The cut-closed-reconnected Roux loop.

BACKGROUND: Motility disturbances in the Roux loop can negatively influence the outcome of reflux gastritis; the uncut Roux loop does not have these disadvantages, but is less suitable for clinical application because of staple dehiscence. The reported "cut-closed-reconnected" Roux loop has the same physiological starting points as the uncut Roux loop, but a difference is an extra closure at the site of the seromuscular level. METHOD: The technique of the cut-closed-reconnected Roux loop is described. RESULTS: After 1 year, the clinical findings in 8 patients were as follows: 1 patient free of symptoms, 4 with gastric pain, 2 patients vomited (1 bilious), and 1 felt fullness. CONCLUSION: Dehiscence of the closure could not be demonstrated by endoscopy, barium contrast roentgenography, and HIDA scan.

Late results of anterior sphincter plication for traumatic faecal incontinence.

OBJECTIVE: To assess the long term clinical results of anterior sphincter plication for traumatic rupture of the anal sphincters. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. SUBJECTS: 28 consecutive patients with traumatic faecal incontinence after injury to the anal sphincters. MAIN OUTCOME MEASURES: Clinical outcome and its correlation with anorectal manometry. RESULTS: After a mean (SD) follow up of 50 (37) months 21 patients were classified grades 1 and 2 (satisfied) and seven patients were grades 3 and 4 (classified). There were significant differences after operation between the 21 patients in grades 1 and 2 compared with the 7 in grades 3 and 4 in median resting pressure (43 compared with 25 mmHg, p = 0.004, 95% CI 9 to 40), and squeeze pressure (100 compared with 40 mmHg, p = 0.001, 95% CI 15 to 80) but not in length of high pressure zone (3.5 compared with 2.3 cm, p = 0.14, 95% CI -0.2 to +2.2). (Mann Whitney U test was used.) CONCLUSION: Long term follow up of patients after anterior sphincter plication showed good results in three quarters of patients, and 57% were fully continent. Good postoperative results correlate with significant increases in resting and squeeze pressures.

Late results of postanal repair for idiopathic faecal incontinence.

OBJECTIVE: To assess the long term clinical results of postanal repair for idiopathic faecal incontinence. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. SUBJECTS: 38 patients with idiopathic faecal incontinence. MAIN OUTCOME MEASURES: Clinical outcome and its correlation with anorectal manometry. RESULTS: After a median follow up of 43 months (15-126) 19 patients were classified grades 1 and 2 (satisfied) and 19 patients grades 3 and 4 (dissatisfied). Six patients deteriorated and went from grades 1 or 2 to grade 3 or 4. Satisfied patients had a significant rise in resting pressure (median 13.5 mmHg, p = 0.01, 95% CI 5 to 25) and dissatisfied patients did not. CONCLUSION: Long term follow up of patients after postanal repair shows that half the patients have a good result, although only 21% are fully continent. Long term follow up is necessary as a number of patients deteriorate.

Secondary surgery after failed postanal or anterior sphincter repair.

Secondary surgery after failed postanal repair or anterior sphincter repair was performed in eight female patients. After failed postanal repair in five patients, anterior sphincter plication and levatorplasty was the secondary procedure. In two patients a defect of the anterior external sphincter was corrected and in two patients an extremely thin external sphincter was augmented. This contributed to an excellent result in three and a good result in one patient. No improvement was achieved in one patient without anterior defect. After failed anterior sphincter repair in three patients, postanal repair was the secondary procedure. A good result was obtained in one patient and failure in two. Secondary surgery failed postanal or anterior sphincter repair may have a good result in the majority of patients.

Cytomegalovirus infection in the pregnant women.

Cytomegaloviruses (CMV) commonly infect man but overt disease only occurs in few patients; in the vast majority the infection is subclinical. We report on a HIV-negative pregnant woman. She suffered from a life-threatening ulcerating colitis due to CMV infection for which laparotomy was indicated. The case history is presented and suggestions are given for the surgical treatment of gastrointestinal complications such as haemorrhage, toxic colitis and perforation. Although CMV disease usually occurs in immunocompromised patients such as AIDS patients and transplant recipients, one should always keep the possibility of CMV infection in mind. The gastrointestinal tract is one of the sites of infection where the colon and terminal ileum are most frequently involved in complications such as bleeding and perforation. Gastrointestinal complications of CMV infection, although rare, can be life threatening and often require extensive surgery.

