Proximal jejunal stoma as ultima ratio in case of traumatic distal duodenal perforation facilitating successful EndoVAC® treatment: A case report.

INTRODUCTION: During damage control surgery for blunt abdominal traumata simultaneous duodenal perforations can be missed making secondary sufficient surgical treatment challenging. Endoluminal vacuum (EndoVAC™) therapy has been shown to be a revolutionary option but has anatomical and technical limits. PRESENTATION OF THE CASE: A 59-year old man with hemorrhagic shock due to rupture of the mesenteric root after blunt abdominal trauma received damage control treatment. Within a scheduled second-look, perforation of the posterior duodenal wall was identified. Due to local and systemic conditions, further surgical treatment was limited. Decision for endoscopic treatment was made but proved to be difficult due to the distal location. Finally, double-barreled jejunal stoma was created for transstomal EndoVAC™ treatment. Complete leakage healing was achieved and jejunostomy reversal followed subsequently. DISCUSSION: During damage control surgery simultaneous bowel injuries can be missed leading to life-threatening complications with limited surgical options. EndoVAC™ treatment is an option for gastrointestinal perforations but has anatomical limitations that can be sufficiently shifted by a transstomal approach for intestinal leakage. CONCLUSION: In trauma related laparotomy complete mobilization of the duodenum is crucial. As ultima ratio, transstomal EndoVAC™ is a safe and feasible option and can be considered for similar cases.

"Rendezvous technique" for intraluminal vacuum therapy of anastomotic leakage of the jejunum.

BACKGROUND: Anastomotic leakage (AL) is one of the most common and serious complications following visceral surgery. In recent years, endoluminal vacuum therapy has dramatically changed therapeutic options for AL, but its use has been limited to areas easily accessible by endoscope. CASE PRESENTATION: We describe the first use of endoluminal vacuum therapy in the small intestine employing a combined surgical and endoscopic "rendezvous technique" in which the surgeon assists the endoscopic placement of an endoluminal vacuum therapy sponge in the jejunum by means of a pullback string. This technique led to a completely closed AL after 27 days and 7 changes of the endosponge. CONCLUSION: The combined surgical and endoscopic rendezvous technique can be useful in cases of otherwise difficult endosponge placement.

[Diagnostics and therapy of achalasia]. / Diagnostik und Therapie der Achalasie.

The low incidence (1:100,000) makes primary idiopathic achalasia a problem of special importance. Patients often have a long medical history of suffering before the diagnosis is established and adequate therapy provided. Surgeons who perform antireflux surgery must be certain of detecting achalasia patients within their collective of gastroesophageal reflux disease (GERD) patients to avoid contraindicated fundoplication. The current gold standard for establishing the diagnosis of achalasia is manometry. Especially in early stages, symptom evaluation, endoscopy and barium swallow lack adequate sensitivity. High-resolution manometry (HRM) is increasingly used and allows characterization of different achalasia types (i.e. type I classical achalasia, type II panesophageal pressurization and type III spasmodic achalasia) and differentiation from other motility disorders (e.g. distal esophageal spasm, jackhammer esophagus and nutcracker esophagus). For patients over 45 years of age additional endoscopic ultrasound and computed tomography are recommended to exclude pseudoachalasia. A curative treatment restoring normal esophageal function does not exist; however, there are good options for symptom control. Therapy aims are abolishment of dysphagia, improvement of esophageal clearance, prevention of reflux and abolishment of chest pain. The current standard treatment is cardiomyotomy, which was first described 100 years ago by the German surgeon Ernst Heller and has been shown to be clearly superior when compared to endoscopic treatment (e.g. botox injection and balloon dilatation). Heller's myotomy procedure is preferentially performed via the laparoscopic route and combined with partial fundoplication. Currently, an alternative to performing Heller's myotomy via the endoscopic route is under intensive investigation in several centers worldwide. The peroral endoscopic myotomy (POEM) procedure has shown very promising initial results and warrants further clinical evaluation.

