Experience with laparoscopic gastric resection: results and outcomes for 37 cases.

BACKGROUND: This study aimed to review the authors' technique, results, and outcomes for laparoscopic gastric wedge and segmental resections in patients with benign gastric diseases. METHODS: A retrospective clinical chart review was performed for all the patients who underwent laparoscopic gastric resection at the Washington University Medical Center from 1997 through March 2004. The surgical approach, operative results, complications, and subsequent clinical course were analyzed. Data are expressed as mean +/- standard deviation. RESULTS: Laparoscopic gastric resection was attempted in 37 cases involving 21 women and 16 men with a mean age of 61 +/- 13 years. The indications for surgery included suspected gastric stromal tumor (GIST) or carcinoid (n = 22), other benign gastric lesions (n = 6), benign gastric outlet obstruction (n = 4), and nonhealing peptic ulcer (n = 5). Segmental resection using gastroenteric anastomosis, with or without vagotomy, was performed in 14 patients, wedge resection in 22 patients, and laparoscopic enucleation in 1 patient. Resection was totally laparoscopic in 25 cases and laparoscopically assisted (with an accessory incision) in 12 cases. The mean operative time was 165 +/- 58 min, and the blood loss was 84 +/- 77 ml. Two patients (5.4%) underwent conversion to open resection. Intraoperative gastroscopy was performed in 16 cases (44%) as an aid to the resection. Regular diet was resumed at a mean of 3.0 +/- 1.7 days, and the mean length of hospital stay was 3.9 +/- 2.1 days. Four patients (10.8%) experienced major complications including subphrenic abscess (n = 1), pneumonia with respiratory failure (n = 1), splenic vein injury requiring splenectomy (n = 1), and gastric outlet obstruction (n = 1) that required reoperation 1 year later. Minor complications included intraabdominal fluid collection (n = 1), postoperative gastroparesis (n = 1), urinary retention (n = 1), and incisional hernia (n = 1). CONCLUSIONS: Laparoscopic gastric resections can be performed safely in patients with a variety of benign gastric disorders. The use of an accessory incision for reanastomosis and specimen extraction facilitates the procedure in difficult cases.

Laparoscopic incisional hernia repair in a porcine model: what do transfixion sutures add?

BACKGROUND: The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh. METHODS: Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean +/- standard deviation. RESULTS: The mean hernia size was 8.5 +/- 0.5 cm by 5.5 +/- 0.7 cm, with no difference between groups. The operative time was significantly longer ( p = 0.006) for the Sutured group (62.1 +/- 16.8 min) than for the Tacks group (32.3 +/- 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly ( p < or = 0.05) higher adhesion score (5.4 +/- 3.3) than the Tacks group (2.0 +/- 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 +/- 1.5 N/cm, Tacks 3.8 +/- 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 +/- 0.6, Tacks 0.2 +/- 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 +/- 0.3 mm, Tacks 3.9 +/- 0.4 mm). CONCLUSIONS: In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.

Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS).

BACKGROUND: Because it has been suggested that obesity adversely affects the outcome of LARS, it is unclear how surgeons should counsel obese patients referred for antireflux surgery. METHODS: A prospective database of patients undergoing LARS from 1992 to 2001 was used to compare obese and nonobese patients. Patients were surveyed preoperatively and annually thereafter. Questionnaires were completed regarding global symptoms and overall satisfaction. RESULTS: Of the 505 patients, the body mass index (BMI) was <25 (normal) in 16%, 25-29 (overweight) in 42%, and >30 (obese) in 42%. Although the operative time was longer in the obese group than in the normal weight group (137 +/- 55 min vs 115 +/- 42 min, p = 0.003), the time to discharge and rate of complications did not differ. At a mean follow-up of 35 +/- 25 months, there were no differences in symptoms, overall improvement, or patient satisfaction. Further, the rates of anatomic failure were similar among the obese, overweight, and normal weight groups. CONCLUSIONS: Although the operative time is longer in the obese, complication and anatomic failure rates are similar to those in the nonobese at long-term follow-up. Obese patients have equivalent symptom relief and are equally satisfied postoperatively. Therefore, obesity should not be a contraindication to LARS.

