Three-dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry.

AIM: Anal sphincter anatomy on two-dimensional endoanal -ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three-dimensional (3D) measurements yield a better correlation. METHOD: The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2-year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF-FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data. RESULTS: Sixty-one patients of median age 53 years (range 15-82) were evaluated. Thirty-two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF-FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact-sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF-FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores. CONCLUSION: Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.

Cholesterol nucleates rapidly from mixed micelles in the prairie dog.

Current theory suggests that the nucleation of cholesterol in human bile requires the aggregation and fusion of cholesterol-enriched phospholipid vesicles. This theory is based on observations which do not exclude the precipitation of cholesterol from mixed micelles. The present study examines the role of mixed micelles and vesicles in the formation of cholesterol monohydrate crystals in the prairie dog. The intermicellar bile salt concentration of prairie dog gallbladder bile was determined using equilibrium dialysis. Model bile equivalent to gallbladder bile from cholesterol-fed prairie dogs was used as dialysant yielding the intermicellar (dialysate) concentration of 9 mM. Cholesterol carriers in gallbladder bile from 11 cholesterol-fed animals were then separated by Sephacryl S200 gel filtration chromatography using eluant buffer containing the intermicellar bile salt concentration. Gel filtration chromatography of fresh bile demonstrated that 100% of cholesterol was carried in the mixed micellar fraction with no vesicles observed in any of the 11 animals. The gallbladder bile nucleation time was 2.0 +/- 0.3 days for the cholesterol-fed animals. Gel filtration chromatography immediately after nucleation again revealed a single mixed micellar peak. These data indicate that cholesterol is carried exclusively in and nucleates rapidly from mixed micelles in the cholesterol-fed prairie dog and that cholesterol-phospholipid vesicles are not required in this process.

Phase II evaluation of preoperative chemoradiation and postoperative adjuvant chemotherapy for squamous cell and adenocarcinoma of the esophagus.

PURPOSE: This phase II trial evaluated continuous-infusion cisplatin and fluorouracil (5-FU) with radiotherapy followed by esophagectomy. The objectives of this trial were to determine the complete pathologic response rate, survival rate, toxicity, pattern of failure, and feasibility of administering adjuvant chemotherapy in patients with resectable cancer of the esophagus treated with preoperative chemoradiation. PATIENTS AND METHODS: Patients were staged using computed tomography, endoscopic ultrasound, and laparoscopy. The preoperative treatment plan consisted of continuous intravenous infusion of cisplatin and 5-FU and a total dose of 44 Gy of radiation. Esophagogastrectomy was planned for approximately 4 weeks after the completion of chemoradiotherapy. Paclitaxel and cisplatin were administered as postoperative adjuvant therapy. RESULTS: Forty-two patients were enrolled onto the trial. Of the 39 patients who proceeded to surgery, 29 responded to preoperative treatment: 11 achieved pathologic complete response (CR) and 18 achieved a lower posttreatment stage. Five patients had no change in stage, whereas eight had progressive disease (four with distant metastases and four with increases in the T and N stages). At a median follow-up of 30.2 months, the median survival time has not been reached and the 2-year survival rate is 62%. The median survival of pathologic complete responders has not been reached, whereas the 2-year survival rate of this group is 91% compared with 51% in patients with complete tumor resection with residual tumor (P =.03). CONCLUSION: An excellent survival rate, comparable to that of our prior preoperative trial, was achieved with lower doses of preoperative cisplatin and 5-FU concurrent with radiotherapy.

Laparoscopic live donor nephrectomy.

A laparoscopic live-donor nephrectomy was performed on a 40-year-old man. The kidney was removed intact via a 9-cm infraumbilical midline incision. Warm ischemia was limited to less than 5 min. Immediately upon revascularization, the allograft produced urine. By the second postoperative day, the recipient's serum creatinine had decreased to 0.7 mg/dl. The donor's postoperative course was uneventful. He experienced minimal discomfort and was discharged home on the first postoperative day. We conclude that laparoscopic donor nephrectomy is feasible. It can be performed without apparent deleterious effects to either the donor or the recipient. The limited discomfort and rapid convalescence enjoyed by our patient indicate that this technique may prove to be advantageous.

The effect of erythromycin on motility of the duodenum, sphincter of Oddi, and gallbladder in the prairie dog.

BACKGROUND: Interdigestive motility of the stomach, duodenum, sphincter of Oddi, and gallbladder is mediated through the migrating myoelectric complex and the action of motilin. Erythromycin, a motilin agonist, has recently been studied as a gastrointestinal and biliary prokinetic agent. We hypothesized that erythromycin would increase interdigestive duodenal and sphincter of Oddi motility in a dose-dependent manner. METHODS: In 10 anesthetized prairie dogs we determined the motility responses of the duodenum, sphincter of Oddi, and gallbladder to erythromycin infusion during a three-log dosing regimen and correlated activity with serum concentrations of the drug. RESULTS: Erythromycin administered at 0.01 and 0.1 mg/kg had no effect on duodenal or sphincter motility. At 1.0 and 10 mg/kg, duodenal motility index increased by 451% +/- 114% and 1070% +/- 480%, respectively, when compared with baseline values, (p < 0.05). Sphincter of Oddi motility index increased by 122% +/- 38% and 323% +/- 99%, respectively, at these same doses of erythromycin (p < 0.05). Gallbladder pressure did not change significantly during erythromycin infusion. Erythromycin serum concentration at 1.0 mg/kg was 1.0 +/- 0.7 micrograms/ml. CONCLUSIONS: These data suggest that erythromycin stimulates interdigestive motility of the duodenum and sphincter of Oddi in a dose-dependent manner at otherwise subtherapeutic concentrations of the drug.