[Peroral endoscopic myotomy for treatment of achalasia. Literature review and own initial experience]. / Perorale endoskopische Myotomie zur Therapie der Achalasie. Literaturüberblick und eigene initiale Erfahrung.

Peroral endoscopic myotomy (POEM) is a new, purely endoscopic procedure for treatment of achalasia. Due to the lack of incisions POEM can be regarded as a true NOTES procedure. With POEM a myotomy is created in a similar fashion to the previous standard treatment, laparoscopic Heller myotomy (LHM). The relatively free choice of length and localization of the myotomy may be regarded as advantages of POEM. The procedure starts with a mucosal incision (mucosal entry) followed by preparation of a submucosal tunnel crossing the esophagogastric junction and creation of a myotomy in an antegrade direction before the mucosal access is closed with endoscopic clip placement. Since the first description of the application of POEM in humans in 2010 by the pioneer Haruhiro Inoue, Yokohama, Japan, it has been used increasingly and investigated in some centers in Asia, the U.S.A. and also Europe. The results are very promising. Although the procedure is technically demanding it can be performed safely with low complication rates. The POEM procedure achieves very good control of dysphagia and gastroesophageal reflux witch is only a rare side-effect witch is well-controllable with proton pump inhibitors (PPI). We review the currently available data from the literature and present our own initial series of 14 patients treated with POEM.

Evaluation of short- and long-term complications after endoscopically assisted gastropexy in dogs.

OBJECTIVE: To determine short- and long-term complications in clinically normal dogs after endoscopically assisted gastropexy. DESIGN: Prospective case series. ANIMALS: 24 dogs. PROCEDURES: Endoscopically assisted gastropexy was performed on each dog. Dogs were evaluated laparoscopically at 1 or 6 months after surgery to assess integrity of the gastropexy. Long-term outcome was determined via telephone conversations conducted with owners > or = 1 year after surgery. RESULTS: Mean +/- SD gastropexy length was 4.5 +/- 0.9 cm, and mean duration of surgery was 22 +/- 5 minutes. One dog had a partially rotated stomach at the time of insufflation, which was corrected by untwisting the stomach with Babcock forceps. Two dogs vomited within 4 weeks after surgery, but the vomiting resolved in both dogs. Four dogs had diarrhea within 4 weeks after surgery, which resolved without medical intervention. In all dogs, the gastropexy site was firmly adhered to the abdominal wall at the level of the pyloric antrum. Long-term follow-up information was available for 23 dogs, none of which had any episodes of gastric dilatation-volvulus a mean of 1.4 years after gastropexy. CONCLUSIONS AND CLINICAL RELEVANCE: Endoscopically assisted gastropexy can be a simple, fast, safe, and reliable method for performing prophylactic gastropexy in dogs. At 1 and 6 months after gastropexy, adequate placement and adhesion of the gastropexy site to the body wall was confirmed. Such a procedure could maximize the benefits of minimally invasive surgery, such as decreases in morbidity rate and anesthetic time. This technique appeared to be suitable as an alternative to laparoscopic-assisted gastropexy.

Array-based DNA methylation profiling in follicular lymphoma.

Quantitative methylation profiling was performed using the Illumina GoldenGate Assay in untreated follicular lymphoma (FL) (164), paired pre- and post-transformation FL (20), benign haematopoietic (24) samples and purified B and T cells from two FL cases. Methylation values allowed separation of untreated FL samples from controls with one exception, based primarily on tumour-specific gains of methylation typically occurring within CpG islands. Genes that are targets for epigenetic repression in stem cells by Polycomb Repressor Complex 2 were significantly over-represented among hypermethylated genes. Methylation profiles were conserved in sequential FL and t-FL biopsies, suggesting that widespread methylation represents an early event in lymphomagenesis and may not contribute substantially to transformation. A significant (P<0.05) correlation between FL methylation values and reduced gene expression was shown for up to 28% of loci. Methylation changes occurred predominantly in B cells with variability in the amount of non-malignant tissue between samples preventing conclusive correlation with survival. This represents an important caveat in attributing prognostic relevance to methylation and future studies in cancer will optimally require purified tumour populations to address the impact of methylation on clinical outcome.

