Severe upper abdominal pain due to a large hepatocellular adenoma.

A large hepatocellular adenoma was diagnosed in a female patient who was referred for severe upper abdominal pain. She had been using oral contraceptives over a period of 14 years. The clinical features, diagnosis and treatment are discussed.

Staging of rectal carcinoma using MR double surface coil, MR endorectal coil, and intrarectal ultrasound: correlation with histopathologic findings.

OBJECTIVE: Our goal was assessment of the preoperative staging of rectal carcinoma with MR with double surface coil, MR with endorectal coil, and intrarectal ultrasound (IUS) as correlated with histopathologic findings. MATERIALS AND METHODS: Fifteen patients with rectal carcinoma had preoperative evaluation using intrarectal ultrasound (all 15 patients), MR with double surface coil alone (6 patients), and MR with double surface coil combined with endorectal surface coil (9 patients). The results of the preoperative staging were correlated with the histopathologic findings. RESULTS: IUS correctly staged the depth of bowel wall invasion in 10 of 15 patients, understaged 4, and overstaged 1. MRI correctly staged 10 of 15 patients. Without the endorectal surface coil, three of six were correct, and with endorectal surface coil seven of nine. MR with the endorectal surface coil is able to show the rectal wall in more detail than the double surface coil. CONCLUSION: Endorectal surface coil MRI provides increased detail of the rectal wall, leading to better delineation of its different layers. This may lead to better staging results than with other MR techniques. The results with endorectal MRI probably equal those of IUS for staging small tumors in the rectal wall. MR with the double surface coil gives additional information about tumor spread in more advanced cases.

The value of parasternal mediastinoscopy in staging bronchial carcinoma.

Computed tomography (CT) is the non-invasive staging procedure of choice for assessment of metastasis to mediastinal lymph nodes in patients with bronchial carcinoma. Cervical mediastinoscopy can provide histologic evidence of mediastinal spread to the peritracheal, tracheobronchial and subcarinal lymph nodes. Sub-aortic and para-aortic nodes cannot be sampled via this route. The present study was performed to assess the staging value of the parasternal mediastinoscopy as a separate entity. Cervical and parasternal mediastinoscopy was performed in 37 patients with a proven diagnosis of non-small cell carcinoma of the left upper lobe. In 16 patients lymph node or tumor tissue could be biopsied via the parasternal route, in 21 patients no parasternal biopsy was taken. Of the 16 cases with biopsies, only one was positive (6%). Histologic examination of lymph node biopsy tissue was false negative in one other patient (6%). Of the 21 patients without biopsies taken during parasternal mediastinoscopy, three (14%) had proven lymphogenic spread to the subaortic and para-aortic nodes, detected at thoracotomy. The parasternal procedure changed treatment in only one patient (3%). Diagnostic sensitivity was 20%. It is concluded that parasternal mediastinoscopy should not be used as a routine staging procedure in patients with left upper lobe lung cancer.

Thoracoscopic treatment of postoperative chylothorax after coronary bypass surgery.

Chylothorax after sternotomy for aortocoronary bypass surgery is a rare but serious complication. To avoid lateral thoracotomy a left sided thoracoscopy was performed and the site of the leakage was immediately found and successfully clipped.

A comparative study of gastrectomy without vagotomy with either Roux-en-Y or Billroth II anastomosis in peptic ulcer.

Since recent small uncontrolled studies have suggested that surgery for peptic ulcer comprising partial gastrectomy with Roux-en-Y anastomosis without vagotomy effectively prevents postoperative enterogastric reflux without increasing ulcer recurrence rate, we have compared mortality, ulcer recurrence rate, and complaints in ulcer patients who had undergone partial gastrectomy with either Roux-en-Y (n = 47) or Billroth II anastomosis (n = 47). The groups were comparable with regard to age, sex, ulcer localisation, indication for surgery and number of emergency procedures. During postoperative follow-up, seven patients with Roux-en-Y have died, compared with nine patients with Billroth II gastrectomy. In two of the seven patients who died after Roux-en-Y gastrectomy, but in none of the nine who died after Billroth II resection, death was unequivocally related to postoperative ulcer recurrences. At 1, 2, 3 and 4 years postoperatively, 90 vs. 100% (not significant), 78 vs. 98% (p < 0.01), 72 vs. 95% (p < 0.01) and 72 vs. 95% (p < 0.01) of the patients were in remission after Roux-en-Y and Billroth II gastrectomy, respectively. All ulcers were localized at or just distal to the anastomosis, and were diagnosed within the first 3 postoperative years. We conclude that in peptic ulcer patients the ulcer recurrence rate after Roux-en-Y gastrectomy without vagotomy is considerably higher than after Billroth II resection. Thus, gastrectomy with Roux-en-Y anastomosis without vagotomy cannot be recommended as the primary procedure in patients undergoing partial gastrectomy for peptic ulcer disease.

