Antimesenteric tapering enteroplasty in an adult patient with clinical evidence of obstruction: a bowel-preserving alternative to resection.

BACKGROUND/AIMS: The approach to small bowel obstruction, when unrelieved with medical management, is open or laparoscopic exploration, often necessitating lysis of adhesions and the resection of any compromised bowel. In patients with prior bowel resections, the surgeon must tread a fine line, so as not to precipitate the clinical derangement known as short bowel syndrome (SBS). Techniques have been described that curtail the extent of intestinal resection, but these are primarily limited to the pediatric literature and are not commonly practiced in the general surgical population. METHODS: We report a case of a complicated small bowel obstruction in a patient with pre-existing short bowel length, in which a tapering enteroplasty was performed. RESULTS: Antimesenteric tapering successfully achieved a return of bowel function, avoiding the morbidity of an extended small bowel resection and the possibility of developing SBS. CONCLUSION: In such patients who are at high risk of developing SBS, in whom a segment of dilated small bowel has become defunctionalized, leading to significant and life-threatening symptoms, this procedure has the potential to help prevent SBS and its lifelong complications and associated mortality.

The role of mental rotation and memory scanning on the performance of laparoscopic skills: a study on the effect of camera rotational angle.

OBJECTIVE: The rotational angle of the laparoscopic image relative to the true horizon has an unknown influence on performance in laparoscopic procedures. This study evaluates the effect of increasing rotational angle on surgical performance. METHODS: Surgical residents (group 1) (n = 6) and attending surgeons (group 2) (n = 4) were tested on two laparoscopic skills. The tasks consisted of passing a suture through an aperture, and laparoscopic knot tying. These tasks were assessed at 15 degrees intervals between 0 degrees and 90 degrees , on three consecutive repetitions. The participant's performance was evaluated based on the time required to complete the tasks and number of errors incurred. RESULTS: There was an increasing deterioration in suturing performance as the degree of image rotation was increased. Participants showed a statistically significant 20-120% progressive increase in time to completion of the tasks (p = 0.004), with error rates increasing from 10% to 30% (p = 0.04) as the angle increased from 0 degrees to 90 degrees. Knot-tying performance similarly showed a decrease in performance that was evident in the less experienced surgeons (p = 0.02) but with no obvious effect on the advanced laparoscopic surgeons. CONCLUSIONS: When evaluated independently and as a group, both novice and experienced laparoscopic surgeons showed significant prolongation to completion of suturing tasks with increased errors as the rotational angle increased. The knot-tying task shows that experienced surgeons may be able to overcome rotational effects to some extent. This is consistent with results from cognitive neuroscience research evaluating the processing of directional information in spatial motor tasks. It appears that these tasks utilize the time-consuming processes of mental rotation and memory scanning. Optimal performance during laparoscopic procedures requires that the rotation of the camera, and thus the image, be kept to a minimum to maintain a stable horizon. New technology that corrects the rotational angle may benefit the surgeon, decrease operating time, and help to prevent adverse outcomes.

Combination chemoimmunotherapy for metastatic colorectal cancer using 5-fluorouracil, leucovorin and interleukin-2.

25 patients with metastatic colorectal cancer were entered into a phase II trial of combination chemoimmunotherapy using a sequential regimen of 5-fluorouracil (5-FU) and leucovorin and high-dose recombinant human interleukin-2 (rIL-2). Patients initially received three cycles of chemotherapy consisting of 500 mg/m2 of intravenous leucovorin followed by 375 mg/m2 of bolus 5-FU both given daily on days 1-5 of a 21 day cycle. Ten days after the last dose of chemotherapy in cycle 3, patients began high-dose rIL-2 at 720,000 IU/kg intravenously every 8 h to the maximum tolerated number of doses. After 7-10 days of recovery, this rIL-2 treatment was repeated to complete one full course of chemoimmunotherapy. There was no grade IV toxicity associated with 183 cycles of chemotherapy. Other than slight increases in the frequency of diarrhoea, stomatitis and hyperbilirubinaemia, rIL-2 toxicity was similar to that seen in patients given rIL-2 without chemotherapy. Of 23 evaluable patients, the overall response rate (partial + complete response) was 46% with 2 complete responses. Only 3 patients showed major tumour regression during the rIL-2 phase of therapy, but these 3 patients included both complete responders and the 3 most durable responses (15, 16 and 24 months). We conclude that sequential 5-FU/leucovorin and rIL-2 can be given safely without major increases in toxicity over either therapy alone, and although nearly all responses seen are largely attributable to chemotherapy, a contribution of immunotherapy to the minority of patients achieving complete or durable responses cannot be ruled out.

