Early derivation operation can restore the pancreas histology and function in chronic obstructive pancreatitis in the cat.

BACKGROUND/AIMS: Obstruction of the main pancreatic duct leads to progressive obstructive and atrophying pancreatitis in the cat. The question remains whether "early" derivative procedures can halt the destructive process or not? METHODOLOGY: Twelve cats submitted to total obstruction of the main pancreatic duct developed chronic obstructive pancreatitis as documented by histopathology. After 5 weeks, five animals underwent a caudal pancreaticojejunostomy, the others served as controls. Pancreatic histopathology and ductography was conducted in both groups, as well as tests of endocrine and exocrine functioning. RESULTS: Three of the five cats that underwent a derivation operation died 3-5 weeks following the second operation mainly due to infection, but 2 cats could be followed-up for up to 52 weeks. The histological signs of inflammation and early fibrosis gradually disappeared and the pancreas returned to normal as assessed by histology, radiology and pancreatic function tests. In contrast, cats not submitted to the derivation procedure developed an atrophic chronic pancreatitis. CONCLUSIONS: A desobstructive operation, carried out 5 weeks after total obstruction of the main pancreatic duct in cats, can halt the progression of chronic obstructive pancreatitis and leads to restitution of the pancreas as assessed by histology, radiology and function tests.

Outcome after 'curative' surgery for carcinoma of the lower third of the rectum.

BACKGROUND: Controversy exists about the optimal surgical resection for lower third rectal carcinoma. The aim of this retrospective study was to analyse whether the type of surgery is a significant predictor of outcome after curative surgery alone. METHODS: Eighty-two consecutive patients underwent abdominoperineal rectum excision (APRE, 41 patients) or sphincter-saving operation (SSO, 41 patients) for adenocarcinoma at 3.5-7.5 cm from the anal margin. Cox proportional hazards technique with univariate and corrected (multivariate) analyses and the Kaplan-Meier life-table method were used to evaluate the data. RESULTS: Tumour wall penetration and lymph node involvement, but not the tumour level or the type of surgery, were found to be significant predictors of outcome. The local recurrence rate at 1, 2 and 5 years was 10, 22 and 26 per cent respectively after APRE, and 5, 13 and 21 per cent after SSO. The disease-free survival rate at 1, 2 and 5 years was 85, 67 and 58 per cent respectively after APRE, and 88, 78 and 62 per cent after SSO. CONCLUSION: Tumour-related factors are significant predictors of outcome. The type of surgery (APRE or SSO) did not seem to be a significant variable in this non-randomized study.

Clinical and manometric effects of combined external beam irradiation and brachytherapy for anal cancer.

This study evaluates anorectal function after combined tele- and brachytherapy for anal cancer using manometric measurements and a standardized questionnaire. Eight patients received 44 +/- 3 Gy external beam radiation followed by 20 +/- 4 Gy interstitial brachytherapy with iridium-192. Patients were examined 43 months (range 25-83) after therapy. Maximum anal basal pressure, squeeze pressure, and squeeze increment were significantly lower in patients (50, 163, 115 mmHg, respectively) than in control subjects (75, 285, 180 mmHg, respectively). Decreased anal elasticity was not observed. Anal prestretch "normalized" the contractility of the internal and external sphincter. Thus damage to the anal epithelium and hemorrhoidal cushions seems to be the most important mechanism explaining reduced anal closing pressure values. The rectoanal inhibitory reflex was observed in all but one patient. Rectal compliance was significantly reduced. Whereas all patients could retain a water filled rectal balloon until the maximum tolerable sensation level was reached, the rectal saline infusion test was strongly abnormal. Four patients were perfectly continent. Four patients were incontinent for gas and presented urgency in case of liquid stools with limited soiling occurring once weekly or less; three of them also had urgency for solids. Defecation frequency was increased but regular in most patients. Reduced anal closure together with reduced rectal compliance are at the basis of stool frequency, urgency and partial incontinence with occasional soiling. However, enough reserve sphincter function was maintained to preserve a clinically acceptable degree of anal continence in our patients.

Delayed remote abscess formation after spillage of infected gallstone during laparoscopic cholecystectomy: CT and US findings.

We report on a patient who presented an abdominal wall abscess two years after percutaneous cholecystectomy. The diagnosis of wall abscess caused by migrating gallstones could be made sonographically, whereas thin-section spiral CT failed to show the cause of the abscess: a non-calcified gallstone.