[A mixed form of mucocele of the colon]. / Een gemengde vorm van mucocele van het colon.

The term mucocele is applied to an accumulation of mucus within a lumen lined with mucus-secreting epithelium as well as to the structure resulting from leakage of mucus into surrounding connective tissue. The case report is presented of a patient with a bizarre, mixed type of mucocele after perforation of a hemicolon retained 26 years previously, a clinical picture which could not be traced in the literature.

Role of Helicobacter pylori in the pathogenesis of complications of Meckel's diverticula.

OBJECTIVE: To assess the possible role of colonisation of ectopic gastric mucosa in Meckel's diverticula by Helicobacter pylori in causing inflammation, ulceration, perforation and bleeding. DESIGN: Retrospective study. SETTING: Three hospitals in Amsterdam, The Netherlands. MATERIAL: Specimens of 65 diverticula, 49 of which had been resected incidentally, and 16 of which had been thought to be the presenting feature. MAIN OUTCOME MEASURE: The presence of H. pylori in gastric mucosa. RESULTS: 19 Diverticula contained ectopic tissue, 18 gastric and one pancreatic tissue. Gastric tissue was found in 10 of the diverticula removed incidentally, and 8 of those that were thought to be symptomatic. In 5 of the 8 there were signs of complications that might have been related directly to the presence of gastric tissue (perforation--n = 3; bleeding--n = 1; and peptic stenosis--n = 1), and none contained H. pylori. H. pylori was found in only one of the 18 diverticula, in which there were also signs of gastritis. CONCLUSION: H. pylori has no role in the pathogenesis of the complications of Meckel's diverticula.

Pressure and X-ray recording of reflux into the thoracic stomach.

Anastomotic leakage, pulmonary aspiration and reflux-esophagitis might be induced or aggravated by the increased duodenogastric reflux observed in the thoracic stomach. In this study, the effect of respiration on the reflux-promoting pressure gradient in the intrathoracally located stomach was assessed. In nine patients pressure recording was done in the duodenum and the abdominal and thoracic part of the stomach. Intrapleural pressure was determined by recording mouth pressure during inspiratory occlusion. In addition, the course of injected contrast was examined fluoroscopically. The mean end-expiratory pressure gradient in the thoracic part of the stomach was 0.8 cm H2O, increasing up to 6.0 cm H2O and 21.3 cm H2O during normal and forced inspiration, respectively. Fluoroscopic examination showed reflux of contrast that coincided with the downward movement of the diaphragm. From this study, we conclude that reflux into the thoracic stomach is promoted by intraluminal pressure fluctuations induced by voluntary breathing. Performing a pyloroplasty or -myotomy after intrathoracic esophagogastrostomy destroys the integrity of the pyloric sphincter as a barrier to reflux, thus promoting duodenogastric reflux.

Gallstone disease in women younger than 30 years.

The relation between symptomatic cholelithiasis in women under 30 years of age and pregnancy, obesity and oral contraceptive use was retrospectively studied. A total of 885 cholecystectomies were carried out in an English district hospital. In the age group under 30 years the female-male ratio was 9.7:1 vs 2.3:I in the total group (p less than 0.01). Gallstones were present in 39 women with a previous pregnancy and in 14 women without pregnancy. Compared to an age and sex matched control group of appendicectomies a relative risk of 1.6 was found for pregnancy related gallstone disease requiring cholecystectomy (p less than 0.05). 455 Cholecystectomies were carried out in a Dutch academic hospital. The female-male ratio in the group younger than 30 years was 7.0:I vs 2.3:I in the total group (p less than 0.01). In the Dutch group more women under 30 years were operated on than in the English group: 23% vs 10% (p less than 0.001). There was no significant association between symptomatic gallstones and previous pregnancies in the Dutch group (p = 0.07). Gallstone disease occurs earlier in women than in men. There appears to be a relationship between early symptomatic cholelithiasis and pregnancy in the English group only. No relationship could be found between cholelithiasis and obesity or oral contraceptive use in either group.

Leiomyosarcoma of large and small veins: clinical findings and results of treatment in six patients.

