Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair.

BACKGROUND: Posterior cruroplasty repair of a large paraesophageal hiatus hernia has a higher than desirable rate of recurrence attributable to the inexorable cyclic negative intrathoracic pressure of respiration and positive intraabdominal pressure produced by straining, physical exertion, and coughing. To reduce the risk of recurrence after repair of a large hiatus hernia and intrathoracic stomach, we have used posterior cruroplasty reinforced with an onlay polypropylene mesh prosthesis. This paper reviews the feasibility of this technique. STUDY DESIGN: We did a retrospective review of 44 patients with large hiatus hernia and intrathoracic stomach who had posterior cruroplasty and onlay of polypropylene mesh prosthesis applied to the crura and adjacent diaphragm to repair the hiatal defect. RESULTS: Preoperative symptoms (mean duration, 26 months) included pain (33 patients), vomiting (21), dysphagia (19) and anemia (8). The typical patient (28 men and 16 women, mean age, 60) had two-thirds or more of the stomach above the diaphragm. Organoaxial gastric volvulus and herniated large or small bowel were present in 10 and 9 patients, respectively. A gastrostomy was performed for temporary drainage in 38 patients in addition to the hernia repair; 11 patients underwent a concomitant Nissen fundoplication. Postoperative complications included pleural effusion (four patients), atrial dysrhythmia (three patients), and superficial wound infection (two patients). Mean followup for 43 patients was 52 months. There have been no clinical recurrences. CONCLUSIONS: Mesh prosthesis reinforced hiatus hernia repair is effective, appears to have a low clinical recurrence rate, and should be an option in the treatment of a large hiatus hernia with intrathoracic stomach.

Penetration of ciprofloxacin and fleroxacin into biliary tract.

Forty patients with chronic cholecystitis or cholelithiasis were prospectively randomized for therapy with either ciprofloxacin or fleroxacin to study the penetration of these two agents into gallbladder tissue, plasma, and bile. Patients received a 3-day course of ciprofloxacin (500 mg twice a day) or fleroxacin (400 mg once daily) and were subdivided into four groups reflecting intraoperative sample collection at 4, 7, 14, and 25 to 26 h following the last quinolone dose. Mean concentrations in plasma for ciprofloxacin and fleroxacin at 4 and 25 to 26 h postdose were 2.5 and 10 micrograms/ml and 0.3 and 1.8 micrograms/ml, respectively. The concentrations of ciprofloxacin and fleroxacin in bile and gallbladder wall tissue at 25 to 26 h postdose were 4.5 and 8.6 micrograms/ml and 1.2 and 4.4 micrograms/ml, respectively. Both agents demonstrate rapid tissue penetration with persistence at levels appropriate for treatment of biliary pathogens.

Use of monoclonal antibodies in colorectal cancer: a review.

This is a review article covering the development of monoclonal antibodies attached to a radioactive isotope which are used in scanning for metastatic adenocarcinoma of the colon. The most recent and complete study described 223 patients, of which 169 were evaluated. All patients required an operation. At operation, biopsies were taken of the resected tumor. Some false negative areas, such as dilated varicosities and inflammatory areas, were encountered. The latter can be seen as a chronic inflammatory process such as a leaking anastomosis with a diverticulum or old traumas in the pelvis. This technique allows a physician to follow patients, especially those who have had an abdominal perineal or exoneration of their pelvic organs, for possible recurrence in this area. There is also some discussion about possible future uses in the treatment of the metastatic disease.

Nonopioid analgesics shorten the duration of postoperative ileus.

Morphine inhibits propagating and stimulates nonpropagating colon contractions in monkeys and humans. The use of morphine or other opioids that inhibit propulsive contractions prolongs postoperative ileus. In contrast, ketorolac tromethamine, a nonsteroidal analgesic, has no effect on colon contractions in monkeys. In 14 patients having elective abdominal operations, bipolar electrodes were implanted on the right (n = 13) and left (n = 10) colon. Group A (n = 8) received ketorolac, 30 mg IM q6h, for pain relief. Group B (n = 6) needed supplemental morphine, 2-10 mg IV or IM, plus ketorolac to control their pain. Myoelectric activity was recorded from each subject on postop Days 1-5 and analyzed by computer for electrical control activity (ECA), short and long electrical response activity (ERA), and propagation of long ERA. There was a difference between the two groups in return of propagated long ERA bursts that correlated with clinical recovery from postoperative ileus. Postoperative analgesia with ketorolac resulted in faster resolution of ileus compared to morphine plus ketorolac because opioid-induced motor abnormalities in the colon were avoided.

