[Two-stage traumatic rupture of the arteria ovarica after high energy trauma]. / Zweizeitige traumatische Ruptur der Ovarialarterie nach Hochrasanztrauma.

INTRODUCTION: Rupture of the Arteria ovarica is a rare but life-threatening injury and occurs primarily in pregnancy. Most previously described ruptures of the Arteria ovarica were in the early postpartum period and in women who were older than 45 years. We report on a two-stage rupture of the Arteria ovarica after a high energy trauma, which has not previously been described in the literature. PATIENT AND METHOD: A 66-year-old female patient was admitted to the emergency room after a car accident. Initial treatment was performed in a regional hospital. Initial clinical and radiological examinations were without any pathologies and the patient was discharged home after ambulatory treatment. Six days later, the patient was referred to our hospital because of increasing headache. A computed tomography of the head showed a subdural haematoma. A follow-up CT scan after three days showed no further progression of the haematoma. RESULTS AND CONCLUSIONS: During the hospital stay, the patient developed abdominal pain, nausea and cardiovascular decompensation. An ultrasound of the abdomen showed free fluids, while a performed CT scan of the abdomen confirmed an arterial bleeding from a pseudoaneurysm of the left ovarian artery. An emergency operation was performed. Postoperative management included ICU monitoring, diuresis control and blood transfusion. The patient was discharged home after 19 days in a good condition. The indication for performing a CT scan and primary hospitalisation after a high energy trauma should be applied generously.

Laparoscopic Heller myotomy relieves dysphagia in patients with achalasia and low LES pressure following pneumatic dilatation.

BACKGROUND: Although pneumatic dilatation is said to relieve dysphagia in achalasia if it decreases lower esophageal sphincter (LES) pressure to 10 mmHg (n = 23); group C, no previous balloon dilatation and LES pressure >10 mmHg (n = 25). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. The severity of dysphagia was gauged on a scale of 0-4. RESULTS: In group A, LES pressure was 7 +/- 2 mmHg preoperatively and 8 +/- 3 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.9 +/- 1.1 postoperatively. Eighty-nine percent of patients had excellent or good results. In group B, LES pressure was 23 +/- 8 mmHg preoperatively and 10 +/- 1 mmHg postoperatively; the dysphagia score was 3.3 +/- 0.7 preoperatively and 0.3 +/- 0.5 postoperatively. All patients had excellent or good results. In group C, LES pressure was 23 +/- 11 mmHg preoperatively and 14 +/- 12 mmHg postoperatively; the dysphagia score was 3.6 +/- 0.6 preoperatively and 0.2 +/- 0.5 postoperatively. All patients had excellent or good results. CONCLUSIONS: These results show that (a) a LES pressure of <10 mmHg after pneumatic dilatation does not guarantee relief of dysphagia, and (b) laparoscopic Heller myotomy relieves dysphagia in most patients with a postdilatation LES pressure <10 mmHg. Thus, a laparoscopic Heller myotomy is indicated if dilatation does not relieve dysphagia, even if LES pressure has been decreased to <10 mmHg. Esophagectomy should be reserved for the occasional failure of this simpler operation.

Esophageal achalasia: preoperative assessment and postoperative follow-up.

Esophageal achalasia is a primary esophageal motility disorder of unknown etiology, characterized by absence of esophageal peristalsis and increased resting pressure of the lower esophageal sphincter (LES), which fails to relax appropriately in response to swallowing. Treatment is palliative and is directed toward elimination of the outflow resistance caused by the abnormal LES function.