Surgery for gastric remnant carcinoma following Billroth II gastrectomy.

Between January 1983 and December 1995, 31 patients with gastric remnant carcinoma were operated on 6-45 years after a Billroth II resection for peptic ulcer disease. Total gastrectomy with Roux-en-Y reconstruction was performed in all cases. In 16 patients (52%) extended resection with removal of one or more adjacent organs was necessary for oncological reasons. In this elderly population with a high incidence of pre-operative risk factors (55%), most tumours were classified as stage III or IV (45%). Although total gastrectomy should be the surgical option of first choice for gastric remnant carcinoma, it resulted in high levels of post-operative mortality and morbidity (13% and 35%, respectively), especially in patients with stage III and IV tumours who underwent resection of an adjacent organ. Despite extended surgery, if necessary, the recurrence rate after 'curative' surgery is high (8/20 patients) and the cumulative disease-free 5-year survival rate was 48%. Detection of the tumour at an earlier stage not only limits the extent of resection and lowers the complication rate, but also improves survival.

Diagnostic accuracy of ultrasonography and surgical decision-making in patients referred for suspicion of appendicitis.

Two groups of patients referred for suspicion of acute appendicitis were compared to evaluate the accuracy of preoperative ultrasonography (US) and surgical decision-making. In one retrospective study, US was performed by trainees using a 3.5 MHz probe (219 patients). In the second prospective study, US was performed by a resident radiologist using a 5 MHz probe (144 patients). US accuracy rose from 65% to 90%, especially due to an improved negative predictive value (from 52% to 92%). The positive predictive value of US was 89%. The sonographically adjusted clinical decision to operate was correct in 85%. Thus, all patients with positive US should be operated. In contrast, clinical judgment must prevail in case of negative US findings in order to prevent surgical delay in about 11%. The negative laparotomy rate decreased by 5% only. This is probably due to the limited influence of negative US findings on surgical decision. US is to be recommended in all patients suspected for acute appendicitis when performed with an appropriate probe by an experienced ultrasonographist. However, it may not, on it self, reduce the rate of unnecessary operative procedures.

Controlled trial of metronidazole treatment for prevention of Crohn's recurrence after ileal resection.

BACKGROUND/AIMS: New lesions recur within weeks to months after ileal resection and ileocolonic anastomosis for Crohn's ileitis. A double-blind controlled trial was performed using metronidazole to prevent recurrence after ileal resection. METHODS: Sixty patients who underwent curative ileal resection and primary anastomosis were included within 1 week after surgery. Thirty patients received metronidazole (20 mg/kg body wt) daily for 3 months, and 30 patients received placebo. Treatment was then discontinued. Nine patients dropped out during treatment, 7 in the metronidazole group and 2 in the placebo arm. RESULTS: At 12 weeks, 21 of 28 patients (75%) in the placebo group had recurrent lesions in the neoterminal ileum as compared with 12 of 23 patients (52%) in the metronidazole group (P = 0.09). The incidence of severe endoscopic recurrence was significantly reduced by metronidazole (3 of 23; 13%) as compared with placebo (12 of 28; 43%; P = 0.02). Patients in the metronidazole arm had more frequent side effects. Metronidazole therapy statistically reduced the clinical recurrence rates at 1 year (4% vs. 25%). Reductions at 2 years (26% vs. 43%) and 3 years (30% vs. 50%) were not significant. CONCLUSIONS: Metronidazole therapy for 3 months decreases the severity of early recurrence of Crohn's disease in the neoterminal ileum after resection and seems to delay symptomatic recurrence.

Manometric evaluation of incontinent patients.

The relationship between symptoms and manometric data was studied in incontinent patients. Conventional anal manometry, the rectal saline infusion test and the balloon-retaining test were performed in 27 control subjects (M:8, F:19; mean age: 47 yr) and in 40 incontinent patients (M:5, F:35; mean age: 49 yr). The correlation coefficient between the clinical degree of continence/incontinence and the maximum anal basal tone, squeeze pressure and the pressure increment during squeeze was -0.74, -0.74 and -0.57, respectively. Discriminatory values of > 40 mmHg for maximum basal pressure and > 92 mmHg for squeeze pressure could identify continent patients with 96%, and incontinent patients with 88% accuracy. The uncontrollable evacuation of a balloon, progressively filled with water at 60 ml/min, before the maximum tolerable sensation level was reached, was related to the degree of clinical incontinence. Also the maximum retained volume and the interval between the first sensation volume and the maximum retained volume ("perceived rectal capacity") were related to the clinical symptoms: r = -0.72 and -0.71, respectively. The balloon-retaining test proved to be superior to the rectal saline infusion test for the determination of the severity of incontinence. The saline infusion test, however, was found to be more adequate to identify minor defects of continence. Thus, the manometric assessment of anorectal continence should consist of routine anal manometry, the rectal saline infusion test and the balloon-retaining test. Some important clinical implications are discussed.