Allelic variation at Psy1-A1 and association with yellow pigment in durum wheat grain.

The yellow pigment (YP) of durum wheat (Triticum turgidum L. var durum) semolina is due in part to the presence of carotenoid pigments found in the endosperm and is an important end-use quality trait. Phytoene synthase (Psy) is considered a rate-limiting enzyme in the carotenoid biosynthetic pathway and in this study, three alleles of Psy1-A1 were sequenced from four durum wheat cultivars and a co-dominant marker was developed for genetic mapping. Psy1-A1 mapped to chromosome 7AL near Xwmc809 in three durum mapping populations and was significantly associated with a pigment quantitative trait loci (QTL) identified on that chromosome. A second QTL localized 25 cM proximal to Psy1-A1 in two populations, and the interaction between the two QTL was not significant. Consistent with QTL mapping data, the Psy1-A1o allele was associated with elevated pigment in a validation population comprising 93 diverse cultivars and breeding lines. These results confirm an earlier hypothesis that Psy1, and at least one additional gene in the distal region of 7AL, are associated with grain YP differences in durum wheat. The functional co-dominant marker developed in this study differentiates the Psy1-A1 alleles reported here and could be used as a target to enhance YP selection in durum wheat breeding programs.

Outcome of permanent tracheostomy for treatment of upper airway obstruction in cats: 21 cases (1990-2007).

OBJECTIVE: To determine clinical outcome of permanent tracheostomy in cats with upper airway obstruction. DESIGN: Retrospective case series. ANIMALS: 21 cats. PROCEDURES: Medical records were reviewed for information on history, signalment, clinical signs, results of preoperative clinicopathologic testing, cause of upper airway obstruction, surgical procedure, postoperative complications, and outcome. RESULTS: Causes of upper airway obstruction included neoplasia (squamous cell carcinoma [n = 6] or malignant lymphoma [2]), inflammatory laryngeal disease (5), laryngeal paralysis (4), trauma (3), and a laryngeal mass of unknown cause (1). Fourteen cats had dyspnea in the immediate postoperative period; dyspnea most often resulted from mucous plugs at the stoma or elsewhere in the respiratory tract. Eleven cats died, including 6 cats that died while hospitalized after surgery and 5 cats that died after discharge; 7 cats were euthanatized, most often because of progression of neoplasia; and 2 were still alive at the time of the study. The remaining cat was lost to follow-up after discharge from the hospital. Overall, median survival time for the 20 cats for which information was available was 20.5 days (range, 1 day to 5 years). Cats that underwent permanent tracheostomy because of inflammatory laryngeal disease were 6.61 times as likely to die as cats that underwent permanent tracheostomy for any other reason. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that permanent tracheostomy was an uncommon procedure in cats with upper airway obstruction that was associated with high complication and mortality rates.

Association mapping of yellow pigment in an elite collection of durum wheat cultivars and breeding lines.

Association mapping (AM) is an alternative or complementary strategy to QTL mapping for describing associations between genotype and phenotype based on linkage disequilibrium (LD). Yellow pigment (YP), an important end-use quality trait in durum wheat (Triticum turgidum L. var. durum), was evaluated to determine the ability of AM to identify previously published QTL and to identify genomic regions for further genetic dissection. The YP concentration was determined for 93 durum wheat accessions sampled from a variety of geographic origins. Analysis of population structure using distance- and model-based estimates indicated the presence of five subpopulations. Using subpopulation assignments as covariates, significant (P < 0.05) marker-trait associations for YP were detected on all chromosomes of the durum genome. Using AM, genomic regions housing known YP QTL were confirmed, most notably the group 7 chromosomes. In addition, several markers on the group 1, 2, and 3 chromosomes were identified where QTL have yet to be reported. A phytoene synthase gene, Psy1-B1, a potential candidate gene for YP, was significantly associated with YP and was in strong LD with microsatellite markers on the distal end of 7BL. Our results demonstrated that AM complemented traditional QTL mapping techniques and identified novel QTL that should be the target of further genetic dissection.