Esophageal dysmotility and gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) produces a spectrum of symptoms ranging from mild to severe. While the role of the lower esophageal sphincter in the pathogenesis of GERD has been studied extensively, less attention has been paid to esophageal peristalsis, even though peristalsis governs esophageal acid clearance. The aim of this study was to evaluate the following in patients with GERD: (1) the nature of esophageal peristalsis and (2) the relationship between esophageal peristalsis and gastroesophageal reflux, mucosal injury, and symptoms. One thousand six consecutive patients with GERD confirmed by 24-hour pH monitoring were divided into three groups based on the character of esophageal peristalsis as shown by esophageal manometry: (1) normal peristalsis (normal amplitude, duration, and velocity of peristaltic waves); (2) ineffective esophageal motility (IEM; distal esophageal amplitude < 30 mm Hg or >30% simultaneous waves); and (3) nonspecific esophageal motility disorder (NSEMD; motor dysfunction intermediate between the other two groups). Peristalsis was classified as normal in 563 patients (56%), IEM in 216 patients (21%), and NSEMD in 227 patients (23%). Patients with abnormal peristalsis had worse reflux and slower esophageal acid clearance. Heartburn, respiratory symptoms, and mucosal injury were all more severe in patients with IEM. These data show that esophageal peristalsis was severely impaired (IEM) in 21% of patients with GERD, and this group had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms. We conclude that esophageal manometry and pH monitoring can be used to stage the severity of GERD, and this, in turn, should help identify those who would benefit most from surgical treatment.

Role of esophageal function tests in diagnosis of gastroesophageal reflux disease.

Clinicians typically make the diagnosis of gastroesophageal reflux disease (GERD) from the clinical findings and then prescribe acid-suppressing drugs. Endoscopy is usually done for persistent or severe symptoms. Esophageal function tests (EFTs: esophageal manometry and 24-hr pH monitoring) are generally reserved for patients who have the most severe disease, including those being considered for surgery. We hypothesized that EFTs are more accurate than symptoms and endoscopy in the diagnosis of GERD. This was a retrospective study undertaken in a university tertiary care center. Between October 1989 and November 1998, 822 patients with a clinical diagnosis of GERD (based on symptoms and endoscopic findings) were referred for EFTs. The patients were divided into two groups depending on whether the 24-hr pH monitoring score showed GERD (group A, GERD-; group B, GERD+). The groups were compared with respect to the incidence and severity of symptoms, presence of a hiatal hernia on barium x-rays, presence and severity of esophagitis on endoscopy, and esophageal motility. In all, 247 patients (30%) had normal reflux scores (group A, GERD-), and 575 patients (70%) had abnormal scores (Group B, GERD+). Eighty percent of group A and 88% of group B had been treated with acid-suppressing medications. The incidence of heartburn and regurgitation was similar in the two groups. Grade I-II esophagitis was diagnosed by endoscopy in 25% of group A and 35% of group B, and grade III esophagitis in 4% of group A and 11% of group B. Esophageal manometry showed that group B more often had esophageal dysmotility, consisting of a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis. These data show that: (1) symptoms were unreliable for diagnosing GERD; (2) endoscopic evidence of grade I-II esophagitis was diagnostically nonspecific, and grade III was much less certain than claimed in other reports; and (3) pH monitoring identified patients with GERD and stratified them according to the severity of the disease. We conclude that esophageal manometry and pH monitoring are important in diagnosing GERD accurately. More liberal use of these tests early in patient management would avoid much improper and costly medical therapy and would help single out for special attention the patients with GERD who have the most severe disease.

Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms.

Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11%). These 39 patients had been symptomatic for an average of 134 months. They were all taking H2-blocking agents (21%) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisone (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antireflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%.

Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia.

Until recently, pneumatic dilatation and intrasphincteric injection of botulinum toxin (Botox) have been used as initial treatments for achalasia, with myotomy reserved for patients with residual dysphagia. It is unknown, however, whether these nonsurgical treatments affect the performance of a subsequent myotomy. We compared the results of laparoscopic Heller myotomy and Dor fundoplication in 44 patients with achalasia who had been treated with medications (group A, 16 patients), pneumatic dilatation (group B, 18 patients), or botulinum toxin (group C, 10 patients). The last group was further subdivided according to whether there was (C2, 4 patients) or was not (C1, 6 patients) a response to the treatment. Results for groups A, B, C1, and C2, respectively, were: anatomic planes identified at surgery (% of patients)--100%, 89%, 100%, and 25%; esophageal perforation (% of patients)--0%, 5%, 0%, and 50%; hospital stay (hrs)--26+/-8, 38+/-25, 26+/-11, and 72+/-65; and excellent/good results (% of patients)--87%, 95%, 100%, and 50%. These results show that: (1) previous pneumatic dilatation did not affect the results of myotomy; (2) in patients who did not respond to botulinum toxin, the myotomy was technically straightforward and the outcome was excellent; (3) in patients who responded to botulinum toxin, the LES muscle had become fibrotic (perforation occurred more often in this setting, and dysphagia was less predictably improved); and (4) myotomy relieved dysphagia in 91% of patients who had not been treated with botulinum toxin. These data support a strategy of reserving botulinum toxin for patients who are not candidates for pneumatic dilatation or laparoscopic Heller myotomy.

