionuclide stasis at 2 min was measured as 70%, 17%, 20%, and 20%, respectively (P=0.001). Manometrically, lower esophageal sphincter (LES) gradient was decreased from 29 to 10, 9, and 9 mmHg, respectively (P=0.001). LES relaxation was improved from 41% preoperatively to 100% postoperatively at each postoperative period (P < 0.001). An abnormal acid exposure was observed in four patients after the operation. Endoscopy documented mucosal damage in three patients (P > 0.25). In conclusion, on long-term follow up, myotomy and partial fundoplication for achalasia relieve obstructive symptoms and improve esophageal emptying, and reduce LES gradient and improve LES relaxation. Acid reflux is recorded in 13% of patients and esophageal mucosal damage is identified in 11% of the patient population. A longer myotomy not covered by the fundoplication results in pseudodiverticulum formation and increased esophageal retention.

Manometric study in Kearns-Sayre syndrome.

Although swallowing difficulties have been described in patients with Kearns-Sayre syndrome (KSS), the spectrum of manometric characteristics of dysphagia is not yet well known. Moreover, it is conceivable that a combination of various degrees of swallowing difficulties with different patterns in manometric studies exist, each playing a major role in the prognosis, natural history, and quality of life of KSS patients. An 18-year-old girl diagnosed at the age of 5 years with KSS (muscle biopsy) was admitted to our department with an upper respiratory tract infection and dysphagia. Clinical examination revealed growth retardation, external ophthalmoplegia, pigmentary retinopathy, impaired hearing, and ataxia. An electrocardiogram revealed cardiac conduction defects (long Q-T), and brain magnetic resonance imaging showed abnormalities in the cerebellar hemispheres. A manometric and motility study for dysphagia was conducted and the pharynx and upper esophageal sphincter (UES) resting pressures were similar to control group values, but the swallowing peak contraction pressure of the pharynx and the closing pressure of the UES were very low and could not promote effective peristaltic waves. Relaxation and coordination of the UES were not affected although pharyngeal and upper esophagus peristaltic waves proved to be very low and, consequently, were practically ineffective. The patient was started on treatment comprising a diet rich in potassium, magnesium, and calcium, and oral administration of vitamin D and co-enzyme Q10 100 mg daily; she was discharged 6 days later with apparent clinical improvement.

Submucosa of canine small intestine as an alternative medium-diameter autogenous arterial graft.

BACKGROUND: Small intestinal canine submucosa has been used in previous studies as a large diameter arterial graft and has shown acceptable patency rates. The aim of our experimental study was to assess its effectiveness when it is used as an autogenous medium-sized diameter arterial graft (5-7 mm). METHODS: Fifteen mongrel dogs were included and underwent laparotomy under general anaesthesia. The mucosa, tunica muscularis and serosa were removed from a resected intestinal segment. The remaining tube, which consisted of the submucosa and the basilar tunica mucosa, represented the experimental graft which was used to replace a proportional gap of the canine infrarenal aorta. Ascertainment of peripheral pulses, measurement of the intra-aortic pressures, aortography and in vivo/in situ observation before the sacrifice of the animals, were the procedures used for verification of the graft's patency. RESULTS: The resistance to thrombogenicity of the graft was considered satisfactory: nine out of 10 grafts remained patent for postoperative intervals ranging from one day to one year; one graft showed partial obstruction due to a technical perioperative error. The grafts showed also excellent physical characteristics (ease of handling and suturing, blood impermeability and durability), resistance to infection and showed no tendency to develop myointimal hyperplasia. CONCLUSIONS: Small intestinal canine submucosa showed satisfactory haemodynamic properties, long-term patency and resistance to infection, when used as a medium-diameter arterial substitute.

Results of the Collis-Nissen gastroplasty in patients with Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) is an advanced stage of gastroesophageal reflux disease. Medical treatment and standard antireflux operations show a high failure rate. An elongated gastroplasty, wrapped by a total fundoplication should provide a tension-free repair with adequate protection against reflux. The aim of this study is to review the operative effects of a Collis-Nissen gastroplasty to treat reflux in Barrett's esophagus. METHODS: From January 1989 to December 1997, 45 patients with BE (38 men, 7 women) aged 53.5 years, underwent a Collis-Nissen gastroplasty. Mean follow-up is 35.9 months (range, 6 to 110 months). Pre- and postoperative evaluations included symptom assessment, esophagogram, endoscopy, manometry, 24-hour pH study, and esophageal emptying scintigrams. RESULTS: There were no operative deaths. All reflux symptoms were controlled. Acid reflux was significantly reduced (percent time exposure decreased from 10% to 1%) and lower esophageal sphincter (LES) pressure were restored to normal (LES gradient increased from 4 mm Hg to 11 mm Hg). LES incomplete relaxation was noted in 50% of patients postoperatively. Endoscopically, mucosal damage from reflux healed but the columnar mucosa with intestinal metaplasia persisted. CONCLUSIONS: The Collis-Nissen gastroplasty, in patients with BE, controls reflux disease, its symptoms, and the mucosal damage associated with this condition. It restores the LES gradient but increases the resistance to bolus transit. There is no regression of the abnormal mucosa despite reflux control.

Protection of the gastroduodenal mucosa from the effects of diclofenac sodium: role of highly selective vagotomy and misoprostol.

The aim of this study was to determine the effectiveness of highly selective vagotomy (HSV) or misoprostol, a prostaglandin E1 (PGE1) analog, for protecting the gastroduodenal mucosa (GDM) from the effects of diclofenac sodium (DS). Fifty mongrel dogs were randomly allocated to five groups. HSV alone was performed in group I dogs (controls) to standardize the operation. DS was given intramuscularly for 12 consecutive days to the group II dogs, whereas in the group III dogs HSV was performed, followed a month later by DS administration, as in group II. DS was given in combination with misoprostol for 12 days to the group IV dogs. HSV was performed on the group V dogs, and a month later DS and misoprostol were given, as in group IV. After sacrificing the animals the GDM was examined for macroscopic and histologic lesions. Statistical analysis was made by Fisher's exact test. HSV alone did not protect the gastric or duodenal mucosa from the effects of DS (p = 0.474 and p = 0.62, respectively). Misoprostol alone also did not offer significant protection to the gastric or the duodenal mucosa (p = 0.08 and p = 0.65, respectively). The combination of HSV plus misoprostol protected the gastric mucosa (group V, p = 0.007) but not the duodenal mucosa (group V, p = 0.08). Hence HSV or misoprostol alone offers no protection to the GDM from the effects of DS. The combination of HSV and misoprostol offers significant protection only to gastric mucosa. Enhancement of the mucosal defense mechanisms combined with strong reduction of gastric acidity may offer adequate protection to gastric mucosa from the effects of nonsteroidal antiinflammatory drugs.

Traumatic cholecystectomy.

Avulsion of the gallbladder from its liver bed with detachment from both cystic duct and artery is an exceedingly rare consequence of blunt abdominal injury. A case is reported in which early recognition by diagnostic peritoneal lavage led to successful treatment.