Influence of spastic motor disorders of the esophageal body on outcomes from laparoscopic antireflux surgery.

BACKGROUND: The clinical outcomes of laparoscopic antireflux surgery (LARS) in patients with the spectrum of nonspecific spastic esophageal motor disorders (NSSDs) are not known. METHODS: From a prospective database of patients undergoing LARS between 1997 and 2000, those with preoperative manometry at our institution and follow-up at ?6 months were identified. RESULTS: Of the 121 patients, 35 had NSSDs. There were no differences in symptoms between groups preoperatively, but in the immediate postoperative period NSSD patients had more symptoms than nonspastic patients. At 18-month mean follow-up, NSSD patients reported significantly more heartburn (22% vs 7%), waterbrash (14% vs 4%), and medication usage (17% vs 5%) than nonspastic patients (p <0.05 for each). Despite this difference, nearly all patients reported subjective improvement postoperatively, and the degree of improvement was similar between groups. CONCLUSIONS: Patients with NSSDs are more likely to have esophageal symptoms following LARS than subjects without these abnormalities. However, these patients still experience significant improvement in preoperative symptoms.

Symptomatic outcomes of laparoscopic antireflux surgery in patients eligible for endoluminal therapies.

BACKGROUND: This study compared clinical outcomes after laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who would be eligible for endoluminal therapies (ET) with those in patients who would be excluded from ET. METHODS: From 1995 to the present, 459 patients who underwent LARS were analyzed prospectively. Of these, 117 patients (25%) without preoperative dysphagia, stricture, esophagitis worse than grade 2 or hiatal hernia larger than 2 cm were considered potential candidates for ET (group 1). By these criteria, 342 patients (75%) were not eligible for ET (group 2). Medication use and GERD symptoms were evaluated and compared between the two groups. RESULTS: Perioperative outcomes including duration of operation, morbidity, length of hospital stay and return to work were similar in the two groups. Although LARS significantly reduced medication use and GERD symptoms in both groups during a mean follow-up period longer than 2 years, there were no outcome differences between groups 1 and 2. The reported improvement in esophageal symptoms and overall satisfaction was 90% or more in both groups. CONCLUSIONS: The findings show that LARS is an effective treatment option in patients with GERD whether they are candidates for ET or not. In patients with uncomplicated GERD who currently meet inclusion criteria for ET, LARS provides excellent symptom relief and marked reduction in medication use during a mean follow-up period longer than 2 years.

Gastrin-mediated effects of omeprazole on rat colon mucosa.

BACKGROUND: Omeprazole increases circulating gastrin levels, which in turn may affect the growth and differentiation of colon mucosa. Chloride transport mechanisms in normal colon were analyzed as markers for possible trophic actions of endogenous hypergastrinemia. METHODS: Four groups of Fischer rats were studied for 10 days. Group 1 (baseline) received no treatment. Group 2 received omeprazole only. Group 3 received omeprazole plus vehicle. Group 4 received omeprazole plus CCK-B gastrin receptor antagonist (GRA) L740,093 in vehicle. On day 10 serum gastrin was assayed. Colon mucosa was analyzed for protein and DNA content. Semiquantitative Northern analysis measured levels of messenger RNA (mRNA) encoding for key Cl- transporters: Na-K-Cl cotransporter (Cl- secretion in crypts), Cl-/HCO3- exchanger (Cl- absorption in villi), and Na/K adenosine triphosphatase (not directly involved in Cl- transport). RESULTS: Omeprazole increased gastrin levels, which were not altered by vehicle or GRA. Omeprazole increased protein, DNA, and Na/K adenosine triphosphatase mRNA levels, with no effect by GRA. In contrast, omeprazole decreased Na-K-Cl and Cl-/HCO3- mRNA levels, effects that were partly reversed by GRA. CONCLUSIONS: Omeprazole augments growth index values of colon mucosa independent of serum gastrin. Against a background of omeprazole-induced achlorhydria hypergastrinemia appears to influence differentiation rather than growth of normal colon mucosa.

