Slippage after adjustable gastric banding according to the pars flaccida and the perigastric approach.

OBJECTIVE: To evaluate laparoscopic adjustable gastric banding and the 'pars flaccida' techniques for treating morbidly obese patients. SUBJECTS AND METHODS: Between May 1999 and July 2002, 64 patients underwent laparoscopic adjustable gastric banding. The 'perigastric' technique was performed in the first 31 patients. From September 2000 the band was positioned according to the 'pars flaccida' technique in the remaining 33 patients. The patients were divided into three groups: group 1 - 'perigastric' technique using Lap-Band size 9.75 and 10 cm (31 patients); group 2 - 'pars flaccida' technique using Lap-Band size 10 cm (12 patients), and group 3 - 'pars flaccida' technique using the Swedish band (21 patients). There were 58 females and 6 males with a mean age of 36.6 years (range 17-56). The preoperative mean body mass index was 46.2 kg/m(2). RESULTS: Band slippage occurred in 10/31 patients (32.2%) of group 1, 3/12 patients (25%) of group 2 and none in group 3 patients (p < 0.01). CONCLUSION: The 'pars flaccida' technique significantly reduces the incidence of postoperative slippage after gastric banding. This complication is further reduced in the Swedish band group. Furthermore, we do not recommend using the 10-cm Lap-Band in the 'pars flaccida' technique.

Laparoscopic splenectomy for hematological disorders.

OBJECTIVES: The aim of this prospective study was to evaluate the safety and feasibility of laparoscopic splenectomy (LS) in patients with hematological disorders of the spleen. SUBJECTS AND METHODS: Between 1999 and 2001, 15 patients (11 female and 4 male), with a mean age of 30 years, underwent LS after preoperative evaluation. If difficulties were encountered in LS, one trocar site incision was enlarged to 7-8 cm to engage the left hand for hand-assisted laparoscopic splenectomy (HALS) and the procedure was completed. Various parameters were reported, including spleen size as assessed by ultrasound scan, postoperative mortality and morbidity rates, accessory spleen removal, conversion rate, operative times and length of hospital stay. LS was successfully completed in 9 patients (60%) and HALS was performed in 4 patients (26.6%). Two patients required conversion to open splenectomy. RESULTS: The mean operative time was 209 min and the mean hospital stay was 8.1 days. The hospital stay was significantly longer among HALS patients than LS patients. The mean age of patients and splenic size were associated with a significantly higher conversion rate. No deaths were attributed to the procedure. Complications occurred in 2 of 15 patients. Accessory spleens were identified in 2 patients. CONCLUSIONS: LS is both a safe and feasible procedure, but it requires great technical care to avoid serious complications.

Pain during mammography: impact of breast pathologies and demographic factors.

OBJECTIVES: The aim of this study was to systematically assess the pain experienced by patients undergoing mammography for various clinical presentations. SUBJECTS AND METHODS: Two hundred and twenty-five patients aged 25-85 years (45.43 +/- 8.25 years) presenting for mammography were included in the study. Presenting symptoms and clinical diagnosis were provided by the referring physicians and demographic information was obtained from self-reported questionnaires. Mammography results were recorded by the radiologist. Two different but reliable and valid measures of pain--Visual Analog Scale (VAS) and Pain/Discomfort Rating Scale (DRS)--were used to assess pain during mammography and data were statistically analyzed to examine the possible predictors of pain. RESULTS: Forty-nine percent of the patients reported pain during mammography when cut-off level of VAS score was 40; however, when the cut-off level was raised to 60 (considering the preexisting pain as presenting symptom in some patients) only 23% reported pain. With DRS, 7% reported pain, 27% discomfort and 66% neither pain nor discomfort. Biserial correlation between the VAS and DRS scores suggested strong positive agreement between the two measures of pain (r = 0.56, d.f. = 90, p < 0.01). Patients presenting with coexisting breast lumps and preexisting breast pain and those diagnosed with inflammatory conditions of the breast and fibrocystic changes experienced more pain during mammography. CONCLUSION: Preexisting breast pathologies and demographic factors such as age and educational level of the patient were important in reporting pain during mammography. This finding indicates that proper assessment of pain using standard measures and its association with breast pathologies and demographic factors is important for planning pain management in women undergoing mammography.

Expression of E-cadherin in human colorectal cancer.