In vitro expansion patterns of ameroid ring constrictors.

OBJECTIVE: To evaluate and quantify in vitro dimensional changes of ameroid ring constrictors (ARCs) with and without the outer stainless steel ring in place over time. SAMPLE POPULATION: 12 ARCs (5.0-mm diameter). PROCEDURES: 6 ARCs were immersed in canine plasma baths for 34 days without the stainless steel outer ring in place (group N), and 6 ARCs were immersed in canine plasma baths with the stainless steel outer ring in place (group R). The ARCs were digitally imaged at day 0, daily for the first 10 days, then on days 14, 20, 27, and 34. Inner diameter, outer diameter, luminal area, and height were measured for each time point. Volume and weight of rings were obtained at the start and completion of the study. RESULTS: The inner diameter, outer diameter, and luminal area were significantly different between the 2 groups over the course of 34 days. The inner diameter and luminal area of the R-group constructs did not change significantly, while the inner diameter, outer diameter, luminal area, and height of N-group constructs all significantly increased over the course of the study. CONCLUSIONS AND CLINICAL RELEVANCE: R-group constructs had insignificant centripetal swelling without ring closure, whereas N-group constructs had significant generalized centrifugal expansion. Results of this study indicated that the outer stainless steel ring of an ARC may not be necessary for attenuation and closure of some single extrahepatic portosystemic shunts.

Evaluation of an endoscopically assisted gastropexy technique in dogs.

OBJECTIVE: To evaluate the use of endoscopy in conjunction with a gastropexy technique in dogs as a potential means to aid prevention of gastric dilatation-volvulus. ANIMALS: 12 healthy adult medium- and large-breed dogs. PROCEDURES: 12 adult research dogs that had no abnormal physical examination findings each underwent an endoscopically assisted gastropexy procedure. On completion of the procedure, the dogs were euthanized and exploratory laparotomies were performed to evaluate the surgical site. Data recorded included anatomic location of the gastropexy, gastropexy length, and duration of procedure as well as any complications. RESULTS: Mean+/-SD gastropexy length was 3.3+/-0.25 cm, and mean duration of surgery was 18+/-7 minutes. In each dog, the stomach was located in its normal anatomic position and all gastropexies were sutured to the abdominal wall at the level of the pyloric antrum. The only complications during the procedure were needle bending and breakage at the time of stay suture placement. CONCLUSIONS AND CLINICAL RELEVANCE: On the basis of these findings, it appears that endoscopically assisted gastropexy is a simple, fast, safe, and reliable method of performing a prophylactic gastropexy in dogs when undertaken by a person who is skilled in endoscopy. Such a procedure maximizes the benefits of decreased morbidity and shorter duration of anesthesia associated with minimally invasive surgery. Further clinical studies are warranted to evaluate the long-term efficacy of this procedure in dogs at risk for development of gastric dilatation-volvulus.

Clinical outcomes of 30 cases (1997-2004) of canine gastrointestinal lymphoma.

In 30 cases of canine gastrointestinal lymphoma, each case was localized to the stomach, small intestine, large intestine, or two or more sites. Treatments consisted of surgery alone (n=4), surgery with chemotherapy (n=8), chemotherapy alone (n=15), or supportive care (n=3). Four dogs died, 24 were euthanized, and two are currently alive. Median survival time for all cases was 13 days. In both surviving dogs, the site of lymphoma was the large intestine. Canine gastrointestinal lymphoma is a severe disease that warrants a poor to grave prognosis. However, cases of colorectal origin may have longer survival times.

Fibrosing gastrointestinal leiomyositis as a cause of chronic intestinal pseudo-obstruction in an 8-month-old dog.