Perinatal management of unanticipated congenital laryngeal atresia.

Unless ventilation is achieved within minutes of delivery, patients with congenital laryngeal atresia will not survive. There are 2 settings in which survival is more likely: a tracheotomy may be immediately performed in the delivery room, or a communication may exist between the airway and the pharynx, allowing for air exchange. In the latter case, there are no characteristic findings on prenatal sonography to suggest the diagnosis and to ensure that preparations for immediate tracheotomy are made. We describe a neonate with unanticipated laryngeal atresia and a high tracheoesophageal fistula. Ventilation was maintained first by face mask and then by esophageal intubation until a tracheotomy could be performed. This report provides detailed photodocumentation of the anomaly, discusses the mechanism of air exchange, reviews the relevant embryological development, and outlines a protocol for perinatal management of unanticipated laryngeal atresia.

Maximizing ovarian salvage when treating idiopathic adnexal torsion.

Idiopathic adnexal torsion threatens ovarian function. The best ways to maximize ovarian salvage have not been stressed widely. The authors describe 2 girls who illustrate the benefit of untwisting the torsion, limiting resection and performing bilateral gonadopexy to prevent both ipsilateral recurrence and contralateral occurrence.

Unsatisfactory experience with 'minimal intervention management' for gastroschisis.

PURPOSE: The authors report, for cautionary reasons, their trial with "minimal intervention management" for gastroschisis. After the successful innovative experience with this approach, which Bianchi and Dickson described, they utilized it in 4 consecutive patients. METHODS: In the delivery room a plastic bag was placed over the intestines, which rested in a dependent position to reduce edema. The stomach was decompressed and the patients kept warm. Intravenous fluid at a maintenance rate was given. After about 5 hours an attempt at closure was undertaken in the newborn intensive care unit without anesthesia. An assistant lifted the anterior abdominal wall by applying upward traction on the umbilical cord. Over about 25 minutes the intestines were placed in the coelom, which was closed with a single suture. RESULTS: The outcome was uncomplicated in the first of 4 consecutive patients. The second patient had abdominal compartment syndrome requiring a silo and subsequent resection and has chronic malabsorption 16 months later. The third had an enterocutaneous fistula at 5 weeks that required a small bowel resection. Bedside closure was abandoned in the final case because too much resistance was encountered. She underwent primary repair in the operating room and eventually died of sepsis with intestinal dysmotility. CONCLUSIONS: The "minimal intervention approach" can be effective in some patients who have gastroschisis. This experience suggests that selection criteria are needed before this method can be recommended.

Restorative proctocolectomy in children with ulcerative colitis utilizing rectal mucosectomy with or without diverting ileostomy.

BACKGROUND: Controversies continue concerning the best way to perform restorative proctectomy (RP) for ulcerative colitis (UC). Can rectal mucosectomy and hand-sewn ileoanal anastomosis (IAA) withstand the challenge posed by extrarectal dissection with a double-stapled technique and no mucosectomy? Is a diverting ileostomy mandatory after RP? METHODS: The authors describe 30 consecutive children with UC who underwent RP with rectal mucosectomy and hand-sewn IAA. The authors assess the results and compare the first 14 patients (group 1) treated with temporary diverting ileostomies with the next 16 consecutive patients (group 2) without diverting ileostomies. RESULTS: The average age (13.8 years in group 1 v 10.4 in group 2), duration of illness before resection (3.2 years in group 1 v 1.5 in group 2), and gender breakdown (10 of 14 were girls in group 1, 10 of 16 were girls in group 2) were similar between the two groups. Outcome was not significantly different between the two groups. Average bowel movements per 24-hour period was 5.5 in group 1 and 4.2 in Group 2. Occasional nighttime staining occurred in two patients in group 1 and five in group 2. No one suffered daytime staining in group 1, and one patient had occasional daytime staining in group 2. Average quality of life (on a scale of 0 to 5) as assessed by the patients or parents was 4.4 in group 1 and 4.9 in group 2. There were 10 total complications in group 1. One child required a permanent stoma for ileoanal separation. Two patients required reoperations for complications caused by the diverting ileostomy. The single instance of peritonitis was in group 1 caused by anastomotic leak after ileostomy closure. There were five total complications in group 2, of which, two required temporary stomas for ileoanal separations. CONCLUSIONS: RP with rectal mucosectomy and hand-sewn IAA in children with UC provides good functional results. Peritonitis did not occur in the absence of diversion. Eliminating routine diverting ileostomy avoids the considerable complications and morbidity from the stoma and its closure.