Selective increase in gastric mucosal mRNA encoding basolateral Na-K-2C1 cotransporter following ileostomy in the rat.

Results of previous studies suggest that major surgical resections or reconstructions of the distal small intestine can alter morphologic and functional properties of the stomach. Little is known about the effect of lesser surgical alterations such as construction of an ileostomy, on the morphology and transport properties of the gastric mucosa. To evaluate the effects of ileostomy, Sprague-Dawley rats underwent sham laparotomy (n = 10) or loop ileostomy construction (n = 10). After body weights had stabilized ( approximately 21 days) the animals were killed. Gastric mucosal scrapings were prepared for Northern blot analysis of messenger RNA levels for (1) H/K ATPase, found in parietal cells; (2) Na-K-2C1 cotransporter, found in both parietal and surface cells; and (3)Na/K ATPase, found in all gastric mucosal cells. Gastric mucosa from ileostomy animals was visibly hypertrophied compared to sham-operated animals. There was a 145% increase in the mRNA levels of the Na-K-2Cl cotransporter in gastric mucosa of the ileostomy group but no significant changes in H/K ATPase or Na/K ATPase mRNA levels. Construction of an ileostomy selectively enhances expression of the Na-K-C1 cotransporter in the gastric mucosa. Further studies are required to understand the neurohumoral stimuli underlying this selective response.

Identification and localization of the extracellular calcium-sensing receptor in human breast.

The extracellular calcium (Ca2+o)-sensing receptor (CaR) plays a critical role in maintaining Ca2+o homeostasis in mammals by virtue of its presence in parathyroid gland and kidney. The breast is well recognized as a Ca(2+)-handling organ, and the effects of altering Ca2+o on the proliferation of breast epithelial cells are well documented. To date there are no data regarding the expression and localization of CaR in breast tissue. In the present study, we assessed the distribution of CaR messenger ribonucleic acid (mRNA) and protein in normal and fibrocystic human breast tissue as well as in ductal carcinoma of the breast using RT-PCR, Northern analysis, and immunohistochemistry with CaR-specific antisera. In all tissues, RT-PCR performed using sense and antisense primers based on the sequence of the human parathyroid CaR complementary DNA amplified a product of the size expected (425 bp) for genuine CaR transcripts. Nucleotide sequencing of RT-PCR products confirmed more than 99% homology with human parathyroid CaR complementary DNA. Although insufficient quantities of mRNA were isolated from normal and fibrocystic tissue for Northern analysis, a single 5.2-kb CaR transcript was expressed in malignant breast tissue similar to the major CaR transcript in human parathyroid. Localization of CaR protein by immunohistochemistry showed specific CaR staining of the ductal epithelial cells of the breast in all three tissue types. These findings indicate the presence of CaR mRNA and protein in the breast, providing indirect evidence that the CaR may have some role(s) in the control of Ca2+ transport, epithelial cell proliferation, and/or other processes in normal and abnormal breast tissue.

Identification and functional assay of an extracellular calcium-sensing receptor in Necturus gastric mucosa.

In mammals and amphibians, increases in extracellular Ca2+ can activate bicarbonate secretion and other protective functions of gastric mucosa. We hypothesized that the recently cloned extracellular Ca(2+)-sensing receptor (CaR) is functioning in the gastric mucosa. In Necturus maculosus gastric mucosa, reverse transcription-polymerase chain reaction using primers based on previously cloned CaR sequences amplified a 326-bp DNA fragment that had 84% nucleotide sequence identity with the rat kidney CaR. Immunohistochemical localization of the CaR using specific anti-CaR antiserum revealed its presence on the basal aspect of gastric epithelial cells. In microelectrode studies of Necturus antral mucosa, exposure to elevated Ca2+ (4.8 mM) and the CaR agonists NPS-467 and neomycin sulfate resulted in significant hyperpolarizations of basal membrane electrical potentials and increases in apical-to-basal membrane resistance ratios. Circuit analysis revealed that these changes reflected specific decreases in basolateral membrane resistance. Inhibition of prostaglandin synthesis using indomethacin significantly attenuated these effects. We conclude that the CaR is present and functioning in Necturus gastric antrum.