An 8-month-old, female, mixed-breed dog presented to the Iowa State University Veterinary Teaching Hospital with a 1-month history of vomiting and diarrhea. An exploratory laparotomy was performed revealing markedly distended and fluid-filled small and large intestines that were not obstructed. The clinical condition of the dog did not improve subsequent to exploratory surgery, and it was euthanized. At necropsy, both the small and large intestines were distended (approximately 4 cm in diameter) and fluid-filled, and the wall was thin. The abdominal cavity contained approximately 500 ml of a brownish clear fluid. Microscopic lesions of the intestines were confined to the intestinal tunica muscularis and muscularis mucosae and consisted of locally extensive-to-diffuse replacement of the smooth muscle by fibrous tissue and multifocal infiltration by a moderately dense mononuclear inflammatory infiltrate. A unique finding was the presence of similar microscopic lesions in the tunica muscularis of the urinary bladder and stomach.

Evaluation of the effects of ischemic injury and ureteral obstruction on delayed graft function in cats after renal autotransplantation.

OBJECTIVE: To determine the relative importance of ischemic injury to delayed graft function (DGF) in cats. STUDY DESIGN: Experimental study. ANIMALS: Six intact female cats. METHODS: Cats had renal autograft transplantation without ureteral transection and reimplantation and a contralateral nephrectomy. Serum creatinine and blood urea nitrogen (BUN) concentrations were measured regularly and abdominal ultrasound was performed before surgery, the day after surgery and twice weekly thereafter. Ultrasound-guided renal biopsy was performed on day 7. Cats were euthanatized on day 21. Histology of the autograft, ureter, bladder, vascular anastomoses sites, and contralateral kidney were performed. Observations were compared with those from an historic group of research cats that had extravesicular ureteroneocystostomy and contralateral nephrectomy. RESULTS: Five cats completed the study. Serum creatinine and BUN concentrations increased after surgery, peaking at 3.2+/-0.8 and 77.6+/-15.9 mg/dL, respectively, 1-2 days after surgery. Serum creatinine concentration returned to the reference interval by 6 days after surgery. BUN gradually decreased in all cats but did not return to the reference interval by study end. Serum creatinine and BUN concentrations were consistently lower but not significantly so (P=.29 and .56, respectively) compared with the historic ureteroneocystostomy group. No ultrasonographic abnormalities or renal biopsy histologic abnormalities were observed. At necropsy, 1 autograft had generalized interstitial fibrosis. CONCLUSION: Harvesting the renal graft and the ischemia before revascularization causes impaired renal function after engraftment. CLINICAL RELEVANCE: The process of harvesting and reimplanting the renal graft can contribute to DGF in cats, independent of ureteral obstruction.

Use of rheolytic thrombectomy in the treatment of feline distal aortic thromboembolism.

The purpose of this prospective clinical trial was to evaluate the safety and efficacy of a commercially available rheolytic thrombectomy system in the treatment of naturally occurring feline aortic thromboembolic disease. All 6 cats enrolled in the investigation were affected at the level of the distal aorta and had signs of the disease affecting both pelvic limbs. Cats were anesthetized and an arteriotomy was performed on 1 carotid artery to gain access to the arterial system. Selective arterial angiography was used to confirm the presence of thromboembolic disease. The thrombectomy system was advanced to the level of the thrombus using fluoroscopic guidance. Repeat angiography was used intermittently to assess progress of thromboembolus dissolution throughout the procedure. The use of the rheolytic thrombectomy system resulted in successful thrombus dissolution in 5 of 6 cats. Three of 6 cats survived to discharge. Both of these results compare favorably with conventional therapies used in the treatment of this disease. Feline distal aortic thromboembolism is a frustrating disease that warrants a guarded to poor prognosis. Rheolytic thrombectomy may provide veterinarians with an alternative therapy in the treatment of thromboembolic diseases, including feline distal aortic thromboembolism.

Multiple endocrine neoplasia type I in a cat.