Opioid and nonopioid analgesic drug effects on colon contractions in monkeys.

Opioid drugs administered postoperatively for pain relief cause increased frequency of nonpropulsive phasic contractions but decreased to absent propulsive migrating contractions in the colon, thus importantly influencing the duration of postoperative ileus. Ketorolac is thought to permit earlier return of bowel function postoperatively compared to morphine. Four monkeys had sets of three strain gauge force transducers implanted on the right and left colon at laparotomy. After recovery, animals were fasted overnight and had colon contractions recorded. After a 1-hr baseline period, 200 micrograms/kg morphine sulfate or 1 mg/kg ketorolac tromethamine was injected intramuscularly and recording continued. Each animal received four injections of each drug. Records were analyzed visually for frequency of phasic on migrating contractions. There was no difference in the frequency of phasic or migrating contractions after injection of ketorolac. Morphine, as expected, increased the frequency of phasic and decreased the frequency of migrating contractions in the colon. Ketorolac does not affect the frequency of colon contractions.

Laparoscopic gastric bypass in a porcine model.

Gastric bypass and vertical banded gastroplasty are the two procedures used most frequently in the treatment of morbid obesity. In a pilot study, we used a porcine model in which laparoscopic gastric stapling and Roux-en-Y gastrojejunostomy were accomplished.

Routine or selective intraoperative cholangiography in laparoscopic cholecystectomy.

The routine versus selective use of intraoperative cholangiography has been the subject of debate for some time. Most authors currently advocate routine intraoperative cholangiography with laparoscopic cholecystectomy. The authors report their experience with the selective and routine utilization of intraoperative cholangiography at two institutions. At institution A, 155 laparoscopic cholecystectomies were attempted, and 21 cholangiograms were performed (based on preoperative criteria of ultrasound, liver function tests, and history of jaundice, or intraoperative anatomical uncertainty). At institution B, 164 laparoscopic cholecystectomies were attempted and 127 cholangiograms were performed (a routine intraoperative cholangiography policy). At institution A, there were no common bile duct injuries but there was one retained stone. At institution B, there was one common bile duct injury and no retained stones. The patient with the retained stone from institution A had a preoperative indication (total bilirubin = 4.4 mg/dl) for a cholangiogram, but it was not performed due to technical difficulties. This patient later required endoscopic sphincterotomy with stone extraction. One patient at institution B had a choledochotomy which was detected by intraoperative cholangiography (IOC). This was managed with a T-tube. The selective use of cholangiograms in laparoscopic cholecystectomy will not yield a higher incidence of common bile duct injuries or retained stones compared to routine use. Further, a cholangiogram may not necessarily prevent choledochotomy but can prevent extension of common bile duct injury. Thus, it should always be performed when there is anatomic uncertainty.

Glucose response to abrupt initiation and discontinuation of total parenteral nutrition.

Plasma glucose was studied during the initiation of total parenteral nutrition (TPN) and the discontinuation of TPN without a tapering schedule. Blood was sampled every 5 minutes for 2 hours after the start of TPN and 1 week later as TPN was discontinued. A total of 14 initiations and 14 discontinuations were studied in 18 patients. Severity of illness in patients ranged from stable condition postoperatively to multiple-system failure; six patients had diabetes mellitus. The TPN solution was a 3:1 admixture that provided a caloric intake equal to 1.2 times the resting energy expenditure, with 40% fat and 60% carbohydrate calories. An average of 1963 kcal was provided per day (340 g of glucose, 79 g of fat). During the initiation phase, the mean increase in plasma glucose was 60 mg/dL. The increase for diabetic patients was 79 +/- 14 mg/dL compared with 52 +/- 23 mg/dL for the nondiabetics. During the discontinuation phase, the mean plasma glucose decreased 40 +/- 20 mg/dL; two patients with high concentrations of regular insulin (50 and 100 units) showed an increase in plasma glucose when the TPN was stopped. Plasma glucose returned to the preinfusion baseline after discontinuation. During both initiation and discontinuation, plasma glucose showed little change after the first 60 minutes. No clinical symptoms of hypoglycemia were observed. In conclusion, TPN as a 3:1 admixture can be safely started as full nutrition support and stopped abruptly without a tapering schedule. Plasma glucose response is rapid, predictable, and mostly complete within 60 minutes.

