The "stamp method": a new treatment for perforated peptic ulcer?

BACKGROUND: The aim of this study was to develop a simple method for closure of a perforated peptic ulcer, making it more accessible for laparoscopic surgery. METHODS: An experimental pilot study was performed using five male Wistar rats. The perforation was closed by a bioabsorbable patch made of lactide-glycolid-caprolactone fixed with glue onto the outside of the stomach. RESULTS: Postoperatively, there were no signs of leakage or other complications. Histologically, there were no signs of inflammation on the inside of the stomach, and there was a 50% reduction of the perforation each successive postoperative week. No adverse reactions because of the degradable material or glue were observed. CONCLUSIONS: Treatment of a perforated peptic ulcer by placing a patch of biodegradable material like a "stamp" on the outside of the stomach is a feasible option.

A hyaluronan-based nerve guide: in vitro cytotoxicity, subcutaneous tissue reactions, and degradation in the rat.

We investigated possible cytotoxic effects, biocompatibility, and degradation of a hyaluronan-based conduit for peripheral nerve repair. We subjected the conduits to an in vitro fibroblast cytotoxicity test and concluded that the conduits were not cytotoxic. Subsequently, we implanted the conduits subcutaneously in rats, in order to investigate tissue reactions and biodegradation. Initially, a fibrin matrix was formed around the material, while the surroundings were relatively quiet. Macrophages (MØ) migrated to the conduits and formed giant cells next to the material after 5 days. The maximum presence of MØ was found after 3-6 weeks. The appearance of MHC class II cells showed a similar pattern. Highest numbers of giants reached a maximum after 6-12 weeks. Angiogenesis was started in the surroundings of the hyaluronan-based conduit within a few days. Massive ingrowth of blood vessels into the biomaterial was found after 6 weeks as well as cellular ingrowth into the lumen of the tube. At that time the tubular structure of the conduit was lost and loose biomaterial fibers were observed. The results show that a hyaluronan-based conduit is not cytotoxic and shows good biocompatibility. Such a conduit may be suitable as a guide in peripheral nerve repair.

Functional nerve recovery after bridging a 15 mm gap in rat sciatic nerve with a biodegradable nerve guide.

Recovery of nerve function was evaluated after bridging a 15 mm sciatic nerve gap in 51 rats with a biodegradable poly(DL-lactide-epsilon-caprolactone) nerve guide. Recovery of function was investigated by analysing the footprints, by analysing video recordings of gait, by electrically eliciting the withdrawal reflex, by nerve conduction velocity and by electromyography (EMG). Sensory nerve function recovered as measured by electrostimulation. Motor nerve function partly recovered but electromyograms remained abnormal throughout the study. We conclude that functional reinnervation by regenerating axons occurs after bridging a 15 mm nerve gap with a biodegradable poly(DL-lactide-epsilon-caprolactone) nerve guide, but the walking patterns remain abnormal. Video analysis is a useful tool to record and analyse the walking patterns of rats. Further studies are necessary to investigate the possibility of obtaining selective reinnervation of specific muscles.

Biodegradable p(DLLA-epsilon-CL) nerve guides versus autologous nerve grafts: electromyographic and video analysis.

The aim of this study was to evaluate the functional effects of bridging a gap in the sciatic nerve of the rat with either a biodegradable copolymer of DL-lactide and epsilon-caprolactone [p(DLLA-epsilon-CL)] nerve guide or an autologous nerve graft. Electromyograms (EMGs) of the gastrocnemius (GC) and tibialis anterior (TA) muscles were recorded 3.5 and 5 months after bridging the nerve gaps. Furthermore, the rats' gait was recorded on video and the quality of the gait was analyzed. EMG patterns of the contralateral nonoperated side were essentially normal. The EMG patterns on the operated side were irregular in all animals, but the quality of gait was better in the nerve guide group. We conclude that the surgical technique (nerve guide or nerve graft) does not influence the occurrence of abnormal EMG patterns, but gait improves to a greater extent when the nerve gap is bridged by a nerve guide.

Long-term follow-up of hypospadias repair.

A long-term follow-up study was carried out on the results of the van der Meulen one stage (vdMI) and two stage (vdMII) technique as well as the combination of a Byars orthoplasty with a Denis Browne urethroplasty (By/DB) for hypospadias. Special attention was paid to the functional outcome (spraying, dribbling, urinary deviation), findings at physical examination (curvature, skin surplus, stenosis, fistula, torsion, etc) and the correlation between complaints on function and physical abnormalities. An attendance score of 32% was achieved out of 567 patients. With the primary referred patients, spraying was encountered infrequently (vdMI 8%, vdMII 12% and By/DB 12%). Postmicturitional dribbling was reported by 16% of patients treated with vdMI repairs, 24% of the vdMII operations and after 30% of the By/DB repairs. Deviation of urinary stream was mentioned by 32% of the vdMI patients, 18% of the vdMII patients and 21% of the By/DB patients. There was no correlation between the findings at physical examination and the functional complaints. Mild torsion of the penile body and skin surplus were observed without having clinical consequences. Fistulae were not seen at follow-up and six patients had mild residual curvature of the penile body without clinical significance. Surplus of skin was observed in approximately 20% of patients, but none of the patients requested correction of this cosmetic problem.