A 13-year-old 4.6-kg (10.2-lb) neutered male domestic long hair cat was evaluated because of a history of lethargy, exercise intolerance, and ventroflexion of the cervical portion of the vertebral column. After extensive assessment at the Veterinary Teaching Hospital at Michigan State University, the clinical signs were attributed to an aldosterone-secreting tumor of the adrenal gland. Subsequently, an insulin-secreting tumor of the pancreas as well as a functional parathyroid gland adenoma were diagnosed. All 3 masses were surgically removed, and the cat made a full recovery with complete resolution of clinical signs. The syndrome of multiple endocrine neoplasia is well described in humans, and the heritability of the condition has been confirmed. In cats and other species with 1 or more endocrine neoplasms, it is important to perform thorough clinical assessments of patients to identify other endocrine organs that may also be affected concurrently with neoplastic disease.

Evaluation of the effect of routine histologic processing on the size of skin samples obtained from dogs.

OBJECTIVE: To determine the effects that routine histologic processing has on the dimensions of samples of normal skin of dogs and assess whether the inclusion of a muscle or fascial layer in such samples alters those effects. SAMPLE POPULATION: Skin samples obtained from 6 medium-sized adult dogs with grossly normal skin. PROCEDURE: From each dog, skin samples (with or without underlying fascia or muscle) were obtained from 3 sites bilaterally (6 samples/dog) and processed routinely for histologic evaluation; their dimensions were measured at intervals during the experiment. RESULTS: As a result of processing, skin samples decreased in size (combined percentage change in length and width) and increased in thickness, compared with their original dimensions. Samples without fascia or muscle decreased in size by 21.1% to 32.0% and increased in thickness by 45.1 % to 75.8%. The site of sample origin influenced processing-associated changes in sample size but did not affect the change in thickness. Decreases in dimensions did not vary with inclusion of fascia but did vary with inclusion of muscle. The change in thickness did not vary with inclusion of a layer of fascia or muscle. CONCLUSIONS AND CLINICAL RELEVANCE: Processing of skin samples obtained from dogs for histologic evaluation can cause changes in sample dimensions; samples may decrease in length and width by as much as 32% and increase in thickness by 75.8%, compared with their original dimensions. The presence of muscle in canine skin samples can restrict the amount of shrinkage in length or width associated with processing.

Resistance to interference in complex negative patterning.

Resistance to interference was examined in rats that received a complex negative patterning discrimination in which XA and XB were followed by food reinforcement and XAB was not Retention of the discrimination was evident after separate reinforcement of both A and B (Experiment 3), but not after reinforcement of either AB (Experiments 1 and 3) or XAB (Experiments 2 and 3). These data suggest that complex negative patterning discriminations are acquired configurally and that the relative similarity of the original discrimination and subsequent interference trials dictates the final degree of retention observed.

Elevated expression and release of tissue-type, but not urokinase-type, plasminogen activator after binding of autoantibodies to bullous pemphigoid antigen 180 in cultured human keratinocytes.

In bullous pemphigoid (BP), the binding of BP180-specific antibodies to their hemidesmosomal target antigen is not sufficient for blister formation, but must be accompanied by the release of proteases. Using plasminogen activator (PA) knock-out mice, the PA system has previously been shown to be a prerequisite for blister formation in experimental murine BP. Here, we found elevated levels of plasmin and tPA, but not of uPA, in blister fluid from BP patients (n = 7) compared to blisters from patients with toxic epidermal necrolysis (n = 4) and suction blisters in healthy controls (n = 7). Subsequently, we addressed the question whether keratinocytes release PA in response to the binding of anti-BP180 antibodies. Treatment of cultured normal human keratinocytes with BP IgG, but not with control IgG, led to both increased protein and mRNA levels of tPA, but not of uPA, as determined by ELISA and RT-PCR, respectively. The specificity of this finding was confirmed using BP180-deficient keratinocytes from a patient with generalized atrophic benign epidermolysis bullosa, where no tPA release was observed after stimulation with BP IgG. Our results show the elevated expression and release of tPA from normal human keratinocytes upon stimulation with antibodies to human BP180. Keratinocytes, by secreting tPA, may thus play an active role in blister formation of BP.