Minimally invasive surgery for achalasia: an 8-year experience with 168 patients.

BACKGROUND: Seven years ago, the authors reported on the feasibility and short-term results of minimally invasive surgical methods to treat esophageal achalasia. In this report, they describe the evolution of the surgical technique and the clinical results in a large group of patients with long follow-up. PATIENTS AND METHODS: Between January 1991 and October 1998, 168 patients (96 men, 72 women; mean age 45 years, median duration of symptoms 48 months), who fulfilled the clinical, radiographic, endoscopic, and manometric criteria for a diagnosis of achalasia, underwent esophagomyotomy by minimally invasive techniques. Forty-eight patients had marked esophageal dilatation (diameter >6.0 cm). Thirty-five patients had a left thoracoscopic myotomy, and 133 patients had a laparoscopic myotomy plus a partial fundoplication. Follow-up to October 1998 was complete in 145 patients (86%). RESULTS: Median hospital stay was 72 hours for the thoracoscopic group and 48 hours for the laparoscopic group. Eight patients required a second operation for recurrent or persistent dysphagia, and two patients required an esophagectomy. There were no deaths. Good or excellent relief of dysphagia was obtained in 90% of patients (85% after thoracoscopic and 93% after laparoscopic myotomy). Gastroesophageal reflux developed in 60% of tested patients after thoracoscopic myotomy and in 17% after laparoscopic myotomy plus fundoplication. Laparoscopic myotomy plus fundoplication corrected reflux present before surgery in five of seven patients. Patients with a dilated esophagus had excellent relief of dysphagia after laparoscopic myotomy; none required an esophagectomy. CONCLUSIONS: Minimally invasive techniques provided effective and long-lasting relief of dysphagia in patients with achalasia. The authors prefer the laparoscopic approach for three reasons: it more effectively relieved dysphagia, it was associated with a shorter hospital stay, and it was associated with less postoperative reflux. Laparoscopic Heller myotomy and partial fundoplication should be considered the primary treatment for esophageal achalasia.

Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated.

BACKGROUND: It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid shaped. Those who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without esophageal dilatation, all of whom had achalasia. METHODS: On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0-6.0 cm; 21 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. RESULTS: The duration of the operation and the length of hospital stay were similar among the four groups. Excellent or good results were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series ultimately required an esophagectomy. CONCLUSIONS: In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) took no longer and was no more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief of dysphagia. We conclude that esophageal dilation by itself should rarely serve as an indication for esophagectomy rather than myotomy as the initial surgical treatment.

Challenges of matching human milk fatty acid patterns technically and functionally.

A vegetable oil fat blend resulting in formula major fatty acid levels similar to human milk is appropriate for infant feedings even though the palmitic acid may have a somewhat different positional distribution. Growth, bone mineral content, and visual acuity (as measured by the Teller acuity card procedure) achieved in normal infants consuming such formulas are at least as good as those from human milk. The quantitatively minor LC-PUFA levels may also be important in infant development and useful once safety of their sources has been adequately demonstrated. Such formula fat blends mimicking the major fatty acid profiles of human milk are appropriate for infants with relatively normal fat absorptive mechanisms including infants with allergy or inborn errors of metabolism. Formulas designed for such infants (e.g., extensively hydrolyzed protein products for allergic infants) do not need to have MCT oil included in the formulation which alters the fatty acid profile. On the other hand, those infants with immaturity, gastrointestinal disease, and/or fat malabsorption often do benefit by the inclusion of MCT oil in the fat blend of the formula.

Meeting lipid needs of infants with allergy and gastrointestinal diseases.

Infant formulas containing medium chain triglycerides (MTC) have been used for the nutritional management of infants with fat malabsorption. The optimal proportion of MTC in the formula remains to be determined. Three infant formulas with varying proportion of MTC in the fat blend were studied in children with cystic fibrosis, cholestasis or persistent diarrhea. The formula containing 48% of the total energy from fat and 55% of the fat component as MTC was found to be the most suitable for the needs of those infants. It leads to an adequate essential fatty acid status and to improved recovery in those conditions.