Laparoscopy for the acute abdomen in the postoperative urologic patient.

OBJECTIVES: Exploratory laparotomy offers the greatest diagnostic accuracy of intra-abdominal pathologic processes, but can be associated with significant morbidity. Laparoscopy provides diagnostic capabilities equivalent to that of open exploration, but with potentially less morbidity. We present 3 cases in which laparoscopy was used to diagnose and manage urologic patients with an acute abdomen in a postoperative period. METHODS: Three patients underwent laparoscopy between 1 and 14 days postoperatively for an acute abdomen (fever, elevated white blood cell count, and peritoneal signs). The initial procedures included a pubovaginal sling repair with fascia lata, endoscopic placement of a percutaneous gastrostomy tube, and a laparoscopic ureterolithotomy for a distal stone. RESULTS: In each of the 3 patients laparoscopy revealed misplacement or malfunction of a previously placed tube. In all cases, the patient was managed laparoscopically without the need for laparotomy. CONCLUSIONS: These cases demonstrate the feasibility of laparoscopy to provide diagnostic and therapeutic solutions to postoperative urologic patients presenting with an acute abdomen.

Results of salvage abdominoperineal resection for recurrent anal carcinoma following combined chemoradiation therapy.

Combined chemotherapy and radiation therapy is the standard treatment for epidermoid carcinoma of the anal canal. Failures are often not associated with distant recurrence and are therefore potentially amenable to salvage abdominoperineal resection. The aim of this study was to review our experience with abdominoperineal resection following failure of chemoradiation therapy for epidermoid carcinoma of the anus. Between 1980 and 1998, 17 patients underwent salvage abdominoperineal resection following failure of chemoradiation therapy. Four patients were excluded from survival analysis because resection was performed with palliative intent. Survival curves were based on the method of Kaplan and Meier, and univariate analysis of predictive variables was performed using the log-rank test. Twelve patients underwent abdominoperineal resection for persistent disease and five patients for recurrent disease. No operative deaths occurred, but local complications including perineal wound infection and wound breakdown was seen in 8 of 17 patients and 6 of 17 patients, respectively. Patients undergoing omental flap reconstruction (n = 3) or no pelvic reconstruction (n = 5) had a higher incidence of perineal breakdown compared to those undergoing muscle flap reconstruction (n = 9) (P <0.05). The median follow-up time for the patients operated on with curative intent was 53 months. The 5-year actuarial survival was 47%. Potential prognostic factors that were not found to have an impact on survival included margin status of resection, sphincter invasion, and degree of differentiation. Only pathologic tumor size greater than 5.0 cm (P <0.001) and age over 55 years (P <0.05) adversely affected survival. Selected patients with recurrent or persistent anal carcinoma following chemoradiation therapy can be offered salvage abdominoperineal resection. This operation is associated with a high incidence of local wound complications, and muscle flap reconstruction should be considered when possible. Prolonged survival can be achieved in some patients following salvage resection for epidermoid carcinoma of the anal canal.

Adenocarcinoma of the duodenum: factors influencing long-term survival.

This single-institution retrospective analysis reviews the management and outcome of patients with surgically treated adenocarcinoma of the duodenum. Between February 1984 and August 1996, fifty-five patients with adenocarcinoma of the duodenum underwent surgery at The Johns Hopkins Hospital. Univariate analysis was performed to identify possible prognostic indicators. Curative resection was performed in 48 patients (87%): 35 of these patients (73%) underwent a pancreaticoduodenectomy (PD), whereas 27% (n = 13) underwent a pancreas-sparing duodenectomy (PSD). Patients undergoing PD were comparable to those undergoing PSD with respect to demographic factors, presenting symptoms, and tumor pathology. The remaining 13% of patients (n = 7) were deemed unresectable at the time of surgery and underwent biopsy and/or palliative bypass. PD was associated with an increase in postoperative complications when compared to PSD (57% vs. 30%), but this difference was not statistically significant. One perioperative death occurred following PD (mortality 2.9%). The overall 5-year survival rate for the 48 patients undergoing potentially curative resection was 53%. Negative resection margins (P <0.001), PD (P <0.005), and tumors in the first and second portions of the duodenum (P <0.05) were favorable predictors of long-term survival by univariate analysis. Nodal status, tumor diameter, degree of differentiation, and the use of adjuvant chemoradiation therapy did not influence survival. These data support an aggressive role for resection in patients with adenocarcinoma of the dueodenum

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Nitric oxide inhibits resting sphincter of Oddi activity.