Results of treatment of the adenocarcinoma of the esophagus.

The results of treatment in 74 patients treated in 1978-1990 for adenocarcinoma of the esophagus were retrospectively analyzed. The overall five-year survival was 7.8%, the median survival 10.0 months. Eighteen patients underwent a resection, in 13 patients with curative and in 5 patients with palliative intent. The median survival for these groups was 13.5 and 5.8 months, respectively. Thirty-one patients were irradiated. The response rate according to the WHO passage score was 79%. The median duration of response and survival was 6.0 and 9.5 months, respectively. Twenty patients were given palliative treatment, in the form of an endoprosthesis (10 patients), an endoprosthesis with chemotherapy (4 patients) or only chemotherapy (6 patients). The median duration of survival of patients in the palliative group was 6.5 months. The data are discussed in relation to results of treatment described in the literature.

Esophageal stricture as a complication in Henoch-Schönlein purpura.

We report on a three-year-old boy with Henoch-Schönlein purpura developing an esophageal stenosis during severe clinical course of this disease. There are to date no reports on the development of such a complication. The possible pathogenesis in relation to stricture formation of ileum and ureter in Henoch-Schönlein's purpura is discussed.

Application of sublingual buprenorphine in combination with naproxen or paracetamol for post-operative pain relief in cholecystectomy patients in a double-blind study.

In a double-blind, placebo-controlled study in 125 patients undergoing a cholecystectomy, a comparison was made of the quality of post-operative pain relief during 'patient-controlled' intake of sublingual buprenorphine in combination with either rectally administered naproxen 1000 mg/24 h, paracetamol 4000 mg/24 h or a placebo. Results obtained in 97 patients were analysed. Five of these patients needed a rescue medication with morphine hydrochloride intramuscularly because of insufficient pain relief or because of nausea and vomiting. The quality of pain relief, as measured on a four-point scale, was comparable in all three groups throughout the study period and no significant differences became apparent. Only on the day of surgery (day 0) was intake of buprenorphine significantly greater in the placebo group (2.3 tablets/24 h) than in the naproxen and paracetamol groups (1.8 and 1.5 tablets/24 h, respectively). It is concluded that after cholecystectomy 'patient-controlled' intake of sublingual buprenorphine as a sole agent provides acceptable pain relief in about 80% of patients. More elaborate methods, such as intravenous patient-controlled analgesia, might be necessary to achieve good pain relief in the remainder of these patients.

Short-term results of gastrectomy with Roux-en-Y or Billroth II anastomosis for peptic ulcer. A prospective comparative study.

Since the Roux-en-Y anastomosis prevents the sequela of postoperative enterogastric reflux after gastrectomy, this approach has been advocated as the primary procedure in patients undergoing gastrectomy for peptic ulcer. We have prospectively followed for 2 years 22 patients, in whom gastrectomy was performed with, at random, either Roux-en-Y (n = 11) or Billroth II (n = 11) anastomosis. Two of the 11 patients who had received the Roux-en-Y procedure had anastomotic ulcers, leading to reresection in one of them. These two patients were found to have the highest values for basal and pentagastrin stimulated gastric acid output. After the Billroth II procedure a single patient had a small anastomotic ulcerative lesion. Apart from differences in intragastric bile acids (p less than 0.0001) and the gastritis activity score (p less than 0.01), no significant differences were found between the patients with Roux-en-Y and Billroth II anastomosis with respect to basal and pentagastrin-stimulated gastric acid secretion, basal, postprandial and bombesin-stimulated serum gastrin secretion, serum pepsinogen A and C concentrations, the serum pepsinogen A/C ratio, postprandial glucose, and for a modified Visick grading. From this small series we conclude that, as compared with the Billroth II-anastomosis, the Roux-en-Y procedure effectively prevents enterogastric reflux, and is associated with a higher gastritis activity score, but not with differences in gastric acid, gastrin, pepsinogens, or Visick grading. Furthermore, inadequate reduction of acid secretion in some patients after the Roux-en-Y procedure may lead to recurrent peptic ulcers.

Effect of partial gastrectomy on serum anti-Helicobacter pylori immunoglobulins in peptic ulcer patients.