The island rotation flap: a better alternative for nasal tip repair.

The use of the island rotation flap for the repair of small and medium-sized partial-thickness defects of the nasal tip and soft triangle has led to extremely favorable aesthetic results far superior to that of full-thickness skin grafts. The color and thickness match have been excellent, and the complication rate was negligible. The aesthetic results and reliability, coupled with the single stage and single operative site, make this flap an excellent option for nasal tip reconstruction. It is our procedure of choice for the reconstruction of small and medium-sized nasal tip and soft triangle defects.

Evidence for Cl(-)-independent HCO3- transport in basolateral membranes of Necturus oxyntopeptic cells.

Luminal H+ secretion by gastric mucosa is accompanied by basolateral HCO3- release. A basolateral Cl-/HCO3- exchanger is known to mediate HCO3- extrusion from oxyntopeptic cells during resting and secretagogue-induced apical HCl secretion. From recent work, we hypothesized that there might be a Cl(-)-independent pathway for basolateral HCO3- exit in Necturus oxyntopeptic cells. In this study, we used a fluorescent pH indicator [2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein] to evaluate Cl(-)-independent HCO3- transport across the basolateral membranes of intact oxyntopeptic cells. Removal of serosal Cl- increased intracellular pH (pHi) (7.05 to 7.25), consistent with Cl(-)-dependent HCO3- extrusion. Removal of serosal Na+ in the absence of Cl- resulted in significant acidification of pHi (7.10 to 6.89), but studies involving amiloride, 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS), and 0 HCO3(-)-N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid-buffered solutions suggest that Na(+)-dependent changes in pHi are due to Na+/H+ exchange. Our studies demonstrate a marked concentration-dependent alkalinization when tissues are exposed to increases in serosal K+. A substantial part of this alkalinization in response to increases in serosal K+ (pHi 7.00 to 7.46) appears to be a HCO3- exit pathway that is independent of both Na+ and Cl-, unaffected by bumetanide or amiloride, but sensitive to DIDS. We propose the presence of a Cl(-)- and Na(+)-independent K(+)-dependent HCO3- cotransporter in Necturus oxyntopeptic cell basolateral membranes.

Laparoscopy for chronic abdominal pain.

BACKGROUND: This purpose of this investigation was to evaluate the utility of laparoscopy in patients with chronic abdominal pain. METHODS: A retrospective review was performed of 34 patients who underwent laparoscopy for chronic abdominal pain. Average patient age was 39 years. The majority were women. Most had undergone abdominal surgery in the past. RESULTS: All procedures were performed laparoscopically. A positive finding was made in 65% of patients. Fifty-six percent of patients underwent adhesiolysis, but 26% required no operative intervention other than laparoscopic exploration. Notably, 73% of patients reported improvement in pain postoperatively, whether or not a positive finding had been made on laparoscopy. CONCLUSIONS: This retrospective study suggests laparoscopy can identify abnormal findings and improve outcome in a majority of selected cases. Recommendations are provided for patient selection. Prior abdominal surgery is not an absolute contraindication to laparoscopic exploration for chronic abdominal pain.

Pentagastrin selectively modulates levels of mRNAs encoding apical H/K adenosine triphosphatase and basolateral Na-K-Cl cotransporter in rat gastric fundic mucosa.