The sphincter of Oddi has basal myogenic phasic activity that is modulated by neural and hormonal pathways. Stimulatory innervation to this organ is cholinergic, whereas the inhibitory pathways are unknown. Nitric oxide (NO), generated from L-arginine, relaxes gastrointestinal smooth muscle in vitro. We, therefore, hypothesized that resting sphincter of Oddi and duodenal motilities are regulated by a NO-mediated inhibitory pathway. In 23 anesthetized prairie dogs, systemic blood pressure and sphincter of Oddi and duodenal motilities were monitored during systemic infusion of N omega-nitro-L-arginine methyl ester (L-NAME), an inhibitor of nitric oxide synthase. L-NAME was infused alone and simultaneously with excess D- and L-arginine. L-NAME alone and L-NAME with D-arginine produced hypertension and increased sphincter of Oddi and duodenal motilities. L-arginine blocked these increases, suggesting that baseline sphincter of Oddi and duodenal motility regulation involves the generation of NO from L-arginine. We conclude that baseline sphincter of Oddi phasic activity is regulated by cholinergic stimulatory and NO-mediated inhibitory neural pathways.

Pancreaticoduodenectomy for benign disease.

BACKGROUND: Surgeons are often called upon to perform pancreaticoduodenectomy for either suspicion of malignancy or symptoms due to benign disease. Perioperative morbidity and mortality following pancreaticoduodenectomy have decreased markedly over the last 2 decades. In response, many surgical centers advocate expanding the indications for pancreaticoduodenectomy to include lesions other than periampullary carcinoma. PATIENTS AND METHODS: A retrospective review of medical records for 108 patients undergoing pancreaticoduodenectomy for benign disease at The Johns Hopkins Medical Institutions over 100 months was completed. The subset of patients with a histopathologic diagnosis of chronic pancreatitis was identified and compared with patients undergoing pancreaticoduodenectomy for other benign conditions. RESULTS: The mortality rate for the present series was less than 1%. Perioperative complications, the majority of which were self-limited, occurred in 51% of patients. The most common complication was delayed gastric emptying. Pancreatic anastamotic leak occurred in 18% of patients and developed significantly more frequently in patients with benign diseases other than chronic pancreatitis (31% versus 8%, P < 0.05). CONCLUSION: Among appropriately selected patients, the rates of perioperative mortality and serious morbidity are low, and concerns about mortality and morbidity should not prevent an aggressive approach to surgical resection in patients with benign disease.

Use of an implantable marker for rapid intraoperative localization of nonpalpable tumors: a pilot study in a swine colorectal model.

BACKGROUND: This study aimed to establish the accuracy and reproducibility of localization of intraluminal markers by laparoscopic and open techniques in a swine colorectal model, using a prototype for a novel wireless system. METHODS: A prototype marker was placed into the colon of an adult pig. The surgeon was blinded to placement and localized the marker using a detection probe (3 surgeons/10 trials/2-D and 3-D systems). RESULTS: Each surgeon was able to accurately locate the marker within 28.7 +/- 20.6 (LAP) and 18.3 +/- 6.7 (OPEN) sec ( p = 0.013). There were no significant differences between surgeons in localization times, regardless of experience. A 3-D interface made no difference in accuracy or time (LAP = 35 vs 28 seconds; p = NS [not significant]). CONCLUSIONS: This study demonstrates the use of a novel system for intraoperative identification of nonpalpable lesions. This technology may have important implications in the surgical management of nonpalpable tumors and in applications of interventional radiology.

T-lymphocytes in venous blood and lymph from the thoracic duct and right lymphatic duct of normal dogs.

The WBC and per cent polymorphonuclear cells in blood increased significantly during the approximately 3 hours of the experiments. The number of lymphocytes did not change significantly. Corresponding cellular components in RD and TD lymph were not significantly different. The per cent of T-rosettes in FVB was more than three times that in RD and TD lymph (33/10). T-rosettes were predominantly formed by medium lymphocytes (68-82%) in both blood and lymph.

All that coughs is not (respiratory) allergy.

A 54-year-old nun was referred to a respiratory specialist for cough, which was subsequently found to be the prodrome of Creutzfeldt-Jakob disease. It is tempting for any specialist to assume whoever enters his office has the disease of his specialty. Potential pitfalls in that sort of diagnostic judgment are displayed in this report.

Parietaria: an unrecognized cause of respiratory allergy in the United States.

Parietaria is considered the ragweed of the Old World. There are no prior reports of respiratory allergy due to Parietaria (P.) in North America. Following the identification of a lead case, 100 grass-sensitive patients who suffered from seasonal respiratory allergy were skin tested to P. judaica (P.j.) and P. officinalis (P.o.). Eight percent reacted. Five of 42 females (12%) and three of 58 males (5%) demonstrated skin test reactivity to extracts of P.j. and P.o. All reacted to P.j. There was a greater incidence (P less than .05) and reaction size (P less than .05) in females.