Transhiatal and transthoracic esophagectomy for adenocarcinoma of the esophagus.

Adenocarcinoma of the esophagus is no longer rare and is treated by resection. To determine whether the approach used for resection influences outcome, we studied 88 patients who underwent resection; 14 had stage I or II disease, 74 had stage III, and 40 had stage IV. One third of those with Barrett's esophagus were noted on screening endoscopy to have potentially curable disease; the others were diagnosed with stage III or IV disease. Transhiatal esophagectomy was performed in 63 patients; 24 patients underwent transthoracic esophagectomy. We found no difference in survival or morbidity between transhiatal and transthoracic esophagectomy. Overall 5-year survival for stage I and II disease was 86%. For stage III and IV disease, 5-year survival was 14.5%. Aggressive surveillance of Barrett's esophagus facilitates the discovery of early disease. Esophagectomy for adenocarcinoma can result in cure of early cancers and improved palliation of more advanced disease.

Arginine vasopressin inhibits phasic contractions and stimulates giant contractions in monkey colon.

Abdominal cramps and urgent defecation are common side effects of clinical doses of arginine vasopressin, indicating that the drug may have stimulating effects on colonic motor activity. Four strain-gauge transducers were implanted on the colon in six monkeys. A blood flow probe was fixed on the inferior mesenteric artery. After a 1-hour control recording, vasopressin, 0.13, 1.3, or 13.0 ng.kg-1.min-1, was infused intravenously for 90 minutes. The frequency of basal colonic contractions was reduced with increasing doses of vasopressin, but their mean amplitude and duration were not altered. Giant migrating contractions associated with defecation were initiated by the highest dose of vasopressin. Atropine had no effect on these giant migrating contractions but completely inhibited normal phasic contractions. Hexamethonium completely inhibited both giant migrating contractions and phasic contractions. Parasympathetic denervation of the colon did not inhibit giant migrating contractions initiated by vasopressin. Our findings suggest that the physiological concentrations of serum vasopressin present perioperatively may transiently inhibit spontaneous colon contractions but are unlikely to be the major cause of postoperative ileus. The giant migrating contractions initiated by vasopressin may account for the defecation associated with pharmacological doses of vasopressin. The initiation of giant migrating contractions by vasopressin may be mediated through a neural pathway.

Gastric secretion pH measurement: what you see is not what you get!

We evaluated the accuracy of gastric secretion pH measurements as performed in three ICUs. The pH of 275 samples was measured with pH paper using established techniques. The pH of 85 additional samples was determined with a hand-held pH meter. All specimens also were measured using a research laboratory pH meter to learn the true pH. Analyses included mean and SD of the difference between the two measurements, the correlation coefficient (r value), and the concordance correlation coefficient. The pH meter values disagreed significantly with pH paper measurements. Measurements of gastric secretion pH with pH indicator paper do not guide therapy reliably. Inaccurate values derived from pH paper measurements could have resulted in inappropriate treatment in 28% of the samples tested. A portable, battery-powered pH meter accurately reproduced laboratory pH meter measurements and is a reasonable device for clinical use.

Effects of morphine on colonic myoelectric and motor activity in subhuman primates.

