Paraduodenal hernia.

An internal hernia is the protrusion of a viscus through a normal or abnormal opening within the confines of the abdominal cavity. Internal hernias account for 0.2 to 0.9 per cent of all cases of intestinal obstruction. Paraduodenal hernias are relatively rare congenital malformations and account for 30 to 53 per cent of all internal hernias. They result from incomplete rotation of the midgut, with part of the small intestine trapped posterior to the mesocolon. Right and left paraduodenal hernias are distinct and separate entities, varying not only in anatomic structure but also in embryological origin. Symptoms are often vague, and a high index of suspicion is required to make the diagnosis. This entity should be considered whenever atypical abdominal symptoms are present. A CT scan or barium upper gastrointestinal radiography provides the best preoperative evidence of this condition, although ultrasonography and plain films are also useful. Elective repair of such a hernia should always be performed to avoid bowel incarceration or strangulation. An understanding of the anatomy of these hernias facilitates the surgery and is necessary in decreasing the likelihood of complications. Careful reduction of the hernia and surgical repair will avoid injury to the major mesenteric vessels juxtaposed to the hernial orifice. The surgical management of three patients, who were diagnosed preoperatively with this condition, is described with a review of its pathogenesis and present surgical treatment.

Retention of "safe" blood donors. The Retrovirus Epidemiology Donor Study.

BACKGROUND: There are obvious advantages to increasing donor retention. However, for reasons of blood safety, certain donors may, in fact, be more desirable to retain than others. "Safe" donors are defined as those who provided a blood donation that was negative on all laboratory screening tests and who subsequently reported no behavioral risks in response to an anonymous survey. This study identifies the most important factors affecting the intention of "safe" donors to provide another donation. STUDY DESIGN AND METHODS: An anonymous survey asking about donation history, sexual history, injecting drug use, and recent donation experience was mailed to 50,162 randomly selected allogeneic donors (including directed donors) who gave blood from April through July or from October through December 1993 at one of the five United States blood centers participating in the Retrovirus Epidemiology Donor Study. Before mailing, questionnaires were coded to designate donors with nonreactive laboratory screening tests at their most recent donation. RESULTS: A total of 34,726 donors (69%) responded, with substantially higher response among repeat donors. According to reported intentions only, the vast majority of "safe" donors indicated a high likelihood of donating again within the next 12 months. Only 3.4 percent reported a low likelihood of donating again. A comparison of those likely to return and those unlikely to return reveals significant differences in demographics and in ratings of the donation experience. A higher proportion of those unlikely to return were first-time donors, minority-group donors, and donors with less education. The highest projected loss among "safe" donors was seen for those who gave a fair to poor assessment of their treatment by blood center staff or of their physical well-being during or after donating. CONCLUSION: These data suggest that efforts to improve donors' perceptions of their donation experience, as well as attention to the physical effects of blood donation, may aid in the retention of both repeat and first-time donors.

Laparoscopic salvage of malfunctioning peritoneal catheters.

BACKGROUND: Malfunction of peritoneal catheters due to mechanical outflow problems is an annoying complication in patients undergoing chronic peritoneal dialysis (PD). Correction often involves catheter replacement or revision via laparotomy. METHODS: Twenty-five patients undergoing PD who developed mechanical catheter flow restriction underwent 28 laparoscopic procedures. Preoperative diagnoses were made by contrast catheter radiography and were: catheter sequestration (36%), omental wrap (64%). Pneumoperitoneum was induced after general anesthesia and laparoscopy was performed using a Storz laparoscope. The catheter was then identified and manipulation was attempted using instruments placed percutaneously. RESULTS: In 26 cases (93%), the catheter was freed and function restored. In two cases (7%), adhesions were so numerous and dense that the distal catheter could not be visualized. Four episodes of peritonitis developed subcutaneous leakage of peritoneal fluid which responded to cessation of PD for 2 weeks. Four patients had recurrent occlusions; three of these were managed laparoscopically. Two patients developed late hernias at the site of insertion of the laparoscope. Catheter patency averaged 9.2 months postoperatively. CONCLUSIONS: Laparoscopic revision is a successful technique for salvage of occluded peritoneal catheters.

Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis.

Malignant tracheo-esophageal fistula (TEF) is a serious complication of cancer arising usually in the esophagus, lung, or tracheobronchial tree. Repeated aspiration and pneumonia lead to rapid deterioration and death. The prognosis is dismal and curative resections are curiosities. Surgical bypass of the lesion has been performed but is associated with 25-61% mortality. Other treatments have been employed, such as enterostomies, esophageal endoprostheses, and supportive care. The reported mortality of palliative procedures using endoprostheses, surgical bypass, or exclusion in almost identical. A retrospective review of the data over the past decade revealed a trend toward insertion of endoprostheses. Insertion of endoprostheses can be performed in an endoscopy suite, under sedation, and has fewer major complications than occur with a surgical approach. The periprocedure mortality rate for these patients is 15%, compared to a 29-47% perioperative mortality for patients undergoing surgery. Even so, patients after surgical procedures could survive for 8 months or more, which is better than survival after endoprosthesis intubation. We conclude that insertion of an esophageal endoprosthesis should be the usual preferred option for palliative treatment of malignant TEF. However, for special candidates a surgical procedure is a valid option.

Diaphragmatic hernia following transhiatal esophagectomy.

Transitional esophagectomy (THE) has been advocated as an alternative to the classic transthoracic approach. A variety of complications have been previously described with THE however, these can be avoided with meticulous detail to its technique. We report a patient who developed a complete small bowel obstruction secondary to a diaphragmatic hernia following transhiatal esophagectomy. Techniques to prevent such a rare complication is described.

Doctor-shopping in Hong Kong: implications for quality of care.

Doctor-shopping is defined as the changing of doctors without professional referral in the same illness episode. Two surveys on samples of patients attending Government Out-Patient Departments (GOPDs) in Hong Kong in 1989 (n = 869) and 1990 (n = 901) estimated the prevalence of shopping at nearly 40%, the main reason being a persistence of symptoms. Doctor-shoppers were likely to be younger with higher expectations of health care and who expressed dissatisfaction about aspects of the present service. In Hong Kong, patients perceive western medicine to be more effective and have high expectations of the effects of western drugs, in particular, in their administration by injection. Patients should be warned about iatrogenic health risks incurred from doctor-shopping; health education programmes are needed to modify unrealistic views about quality care. Health care providers in a mixed care system should promote greater continuity of care between doctors and both the public and private sectors, and identify and resolve problems which may be responsible for discontinuity of care.

Selective management of colonoscopic perforations.

BACKGROUND: Colonoscopy is a safe procedure if performed properly. Perforations from such procedures are rare, but not entirely avoidable. Usually perforations from diagnostic colonoscopy result in large defects requiring surgical management. Perforations from therapeutic colonoscopy occur by a different mechanism and frequently result in a smaller perforation. STUDY DESIGN: This is a retrospective review of 26,708 consecutive colonoscopic procedures performed from January 1986 to June 1992. RESULTS: There were 12 perforations, five from diagnostic colonoscopy and seven from therapeutic colonoscopy. All patients with perforation from diagnostic colonoscopy were treated operatively, while six of the seven perforations from therapeutic colonoscopy were managed nonoperatively. The type of operation depended upon the intraoperative findings. CONCLUSIONS: Perforations from therapeutic colonoscopy occur by a different mechanism than from diagnostic colonoscopy and may be selectively managed without an operation and with a low mortality and morbidity rate, provided proper guidelines are adhered to.

Splenic trauma following endoscopic retrograde cholangiopancreatography (ERCP).

Endoscopic retrograde cholangiopancreatography (ERCP) is a safe diagnostic and therapeutic procedure. Splenic injury after ERCP is extremely rare and only two cases have been reported in the English literature. A subcapsular splenic hematoma is reported after ERCP and the mechanism of injury and possible preventive measures are discussed.

