Should needle localization breast biopsy give way to the new technology; the advanced breast biopsy instrumentation.

Between July 1995 and June 1997, 114 consecutive women underwent 118 breast biopsies for nonpalpable lesions. A limited procedure room and local anesthesia were used in 96.5 per cent of patients. Intravenous access was not established in 95 per cent of patients. Oral diazepam was given to 51 per cent of patients. Needle localization technique was used with a success rate of 97.5 per cent and average operative time of 18 minutes. Breast carcinoma was found in 29 (24.6 per cent) biopsies. A review of 99 of the 118 mammograms showed only 45 per cent of the lesions being amenable to the new technology, the advanced breast biopsy instrumentation. Advantages of the needle localization include short operative time; supine position for the patient; easy access to control bleeding; ability to choose a cosmetic site for the skin incision; minimal tissue removal before reaching the lesion; ability to maintain a sterile field; and applicability to almost any mammographic lesion identified, whether single or multiple. Disadvantages include the need for a separate procedure to place the wire and potential of missing the lesion in 2.5 per cent, requiring additional surgery.

Mechanical stretch-induced fibronectin and transforming growth factor-beta1 production in human mesangial cells is p38 mitogen-activated protein kinase-dependent.

Hemodynamic abnormalities are important in the pathogenesis of the excess mesangial matrix deposition of diabetic and other glomerulopathies. p38-Mitogen-activated protein (MAP) kinase, an important intracellular signaling molecule, is activated in the glomeruli of diabetic rats. We studied, in human mesangial cells, the effect of stretch on p38 MAP kinase activation and the role of p38 MAP kinase in stretch-induced fibronectin and transforming growth factor-beta1 (TGF-beta1) accumulation. p38 MAP kinase was activated by stretch in a rapid (11-fold increase at 30 min, P < 0.001) and sustained manner (3-fold increase at 33 h, P < 0.001); this activation was mediated by protein kinase C (PKC). Stretch-induced fibronectin and TGF-beta1 protein levels were completely abolished (100% inhibition, P < 0.001; and 92% inhibition, P < 0.01, respectively) by SB203580, a specific p38 MAP kinase inhibitor. At 33 h, TGF-beta1 blockade did not affect stretch-induced fibronectin production, but partially prevented stretch-induced p38 MAP kinase activation (59% inhibition, P < 0.05). TGF-beta1 induced fibronectin accumulation after 72 h of exposure via a p38 MAP kinase-dependent mechanism (30% increase over control, P < 0.01). In human mesangial cells, stretch activates, via a PKC-dependent mechanism, p38 MAP kinase, which independently induces TGF-beta1 and fibronectin. In turn, TGF-beta1 contributes to maintaining late p38 MAP kinase activation, which perpetuates fibronectin accumulation.

Alteration of the Roux Stasis syndrome by an isolated Roux limb: correlation of slow waves and clinical course.

The Roux-Y stasis syndrome after antrectomy and vagotomy has been well described. Delayed gastric emptying after vagotomy and antrectomy with Roux-Y anastomosis has been attributed to loss of the duodenal pacemaker and to the effects of retrograde slow-wave activity arising from distal small bowel pacemakers. Small bowel contractions are closely coupled with slow-wave activity. Transection and anastomosis of the small bowel distal to the jejuno-jejunostomy has been shown to electrically isolate the Roux limb from distal small bowel pacemakers. Using a canine model, a vagotomy and hemigastrectomy with Roux-Y were performed in five dogs using the standard operation (control); in four dogs (experimental), an additional transection and reanastomosis of the jejunum 25 cm distal to the Y anastomosis of the Roux limb was performed. All specimens had six electrodes implanted along the Roux limb at 5-cm intervals, used for weekly analysis of the jejunal slow-wave activity. The isolated loop cohort had reduced incidence of retrograde slow waves, reduced emesis, improved gastric emptying by upper gastrointestinal series, and reduced gastric pouch size at autopsy. Adding a distal transection and anastomosis, thus creating an isolated Roux-Y segment, may improve the course of the Roux stasis syndrome.

Laparoscopic repair of paraesophageal hiatal hernia.

Twenty-seven patients underwent consecutive elective laparoscopic repair of paraesophageal hiatal hernia between October 1992 and June 1997. There were 24 females and 3 males. The average age was 68 years (range, 46-86) and average weight was 173 pounds (range, 122-243 lb.). Presenting symptoms were: postprandial epigastric pain or pressure in 19 patients, postprandial dyspnea in 7 patients, anemia in 5 patients, postprandial vomiting of food in 5 patients, and 1 patient had postprandial palpitation. Heartburn was present in 9 patients. Five patients had a history of symptoms of intermittent volvulus. History of hiatal hernia was present in 19 patients ranging from 6 months to 38 years in duration. The operative procedure included a laparoscopic reduction of the herniated stomach, excision of the hernia sac, and closure of the diaphragmatic defect with placement of mesh graft. Anterior gastropexy was performed on all patients except two who had a Nissen fundoplication due to severe reflux symptoms. Seven patients had laparoscopic cholecystectomy at the same time and one patient had an excision of a small benign gastric leiomyoma of the fundus. The average operative time was 2:54 hours (range, 1:35-4:05 hrs.). The average hospital stay was 3.8 days (range, 2-8 days). One patient had a postoperative stroke and recovered quickly. Follow-up of 1 to 56 months showed no recurrence of the hernia. Two patients complained of some epigastric pain and six patients had occasional mild reflux that was easily controlled medically. Laparoscopic repair of paraesophageal hernia is a safe procedure with a short hospital stay and recovery time. Using mesh graft decreases the risk of developing an iatrogenic parahiatal hernia. The addition of Nissen fundoplication is not necessary unless the patient has objective findings of reflux.