We investigated the effects of numerous doses of morphine on colonic myoelectric and motor activity in monkeys. In each of four monkeys (Macaca arctoides), combined strain gauge transducers and bipolar electrodes were chronically implanted at four defined sites in the colon and recordings were made for 3 h in fasted, unanesthetized animals before and after intravenous administration of morphine sulfate (10-1,000 micrograms/kg). The basal fasting pattern of colonic motility was characterized by random contractions, nonmigrating clusters of contractions, and migrating individual contractions. Morphine at very low doses (10-25 micrograms/kg) had no effect on colonic motility at any site. At doses of 50-200 micrograms/kg, clusters and migrating contractions were eliminated, but there was an overall increase in the frequency of random contractions without an alteration in contraction amplitude or duration. At morphine doses of 500 and 1,000 micrograms/kg, contraction clusters and migrating contractions also were not seen, but there was a decrease in the colonic motility index caused entirely by a decreased frequency of random contractions. Both stimulation and inhibition were most marked in the sigmoid colon. Morphine has a dose-dependent biphasic effect on colonic myoelectric and contractile activity and alters colonic motility patterns by inhibiting migrating contractions and clusters of contractions.

Effects of vagal cryo-interruption on colon contractions in monkeys.

The influence of the vagus nerve on normal colon contractions, and the distal extent of this influence along the colon, is unknown. It is generally thought that the vagus nerve has little, if any, influence on normal colon contractions, and if there is any effect, it is limited to the proximal colon. The technique of reversible truncal vagotomy by cooling (vagal cryo-interruption) was used to explore the influence, and extent of any influence, of the vagus nerve on contractions of the colon in unanesthetized monkeys. Each monkey was subjected to vagal cryo-interruption in the fasted and fed states. In both states this caused a significant decrease in contractions in the proximal, middle, and distal portions of the colon, compared with baseline control and recovery periods. These studies indicate that the vagus nerve plays a role in normal contractions of the intra-abdominal colon in both the fasted and the fed states and that it also plays a role in the gastrocolic response.

Zona fasciculata cortical adenoma and adrenal medullary hyperplasia in MEN II patient: unique concurrent presentation.

I-131 MIBG for the localization of pheochromocytoma is a highly specific agent. In this case report, an apparent false-positive finding attributed to the presence of three zona fasciculata cortical adenomata was ultimately deduced to be due to the presence of adrenal medullary hyperplasia in this MEN patient.

Effects of halothane, enflurane, and nitrous oxide on colon motility.

Previous work from this laboratory has demonstrated that the colon, particularly the left colon, is the major site of persistent postoperative ileus after both minimal and more extensive abdominal operations. Inhalation anesthetics have been implicated in the past as a possible cause of altered postoperative bowel function, but direct evidence of such a role in postoperative ileus is lacking. In this investigation, the effects of three inhalation anesthetic agents, halothane, enflurane, and nitrous oxide, on contractile function of the right and left colon were investigated in monkeys. Enflurane and halothane administration caused cessation of contractions in both the left and right colon; suppression of motor activity continued throughout the period of anesthetic administration. Recovery of normal contractile function occurred relatively promptly after cessation of anesthesia with these drugs. Return of normal contractions was more prompt in the right than in the left colon. Administration of nitrous oxide was not associated with significant suppression of contractile function of either the the right or left colon. None of the three agents studied appear to have any role in typical postoperative ileus.

The effect of whole-gut lavage on colon motility and gastrocolic response in a monkey.

The effects of thorough colon lavage on fasting electrical control and response activities, as well as on muscular contractions, were recorded from the right, transverse, mid, and left colon of four conditioned monkeys. The gastrocolic response of monkeys to feeding is most prominent in the right and transverse colon in both duration and frequency of contractions. The response is reduced in midcolon and is just discernible in the left colon in fasted but otherwise unprepared animals. After lavage of the colon, a gastrocolic response to feeding is vigorously present throughout the colon. The removal of colonic content by lavage also leads to an increase in the duration of the gastrocolic response. These experimental observations are consistent with the results noted in humans in similar although less systematic experiments. Although the mechanism is unknown, the presence of stool in the lumen appears to blunt the contractile gastrocolic response of the colon to feeding.

Resolution of postoperative ileus in humans.

