The diagnosis of occupational myofibrosis]

110 cases of resection of the stomach with transection of the stomach and the duodenum by plasmic scalpel and suturing of curvatura minor of the stump and anastomosis with the use of original one-layer sero-muscular-submucosal suture have been analysed. Changes in gastric wound at the site of plasma transection were evaluated microscopically. It was established that plasma transection of the stomach is aseptic, hemostatic, thermal trauma is minimal and does not exceed the level of 3-4 mm from transection line. Favourable conditions for applications of one-layer suture contribute much to a decrease of the number of stitch puncture, to rejection of catgut, to reduction of tissue mass involved and deformation of intestinal wall. In the early postoperative period wound and anastomoses healing occurred without substantial inflammatory changes. 109 patients were operated by Billroth-1 and 1 patient--by Billroth-II. One patient died (lethality 0.9%). Early postoperative complications occurred in 7.2% of operated patients.     

Results of esophageal cancer surgical treatment in multiple primary neoplasms

Available are the results of surgical treatment of 11 patients with cancer of the esophagus revealed metachronously through 6 months--3 years after treatment of oro-pharyngeolaryngeal cancer (5 patients) and diagnosed synchronously with cancer of the stomach (3 patients), the lung (2 patients) and leiomyoma of the esophagus (1 patient). Radical operations on the esophagus were performed in all the patients, in synchronous tumors they were one-stage surgical intervention. Postoperative complications such as pneumonia were observed in the majority of patients, who previously underwent radiation or combined treatment for laryngeal cancer, as well as in all patients, who were operated on the esophagus and the lung in one stage. The necessity of active bronchial sanation in pre- and postoperative period of patients after treatment of laryngeal cancer and advisability of two-stage surgical treatment of synchronous tumors of the esophagus and the lung, the operation for lung cancer being performed at the second stage of treatment, are stressed in conclusion. In synchronous involvement of the esophagus and the stomach one-stage intervention on these organs is the most advisable.     

Circular intestinal and esophageal suture with universal suture device (experimental trial)

A universal suture device (USD) able to make simultaneous two-line and cross-shaped circular clips stitches on various tube-shaped organs (vessels, intestines, esophagus, stomach, ets), creating end-to-end and end-to-side anastomosis with the external cuff is proposed. The results of experimental trials of USD and its clinical use in anastomosing main vessels were published before (8, 9, 11, 12). In this article the results of experiments with the use of USD in intestinal and esophageal sutures in 35 dogs are analysed. There were 4 series of experiments with 45 anastomoses (31 intestinal and 14 esophageal anastomoses). The anastomosed segments of the intestines and esophagus healed at the level of the lower side of the cuff. The cuff completely resumes its shape in 2.5-5 months, and the clips come off by month 7-8 after the surgery. The mucous layer of the esophagus straightened by the 2-3d month, while adventitial-muscular layer does not straigheten at all, and the clips from it could be found till the 10th month after the surgery. There were no cases of anastomotic incompetence.     

Necrosis of the femoral head after kidney transplantation

OBJECTIVE: Presentation of our experience in the treatment of war injuries to the thoracic esophagus at the Split University Hospital, Croatia, during the 1991-1995 wars in Croatia and Bosnia-Herzegovina. METHODS: Retrospective analysis of clinical and surgical data on patients with war injuries to the esophagus. RESULTS: Of 2494 treated injured persons, 5 patients (0.2%) had injuries to the esophagus. We performed temporary double-exclusion of the esophagus in all our patients, followed by gastric interposition after partial esophagegtomy in three patients and simple suturing with pericardial protection of the esophagus in one patient. One of our patients died after double-exclusion due to septic complications in spite of antimicrobial chemoprophylaxis regularly performed in all injured persons. Final surgical outcome and mortality rate (20%) in our patients were quite satisfactory. CONCLUSION: Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the thoracic esophagus.     