Analysis of ras mutations in human melanocytic lesions: activation of the ras gene seems to be associated with the nodular type of human malignant melanoma.

We have analyzed the Ha-ras, Ki-ras and N-ras gene for point mutations at codons 12, 13 and 61 via restriction fragment length polymorphism/polymerase chain reaction analysis and subsequent direct sequencing in non-cultured fresh-frozen tissues of 16 superficial spreading melanomas (SSM), 13 nodular malignant melanomas (NMM), 2 lentigo malignant melanomas (LMM), 1 dysplastic nevus, 1 congenital nevus and 5 normal nevi from 38 patients. Mutations were found in 4 melanoma samples, all belonging to the nodular malignant type. Three of them were mutated in N-ras and one in the Ha-ras gene. Mutation in N-ras was also detected in the congenital nevus. All mutations were exclusively located at the first two base pairs of codon 61. No Ki-ras mutation was detected in any lesion. No mutation could be found in SSM and LMM in addition to dysplastic and normal nevi. The frequency of ras mutation in NMM was 31%, whereas in SSM it was 0%. Our study suggests (a) an association between ras mutations (mainly N-ras) and the NMM as a subgroup of human melanoma; (b) that activation of Ki-ras is not involved in the pathogenesis of melanoma. The role of UV radiation in point mutations of ras genes in human melanoma is discussed.

Improved method of screening for aflatoxin with a coconut agar medium.

Nine isolates of Aspergillus flavus and Aspergillus parasiticus were screened for aflatoxin production on a coconut extract agar medium. Aflatoxin-producing colonies were detected under long-wave UV light (365 nm) by blue fluorescence on the reverse side after 2 to 5 days of growth. Aflatoxin production was verified by chemical analysis. Several types of shredded coconut available in the United States were tested and found to be satisfactory. No additives were required. Various parameters affecting the test were investigated.

In Vitro Growth of Acremonium coenophialum, an Endophyte of Toxic Tall Fescue Grass.

Acremonium coenophialum, an endophytic fungus present in toxic tall fescue grass and seed, grew very slowly or not at all with conventional media and cultural practices. However, a considerable increase in growth was achieved in a relatively dilute medium consisting solely of glucose and yeast extract. The optimal levels of glucose and yeast extract were 3 to 6% and 0.35% (wt/vol), respectively. The addition of salts which lowered the pH suppressed growth. Even when the pH was controlled, the addition of KH(2)PO(4) at a level of 3.2% or more greatly inhibited growth. A. coenophialum grew better in shake culture than in stationary culture. The optimal temperature was 23 degrees C, and the optimal pH was 6.5.

A toxic metabolite of Nigrospora oryzae (Berk and Br.) petch.

Nigrospora oryzae was isolated from dallisgrass (Paspalum dilatatum Poir.) collected in Auburn and from hay shipped under refrigeration to Florida. Some of these samples were eaten by cattle and horses that subsequently developed lameness. Metabolites of N. oryzae were separated by thin layer chromatography and tested for toxicity. Only one metabolite was toxic. Metabolite A showed toxicity to brine shrimp with an LD50 = 500 micrograms/ml in 8 h. It also had an antibiotic effect on Bacillus megaterium ATCC 14581 with a minimum inhibitory level of 10.1 micrograms/disc. As little as 435 micrograms of a crude methanolic extract of N. oryzae showed mild toxicity to chick embryos. The metabolite was not toxic to mice nor rats at the levels tested. Quantitative procedures developed for the determination of metabolite A showed that the maximum production occurred in yeast extract-sucrose liquid medium with an initial pH of 5-6, when incubated as a stationary culture for 28 days at 25 degrees C. It was concluded that metabolite A is a weak antibiotic rather than a mycotoxin, and was probably not associated with the symptoms of lameness observed in cattle and horses. The antibiotic is not one previously reported for N. oryzae.

Effects of aflatoxin on the growth performance and immune responses of weanling swine.