AIM: To investigate the expression of E-cadherin, a calcium-dependent cell-cell adhesion molecule in colorectal carcinoma. Antibodies to E-Cadherin were used to establish the association of their expression with the clinicopathological characteristics of this disease using immunohistochemical methods. METHODS: Immunohistochemical analysis for E-cadherin was carried out in formalin-fixed, paraffin-embedded sections of neoplastic colorectal tissues and non-neoplastic ones adjacent to the lesion from 49 patients who underwent surgery, by the standard peroxidase-antiperoxidase method. Expression of this antigen in normal and malignant epithelium and stromal cells was compared. RESULTS: Both neoplastic and normal tissues showed expression of E-cadherin. There was, however, higher expression of E-cadherin in epithelial cells in both tumour and normal tissues than stromal cells. The percentage of expression in epithelial cells of well-differentiated tumours was significantly higher than moderately differentiated tumours. Loss of normal membranous expression and the presence of cytoplasmic and mixed staining were found frequently in tumour tissues (p = 0.004). This loss of membranous expression, however, did not correlate with Duke's staging, tumour grade, sex, size or site of the tumour. CONCLUSION: This study suggests that the lower expression of E-cadherin in less differentiated tumours may explain their aggressive nature, although loss of membranous expression was not significantly correlated to Duke's staging, tumour grade, sex, size and site of tumour.

Effectiveness of laparoscopic fundoplication for gastro-oesophageal reflux.

BACKGROUND: Gastro-oesophageal reflux (GERD) is a common condition. Many patients respond to conservative therapy. Severe symptomatic cases and those who fail medical treatment are referred to surgery. The long-term results of open fundoplication surgery have been good with a more than 90% response after 10 years of follow-up. The introduction of laparoscopic fundoplication achieved the same results with shorter hospital stay, a better cosmetic result and less cost to the health care providers. PATIENTS AND METHODS: 74 patients who failed medical treatment for GERD were treated by laparoscopic fundoplication. The Toupet procedure was performed in 66 of these patients, the others patients had a Nissen-type fundoplication. The patients were followed up for a mean period (+/- SD) of 14.8 +/- 8.8 months (range 3-33 months). RESULTS: Most of the patients were males (n = 65). The mean age (+/- SD) of all the patients was 36.1 +/- 9.5 years (range 17-60 years). The majority (93.8%) reported disappearance of symptoms and are not using any antireflux medications. Five patients (6.7%) are considered failures of the procedures. Of these, three patients developed recurrence of reflux symptoms during the follow-up period. The other two patients developed complications, i.e. gas bloat, persistent vomiting and dysphagia which warranted taking down the wraps laparoscopically. Two patients developed a small incisional hernia at the site of the 10 mm port. The mean of hospital stay (+/- SD) was 3.1 +/- 1.3 days (range 1-7 days). CONCLUSION: Laparoscopic fundoplication is safe and effectively relieves reflux symptoms in patients who fail medical treatment.

Basidiobolus ranarum as an etiologic agent of gastrointestinal zygomycosis.

Basidiobolus ranarum is a known cause of subcutaneous zygomycosis. Recently, its etiologic role in gastrointestinal infections has been increasingly recognized. While the clinical presentation of the subcutaneous disease is quite characteristic and the disease is easy to diagnose, gastrointestinal basidiobolomycosis poses diagnostic difficulties; its clinical presentation is nonspecific, there are no identifiable risk factors, and all age groups are susceptible. The case of gastrointestinal basidiobolomycosis described in the present report occurred in a 41-year-old Indian male who had a history of repair of a left inguinal hernia 2 years earlier and who is native to the southern part of India, where the subcutaneous form of the disease is indigenous. Diagnosis is based on the isolation of B. ranarum from cultures of urine and demonstration of broad, sparsely septate hyphal elements in histopathologic sections of the colon, with characteristic eosinophilic infiltration and the Splendore-Hoeppli phenomenon. The titers of both immunoglobulin G (IgG) and IgM antibodies to locally produced antigen of the fungus were elevated. The patient failed to respond to 8 weeks of amphotericin B therapy, and the isolate was later found to be resistant to amphotericin B, itraconazole, fluconazole, and flucytosine but susceptible to ketoconazole and miconazole. One other noteworthy feature of the fungus was that the patient's serum showed raised levels of Th2-type cytokines (interleukins 4 and 10) and tumor necrosis factor alpha. The present report underscores the need to consider gastrointestinal basidiobolomycosis in the differential diagnosis of inflammatory bowel diseases and suggests that, perhaps, more time should be invested in developing standardized serologic reagents that can be used as part of a less invasive means of diagnosis of the disease.

Thioacetamide toxicity and the spleen: histological and biochemical analysis.