BACKGROUND: Gastrin regulates gastric acid secretion and gastric mucosal cell proliferation. We hypothesized that pentagastrin administration would affect mRNA levels of two membrane proteins that are important during stimulated states of HCl secretion, the basolateral Na-K-Cl cotransporter (BSC) and the apical H/K adenosine triphosphatase (H/K). METHODS: Two groups of Fischer rats received intraperitoneal injections of pentagastrin (2.5 or 25 micrograms/kg) every 8 hours for three doses. A third group served as controls. An additional group received pentagastrin plus the gastrin receptor antagonist (GRA) L740,093. Fundic mucosae were subjected to semiquantitative Northern analysis of mRNAs encoding H/K and BSC. The mRNA for Na/K adenosine triphosphatase (Na/K), a transport protein not involved directly in acid secretion, also was evaluated. RESULTS: Administration of pentagastrin caused dose-dependent increases in levels of mRNAs encoding H/K and BSC but had no significant effect on levels of Na/K mRNA. Administration of GRA prevented the pentagastrin-induced changes in mRNA levels for these transporters. CONCLUSIONS: Pentagastrin administration selectively up-regulates levels of mRNA encoding membrane proteins involved in acid secretion. The up-regulation of the mRNAs encoding BSC during pentagastrin stimulation indicates that regulation of basolateral Cl- movement may be as important as the regulation of apical H+ movement under stimulated states.

Effects of serosal-side acidosis on cell pH (pHi) and membrane electrical properties in gastric mucosa.

Acute gastric mucosal injury and bleeding occur in the settings of both respiratory acidosis or metabolic acidosis secondary to systemic sepsis or shock. Respiratory acidosis, however, is more predictably associated with acute injury than metabolic acidosis. We hypothesized that the gastric surface epithelial cells are more susceptible to acute increases in PCO2 than to acute decreases in HCO3-, even for the same level of extracellular acidification. To evaluate this hypothesis, we used intracellular microelectrodes to measure pHi, cell membrane potential (Vc), as well as ion conductances of the apical (Ga) and basolateral (Gb) membranes and the paracellular pathway (Gs) in gastric mucosal cells during acute changes in serosal PCO2 or HCO3-. Necturus antral mucosae were mounted in Ussing chambers, perfused on both sides by Ringer solution (40 mmHg PCO2, 18 mM HCO3-, pH 7.3). Measurements were performed before and during increases in PCO2 (80 mmHg, pH 7.0) or decreases in HCO3- (7.2 mM, pH 6.8 or 2.4 mM, pH 6.4). Both forms of acidosis acidified pHi, depolarized membrane potentials, and decreased ion conductances across apical and basolateral membranes, but not the paracellular pathways. For the same level of extracellular acidification, increases in PCO2 were more effective than acute decreases in HCO3- in acidifying pHi and eliciting disturbances in voltage-generating and ion permeability properties of the cell membranes. These findings suggest that pH-buffering mechanisms in gastric surface cells respond less effectively to high PCO2 than low HCO3.

Electrophysiological effects of cholinergic agonists in surface epithelium of Necturus gastric antrum.

Intracellular microelectrode techniques were used to characterize voltage and conductance properties of the basolateral membrane of surface epithelial cells in in vitro Necturus antral mucosa. Flux studies confirmed that this tissue secretes HCO3- under resting conditions and during response to cholinergic stimulation. In studies using intracellular microelectrodes, exposure to cholinergic agonists such as acetylcholine, bethanechol, or carbachol elicited an initial hyperpolarization followed by depolarization of the basolateral cell membranes associated with up to fourfold increases in basolateral membrane conductance. Effects of acetylcholine were dose dependent (10(-6) - 10(-4) M) and prevented by pretreatment of tissues with the nonselective muscarinic receptor blocker atropine. Some variation in this response to cholinergic stimulation was observed and appeared to be related to the season (fall/winter/early spring vs. late spring/summer). Despite such variability, circuit analysis and ion substitution studies indicated that the carbachol-induced increases in basolateral conductance were due to increases in conductance to K+ and Cl- . These increases in basolateral transport processes may serve to stabilize cell ion composition and membrane electrical properties during cholinergic stimulation of mucus and HCO3- secretions.

The chondrocutaneous helical rim advancement flap of Antia and Buch.