Nonoperative management of esophageal perforation secondary to balloon dilatation.

Esophageal perforation is usually considered a surgical emergency. However, esophageal perforation after therapeutic endoscopic manipulation is a different entity. This type of perforation occurs in a controlled environment and the perforation is usually detected early. Three documented cases of perforation during endoscopic balloon dilatation are described. They were successfully treated nonoperatively.

Endoscopic placement of long intestinal tubes.

Partial intestinal obstruction has been successfully managed by the use of long intestinal tubes. For proper decompression, the long tube must pass beyond the pylorus; however, failure of the tube to progress by gravity alone has been reported to be as high as 46 per cent. A simple method of endoscopic placement of the long tube into the duodenum is described. If one is familiar with performing upper endoscopy, this technique can be learned easily.

Two years experience with the Palmaz-Schatz coronary stent in a heterogeneous patient population.

Between January 1991 and December 1992, 136 Palmaz-Schatz coronary stents were implanted in 113 native coronary arteries in 106 patients. Forty-seven patients presented with stable angina, 50 with unstable angina, 7 with congestive cardiac failure and unstable angina and 2 were asymptomatic. Stenting was carried out in 15 patients for restenosis after coronary angioplasty (PTCA), 32 for significant dissection during PTCA (with 19 acute and 13 threatened closure), 10 for suboptimal PTCA results and 56 for de novo lesions, 52 (92.9%) of which were either ACC/AHA type B or C. Successful delivery was achieved in 97.2% (103/106) of patients or 97.3% (110/113) of vessels. Percent diameter stenosis was reduced from 78 +/- 13% to 4 +/- 11%. There were two subacute stent thromboses (1.9%), resulting in Q-Wave myocardial infarction. Three deaths (2.9%) occurred, all from the group with congestive cardiac failure and unstable angina. Major bleeding/vascular complications occurred in 4 patients (3.9%). All patients were followed up for a mean of 18 months (6 months to 30 months). Eighty-five patients were asymptomatic. Three patients were angina-free but continued to have, albeit improved, congestive cardiac failure. Ten patients had recurrence of angina, all within 6 months of the stenting procedure. Four were treated medically and 4 had PTCA of whom one eventually had coronary bypass surgery. Two patients had new lesions, successfully treated by PTCA or stenting. In conclusion, a high rate of successful delivery of the Palmaz-Schatz coronary stent can be achieved in a wide spectrum of patients with few complications which are mostly related to anticoagulation. It offers very effective bailout for acute closure during PTCA. Despite the presence of unfavorable pre-procedure patient and lesion characteristics, the acute and long term clinical results are encouraging.

Moxalactam disodium compatibility with intramuscular and intravenous diluents.

The stability of moxalactam disodium with mannitol injection in combination with intramuscular and intravenous diluents was investigated. Solutions were stored in original glass containers stoppered with butyl rubber closures or in polyvinyl chloride bags. Five diluents were evaluated at an intramuscular concentration of moxalactam 1 g (as the disodium salt) in 3 ml of diluent. Twenty intravenous diluents were evaluated with moxalactam 1 g (as the disodium salt) in 50 or 500 ml of diluent. High-performance liquid chromatography, polarography, thin-layer chromatography, spectrophotometric color evaluations, nephelometry, and pH determinations were performed. Solutions were assayed initially after reconstitution and stored for subsequent assay at refrigerator (5 degrees C) and room (25 degrees C) temperatures. The moxalactam disodium solutions were stable for up to 96 hours when stored at 5 degrees C or 24 hours when stored at 25 degrees C. The color, clarity, and TLC data were satisfactory for all diluent combinations tested. Polarographic, HPLC, and TLC data showed that the degradation products remained within acceptable limits when stored for 96 hours at 5 degrees C or 24 hours at 25 degrees C. The slight pH changes were within regulatory limits for moxalactam. The moxalactam disodium solutions maintained at least 90% of initial potency for up to 96 hours when stored in a refrigerator. If kept at room temperature, the reconstituted solutions should be used within 24 hours.