Exposure to thioacetamide is associated with the development of liver cirrhosis in experimental animals. In addition to liver, thioacetamide toxicity has been observed in other organs. In this study, the toxic effect of thioacetamide on the spleen was investigated at 0, 4, 8 and 12 weeks post-treatment durations. The level of tissue copper and selenium increased until the eighth week when a significant drop was observed. The zinc level was also increased but returned back to normal by week 8, thereafter it showed further increase. Calculation of the copper/zinc ratio showed an increase, but, recovered and returned to normal value by week 12. The level of manganese fluctuated until the eighth week. It then increased rapidly. Histological studies of the spleen tissue showed a significant increase in extramedullary haematopoiesis in the red pulp region and marked hyperplasia in the marginal zone and follicles. The results of this study, demonstrate an intimate association between trace element levels and spleen pathology, as observed in studies of other organs.

Would measurement of C-reactive protein reduce the rate of negative exploration for acute appendicitis?

BACKGROUND: Appendicectomy for suspected acute appendicitis is a common procedure. The rate of normal appendices unnecessarily removed remains high (15-30%) despite several techniques and investigations used to improve the diagnostic accuracy. Many studies investigated the role of raised C-reactive protein in improving the diagnosis of acute appendicitis, but with conflicting results. This study emphasies the impact of a normal (rather than raised) serum C-reactive protein in reducing the rate of negative explorations. METHODS: In a double blind study, blood for the measurement of serum C-reactive protein (CRP) was collected pre-operatively from 78 patients just before going to the operating room for appendicectomy. The histopathology of the 78 appendices were grouped into positive (acute appendicitis) and negative (normal appendix). White blood count (WBC), CRP and the histopathology findings were correlated. RESULTS: In patients with histopathologically proven acute appendicitis both the WBC count and serum CRP level were significantly raised (P = 0.025 and P < 0.000,1 respectively). Serum CRP level was normal in 13 out of 15 negative explorations (normal appendix on histopathology). The specificity and sensitivity of serum CRP was 86.6% and 93.6%, respectively. CONCLUSION: A normal pre-operative serum CRP measurement in patients with suspected acute appendicitis is most likely associated with a normal appendix. Deferring surgery in this group of patients would probably reduce the rate of unnecessary appendicectomies.

Laparoscopic closure of perforated duodenal ulcer.

BACKGROUND: Medical treatment of peptic ulcer is highly successful, and the eradication of Helicobacter pylori (H. pylori) reduces ulcer recurrence. However, the incidence of perforated duodenal ulcer and its associated mortality have not been reduced by modern methods of therapy. Laparoscopic simple closure and omental plug by suturing, fibrin glue, and stapler have been successful. METHODS: Over a 1-year period (1996-97), 21 patients with perforated duodenal ulcer were operated on in our hospital by laparoscopic simple closure and omental patch. The mean age was 36.4 +/- 11.8 years (range, 18-61). Twenty patients were male (93.7%). The mean duration of pain was 9.1 +/- 11.7 hs (range, 2-48). Three patients had a previous history of duodenal ulcer (14.3%), and another three (14.3%) patients had a history of nonsteroidal antiinflammatory drug (NSAID) intake. Erect chest radiograph showed that 19 patients had air under the diaphragm (90.5%). Sixteen patients (76.2%) had frank pus in the abdomen, and five patients had a minimal peritoneal reaction (23.8%). RESULTS: The mean operative time was 71.6 +/- 24.6 mins (range, 40-120), and the mean hospital stay was 5.2 +/- 1.6 days (range, 3-9). The mean time to resume oral fluids was 3.1 +/- 0.8 days (range, 2-4). Only one patient was reoperated due to leakage identified by gastrographin swallow. CONCLUSIONS: This procedure is safe and efficient; however, further study of its long-term effectiveness and comparability to existing therapy is still needed.

Emotional distress in women presenting for breast imaging.

BACKGROUND: The aim of this study was to assess anxiety and depression in a sample of women presenting for imaging of the breast following a clinical referral. Emotional distress in the women was also assessed in relation to demographic factors, reason for referral, presence of breast symptoms, type of imaging procedure performed, and self-reported pain and discomfort during imaging. PATIENTS AND METHODS: The study comprised 167 patients. The Hopkins Symptom Checklist-25 (HSCL-25) and a discomfort rating scale were used to assess emotional distress and discomfort or pain experienced during the imaging. RESULTS: While less than 10% of all subjects scored above psychiatric cut-off points for anxiety and depression, 25% and 20% reported significant distress associated with anxiety and depression symptoms, respectively. Education alone was associated with higher anxiety scores, while the presence of breast symptoms significantly increased depression scores and reports of specific nonsomatic symptoms of depression. Higher anxiety and depression scores were also associated with pain experienced during the imaging procedure. CONCLUSION: Emotional distress may negatively impact womenâs experience of breast imaging. Screening for emotional distress is important within the context of breast imaging.