Radical versus local surgical treatment for rectum carcinoma. A variety of options?

Local excision has to be classified as either indeterminate or non curative from a surgical oncological point of view. It seems to be an acceptable procedure for well differentiated, exophytic/polypoid pT1 lesions of less than 3 cm in diameter, providing the resection margins are tumour-free. For all other lesions radical surgery is to be preferred, unless the patient is unfit for major surgery or refuses an eventual permanent colostomy. Complete local excision followed by radiation therapy may become a valuable alternative for well differentiated, small pT2 lesions, but results are too preliminary. If radical surgery is indicated, the distal clearance margin (to be measured in the fresh, unstretched specimen) may be reduced to 2 cm if taking more distal tissue would jeopardise the anal sphincter. The mesorectum should be completely cleared in patients with low- or mid-rectal cancer. A benefit of excision of the internal iliac nodes in rectal cancer below the peritoneal reflection has not been demonstrated. Low anterior resection is the operation of choice for carcinoma with its lower border above 8 cm from the anal verge. Complete, restorative rectum excision with colo-anal anastomosis (CAA) is the option for tumours with their lower border between 6 and 8 cm from the anal verge if an acceptable margin of distal clearance is obtained. Rectal cancer with its distal border below 6 cm usually requires abdominoperineal rectum excision, although restorative proctectomy with CAA may be a valuable alternative in selected patients with small, well or moderately differentiated tumours.

Three cases of non-tumoural tight stenosis of the bifurcation of the hilar bile ducts.

Stenosis of the bifurcation of the hepatic bile duct is usually caused by malignant lesion. We report on three different causes of benign stenosis of the hepatic confluence with a similar radiological pattern on direct cholangiography. The first case is considered a spontaneous neuroma, the second a periductal abscess, and the third case a postoperative stricture Bismuth type 4.

Clinical value of whole-body positron emission tomography with [18F]fluorodeoxyglucose in recurrent colorectal cancer.

To assess the clinical value of whole-body positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) in recurrent colorectal cancer, 35 patients were studied: 15 had resectable liver metastases, one a resectable lung metastasis, eight resectable pelvic recurrence, eight a presacral mass with equivocal findings on imaging, and three increasing serum levels of carcinoembryonic antigen (CEA) without clinical or radiological signs of recurrent disease. PET affected management decisions in seven of 16 patients with metastatic disease. In one of eight patients with pelvic recurrence demonstrated by computed tomography (CT), PET detected unknown pulmonary metastases. In five of eight presacral masses with equivocal CT findings, PET was correct and unexpected distant metastases were detected in one of these patients. In two of three patients with increasing CEA levels and normal pelvic CT findings, pelvic recurrence was identified. Overall, whole-body PET affected management in 14 patients. PET is a valuable tool for staging local recurrence and metastatic disease.

Interleukin-6 and coagulation-fibrinolysis fluctuations after laparoscopic and conventional cholecystectomy.

This study assesses quantitatively the fluctuations of interleukin-6 (IL-6) and coagulation-fibrinolysis proteins in patients undergoing elective laparoscopic (n = 14) and conventional (n = 10) cholecystectomy. The patients in both groups were comparable in age and sex. Serum levels of interleukin-6, and plasma levels of fibrinogen, von Willebrand factor-antigen, tissue-type plasminogen activator-antigen, and plasminogen activator inhibitor-1 were determined for up to 48 h postoperatively. The postoperative changes of all parameters tested were comparable in both patient groups with a trend toward a higher interleukin-6 response at 8 h postincision (NS) and a trend toward a higher fibrinolysis inhibition (NS) after conventional cholecystectomy.

Imaging of polypoid endoluminal growing bile duct tumors.