Treatment modalities for hypospadias cripples.

Hypospadias cripples can be defined as patients with remaining functional complications after previous hypospadias repair. A retrospective follow-up study was performed on the long-term results of a group of 94 patients disabled by hypospadias. The records of 94 patients showed that they presented with the following problems: 82 had a major meatal dystopia (87 percent), 43 (46 percent) had residual curvature of the penile body, 19 (20 percent) showed meatal stenosis, and only 5 (5 percent) had one or more fistulas. The techniques used to solve these problems were circumferential advancement of penile skin, dorsal transposition flap of preputial skin, distally based transposition flap of penile skin, and full-thickness skin graft. Between one and nine operations were needed to achieve the desired result (mean and median of two operations). The complications after these procedures were 11 fistulas in nine patients, meatal stenosis caused by tight scarring in six patients, and a residual curvature after an orthoplasty that had to be released once before a urethroplasty could be performed. Forty-three men were seen at long-term follow-up (range, 2 to 25 years; mean, 12 years). Functional complaints that were seen included spraying at micturition (5 patients, 12 percent), dribbling (6 patients, 14 percent), and deviation of urinary stream (7 patients, 16 percent). No patients complained of painful miction, hesitation, or straining. At physical examination, 4 patients had a residual curvature (three of which were mild without functional problems), 5 had a skin surplus, 1 presented with a fistula after an operation in another hospital, and 13 had a penile torsion. Only 6 patients had a penile torsion greater than 10 degrees, which was evenly distributed to the left and right. There was no correlation between any functional complaint and the presence of a physical abnormality.

Normal development of the male anterior urethra.

A histological study was performed on serially sectioned human and mouse embryos to study the influences of programmed cell death (PCD) during morphogenesis for clarifying the existing controversies on the morphology and basic processes involved in the embryonic development of the male anterior urethra. The following new insights into the development of the anterior urethra could be established. The formation of the urethra starts with the early adhesion of the arms of the genital tubercle. In this way an epithelial plate is formed, located in the ventral midline, that is in continuity with the cloacal membrane. Male sex differentiation takes place following rupture of this cloacal membrane through programmed cell death. Fusion of the urogenital swellings with primary luminization gives rise to the penile urethra, whereas the glandular part of the urethra is formed through secondary luminization of the epithelial cord that is formed during fusion of the arms of the genital tubercle, i.e., the glans. In both fusion processes, apoptosis plays a key role. The consequence of fusion of the urogenital swellings is that their mesodermal cores unite on the ventral aspect of the penile urethra, where they differentiate into the integumental structures. The prepuce starts to develop as a fold of ectoderm with a mesodermal core after complete fusion of the entire urethra. Finally, the scrotum was found to develop through merging of the labioscrotal swellings and not by fusion.

Symmetry and morbidity assessment of unilateral complete cleft lip nose corrected with or without primary nasal correction.

OBJECTIVE: Unilateral complete cleft lip patients treated with or without a primary nasal correction at the time of cleft lip repair were compared to evaluate the relevance of early surgical correction of the nose by using two assessments: nasal symmetry and morbidity. DESIGN, SETTING, PATIENTS: The no nasal correction group (NNC, n = 19) was operated by surgeon A using the Millard technique. The primary nasal correction group (PNC, n = 9) was operated by surgeon B combining the modified Millard technique with a columellar lift and alar mobilization. Symmetry was assessed on two sets of standardized photographs at 9 years of age using a computer-assisted analysis. Both cleft groups were compared with normal controls (NC, n = 20). The computer method included area and angular measurements. Morbidity was assessed by the number of procedures on the vermilion, the lip, and/ or nose for revisional surgery up to the age of 9 (NNC, n = 26; PNC, n = 12). RESULTS: No significant differences in symmetry were found between the NNC and PNC groups regarding the area and angular measurements. With regard to the area measurements, both cleft groups produced a significant asymmetry when compared to the NC group. Concerning the angular measurements, however, the NNC group differed significantly from the NC group, whereas such a difference could not be noted between the PNC group and NC group. With respect to morbidity, no revisional procedures were performed in the PNC group. The number of revisional procedures in the NNC group was 16 in 10 patients. CONCLUSION: Results are presented that favor, up to the age of 9 years, a primary nasal correction at the time of cleft lip repair.