Neurogenic control of the ovine gallbladder: ultrastructural and functional study.

The purpose of this study was to investigate the ultrastructure of the local nerve supply of ovine gallbladders as well as the functional characteristics of inhibitory nerves. We used electron microscopy of thin sections of ovine gallbladders and in vitro isometric tension recording using gallbladder strips. Specifically, we measured contractile and inhibitory responses induced by transmural electrical field stimulation (EFS). We found a ganglionated plexus with intramural nerve cells and interconnecting axons. Clear and large dense-core vesicles colocalized in axons close to smooth muscle cells. EFS elicited gallbladder contractions which were converted to relaxation after atropine. EFS-induced relaxation was reduced by the nitric oxide (NO) synthase inhibitor, L-NOARG and blocked by propranolol and/or tetrodotoxin. In conclusion, enteric ganglia and neurones with synaptic vesicles (clear and dense core) were detected close to smooth muscle bundles. Neural inhibition of gallbladder contraction was mediated by beta-adrenoceptors coupled to NO generation.

The anaesthetist and the antiphospholipid syndrome.

Antiphospholipid syndrome is a paradoxical disease state with in vitro prolongation of activated partial thromboplastin time and a strong predilection for in vivo thrombosis. The syndrome can be associated with systemic lupus erythematosus or lupus-like diseases or may be primary, presenting with thrombotic phenomena in young patients with no risk factors for thrombosis. We present two cases seen in two different settings in the hospital.

Gallbladder motility in laparoscopic cholecystectomy specimens.

In vitro contractility of human and sheep gallbladders to cholinergic stimulation with carbachol and the effects of indomethacin on abnormal rhythmic activity were studied. Once hundred and thirty-two gallbladders were obtained at laparoscopic cholecystectomy, 38 from patients with acute and 94 with chronic cholecystitis. In addition, 27 specimens of sheep gallbladders served as controls. Fundal preparations from patients with cholecystitis exhibit hypocontractility: no response in 72% or in the remainder a significantly reduced maximal contraction to carbachol. Regionally graded motor responses favoring propulsion of bile were abnormal in 44% of the gallbladders studied with more forceful contractions of the duct compared to the fundus. Abnormal early rhythmic activity (ERA) of fundal preparations was only detected in gallbladders of patients (in 33%) but never in controls. In 80% of these, ERA was blocked or reduced by indomethacin which can be interpreted as evidence for a prostaglandin-mediated inflammatory response. We conclude that gallbladder motility in cholelithiasis secondary to muscarinic stimulation is reduced and regionally graded motor responses favoring bile expulsion are impaired. ERA can be blocked by indomethacin.

Metabolic effects of troglitazone on fat-induced insulin resistance in the rat.

Troglitazone is a new orally active hypoglycemic agent that has been shown to ameliorate insulin resistance and hyperinsulinemia in both diabetic animal models and non-insulin-dependent diabetes mellitus (NIDDM) subjects. To determine whether this drug could prevent the development of diet-induced insulin resistance and related abnormalities, we studied its effect on insulin resistance induced by high-fat feeding in rats. Normal male Sprague-Dawley rats were fed a high-fat diet for 3 weeks with and without troglitazone as a food mixture (0.2%) or were fed normal chow. In vivo insulin action was measured using a euglycemic-hyperinsulinemic clamp at two different insulin infusion rates, 4 (submaximal stimulation) and 40 (maximal stimulation) mU/kg/min. Fat feeding markedly reduced the submaximal glucose disposal rate ([GDR], 26.4 +/- 1.3 v 37.5 +/- 1.4 mg/kg/min, P < .01) and maximal GDR (55.9 +/- 1.3 v 64.5 +/- 1.3 mg/kg/min, P < 0.5), reduced the suppressibility of submaximal hepatic glucose production ([HGP], 3.2 +/- 0.9 v 1.5 +/- 0.5 mg/kg/min, P < .05), and resulted in hyperlipidemia. Troglitazone treatment did not affect any of these parameters. Insulin resistance induced by fat feeding is the first experimental model in which troglitazone failed to correct or partially correct the insulin resistance.