Vascular leiomyosarcomas are rare malignant tumours originating from the media of the vessel wall. Six patients (five women and one man, aged 44-66 years) have been treated for a vascular leiomyosarcoma located in the inferior vena cava (three patients), the suprarenal, the external iliac and an antecubital vein. In four patients, the tumour was large and extended beyond the vessel wall giving rise to a retroperitoneal mass. In two patients the tumour was confined to the inner wall of respectively a large and small vein, occluding the lumen; the former was in the inferior vena cava and the latter in an antecubital vein. Block resection was performed in all patients. The tumours showed mitotic indices ranging from 6-32 mitoses/10 high power fields. The five patients with retroperitoneal tumours received additional radiotherapy varying from 50.00-70.00 Gy, on the basis of either macroscopic residual tumour or indefinite radicality. One of these five patients developed distant metastases within 2.5 years without local recurrence, the other four had no evidence of recurrence at follow-up, 3-7 years (mean 4.2 years) after surgery. The results illustrate the role of adjuvant radiotherapy in the control of local recurrence, when resection in this type of tumour proves to be either non-radical or totally radical.

What happens to the rectal muscular cuff? An experimental study in dogs.

The anatomy and histology of the rectal muscular cuff was studied in 15 dogs with an ileal pouch-anal anastomosis. Eight channel, three-dimensional anal manometry showed normal maximal squeeze pressure (128 +/- 20 mm Hg) compared to a control group (135 +/- 4 mm Hg). The rectal muscular cuff showed complete absence of the cuff in three cases. In 12 dogs, the rectal cuff was retracted to a length of less than 1 cm, the muscle fibers were degenerated and fibrotic. The results in the canine model and the clinical results of patients with an ileal pouch-anal anastomosis with a cuff demonstrated that a rectal muscular cuff is not essential to maintain continence after ileal pouch-anal anastomosis.

High-vacuum drainage and primary perineal wound closure in abdominoperineal excision of the rectum.

The result of perineal wound healing after rectal excision with primary perineal closure by high-vacuum drainage was studied prospectively. High vacuum drainage was performed via a wide-bore catheter (Ch. 27) placed through a stabwound on the thigh. The method was applied in 114 of 127 patients who had abdominoperineal excision of the rectum (89.7 per cent). Contra-indications were inadequate haemostasis and pre-existing massive perineal sepsis. Primary perineal wound closure was present in 85.9 per cent of patients, delayed healing in 12.3 per cent and a perineal sinus developed in two patients (1.8 per cent).

Enteroglucagon and peptide Y-Y response after construction of a pelvic reservoir in humans.

The results of an investigation of plasma levels of gastrointestinal hormones in patients after the construction of a pelvic reservoir are reported. Enteroglucagon (EG) and peptide tyrosine-tyrosine (PYY), two hormones believed to play a relevant role in the adaptive response to bowel resection, were investigated using a specific radioimmunoassay in basal conditions and after a standard meal. Pouch patients showed a statistically significant increase in basal levels of both enteroglucagon and PYY compared with control subjects (P less than 0.02 and P less than 0.001, respectively). The response of enteroglucagon to food ingestion, evaluated by means of the total integrated response, was similar in patients and controls. Conversely, the response of PYY was significantly increased in pouch patients compared with control cases (P less than 0.02). Results of this investigation suggest that gut hormones may be involved in mediating the adaptive response of the intestine to pouch construction. Changes of gut peptides may explain, at least in part, the functional results observed after pouch construction.

[The clinical aspects and treatment of renal angiolipomas in patients with tuberous sclerosis]. / Het klinische beeld en de behandeling van renal angiomyolipomen bij patiënten met tubereuze sclerose.

The incidence of multiple and bilateral renal angiomyolipomas in tuberous sclerosis patients is 40-80%. These benign abundantly vascularised tumours are almost always asymptomatic. Most of the symptomatic renal angiomyolipomas measure more than 4 cm. These lesions are attended by a high risk of spontaneous rupture and massive haemorrhage. In our series of 23 tuberous sclerosis patients with renal angiomyolipomas 4 became symptomatic. Three of them were successfully treated wtih transcatheter selective embolization. Preventive embolization of renal angiomyolipomas appears indicated if these measure more than 4 cm. A fifth patient became symptomatic before the diagnosis of tuberous sclerosis was made. She had a forme fruste. She was also successfully treated by the same method.

Renal angiomyolipomas: could the histology serve as a marker for tuberous sclerosis?