Aflatoxin (AF)-contaminated ground corn was mixed with a commercial swine ration to yield 2 concentrations (500 mg of AFB1/kg of feed [A] and 300 mg of AFB1/kg [B]) and was fed to 2 groups of pigs. Groups A and B were fed the AF-containing ration, whereas control group C was fed the same commercial ration mixed with ground corn devoid of AF. A comparative analysis of the average weight gain per pig in each of the treatment groups, compared with that in the control group, indicated a significantly (P less than 0.01) greater weight gain in the control group. The average feed conversion rate was also significantly (P less than 0.01) lower in group A pigs, compared with that in the control group. The humoral immune response to Erysipelothrix rhusiopathiae, measured by enzyme-linked immunosorbent assay, did not reveal a significant difference among groups; there were no consistent differences observed in the proliferative responses of lymphocytes to mitogens. In contrast, a significant (P less than 0.05) reduction in complement titers was observed, whereas an increase in serum immunoglobulin G and M values occurred in the AF-treated group A, compared with that in group C. Gross enlargement of the liver, substantiated by histologic evidence of toxic damage to the hepatic parenchyma, revealed that AF at concentrations of 500 mg/kg of feed was toxigenic and produced an adverse effect on the growth rate, feed efficiency, and general well-being of young pigs.

Effects of aflatoxin on young turkeys and broiler chickens.

The effect of crude aflatoxin (AF) on the growth, performance, and immune response of turkeys and broilers was studied. Crude AF, produced from a natural outbreak of Aspergillus flavus on corn, was ground and mixed in rations to contain either 0, 100, 200, 400, or 800 ppb of aflatoxin B1 (AFB1). Turkeys (Experiment 1) and broilers (Experiment 2) were used in identical experimental designs. In each, 200, 14-day-old birds were divided equally by sex into five groups of 40 and were fed one of five AF diets for 35 days. In Experiment 1, crude AF greater than or equal to 400 ppb was highly toxic to turkeys. These levels produced signs and lesions of aflatoxicosis as well as a significant decrease in weight gain and feed conversion during 5 weeks. In addition, microscopic lesions, indicative of aflatoxicosis, were evident as low as 100 ppb, and significant decreases in cell-mediated immunity were noted in the 200 ppb group birds. Experiment 2 indicated that chickens were less susceptible to crude AF than turkeys. Neither morbidity nor mortality occurred in broilers. Gross lesions consistent with AF toxicity were evident in birds given 800 ppb and microscopic lesions were observed in birds given 100 ppb. Feed conversion was significantly increased in the 800 ppb broilers only. Cell-mediated immunity, measured by a delayed hypersensitive skin test, was significantly decreased in broilers receiving AF at 200 ppb or greater. Neither humoral immunity nor the development of the acquired immunity to Newcastle disease or fowl cholera vaccination were decreased in turkeys or broilers given AF.

Effects of purified aflatoxin on broiler chickens.

Purified aflatoxin B1 (AFB1) or AFB1 plus aflatoxin B2 (AFB2) was given daily for 5 weeks in gelatin capsules to 2-week-old feather-sexed broilers. In Experiment 1, pure AFB1 was given in doses equivalent to the quantity of toxin received, if diets containing either 0, 200, 500 or 1000 ppb of AFB1 were consumed. In Experiment 2, pure AFB1 or AFB1 plus B2 was administered in capsules in doses equivalent to the quantity of toxin received, if diets containing either 0, 100, 200, or 400 ppb of AFB1 were consumed. In Experiment 1, pure AFB1 greater than or equal to 500 ppb was only mildly toxic. These levels produced a significant decrease in the 5-week weight gain and microscopic lesions indicative of alfatoxicosis. No morbidity, mortality, or effects on feed conversion or immune responses, however, were noted in birds given pure AFB1 at these levels. Gross liver lesions indicative of aflatoxin toxicity occurred at the 1000 ppb only. Results of Experiment 2 were similar to the first. Weight gain and feed conversion were not affected for broilers receiving pure AFB1 as low as 200 ppb. No morbidity, mortality, or gross lesions were evident in birds given either pure AFB1 or AFB1 plus AFB2 as high as 400 ppb. However, cell-mediated immunity as measured by a delayed hypersensitive skin test was significantly affected in birds receiving 400 ppb AFB1 plus AFB2. No effects on humoral immunity or the development of acquired immunity to Newcastle disease or fowl cholera vaccination were noted.