Compression anastomosis for Roux-en-Y gastric bypass: observations in a large animal model.

BACKGROUND: In the morbidly obese, laparoscopic Roux-en-Y gastric bypass (RYGB) effectively achieves weight loss with the resolution of co-morbidities. The goal is to create a small-volume gastric pouch with a narrow gastrojejunal anastomosis (GJA). The procedure is associated with a GJA stricture rate of approximately 3%. The use of a compression anastomotic device to create a sutureless gastrointestinal anastomosis, replacing sutures or staples, might reduce tissue trauma and improve the GJA patency rate. A temperature-dependent, memory-shape, Nitinol Compression Anastomosis Clip (CAC) has been successfully used in intestinal anastomoses. Compression of the entrapped bowel leads to necrosis, with device expulsion after 7-10 days. METHODS: We designed a pilot animal model study of open RYGB to examine the clip's safety in the performance of upper gastrointestinal anastomoses. Six 40-kg female pigs underwent RYGB. Group 1 (n = 3) underwent GJA with the CAC and a stapled jejunojejunal anastomosis (JJA). Group 2 (n = 3) underwent GJA and JJA with the CAC. One pig from each group was euthanized at 1, 4, and 8 weeks postoperatively. RESULTS: Two pigs, one from each group, developed gastroparesis. At autopsy, all anastomoses were patent; the mean GJA diameter with the CAC was 1.6 cm (range 0.6-3), the mean JJA diameter with the stapler was 3.8 cm (range 35-40), and the mean JJA diameter with the CAC was 3 cm (range 3-3.2). Anastomotic burst pressures were similar between the stapled and CAC anastomoses. The device was passed per rectum by postoperative day 9 (range 8-12). Histologic examination of the CAC anastomoses demonstrated a complete mucosal lining with no evidence of stricture formation at 2 months. CONCLUSION: The results of this small animal study have demonstrated the safety of sutureless compression anastomoses in an animal model of open RYGB.

The effect of a low-carbohydrate diet on the nonalcoholic fatty liver in morbidly obese patients before bariatric surgery.

BACKGROUND: Bariatric surgery may be complicated by enlargement of the liver, especially of the left lobe, caused by nonalcoholic fatty liver disease often present with morbid obesity. METHODS: The effect of a very low carbohydrate diet for 4 weeks before surgery on liver density and volume was assessed in 14 candidates for bariatric surgery. Computed tomography (CT) scans were performed before and at termination of the diet period. RESULTS: The CT scans clearly showed a significant increase in mean liver density (p = 0.06) and a decrease in mean liver volume (p = 0.01). The increased mean density of the left lobe was markedly greater than that of the right lobe. CONCLUSIONS: The findings show that 4 weeks of a very low carbohydrate diet reduces liver fat content and liver size, particularly of the left lobe. This approach may render bariatric surgery or any foregut operations less difficult in morbidly obese patients and may be a useful treatment for nonalcoholic fatty liver disease.

Failure of medical treatment in an adult cystic fibrosis patient with meconium ileus equivalent.

Meconium ileus equivalent is one of the lesser-known manifestations of cystic fibrosis. It manifests as distant small bowel obstruction caused by meconium-like stool plugs and occurs mostly in adult patients. With the improved overall survival of patients with cystic fibrosis, general surgeons may encounter this condition more often in the future. We treated a 19-year-old woman with cystic fibrosis who presented with complete distal small bowel obstruction. Medical therapy with Gastrografin and N-acetylcysteine failed to resolve the obstruction. At surgery, a meconium-like plug in the distal ileum was manually pushed into the colon with subsequent relief of symptoms. Meconium ileus equivalent should be considered and treated in cystic fibrosis patients presenting with small bowel obstruction.

Thoracoscopic surgery in a general surgical service.

Following the great success and wide acceptance of laparoscopic surgery, the mini-invasive approach has been adopted for use in thoracic surgery. Thoracoscopic surgery is gaining acceptability as the procedure of choice for the treatment of recurrent pneumothorax and bullous lung disease, peripheral benign and malignant lesions, diffuse pulmonary infiltrates, mediastinal and pleural lesions, esophageal surgery, and major pulmonary resections for primary lung tumors. We present the 4-year experience of a general surgery service that extended the use of its advanced laparoscopic skills to the performance of thoracoscopic surgery in 80 patients. Using thoracoscopy, we performed biopsy or excision of pulmonary lesions (23 patients), spontaneous pneumothorax (14 patients), thoracic sympathectomy (41 patients), and Heller's esophagomyotomy and pericardiotomy (1 patient each). The results are excellent, and we believe the procedures presented in this series, and similar ones, can be accomplished safely and successfully by well-trained laparoscopic surgeons.