Mechanical penetrating esophageal injuries

Results of combined treatment of 850 patients with penetrating mechanical injuries of the esophagus are presented. 368 patients had instrumental lesions, 328--foreign bodies, 53--spontaneous and hydraulic ruptures, 83--gun-shot and cut wounds. Complex of roentgenologic, endoscopic, ultrasound and immunologic methods of examination were used for diagnosis of penetrating injuries of the esophagus and their complications. The authors have developed indications for conservative and operative methods of treatment. 650 patients underwent surgery. In 388 patients drainage procedures were used, other procedures used were suturing of defect of esophageal wall (288p), exclusion of distal part of the esophagus (30p). Mortality rate in such operations made up, respectively, 33, 11.8 and 6.6%. Methods of active drainage were successfully used in treatment of complication in ruptures of the esophagus (mediastinitis, empyema of the pleura). The most severe complications of the ruptures of the esophagus and mediastinitis were arrosion bleedings and esophageal fistulas. Methods of treatment of these complications are described.     

Management of presumed intraocular tuberculosis: possible role of the polymerase chain reaction

Sixty-eight patients with Crohn's disease who underwent intestinal resection were randomly divided into 2 groups: the stapled group (32 patients, 40 anastomoses) with functional end-to-end anastomoses made with linear staplers and with circular stapling anastomoses, and the hand-sewn group (36 patients, 48 anastomoses), with anastomoses achieved by layer-to-layer suturing. There were no significant differences in operative indications, age, sex, blood loss, or length of hospital stay between the groups. The operation times for right hemicolectomy and total colectomy in the stapled group were significantly shorter than those in the hand-sewn group. There were no significant differences in anastomotic dehiscence or recurrence between the stapling and hand-sewn procedures. These results indicate that these stapling techniques, even though producing an everted anastomosis, are not an adverse procedure for Crohn's disease.     

Cutaneous lesions in patients with visceral leishmaniasis and HIV infection

The authors studied the venous drainage pattern of the stomach in 30 adult laboratory mice (Mus musculus v. alba) and in 31 adult laboratory rats (Rattus norvegicus v. alba) of both sexes. In mice, two basic patterns of the venous drainage of the stomach have been found, the first one (50.0% of cases) with a vena gastroepiploica dextra, while in the second pattern (50.0% of cases) the vena gastroepiploica dextra is absent and the venous blood from the curvatura major ventriculi and fundus ventriculi is drained only via the v. lienalis. In rats, three basic patterns of venous drainage of the stomach were found, the first group (35.2%) with the v. gastroepiploica dextra, the second group (38.4%) with prevalence of the v. gastrica sinistra and the third group with various tributaries of the v. lienalis from the stomach (25.6%). The vena gastrica sinistra is the only constant venous channel in both animals examined. Between interorganic venous anastomoses in the mouse and the rat no great differences exist. In spite of the great variability of veins the results indicate that it is possible to differentiate some basic patterns of the venous drainage of the stomach in the animals studied.     

Comparative results of surgical treatment for perforating and bleeding pyloroduodenal ulcers

Results of treatment of 1309 patients with perforated and bleeding pyloroduodenal ulcers for 20-years period have been analysed. Resection of the stomach performed in 85 cases resulted in high postoperative lethality which made up in bleeding ulcers 14.8%. Drainage operations of the stomach with excision or suturing of ulcer combined with bilateral truncal vagotomy was performed in 60 patients, postoperative lethality rate being 8.4%. 128 patients underwent selective proximal vagotomy together with pyloro- and duodenoplasty, lethality rate being 1.6%. Combined vagotomy (posterior truncal and anterior sero-muscular) with excision of ulcer, transversal pyloroplasty and duodenoplasty was carried out in 1036 patients (postoperative lethality--2.4%). Excellent and good functional results were achieved in 79.6% of the patients.     