Since biliary enterogastric reflux is suggested to eradicate gastric infection with Helicobacter pylori (HP), we have investigated in a prospective randomized study the effect of partial gastrectomy with either Billroth II or Roux-en-Y anastomosis on infection with HP as assessed by the titers of IgG and IgA antibodies against HP in serum. These antibodies were measured by ELISA in serum of 22 patients before and at 10 days and 6, 15, and 24 months after either Billroth II (N = 11) or Roux-en-Y (N = 11) gastrectomy for peptic ulcer. All patients had HP demonstrated in their preoperative endoscopic gastric biopsies. The preoperative serum IgA antibodies against HP (anti-HP IgA) were increased in 20 of the 22 patients (range 0.21-1.69) while the IgG antibodies (anti-HP IgG) were increased in all 22 patients (range 0.38-1.31). Four of the Billroth II patients had clearance of HP from gastric biopsies accompanied by rapid and pronounced decrease of anti-HP IgA. In contrast, the patients with Roux-en-Y gastrectomy and the Billroth II patients with persistent HP infection had no change in anti-HP IgA after surgery. Anti-HP IgG showed variable results in the four patients without gastric HP infection and was not affected by gastrectomy in the patients with persistent HP infection. We concluded that serum anti-HP IgA, but not anti-HP IgG, is helpful in identifying those patients in whom HP is no longer demonstrable after Billroth II gastrectomy. Gastrectomy with Roux-en-Y anastomosis had no effect on gastric HP infection.

Effect of partial gastrectomy with Billroth II or Roux-en-Y anastomosis on postprandial and cholecystokinin-stimulated gallbladder contraction and secretion of cholecystokinin and pancreatic polypeptide.

This prospective study was undertaken to determine the effect of partial gastrectomy without vagotomy on postprandial gallbladder contraction and secretion of cholecystokinin (CCK) and pancreatic polypeptide (PP) in 22 peptic ulcer patients randomly assigned to either Billroth II (N = 11) or Roux-en-Y (N = 11) anastomosis. The patients were studied within two weeks before surgery and at six months postoperatively. After surgery basal gallbladder volumes were larger than preoperatively (P less than 0.02). Integrated postprandial gallbladder contraction was not significantly affected by gastrectomy, either in the patients with Billroth II anastomosis (2276 +/- 268 vs 1985 +/- 362%/60 min) or in those with Roux-en-Y anastomosis (2045 +/- 327 vs 2445 +/- 352%/60 min) when studied pre- and postoperatively, respectively. Similarly, integrated postprandial plasma CCK secretion was not significantly changed by either Billroth II gastrectomy (200 +/- 31 vs 166 +/- 21 pM/60 min) or Roux-en-Y gastrectomy (146 +/- 26 vs 147 +/- 12 pM/60 min). However, integrated postprandial PP secretion was significantly (P less than 0.05) lower after Billroth II gastrectomy (6.8 +/- 2.4 vs 2.2 +/- 1.0 nM/60 min), while the reduction in plasma PP after Roux-en-Y gastrectomy just failed to reach statistical significance (6.0 +/- 1.5 vs 3.4 +/- 0.9 nM/60 min). Similarly, the PP response, but not the gallbladder response, to an intravenous bolus injection of 1 IDU CCK/kg body weight was significantly decreased after gastrectomy independent of the type of anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Atypical characteristics of a group of children with intussusception.

We describe the characteristics of a group of 140 children with intussusception. They differed strikingly from the classical picture of intussusception given in textbooks and in publications concerning large series. We found a low incidence of intussusception especially in infants and young children. There were far more children of older ages, the delay in diagnosis was significantly longer and there was a very high percentage of leading points. These factors explained our low hydrostatic reduction rate. The weight of most children was under the fiftieth percentile. The percentage of small bowel intussusceptions was somewhat higher. These differences are important in the light of early diagnosis and evaluating the results of treatment.

Effect of gastrectomy with either Roux-en-Y or Billroth II anastomosis on small-intestinal function.

This prospective study was undertaken in patients scheduled for gastrectomy for peptic ulcer disease to determine the effect of partial gastrectomy with either Roux-en-Y (n = 11) or Billroth II anastomosis (n = 11) on the function of the small intestine. Patients were studied before and at 6 months (blood and small-intestinal function tests) and at 24 months (blood tests) postoperatively. Median postoperative body weights at 6 months (70.5 kg; p less than 0.01) and 12 months (70.3 kg; NS) were lower than preoperatively (73.0 kg). Haemoglobin concentrations at 6 months (8.9 mM; p less than 0.01) and at 24 months (9.1 mM; p less than 0.05) were also significantly reduced compared with the preoperative value (9.5 mM). However, neither at 6 nor at 24 months postoperatively were there significant changes for serum iron, iron saturation, folic acid, vitamin B12, protein, albumin, alkaline phosphatase, and calcium concentrations. Whereas no significant deterioration of the absorption of D-xylose and vitamin B12 or of faecal fat excretion was observed, the orocoecal transit time was significantly shortened from 98 to 50 min (p less than 0.01), the expiratory hydrogen excretion after a 50-g oral glucose load was significantly increased from 8 to 54 ppm (p less than 0.01), as was indicanuria from 257 to 368 mumol/24 h (p less than 0.01). Apart from a lower serum iron concentration and iron saturation index in the Roux-en-Y patients 6 months postoperatively (p less than 0.05), no significant differences between the two types of anastomosis were observed. It is therefore concluded that both in patients with Roux-en-Y and in those with Billroth II anastomosis most abnormalities observed after gastrectomy are secondary to an accelerated small-intestinal transit.