A direct inhibitory effect of erythromycin on rat urinary bladder smooth muscle.

Erythromycin (EM) exerts a dual effect on the contractility of smooth muscle. An excitatory effect mediated via motilin receptors is expressed mainly in the smooth muscle of the stomach and duodenum. The other, a direct inhibitory effect mediated via an unknown mechanism, has been described in guinea-pig and human gallbladder, in the longitudinal smooth muscle of the guinea-pig small intestine and in bronchial smooth muscle. In the present study, the effect of EM on the isolated urinary bladder of the rat was examined using isometric force measurements. The muscarinic agonist carbachol evoked contractions that were reduced by EM in a concentration-dependent manner; at 5 x 10(4) M by 46% [from 1.04+/-0.42 gm. to 0.56+/-0.22 gm., (p <0.001)] and at 10(-3) M by 57% [from 1.04+/-0.42 gm. to 0.45+/-0.20 gm., (p <0.001)]. The inhibitory effect of EM was not altered by the nerve blocker tetrodotoxin. Electric field stimulation of 0.5 Hz, 1 Hz, and 2 Hz contracted the urinary bladder. Erythromycin at 5 x 10(-4) M reduced the contractions evoked at 0.5 Hz by 15% [from 0.60+/-0.22 gm. to 0.51+/-0.20 gm., (p = 0.004)] and at 10(-3) M by 23% [from 0.60+/-0.22 gm. to 0.46+/-0.12 gm., (p <0.001)]. Erythromycin failed to affect the contractions evoked by bradykinin, phenylephrine or substance P. It is concluded that EM has a direct inhibitory effect on the rat urinary bladder smooth muscle.

[Video assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax].

We report our initial experience with thoracoscopic surgery in the treatment of spontaneous pneumothorax in 14 patients, mean age 30.7 years. 7 were operated following 2 episodes of spontaneous pneumothorax, 6 after their first episode, and 1 after multiple episodes. All underwent bleb resection, pleurodesis and tube thoracostomy; in 1 we converted to a limited thoracotomy (93% success rate). Only oral analgesia was required for postoperative pain control and patients were discharged 2.6 days after surgery, on average. The apparent superiority of thoracoscopic over conventional, even limited, thoracotomy seems to justify such therapy even during the first episode.

A more liberal approach to the surgical treatment of Crohn's disease.

BACKGROUND: Surgery for Crohn's disease is not intended for cure, but rather to relieve symptoms and treat complications. Perioperative morbidity, the fear of creating short bowel syndrome, and the tendency of the disease to recur convinced many physicians to refer their Crohn's patients for surgery only when life-threatening complications occur. METHODS: This is a retrospective analysis of 47 patients operated on for Crohn's disease between 1989 and 1994. Twenty-six patients were operated on for "classic" indications ("classic" group) and the other 21 were operated on to improve their quality of life ("quality" group). RESULTS: There was no operative or postoperative mortality during a mean follow-up period of 50 (27 to 84) months. All major postoperative complications occurred only in patients operated on for the classic indications (four abscesses, two fistulas, one wound dehiscence, and two small bowel obstructions). During the follow-up period, a total of 13 patients (50%) in the classic group and only 5 patients (24%) in the quality group required reintroduction of medical therapy or additional operations for exacerbations and complications of Crohn's disease. CONCLUSIONS: Our data suggest that surgical intervention intended to improve the quality of life for Crohn's disease patients is safe and effective for carefully selected patients. It does improve quality of life, may prevent life-threatening complications, and offers a lower recurrence rate following surgery.

Mammary arteritis mimicking cancer. Case report.

Giant cell arteritis and polyarteritis nodosa are systemic diseases which rarely involve the breasts. Two cases are reported in which breast masses, clinically suspected to be malignant, were found to be isolated vasculitis--bilateral giant cell mammary arteritis in a 67-year-old woman and isolated mammary polyarteritis nodosa in a 45-year-old woman. Vasculitis should be considered in the differential diagnosis of breast masses.