Normal and abnormal embryonic development of the anorectum in human embryos.

In the literature, some controversy still exists about the normal and abnormal development of the human anorectum. Therefore, a three-dimensional and histological study was performed on human embryos. In early anorectal development (< or = 49 days postfertilization), the cloaca plays a crucial role, separated from the amniotic cavity by its cloacal membrane. In the cloaca, the yolk sac/primitive hindgut and allantois/primitive urogenital sinus enter. During the embryonic caudal folding process, incorporation of these structures occurs, including their surrounding extraembryonic mesoderm, which fuses to form the urorectal septum. Consequently, this septum does not grow in the direction of the cloacal membrane, and fusion of these structures is likewise never observed. The cloaca remains as such until the cloacal membrane ruptures by apoptotic cell death. The dorsal part of the cloaca then becomes part of the amniotic cavity, and is by no means involved in the development of the anorectum. The tip of the urorectal septum will become the perineal area. Soon after rupture of the cloacal membrane, during late anorectal development (> or = 49 days postfertilization), a secondary occlusion of the anorectal canal occurs, first due to adhesion, followed by formation of an epithelial "plug" at the level of the anal orifice. Recanalization, by apoptotic cell death, of this secondary occluded anal orifice occurs later during development. Based on these embryological observations, congenital anorectal malformations with an abnormal communication to the exterior are best explained as early embryonic defects. The abnormal communications, usually called fistulae, should be regarded as ectopic anal orifices. Anorectal malformations with the anus in normal position are best explained as late embryonic defects.

Urodynamic evaluation of hypospadias repair.

PURPOSE: We performed a cross-sectional evaluation of voiding in a population undergoing hypospadias repair to determine whether patients had urinary obstruction at various intervals of followup after the last operation. MATERIALS AND METHODS: Of approximately 600 patients undergoing hypospadias repair at our department during a 30-year interval 175, 40 months to 66 years old were evaluated. Therefore, we created a cross-sectional study group for evaluation of voiding function. All patients had undergone the final operation for hypospadias at least 1 year previously and were toilet trained. Severity of the initial hypospadias was scored together with the operative technique. Parameters evaluated were medical history, physical examination and uroflowmetry using a rotating disk. Uroflowmetry data (maximum flow rate and voided volume) were plotted in age-related nomograms in 4 different age groups: less than 8 (28 patients), 9 to 14 (18), 15 to 21 (39) and more than 21 (91) years old. All flow charts were evaluated by 2 of us (J. F. A. v. d. W. and E. B.). RESULTS: The severity of initial disease was grade 1 in 30% of the patients, grade 2 in 57%, grade 3 in 10%, grade 4 in 2% and unknown in 2%. The operative technique performed was a van der Meulen repair in 113 patients (65%), a combined Byars-Denis Browne repair in 56 (32%) and miscellaneous in 6 (3%). According to the uroflowmetry nomograms there was a tendency for an increased number of patients to have a normal maximum flow rate with increasing age. A total of 14 patients had a flow curve that suggested distal urethra obstruction and none was symptomatic. There was no difference in uroflowmetry characteristics regarding the operative technique. CONCLUSIONS: No difference in uroflowmetry could be established among the operations. There seemed to be a tendency towards improvement in uroflowmetry with increasing followup. There was no direct relationship between low maximum flow rates and clinical apparent obstruction.

Embryonic development of the ventral body wall and its congenital malformations.

Congenital abdominal wall defects, frequently associated with other anomalies, are found in many forms. Consequently, there is still controversy in the literature concerning nomenclature, classification, and pathogenesis. Recently, we proposed a new nomenclature and classification of abdominal wall defects based on the early development of the umbilical cord and of the ventral body wall. According to this classification the complete spectrum of abdominal wall defects, including cloacal exstrophy, bladder exstrophy, and epispadias, can be subdivided into four types: primary (thoraco-)abdominoschisis, omphalocele, body wall dysplasia, and secondary (thoraco-)abdominoschisis. Each type is characterized by its specific configuration of the placenta, the membranes, the umbilical cord, and the fetus. Anomalies such as urachal remnants and omphalomesenteric duct malformations can be explained by disturbances during later stages of umbilical cord development.

Axillary plexus blockade in microvascular surgery, a steal phenomenon?

A case report is presented of an axillary plexus blockade following a second toe-to-hand transfer. After completion of the microvascular anastomoses and restoration of blood flow to the transplanted toe, the axillary plexus blockade was started. Together with the vasodilation of the hand and forearm there was a marked drop in blood flow in the transplanted toe. Possible explanations for this phenomenon are considered. We suggest starting axillary plexus blockade before completion of microvascular anastomoses and maintaining a continuous postoperative blockade.