BACKGROUND: The cutaneous surgeon commonly encounters defects of the helix, as 2-4% of all skin cancers occur at this site. OBJECTIVE: We report our experience with 47 patients using the chondrocutaneous helical rim advancement flap of Antia and Buch. METHODS: Incisions are made from the defect inferiorly into the lobule and, when necessary, superiorly along the helical sulcus into the helical crus. The postauricular skin is extensively undermined to allow maximal movement of the resulting broadbased, well-vascularized flap(s). RESULTS: We experienced very favorable results using this technique with our patients. No necrosis due to ischemia occurred in any of our cases. Hematomas formed postoperatively in two patients, but healing proceeded uneventfully after removal of coagulated blood. CONCLUSION: This technique is an excellent method of repairing many defects of the helical rim. Its advantages include technical simplicity, little risk of tip necrosis, patient convenience, and superior cosmesis.

Analysis of methods for nasal tip reconstruction.

BACKGROUND: Numerous traditional and contemporary methods for nasal reconstruction are used today. Our investigation qualitatively analyzed different methods of nasal tip reconstruction which led to the development of an algorithm for repair based on the size, depth, and location of tissue loss. METHODS: A case series of 165 nasal tip reconstructions performed during a 2-year period followed for at least 6 months was critically analyzed with photographic documentation. RESULTS: Different methods of reconstruction exhibited varying aesthetic results. Analysis of surgical reconstructions led to the development of an algorithm based on the area of tissue defect. CONCLUSIONS: An algorithm was developed for nasal tip reconstructions based on the size and location of tissue defect. Both the recipient and donor sites were analyzed for aesthetic result and complications.

Cerebral metabolism and circulatory arrest: effects of duration and strategies for protection.

Hypothermic total circulatory arrest (CA) is commonly used to facilitate repair of complex congenital heart defects. However, the "safe" period of CA remains to be defined. Extended periods of hypothermic total circulatory arrest may impair cerebral metabolism and cause ischemic brain injury. This study defines the relationship between increasing durations of CA at 18 degrees C and cerebral metabolism, and examines the protective value of topical cooling of the head or continuous "trickle" flow (5 to 10 mL.kg-1.min-1). Thirty-three 1-week-old piglets were randomized to six experimental groups: control; 15, 30, or 60 minutes of CA; 60 minutes of CA with topical cooling of the head; and 60 minutes of trickle flow. Animals were placed on cardiopulmonary bypass (CPB) at 100 mL.kg-1.min-1 and cooled to 18 degrees C. After the experimental period of CA or trickle flow (or 60 minutes of CPB at normal flow for the control group), animals were rewarmed to 37 degrees C and weaned from CPB. Data were obtained before and immediately after CPB at 37 degrees C, and before and immediately after the experimental period at 18 degrees C. Parameters measured included cerebral blood flow by xenon 133 clearance, arterial and sagittal sinus blood gases, and cerebral metabolism. Hypothermic total circulatory arrest caused an impairment of cerebral metabolism that was directly proportional to CA duration (r2 = 0.73; p = 0.0001), and recovery of metabolic function after 60 minutes of CA improved more than 50% if the head was packed in ice.(ABSTRACT TRUNCATED AT 250 WORDS)

The tooth as a foreign body in soft tissue after head and neck trauma.

Thorough evaluation of dentition is important in the management of craniofacial trauma. Avulsed or fractured teeth in the pulmonary and gastrointestinal tracts can lead to serious complications that are well described. However, the penetration of avulsed teeth into soft tissues of the head and neck is unusual and may not be recognized. Two cases in which a tooth became a foreign body in these soft tissues are illustrative. One patient had bronchoscopy for possible aspiration of an avulsed maxillary canine; it was later found embedded in the premaxillary tissues. The other patient had a right mandibular molar propelled into the posterior triangle of the left side of the neck. Physicians must be aware of dental injury resulting from facial trauma and account for all teeth as part of their evaluation, keeping an open mind as to where a missing tooth might be located.