Kinetics of insulin action in vivo. Identification of rate-limiting steps.

To examine the kinetic steps in insulin's in vivo action, we have assessed the temporal relationship between arterial insulin, interstitial insulin, glucose disposal rate (GDR), and insulin receptor kinase (IRK) activity in muscle and between portal insulin, hepatic glucose production (HGP), and IRK activity in liver. Interstitial insulin, as measured by lymph-insulin concentration (muscle only), and IRK activity were used as independent methods to determine the arrival of insulin at its tissue site of action. Euglycemic clamps were conducted in seven mongrel dogs and consisted of an activation phase with a venous insulin infusion (7.2 nmol.kg-1.min-1, 100 min) and a deactivation phase. Liver and muscle biopsies were taken to assess IRK activity. Arterial, portal, and lymph insulin rose to 636 +/- 12, 558 +/- 18, and 402 +/- 24 pmol/l, respectively. GDR increased from 13.9 +/- 0.6 to 41.7 +/- 2.8, and HGP declined from 14.4 +/- 0.6 to 1.1 +/- 0.6 mumol.kg-1.min-1. Muscle and liver IRK activity increased significantly from 5.9 +/- 0.9 to 14.6 +/- 0.6 and 5.5 +/- 0.7 to 23.7 +/- 1.9 fmol P/fmol insulin receptor (IR), respectively. The time to half-maximum response (t1/2a) for stimulation of GDR (19.8 +/- 4.8 min) and suppression of HGP (21.5 +/- 3.7 min) were similar. The t1/2a for stimulation of GDR, muscle IRK, and rise in lymph insulin were not significantly different from one another and were all markedly greater than that for the approach to steady state of arterial insulin (2.3 +/- 1.2 min, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic effects of troglitazone on fructose-induced insulin resistance in the rat.

Troglitazone is a new orally active hypoglycemic agent that has been shown to reduce insulin resistance and hyperinsulinemia in both diabetic animal models and non-insulin-dependent diabetes mellitus (NIDDM) subjects. To determine whether this drug could prevent the development of fructose-induced insulin resistance and related abnormalities, we studied the effects of troglitazone on the insulin resistance induced by fructose feeding in rats. Normal male Sprague-Dawley rats were fed a high-fructose diet for 3 weeks with and without troglitazone as a food admixture (0.2%) or were fed normal chow to serve as a control group. In vivo insulin resistnace was measured by the euglycemic hyperinsulinemic clamp technique at two different insulin infusion rates, 29 (submaximal stimulation) and 290 (maximal stimulation) pmol.kg-1.min-1. Fructose feeding markedly reduced submaximal glucose disposal rate (GDR) (113.8 +/- 8.3 vs. 176.0 +/- 5.6 mumol.kg-1.min-1, P < 0.05) and maximal GDR (255.9 +/- 5.6 vs. 313.6 +/- 10.5 mumol.kg-1.min-1, P < 0.05), reduced the suppressibility of submaximal hepatic glucose production (HGP; 45.5 +/- 5.0 vs. 11.7 +/- 5.0 mumol.kg-1.min-1, P < 0.05), and resulted in hypertriglyceridemia and hypertension. Troglitazone treatment completely restored the GDR (submaximal 158.2 +/- 5.6, maximal 305.3 +/- 6.1 mumol.kg-1.min-1) and submaximal HGP (9.4 +/- 2.8 mumol.kg-1.min-1) to control levels and also normalized the elevated plasma triglyceride concentration and systolic blood pressure levels in fructose-fed rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Embolization in the palliation of complications of inoperable primary pancreatic neoplasms.

Primary pancreatic neoplasm typically presents at an advanced stage where surgical management may not be feasible. These patients are often symptomatic due to biliary obstruction but problems may also include gastrointestinal bleeding and endocrinological complications. We describe two cases illustrating the use of palliative embolization in the control of biochemical and haemorrhagic complications of primary pancreatic neoplasm. In one case, massive gastrointestinal bleeding from an inoperable primary pancreatic carcinoma was controlled by two embolization procedures to produce devascularization of the primary lesion. In a second case, life-threatening hypercalcaemia was thought to be due to secretion of a parathormone-like material from an inoperable islet cell tumour. There was no evidence of liver metastases and the pancreatic mass was embolized, following which serum calcium was reduced to near normal levels with considerable clinical improvement. We conclude that there is a role for embolization of inoperable primary pancreatic neoplasm in the palliation of biochemical or haemorrhagic complications of these tumours.