Prospective comparative study of the influence of postoperative bile reflux on gastric mucosal histology and Campylobacter pylori infection.

Biopsies of 17 peptic ulcer patients, randomly treated by partial gastrectomy with either Billroth-II (n = 9) or Roux-en-Y (n = 8) anastomosis were studied before and six months after surgery to determine the role of bile reflux in the early postoperative histological alterations of the gastric mucosa. After BII-gastrectomy bile acid reflux (median 16.1 mumol/h) was significantly higher (p less than 0.0001) than after RY-gastrectomy (0.1 mumol/h). Campylobacter pylori was present in the preoperative biopsies of all 17 patients. After RY-gastrectomy biopsies of all eight patients were positive for Campylobacter pylori, but was detected in only five of the nine patients with BII-gastrectomy. Preoperative scores of gastritis grading were similar in both groups and no significant differences were found postoperatively. Gastritis scores of the anastomotic mucosa in patients with BII-gastrectomy were significantly higher (p less than 0.02) than in the RY-gastrectomy group. Moreover, the reflux gastritis score in the four BII-gastrectomy patients cleared from Campylobacter pylori was significantly higher (p less than 0.02) than in the postgastrectomy patients harbouring Campylobacter pylori. The results suggest that reflux gastritis and Campylobacter pylori related gastritis are distinct microscopic entities and that bile reflux may play a role in the eradication of Campylobacter pylori after gastrectomy.

Gastric emptying after partial gastrectomy without vagotomy with primary Roux-en-Y or Billroth II anastomosis.

Several clinical studies have indicated that gastric emptying is delayed in patients with Roux-en-Y biliary diversion with vagotomy. In order to determine whether Roux-en-Y diversion without vagotomy also induces delayed gastric emptying, we have compared the effect of gastrectomy without vagotomy with either Billroth II or Roux-en-Y anastomosis on gastric emptying of a liquid and solid meal in 22 peptic ulcer patients. The emptying half-times (t1/2) for solid food were not significantly different, 54; 24-122 min (median and range) in the 11 patients with Billroth II gastrectomy, 68; 44-189 min in the 11 patients with Roux-en-Y gastrectomy, and 83; 27-114 min in 11 normal control subjects. However, the lag phase was significantly (p less than 0.01) shorter in the patients with Billroth II gastrectomy (5; 0-43 min) and Roux-en-Y gastrectomy (4; 2-12 min) than in the control subjects (10; 4-22 min). The t1/2's for the fluid meal were similar, 7; 4-49 min after Billroth II gastrectomy, 8; 4-32 min after Roux-en-Y gastrectomy, and 9; 3-20 min in the control subjects. In all subjects the lag phase for the fluid meal was very short, ranging from 0 to 3 min. It is concluded that Roux-en-Y diversion per se does not delay gastric emptying in man.

Chronic intussusception in children.

Nine children presented with intussusception lasting for 14 days or more. Their mean age was 8.5 years. Diagnosis of intussusception was delayed considerably, probably due to an unusual presentation. Compared with acute intussusception, symptoms consist of infrequent attacks of abdominal pain, sporadic vomiting and no, or small, changes in defecation. Marked weight loss and an abdominal mass assume diagnostic significance, in contradiction to bloody stools. Ultrasonography can be of diagnostic value. An attempt at hydrostatic reduction is often unsuccessful. A high frequency of organic lesions precipitating intussusception warrants early surgical intervention.

Diagnosis and treatment of adult intussusception.

Twenty adults were treated for intussusception in two large hospitals from 1969 to 1988. Fourteen intussusceptions originated in the small intestine and 6 in the large intestine. Diagnosis was reached preoperatively in only 10 patients, probably due to the atypical clinical picture. In addition to a high degree of suspicion, careful examination of plain abdominal radiograph and ultrasonography are helpful in diagnosing adult intussusception. In 18 of 20 patients, an organic lesion causing intussusception was found. In six patients the cause was a malignancy. In such cases surgical treatment is necessary. In jejunojejunal and ileoileal intussusceptions, an attempt at primary reduction followed by resection or enterotomy is justified. In most cases of ileocolic, ileocecocolic, and colocolic intussusception, primary resection is the treatment of choice, especially in patients over 60 years old because of the high incidence of malignancy.