Macrophage apoptosis in muscle tissue in experimental autoimmune myasthenia gravis

BACKGROUND: In adhesive small bowel obstruction, the early recognition of complications such as strangulation or volvulus is essential to choose between surgical or conservative initial treatment. The objective of this study was to determine prospectively the contribution of computed tomography (CT) to decision making in the management of these patients. METHODS: Patients with suspected adhesive small bowel obstruction had CT at admission. Patients with CT signs of volvulus or strangulation and/or clinical signs of peritoneal irritation underwent urgent surgery; other patients had conservative initial treatment. RESULTS: Fifty-four patients were evaluated. CT demonstrated signs of strangulation or volvulus in 19 patients, including three with signs of peritoneal irritation. Within this group, urgent laparotomy was performed in 17 patients and confirmed the CT diagnosis in 16. Thirty-seven patients without clinical or CT signs of complications had initial conservative treatment; among them, seven of 12 with a distal obstruction determined by CT required a delayed operation for persisting obstruction, compared with two of 25 patients with a proximal obstruction (P < 0.01). CONCLUSION: CT is useful for the evaluation of adhesive small bowel obstruction, to detect accurately patients with complications who require urgent operation and to determine the location of the adhesion, which represents a significant prognostic factor for success of conservative treatment.     

Differential diagnostic problems in primary volvulus of the small intestine in adulthood

Primary small bowel volvulus in the adult is a rare, life-threatening emergency. The preoperative diagnosis is difficult and in most of the cases incorrect. We present a case of primary small bowel volvulus in the adult. Preoperative diagnosis of intraabdominal bleeding following blunt abdominal trauma was erroneously made and the patient underwent laparotomy. Review of the literature is presented and discussed.     

Lipoma of the small intestine as a rare cause of intestinal occlusion

Lipoma is a benign tumour of mesenchymal origin which is not frequently localized in the gastroenteric tract; in anatomopathological statistics it is less rare: this is due to the fact that it rarely reaches dimensions which warrant surgical treatment. It is usually either an occasional finding during the course of laparotomy due to other motives or is the cause of complications, as in the present case of intestinal occlusion due to ileocolic invagination, resulting in emergency surgery. As a cause of occlusion tumours of the small bowel are second in terms of incidence to adhesive factors, volvuli and hernias. Invaginations account for 2/3 of small bowel occlusions caused by up to 80% of tumours: the lipoma is the most frequent benign tumour to cause invagination in its submucous polypoid and more or less scissile form. Symptoms are not specific and this causes a delay in diagnosis. Patients are often young subjects with a history of recurrent abdominal colic and sensitivity to anti-spastic drugs so much so that in the past they were diagnosed as "chronic colic" sufferers. Sometimes the only symptom is dyspepsia, or nausea and vomiting, or occasionally abdominal distension with constipation or attacks of diarrhoea. Radiology is not of great value in the diagnosis except for indicating the possible need for emergency surgery. There are no radiological tests, with or without contrast mediums, echography, CAT or MNR which can diagnose this pathology. The decision to operate is usually triggered by the presence of a complication, but perioperative extemporary histological tests are advisable for a correct surgical approach: if the form is scissile, segmentary resection of the small bowel is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)     

A new method of intestinal salvage for severe small bowel ischemia

The morbidity and mortality in short bowel syndrome are directly related to the length of the remaining small bowel and to the duration of total parenteral nutrition. We describe the successful salvage of an infant with extensive small bowel infarction for whom a new technique was used to preserve all viable mucosal surfaces. The infant, with gastroschisis, was found to have a tight volvulus of the extruded bowel and extensive small bowel ischemia at the time of delivery. Forty-eight hours after reduction of the volvulus and abdominal decompression, a second-look laparotomy was performed. Although only the terminal 13 cm of ileum was completely viable, 25% of the circumference of a further 23 cm of proximal jejunum/ileum was considered salvageable. After debridement of the dead tissue, the remaining gutter of jejunum was divided at its midpoint, and the two halves were anastomosed longitudinally to provide a "neojejunum" of 12 cm in length, which was anastomosed between the duodenum and terminal ileum. Full enteral feeding was tolerated from day 47. Although the neojejunum was excised on day 149, after becoming dilated and atonic, by that time the remaining small bowel had elongated to 30 cm. Because of the early institution of full enteral feeding, there were no long-term complications related to total parenteral nutrition.     