Bipolar electrodes were placed in the ascending and descending colon of 13 patients during laparotomy. The magnitude of their operations varied from exploratory laparotomy to total gastrectomy. The magnitude and length of the operations performed did not correlate positively with the duration of postoperative ileus. Signals were recorded for up to 4 hours daily for up to 8 days after operation during periods of rest and, in some patients, after administration of epidural or parenteral morphine sulfate. Power spectrum analyses of electrical control activity (ECA) showed dominant frequencies in both lower (2-9 cpm) and higher (9-14 cpm) ranges. During postoperative recovery, the mean ECA frequencies in right and left colon were relatively constant, but a variety of dominant ECA frequency relationships were observed. The modal pattern in the right colon was a shift in the dominant frequency from the higher to the lower range as recovery progressed, while the modal pattern in the left colon was persistent dominance of ECA in the higher frequency range. Electrical response activity (ERA) initially was comprised of only random, disorganized single bursts but became progressively more complex through the initial 3 postoperative days with the appearance of more organized bursts and clusters, some of which propagated very slowly (about 5 cm/min) both orad and aborad. ERA recovery culminated, typically on the third or fourth postoperative day, with the return of long bursts of continuous ERA, some of which propagated at a higher velocity (about 80 cm/min) and exclusively in the aborad direction and which were accompanied by passage of flatus or by defecation.

Carcinoid tumors.

A retrospective study of 86 patients with carcinoid tumors was undertaken covering an 18-year period. The most common sites of tumor were the jejunoileum (28 cases), appendix (22), and rectum (16). These were followed by the bronchus, duodenum, colon, and stomach. Three tumors had such wide-spread metastasis that their primary sites of origin could not be determined. The appendiceal and rectal carcinoids were often benign and usually found as incidental tumors, whereas colon and jejunoileal carcinoids were often metastatic. The jejunoileal carcinoids were commonly associated with multiple tumor sites and had a high frequency of secondary neoplasms. Symptomatic tumors were often metastatic. Chronic intermittent intestinal obstruction was often present with mesenteric metastasis, and liver metastasis was associated with the carcinoid syndrome. The patients' survival was good if aggressive surgical therapy was undertaken for palliation of the tumors.

Inguinal hernia repair before and after prostatic resection.

From 1976 through 1981, 864 men had inguinal hernia repairs and 328 had prostatic resections at our Veterans Administration Hospital. Forty-four patients had symptomatic prostatic obstruction that required either transurethral or open prostatic resection within 12 months of hernia repair. Twenty-seven patients had prostatectomy prior to hernia repair, 16 had hernia repair before prostatic resection, and one had simultaneous procedures. There were no urinary tract infections (UTIs) after hernia repair in patients who had had prostatectomy first, while five patients who had hernia repair before prostatectomy developed UTI after hernia repair (P less than 0.01). The incidence of UTI after hernia repair correlated with the need for and duration of bladder catheterization as a result of prostatic obstruction. Complications after prostatectomy were similar regardless of the order of operation. There were no episodes of incarceration or strangulation in patients awaiting hernia repair after prostatectomy. These results suggest that, when an inguinal hernia and symptomatic prostatic obstruction occur together, the performance of prostectomy before hernia repair lowers the risk of morbidity by decreasing the incidence of UTI after hernia repair. This approach does not expose the patient to any additional risk related to the inguinal hernia.

Efficacy of oral and systemic antibiotic prophylaxis in colorectal operations.

A cooperative Veterans Administration study of the septic complication rate during large-bowel surgery was undertaken in two groups of patients. The first group received oral neomycin and erythromycin base plus parenteral placebo; the second, the oral antibiotics plus parenteral cephalothin sodium. During a five-year period, 1,128 patients were studied. The overall septic complication rate was 7.8% in patients receiving only oral antibiotics, and 5.7% in patients receiving both oral and parenteral antibiotics. This difference was not significant. The only significant finding was a greater incidence of fever of unknown origin in patients receiving only oral antibiotics. None of those patients were treated with additional antibiotics, and all fevers cleared spontaneously. There seems to be no discernible benefit from adding parenteral antibiotic prophylaxis when performing elective colon surgery if appropriate mechanical cleansing and oral neomycin and erythromycin therapy are employed.