The histological features of 43 renal angiomyolipomas were studied in an attempt to evaluate whether the isolated forms and those that present as part of the tuberous sclerosis complex can be distinguished. In two patients the mass was classified as an angioleiomyoma, because no adipose tissue was present. All renal angiomyolipomas showed the same basic histological picture. The combined forms, however, showed additional features such as extension into pre-existent renal parenchyma, scattered foci of hamartomatous lesions, calcified spicules and tubular inclusions. The findings suggest that these features, in an otherwise classical angiomyolipoma, should alert the pathologist to the possibility of tuberous sclerosis.

Immunocytochemical study of endocrine cells in pelvic ileal reservoirs.

The distribution and morphology of intestinal endocrine cells was investigated in the mucosa of pelvic ileal reservoirs using immunocytochemical methods. Endoscopic biopsies were obtained from 15 patients after the construction of a modified J-pouch. The mucosa of the reservoir showed a variable degree of colonic metaplasia in all cases. No relevant quantitative variations of gut endocrine cells were detected, as revealed by immunostaining for the general marker, chromogranin, compared with normal ileal mucosa. Immunostaining for different peptide-containing cells resulted in normal number and morphology of serotonin, enteroglucagon, peptide tyrosine-tyrosine, and somatostatin-containing cells. Neurotensin cells were less numerous than in normal mucosa. The role played by gastrointestinal hormones in the adaptive response of the intestine to pouch construction is, presently, unclear. Further studies involving measurements of fasting and meal-stimulated levels of gut hormones in pouch patients might clarify this aspect.

Percutaneous transcatheter embolization of symptomatic renal angiomyolipomas: a report of four cases.

Successful percutaneous transcatheter embolization of renal angiomyolipoma is reported in four female patients. The angiomyolipomas measured more than 4 cm in diameter. Three patients had severe haemorrhage and one patient had a growing angiomyolipoma in a solitary kidney. This patient had percutaneous transcatheter embolization to prevent further deterioration of kidney function. Three patients had multiple renal angiomyolipomas as part of tuberous sclerosis. Two of them had selective transcatheter embolization of more than one angiomyolipoma. After embolization, one patient had partial loss of kidney function and one patient developed an abscess that could successfully be drained percutaneously under ultrasound guidance. The following conclusions can be drawn. All patients with tuberous sclerosis should be screened for renal angiomyolipomas. All symptomatic renal angiomyolipomas and all angiomyolipomas that measure more than 4 cm in diameter require treatment. Embolization should be considered as a primary therapeutic modality for multiple angiomyolipomas.

Endoscopic balloon dilation of the pylorus after esophagogastrostomy without a drainage procedure.

The necessity to perform a drainage procedure after esophagectomy using the stomach for substitution remains controversial. Transection of the pyloric sphincter may cause severe and debilitating gastroesophagitis because of increased duodenogastric reflux. Omitting the drainage procedure may lead to gastric stasis. In the patient group we studied (n = 50), 42 had partial esophagogastrectomy and intrathoracic esophagogastrostomy, 12 with and 30 without a drainage procedure. Eight had total thoracic esophagectomy and cervical esophagastrostomy using the entire stomach without a drainage procedure. Gastric stasis was not observed in the 12 patients with a drainage procedure, but in six, duodenal reflux gastroesophagitis caused considerable morbidity. This complication was seen only once in the group (n = 38) who did not have a drainage procedure. Four of the 38 patients with an intact pylorus (one patient after partial esophagogastrectomy and three patients after total thoracic esophagectomy) showed persistent pyloric closure. However, this complication was successfully managed by endoscopic balloon dilation under fluoroscopic survey. The results suggest that, after esophagectomy, the integrity of the pyloric sphincter should be preserved, since the complication arising from this policy can be simply managed by endoscopic balloon dilation.

[Ileo-anal anastomosis with ileum reservoir]. / De ileo-anale anastomose met ileumreservoir.

Ileo-anal anastomosis with an ileal pouch is a reasonable alternative for patients with ulcerative colitis and adenomatous polyposis coli. The type of the reservoir, the length of the rectal cuff and the level of the anastomosis are still topics of discussion. This operation was performed in 41 patients. A modified J-reservoir (B-reservoir) was constructed in 34 patients in an attempt to improve the function of the neorectum. Twenty patients underwent inter-sphincteric freeing of the rectum and subsequent resection without leaving a rectal cuff. Although this procedure is associated with a considerable morbidity, the ultimate result is satisfactory.