Covered exstrophy: a rare variant

A case of covered exstrophy without sequestration of a bowel segment is reported. A 4-year-old female presented with dribbling of urine. Treatment to date has been simple excision of the covered membrane with functional closure of the bladder and bilateral posterior iliac osteotomies, with reconstruction of the bladder neck and genitalia to be performed at a later date. The embryogenesis of this rare variant, a review of the reported cases, and management options are discussed. Keyword Covered exstrophy. Exstrophy. Bladder variants     

Volvulus of the Roux-en-Y hepaticojejunostomy. A rare complication manifested by recurrent ascending cholangitis

A case of volvulus of a Roux-en-Y hepaticojejunostomy causing recurrent ascending cholangitis is reported. This rare complication of biliary reconstruction was diagnosed preoperatively by percutaneous transhepatic cholangiogram, and successfully treated by resection of the involved segment. The impaired myoelectric activity of the isolated Roux limb may contribute to this pathology.     

Large bowel volvulus in children. Review of a case material and the literature

Four pediatric patients with volvulus of the right colon, and three others with twisting of the sigmoid colon are reported. The clinical manifestations, mainly pain, were vague. Radiological plain film findings were occasionally characteristic, but were in the majority of cases equivocal. An active radiological approach including a supplementary barium enema in any patient with inconclusive plain abdominal roentgenograms will, in addition to other unexpected diagnoses, reveal rare cases of large bowel volvulus. Elective surgical procedures, carried out on viable bowel do not necessarily provide advantages over a non-operative approach. In addition spontaneous reduction of the volvulus may result in permanent cure.     

Aseptic wound dehiscence after rotator cuff surgery: early revision recommended

We herein present a patient with lipomatosis of the ileum including diverticulosis and volvulus. The patient presented with abdominal pain and vomiting. Preoperatively, we diagnosed lipomatosis with volvulus of the ileum based on the findings of abdominal ultrasonography (US) and computed tomography (CT). During surgery, the dilated ileum had rotated 720 degrees counterclockwise, and was found to contain lipomatosis and multiple diverticula. Although lipomatosis of the small bowel is extremely rare, it does show characteristic US and CT findings, thus making a preoperative diagnosis possible if this disease is included in the differential diagnosis.     

Granulation tissue polyposis associated with carcinoid tumours of the small intestine

We report two patients with ileal carcinoid tumours which were associated with polyps due to mucosal granulation tissue proliferation. In both cases the tumours had extensively infiltrated the small bowel wall and mesentery, and one had hepatic metastases. The mucosal surface of each specimen showed numerous, pale brown, sessile polyps which were restricted to the intestinal segment involved by carcinoid tumour, although not always closely related to neoplastic cells. The polyps were formed by the proliferation of capillaries, smooth muscle cells and myofibroblasts as demonstrated by immunohistochemistry and electronmicroscopy.     

Volvulus of the sigmoid colon

The clinical presentation and treatment of 31 consecutive patients with sigmoid volvulus are reviewed. Nearly half of these patients had a history of mental illness and one-third of all patients were chronically constipated. The main clinical features of abdominal pain and gross abdominal distension had been present for an average of 8 days before presentation of the patient to hospital. The clinical diagnosis of sigmoid volvulus was not difficult but the presence of non-viable bowel was more difficult to establish. A silent abdomen was the most valuable indication of the presence of gangrenous bowel. Conservative measures, including sigmoidoscopy and therapeutic barium enema, successfully reduced the volvulus in half of the cases so treated. In those patients undergoing surgery the procedure associated with the lowest mortality was sigmoid resection with end-to-end anastomosis. The overall mortality was 35%.     

Resolution of late potentials with improvement in left ventricular systolic function in patients with first acute myocardial infarction

BACKGROUND: Little has been written about the use of computed tomography (CT) in the evaluation of small bowel obstruction (SBO) in children. The purpose of this study is to review the CT findings of SBO in a pediatric series and to increase awareness of CT as potential problem-solving tool for SBO in children. METHODS: The medical, surgical, radiographic, and CT scan records of 20 consecutive children with surgically proven SBO were retrospectively reviewed. Duodenal and neonatal obstruction was excluded. CT scans were evaluated for small and large bowel caliber, bowel wall thickening, the appearance of the mesentery, extraluminal abnormalities, and the ability to detect the cause of obstruction. RESULTS: Causes of obstruction included adhesions (nine), small bowel intussusception (four), abscess (two), segmental volvulus (two), Crohn disease (one), focal stricture (one), and internal hernia (one). Small bowel dilatation was present in 19/20 children. Small bowel caliber transition was noted in 17/19 children. Two children with no small bowel caliber transition had a collapsed colon. The colon appeared normal in caliber in nine children, collapsed in nine, and filled with stool proximally and collapsed distally in two. Small bowel thickening was present in six children and mesenteric venous engorgement in three. Specific causes of obstruction were identified on CT in nine children (45%) and could be correctly predicted in seven of nine children with adhesions. In four children, the causes were either not evident or alternate diagnoses could be made. CONCLUSION: CT can be a useful adjunct in evaluating the presence or causes of SBO in children.     