We reviewed the radiological documents and protocols of 196 cases of bile duct tumors examined over a period of 12 years: 20 of them (10.2%) presented with a polypoid endoluminal growth. The aim of this study was to provide a better knowledge about the radiological features of this less frequent kind of tumor. In these 20 cases, the correct diagnosis of bile duct lesion was provided in 100% by E.R.C.P., P.T.C., U.S. as well as C.T., and in 42% by arteriography. The correct diagnosis of tumor was made by E.R.C.P. in 86%, by P.T.C. in 88%, by U.S. in 61%, by C.T. in 63%, and by arteriography in 25%. A correct diagnosis of tumor could be reached in all cases by combination of several examination techniques. The anatomopathological diagnosis was: bile duct adenocarcinoma (7 cases), adenocarcinoma of the ampulla of Vater (4), villous adenoma of Vater's ampulla (2), cystadenoma (1), cystadenocarcinoma (1), hepatocellular carcinoma (1), apudoma (1), and metastases (3).

Restorative proctocolectomy in elective and emergency cases of ulcerative colitis.

A consecutive series of restorative proctocolectomy for ulcerative colitis was reviewed to determine whether an emergency restorative proctocolectomy procedure leads to a higher morbidity, more especially anastomotic leakage. Severity of illness and nature of surgery were divided in two categories: (1) no acute disease and elective surgery (18 patients), (2) acute disease requiring emergency surgery either immediately or within one week of admission (12 patients). Morbidity after elective surgery was 27% and after emergency surgery 66% (P < 0.06). Pouch-anal leakage occurred in 11% and 41% respectively (P = 0.08). Five risk factors significantly influenced the leak rate including preoperative white blood cell count > 10,000/microliter (P < 0.02), urgent nature of surgery (P < 0.02), the combination of leucocytosis and urgent nature of surgery (P = 0.02), the combination of leucocytosis and preoperative corticosteroid dose equivalent to > or = 200 mg hydrocortisone/24 h (P = 0.006), postoperative pelvic haematoma (P < 0.05). In conclusion, restorative proctocolectomy is contraindicated in emergency circumstances, especially in patients with signs of sepsis on a high corticosteroid dose. To reduce operative risk and number of procedures required, patients with relapsing ulcerative colitis should be referred for restorative proctocolectomy while being in remission.

The trigger for rectal filling sensation.

In order to evaluate whether rectal volume, weight or pressure is the main trigger for rectal sensation, their respective values were determined at each of the rectal filling sensation thresholds (first, constant, urge, maximum) in 12 adult control subjects. The rectal balloon was filled at 60 ml/min in sitting position using water (twice), air and mercury consecutively. Pressure values were corrected for the elastic properties of the balloon, while the volume of inflated air was recalculated taking into account the prevalent rectal pressure and temperature. The results obtained using water, air and mercury demonstrated a constant relationship between a given rectal sensation level and the pressure recorded in the distending balloon, but not its volume or weight. Pressure values recorded at each sensation level were constant during repeated determinations of rectal sensation, the volume of rectal distension increased, probably because the rectum had already been dilated by previous testing. Balloon distension using air with the patient in the lateral position were found to be most practical for routine evaluation of rectal sensation. It is therefore concluded that any disturbance of rectal sensation will be reflected by changes in pressure and not by changes in the volume needed to produce a given sensation level. The location of the receptors involved has to be elucidated, but it seems that the pelvic floor can be excluded since the weight of the rectal contents was not related to sensation.

Duodenal leiomyosarcoma.

We present a case of duodenal leiomyosarcoma studied with computerized tomographic (CT) and magnetic resonance (MR) images. Some differential diagnostic remarks are mentioned. The topographic abilities of MR to determine the exact origin of the tumor are stressed. A stellar "scar", hypointense on T1 and hyperintense on T2-weighted images (1 Tesla) in association with gastrointestinal leiomyosarcoma was, at least to the best of our knowledge, never mentioned before in the literature.

Paraprosthetic fistula after aortobifemoral prosthetic reconstruction: treatment by autogenous saphenous venous replacement. A case report.

Paraprosthetic fistula is a rare but dramatic complication of aortofemoral prosthetic reconstruction. Conventional treatment consisting of removal of the prosthesis and extra-anatomical revascularization results in a high morbidity and mortality rate. The authors present a patient with a paraprosthetic fistula, who was successfully treated by excision of the graft and "in situ" replacement by autogenous saphenous vein.