Acalculous cholecystitis in a two year old.

The patient is a 2-year-old Caucasian boy with acute acalculous cholecystitis (AC) but none of the predisposing factors that are typically found in patients with this disease. The presentation and clinical course of the disease was typical of AC. Nonsurgical intervention resulted in resolution of the child's initial symptoms. After recurrent bouts of biliary colic over the ensuing ten weeks, further evaluations were completed. Persistent inflammation of the gallbladder was seen on computerized tomographic scans and a nonfunction of the gallbladder was demonstrated through radio-nucleotide scanning. After discussing the findings with the parents, we performed a routine laparoscopic cholecystectomy on the child. The typical presentation, diagnosis, and pathogenesis of AC are discussed.

Laceration of a saphenous vein graft by an epicardial pacemaker wire.

The use of temporary pacing wires has become wide-spread in cardiac surgery. Complications related to their use are rare. We report a case of cardiac tamponade following removal of an atrial pacing wire.

Nitric oxide: an overview.

Nitric oxide (NO), a paracrine-acting gas enzymatically synthesized from L-arginine, is a unique biologic mediator that has been implicated in a myriad of physiologic and pathophysiologic states. It is an important regulator of vascular tone and may be the mediator of the hemodynamic changes involved in sepsis and cirrhosis. In addition, there is increasing evidence that NO is involved in coagulation, immune function, inhibitory innervation of the gastrointestinal tract, protection of gastrointestinal mucosa, and the hepatotoxicity of cirrhosis. It has already been speculated that NO may represent a point of control or intervention in a number of disease states. The purpose of this paper is to provide the surgeon with a broad overview of the scientific and clinical aspects of this important molecule.

Management of multiple jejunoileal atresias with an intraluminal SILASTIC stent.

Multiple small bowel atresias present a unique challenge because maximum intestinal conservation is mandatory for survival. We recently treated a patient who had multiple atresias using a 7F SILASTIC catheter as an intraluminal stent. The catheter facilitated the completion of multiple primary anastomoses and served as a conduit for radiological evaluation and enteral feeding. The patient was a 1,860-g boy with 23 atresias of the jejunum and ileum. All stenotic segments were resected, and seven primary anastomoses were completed over the catheter. The distal 34 cm of bowel were exteriorized as a mucus fistula, with the catheter extending through to the level of the ileocecal valve. The proximal jejunal limb also was exteriorized. Eleven days later, contrast was instilled through the catheter and showed no leak or stricture. The catheter was then used for enteral nutrition and administration of the proximal jejunal effluent. Bowel continuity was reestablished after a tapering enteroplasty of the proximal jejunal limb. Parenteral nutrition was ultimately discontinued. Thirty-one months later, the patient no longer requires supplemental nutritional support. This case demonstrates the safety of multiple primary anastomoses over an exteriorized intraluminal stent. The catheter was useful in the radiological evaluation of the distal limb before it was used as an access route for enteral nutrition.

Intensive nutritional support and remedial surgical intervention for extreme short bowel syndrome.

Management of extreme short bowel syndrome (SBS) has changed dramatically over the last 20 years with notable improvements in survival and quality of life in patients with this syndrome. A review of our institution's medical records over a 12-year period (1980-1992) revealed 32 patients with < 100 cm (range, 14-94; median, 40) of functional small bowel after intestinal resection. The causes of intestinal loss included necrotizing enterocolitis (11 cases), atresias (8 cases), long-segment Hirschsprung's disease (5 cases), midgut volvulus (5 cases) and gastroschisis (3 cases). The mean follow-up period was 4.2 years, and four deaths were recorded (12.5%). Survival of eight of nine (88.9%) patients without an ileocecal valve (ICV) and with < 40 cm of small bowel was noted. The absence of an ICV, however, was associated with significantly prolonged total parenteral nutrition. Follow-up surgical procedures, including intestinal lengthening, tapering enteroplasty. Martin's procedure, longitudinal myectomy-myotomy, and ostomy take-down, were performed in 20 of the patients (64%). Prolonged survival and normal development can be expected for the patient with severe SBS who is given meticulous nutritional support and treated with carefully planned secondary surgical intervention. These results are also seen in patients with extreme SBS (< 40 cm residual small bowel length) and no ICV.

Epidermal growth factor enhances intestinal adaptation after massive small bowel resection.

Epidermal growth factor (EGF) has documented trophic effects on several tissues, including small bowel (SB) mucosa. The purpose of this study was to determine the effect of EGF on intestinal adaptation after massive resection. Young Sprague-Dawley rats (weight, 154 +/- 8.6 g) underwent a 75% proximal SB resection, with primary reanastomosis, and were continuously infused with equivalent volumes of either saline or human recombinant EGF (6.25 micrograms/kg/h) via a subcutaneous osmotic pump. In other animals, the SB was transected and reanastomosed without resection and either saline or EGF was infused. The animals were allowed standard rat chow and water ad libitum and were killed after 28 days. SB was harvested and subjected to histological examination. Intestinal mucosa was analyzed for total DNA and protein contents. After massive SB resection, subcutaneous administration of EGF resulted in significantly increased animal weight (294.5 +/- 16 v 242.8 +/- 14g; P < .05), SB weight (52.8 +/- 7.0 v 37.2 +/- 6.0 cm; P < .05), SB length (14.0 +/- 1.3 v 7.4 +/- 1.6 g; P < .05), and mucosal thickness (1.04 +/- 0.2 v 0.68 +/- 0.2 mm; P < .05). DNA and protein analyses suggest that EGF may augment the mucosal hyperplasia response to massive SB resection. Administration of EGF after massive SB loss may be of nutritional benefit to the host through its enhancement of the normal postresection intestinal response.

Dietary fish oil enhances macrophage production of nitric oxide.

Nitric oxide (NO) is recognized as an important mediator of hemodynamic regulation and multisystem organ failure (MOF). Although polyunsaturated fatty acids (PUFA) are known to modify the elaboration of some humoral mediators in MOF, their effect upon NO production has not been evaluated. This study was designed to examine the effect of omega-3 (omega 3) and omega-6 (omega 6) PUFA on macrophage production of NO, TNF, PGE2, and PGI2. Rats were fed diets of 18% by calorie safflower oil (omega 6) or fish oil (omega 3) for 12 days. Bronchoalveolar macrophages (BAM) were divided into group A (medium only), group B (0.5 microgram/ml PGE2 or PGI2 + medium) or group C (10 microM indomethacin+medium). Cells were stimulated with 100 U/ml interferon-gamma and 10 micrograms/ml Escherichia coli-LPS. In group A, BAM from animals fed omega 3 produced significantly more NO (3.64 vs 1.92 microM, P < 0.05) and TNF (8.52 vs 1.75 micrograms/ml, P < 0.05) than BAM from omega 6-fed animals. The addition of exogenous PGE2 or PGI2 (group B) ablated the difference in NO and TNF observed in group A. Indomethacin also (group C) ablated the difference in NO and TNF production seen in omega 3- and omega 6-fed animals noted in group A. These data demonstrate that PUFA influence BAM production of NO and TNF. Changes in the omega 6-derived prostanoids may account for the differences in TNF production, but these data suggest that PGE2 and PGI2 are not responsible for the observed differences in NO production.(ABSTRACT TRUNCATED AT 250 WORDS)