Computed tomographic appearance of closed-loop obstruction

The obstruction of a bowel segment at two points results in closed-loop obstruction, and is apt to cause strangulation. Thus, the early recognition of closed-loop small bowel obstruction might reduce the mortality rate. However, plain films are limited in their ability to diagnose it. Using previously described criteria, we retrospectively reviewed the CT images of six surgically confirmed cases of closed loop obstruction. In all patients, CT showed the characteristic configuration of closed loops, specific findings detected at the site of obstruction, or both. On the basis of our experience, CT is a useful, non invasive method for the investigation of patients with suspected closed-loop obstruction.     

Actinomyces infection in a compound odontoma

Intestinal obstruction as a result of postnephrectomy adhesions occurs in up to 7% of children treated for Wilms' tumor. The authors report two children who developed small-bowel volvulus during the treatment of their renal tumor. Both underwent urgent resection of their ischemic bowel with primary anastamosis and are long-term survivors. The risk of this complication may be increased in young children with bulky tumors who receive abdominal radiotherapy.     

Short bowel syndrome--surgical aspects

INTRODUCTION: Long-term survival after massive intestinal resection is now possible with parenteral nutritional support. The expense, morbidity, and inconvenience of this therapy, however, have led to continued interest in alternatives for the treatment of the short bowel syndrome. Patients with short bowel require a multi disciplinary approach over a prolonged period. HISTORICAL CONSIDERATIONS: The history of small bowel transplantation started in 1959 when Lillehei showed that autotransplantation of the small intestine in a dog was feasible. From 1964 to 1971, 7 attempts of small bowel allotransplantations in humans have been reported. All 7 patients died. DEFINITION: Short gut syndrome is a malabsorptive condition occurring after significant loss of intestinal absorptive capacity. The clinical syndrome is manifested by malnutrition, steatorrhea, weight loss, and diarrhea due to decreased absorptive capacity. ETIOLOGY: Etiologic factors leading to the short gut state include necrotizing enterocolitis, midgut volvulus, trauma, embolic phenomenon, and Crohn's disease. PATHOPHYSIOLOGY: Intestinal failure is the end result of several complex interacting mechanisms related to: reduced enterocyte mass, short small bowel length with consequent reduced mucosal contact time for absorption, massive proximal loop dilatation with poor propulsion, and intraluminal stasis and bacterial overgrowth lead to bacterial translocation to the liver systemically. MANAGEMENT: Patients with short bowel must be totally or partly supported with intravenous nutrition until enteral absorption can sustain survival and growth. Autologous bowel reconstruction attempts to reconfigure the residual bowel to eliminate negative factors of bowel dilatation and stasis, and redistribute the absorptive mucosa to enhance the adaptation response. Several procedures have been suggested to: prolong transmitting time and increase mucosal contact time, enhance absorption by bowel tailoring and bowel lengthening, and increasing the Enterocyte mass. CONCLUSION: Autologous gastro-intestinal reconstruction is still in its infacny with prospect of new and different concepts for the future.     

Granulocytic sarcoma of the jejunum: a rare cause of small bowel obstruction

We report the case of a 40-yr-old man presenting with symptoms of small bowel obstruction. Small bowel x-rays revealed a stricture of the mid-jejunum. Push enteroscopy found a polypoid mass at 1 meter of the ligament of Treitz. Histopathological examination of the biopsy and surgical specimens showed a diffuse infiltrate of the mucosa made of medium to large cells, which were stained on immunohistochemistry by the leucocyte marker CD45 and the histiocyte/monocyte marker CD68 but were negative for the B and T cell markers. Cytological examination of the ascitic fluid revealed many myelobasts with cytoplasmic Auer rods and positive myeloperoxidase staining. There was no evidence of blood or bone marrow involvement suggestive of acute leukemia or myeloproliferative disorders. These findings were consistent with the diagnosis of preleukemic granulocytic sarcoma (or chloroma). Chemotherapy led to complete remission, but 21 months later the patient developed an acute myeloid leukemia. He died from aspergillus pneumonitis, 10 months after bone marrow allograft. Preleukemic granulocytic sarcoma of the small bowel is a rare condition and its diagnosis is usually not easy, requiring histochemical or immunohistochemical studies. Most cases have progressed to acute myeloid leukemia.     