Pneumatosis intestinalis and portal vein gas after blunt abdominal trauma.

The authors report on a 2-year-old boy in whom pneumatosis intestinalis (PI) and portal vein gas (PVG) resulted from blunt abdominal trauma after child abuse. The presumed pathophysiology of PI and PVG is mechanical in this setting. Its presence establishes mucosal injury but does not necessarily imply intestinal necrosis.

Alterations in respiratory status: early signs of severe necrotizing enterocolitis.

BACKGROUND: Necrotizing enterocolitis (NEC) presents with well-recognized signs of intestinal inflammation such as bilious vomiting, bloody stool, abdominal distension, and tenderness. The authors observed otherwise unexplained changes in the respiratory status requiring increased respiratory support during the 24 hours before direct evidence of the intestinal disorder in patients with severe NEC. METHODS: To study this observation the authors collected data on 10 consecutive patients in whom NEC required an operation. RESULTS: Eight of these patients were recovering from respiratory distress syndrome (RDS). During the 24 hours before any direct sign of intestinal dysfunction seven of these eight had a respiratory prodrome needing increased respiratory support. Two patients required intubation and mechanical ventilation. Five needed increased supplemental oxygen. This prodrome included decreased oxygenation in seven, increased respiratory rate in five, and increased PCO2 in five, preceded by hypocarbia in three. CONCLUSIONS: These changes in the respiratory condition revisit the concept of high output respiratory failure. This term was introduced to describe the respiratory failure in adult patients who suffer acute intestinal illness. Increased metabolic demand from the intestinal illness was thought to stress the ability of the patient to delivery oxygen and remove carbon dioxide. The ability of the respiratory system to meet the increased demands is limited by the intestinal dysfunction itself (abdominal pain and distension). In our patients recovering from RDS the pulmonary reserve is inherently limited. Because they are carefully monitored, it is easy to retrieve evidence of respiratory changes that precede the direct signs of intestinal disease. In the earliest stages of intestinal illness before the direct signs of intestinal dysfunction, these patients often manifest unexplained signs of respiratory compensation and decompensation and require increased respiratory support. Regardless of the pathophysiology, these alterations in respiratory status represent an early warning sign of NEC.

The thymus. Pediatric surgical aspects.

Since the original description of thymic death in an infant 400 years ago, the thymus has been recognized as an important structure to practitioners caring for infants and children. The source of many cysts, masses, and tumors in the neck and mediastinum, the thymus gland merits the pediatric surgeon's attention. The thymus is clearly an important lymphoid organ, the removal of which may be therapeutic in MG, but congenital absence leads to profound cell-mediated immunodeficiency. The immunologic sequelae of its neonatal extirpation remains obscure. It is apparent that further research is needed to clarify the functional role of the thymus gland in the developing immune system. Until better elucidated, a conservative approach to neonatal thymectomy may be justified.

Toxic shock syndrome after pilonidal cystectomy. Report of a case.

Toxic shock syndrome is an uncommon disease associated with staphylococcal infections. Although most frequently reported in menstruating women and associated with tampon use, toxic shock syndrome has been described following many types of surgical procedures. In this report we describe a case of toxic shock syndrome occurring in a previously healthy young man after elective surgery for a pilonidal cyst.

Intestinal perforation 14 years after abdominal irradiation and chemotherapy for Wilms tumor.

A 3-year-old girl underwent left nephrectomy and removal of a tumor thrombus from the inferior vena cava and right atrium in 1978 because of Wilms tumor. Her treatment consisted of tumor bed irradiation (4,000 cGy) and chemotherapy with actinomycin D, vincristine, and doxorubicin. The patient underwent laparotomy 2 months after completion of abdominal irradiation to relieve intestinal obstruction. Fourteen years later, she underwent another laparotomy because of an "acute abdomen" and was found to have perforation of the jejunum in the radiation field. Histopathological examination of resected intestine revealed evidence of severe chronic radiation enteritis, A diagnosis of chronic radiation enteritis should be considered in patients who had received abdominal irradiation and who manifest abdominal pain/vomiting even several years after irradiation.