Esophageal reconstruction with free jejunal grafts: an experimental study

Replacement of a long segment of esophagus for esophageal atresia or severe stenosis remains a special problem in children. The following studies were designed to test the hypothesis that a section of small bowel without serosa could survive as a free autologous transplant to replace part of the mediastinal esophagus. Laparotomy was performed in 20 adult cats, a loop of small bowel was resected and an end-to-end jejunojejunostomy was completed. The serosa of the resected bowel was removed and the mucosa-muscularis graft was used to replace a segment of the middle esophagus that was resected via a right thoracotomy. The interposed graft was entirely wrapped with adjacent skeletal muscle flaps. Postoperative studies include barium swallow and cine esophagograms, histology and blood vessel casts. Results are presented which show anatomical and functional survival of 16 grafts without blood vessel anastomoses or intrinsic vascular pedicles.     

Laparoscopic treatment of intestinal malrotation in children

BACKGROUND: Laparoscopic treatment of intestinal malrotation in children is difficult, and most of our pediatric surgeon colleagues active in the field of laparoscopic surgery tell us that more often than not they must convert to an open procedure. Initially, we experienced much difficulty too, but after modification we were able to master the technique, and now we feel confident. We here describe the actual technique we use. METHODS: Our experience encompasses nine children treated during the past 18 months. Five of the children presented in the newborn period and four later. During laparoscopic surgery, it is of paramount importance to concentrate not on the loops of bowel, but on the duodenum. By starting to identify the duodenum, mobilizing it, and carrying on the mobilization of the small bowel down until the whole small bowel has been seen, the pathologic anatomy is easily unraveled. Moreover, an existing volvulus is automatically reduced and the bowel automatically put in a nonrotation position in the abdomen. RESULTS: All patients have done well, and no complications have been noted. Operative time has been reduced to about 1 hour. CONCLUSIONS: Laparoscopic treatment of intestinal malrotation in children is not so difficult provided certain rules, as described, are followed.     

Intraoperative determination of small intestinal viability following ischemic injury: a prospective, controlled trial of two adjuvant methods (Doppler and fluorescein) compared with standard clinical judgment

Two adjuvant techniques for the intraoperative assessment of small intestinal viability were compared with standard clinical judgment in a prospective, controlled study of 71 ischemic bowel segments in 28 consecutive patients operated on for acute intestinal ischemic disease. Each segment was independently assessed 15 minutes after surgical correction of the underlying lesion by: 1) standard clinical judgment; 2) Doppler-detected pulsatile mural blood flow; and 3) fluorescein ultraviolet fluorescence pattern. Viability endpoint for each segment was determined objectively by patient follow-up or "blinded" microscopic evaluation of histologically unequivocal resection specimens using criteria established by previous animal studies. Seventeen histologically equivocal specimens were excluded from the final results. Standard clinical judgment proved moderately accurate overall (89%) but would have led to a relatively high rate (46%) of unnecessary bowel resection. The Doppler technique did not increase accuracy in any category of evaluation. The fluorescein fluorescent pattern was correct in all 54 determinant bowel segments, and proved more sensitive specific, predictive, and significantly more accurate overall than either standard clinical judgment or the Doppler method. This controlled study suggests that the fluorescein technique is the method of choice for the prediction of small intestinal recovery following ischemic injury.     

Ileal penetration by a Multiload-Cu 375 intrauterine contraceptive device. A case report with review of the literature

A case of a 28-year-old gravida 3 para 2 woman with an ileal penetration by an intrauterine device (IUD) is reported. Four weeks following insertion of a Multiload-Cu 375, the woman underwent laparotomy due to persistent vague abdominal pain and translocation of the IUD. The device had perforated the fundal uterine wall and the two flexible side arms and the copper-bearing rod had completely eroded into the wall of the ileum with only the strings protruding outside the small bowel mesentery. Resection of an ileal segment with end-to-end anastomosis was performed. The woman made an uneventful recovery. It appears that a translocated Multiload-Cu 375 IUD body can penetrate and be entirely embedded within the bowel wall as early as 4 weeks following translocation. This report documents the shortest interval between insertion and proven bowel injury by an IUD.     

A gonadotrophin dependent stromal luteoma: a rare cause of post-menopausal virilization

A stromal luteoma is an uncommon ovarian tumour in post-menopausal women, which presents rarely with hyperandrogenism and virilization. We present the case of a 64-year-old woman referred for evaluation of virilization which had developed over 5 years. Testosterone, FSH and LH were markedly inhibited following the administration of a GnRH analogue, suggesting a gonadotrophin dependent, testosterone secreting ovarian tumour, which could not be localized with imaging techniques. Surgery revealed normal sized ovaries with no apparent lesions, but microscopic examination showed a small stromal luteoma in the right ovary and severe stromal hyperthecosis in the adjacent and contralateral ovarian stroma. We conclude that stromal luteoma is an uncommon cause of virilization in post-menopausal women. This case illustrates, to our knowledge for the first time, that a stromal luteoma is not autonomous but is gonadotrophin dependent.