Total thoracic esophagectomy for esophageal cancer

BACKGROUND: Many current methods of esophageal resection have drawbacks that result in inadequate proximal resection, inadequate lymphadenectomy, and difficult gastric and splenic access. We describe a technique that allows reliable and safe access to the chest, abdomen, and neck. STUDY DESIGN: From 1988 to 1995, 113 patients (82 men; mean age 65.3 +/- 4.5 years) with carcinoma of the esophagus or esophagogastric junction (middle third in 34, lower third in 41, and cardia in 38) underwent total thoracic esophagectomy. The histology was adenocarcinoma in 71 (62.8%), squamous cell carcinoma in 32 (28.3%), and undifferentiated carcinoma in 10 (8.9%) of the patients; 57 tumors (50.5%) were stage III. The esophagus and stomach were mobilized through a left thoracoabdominal incision. After completion of the esophageal resection, the fundus of the stomach was sutured to the esophageal stump to allow later delivery of the stomach into the neck. The esophagogastric anastomosis was performed with continuous single-layer absorbable suture through a left oblique cervical incision. RESULTS: The mean duration of the operation was 309.2 +/- 47.9 minutes. Hospital stay ranged from 5 to 49 days (median, 12 days). The perioperative mortality rate was 4.4%. Anastomotic leak occurred in six patients (5.3%), one of whom died. The proximal resection margin was microscopically free of tumor in all cases, and with a minimum followup period of 18 months, there has been no anastomotic recurrence in any patient. Actuarial survival at 1 year was 63.4% +/- 4.9%, at 3 years 41.4% +/- 5.9%, and at 5 years 22.7% +/- 6.3%. CONCLUSIONS: Total thoracic esophagectomy through the left chest with a separate left cervical incision allows clear access to the esophagus and stomach and good tumor clearance. This procedure may be performed with a low rate of anastomotic leakage, a very low mortality rate, and no anastomotic tumor recurrence.     

Efficient accomplishment of anastomosis in gastrointestinal operations

In experimental study (40 dogs) variant of precisional (microsurgical) suture and anastomosis was developed, which was successfully carried out in clinical practice in 72 patients with various diseases of gastro-intestinal tract. For precisional formation of gastro-intestinal and bowel anastomoses magnifying optics, atraumatic suturing material and microsurgical instruments were used. Separately were sutured by knot sutures gastric or bowel serosa (external layer) and musculosubcutaneos layer of these organs together with mucous membrane tangentially, without its penetrating puncture (internal layer). The developed precisional method of formation of the anastomoses promotes healing of gastro-intestinal wound by primary intention and may be recommended for wider practical application.     

Presence of Streptococcus anginosus DNA in esophageal cancer, dysplasia of esophagus, and gastric cancer

We recently reported cloning of Streptococcus anginosus (S. anginosus) DNA fragments containing the 16S ribosomal gene from DNA samples of surgical specimens of gastric cancers. To investigate the specificity of S. anginosus infection, Southern blot analysis with S. anginosus 16S ribosomal DNA probe and PCR analysis with S. anginosus-specific primers were performed in DNA samples prepared from 15 esophageal cancers, 43 gastric cancers, 16 lung cancers, 10 cervical cancers, 14 renal cell carcinomas, 10 colorectal cancers, and 19 bladder cancers. We frequently found S. anginosus DNA sequences in DNA samples from esophageal cancer and gastric cancer tissues, as well as in those from dysplasia of the esophagus of esophageal cancer patients. No S. anginosus DNA bands were detected by Southern blot analysis on DNAs from the noncancerous portions of the esophagus or the stomach. By PCR analysis with 35 cycles, only 7% of the noncancerous portion of the esophagus was shown to contain S. anginosus sequences. No S. anginosus sequences were found in DNAs from cancers in lung, cervix, and kidney, but they were found in 1 of 10 colon cancers.     

Evaluation of high-resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula

BACKGROUND & AIMS: Whether inflammation of the cardia indicates gastroesophageal reflux disease (GERD) and/or is a manifestation of pangastritis caused by Helicobacter pylori infection is unknown. The aim of this study was to evaluate the relationship between cardia inflammation, H. pylori infection, and cardia intestinal metaplasia in patients with and without GERD. METHODS: Patients with GERD were compared with controls undergoing endoscopy for a variety of other conditions. Endoscopic biopsy specimens from the distal esophagus and cardia, fundus, and antrum were evaluated for inflammation, H. pylori infection, and intestinal metaplasia. RESULTS: Neither the prevalence of H. pylori infection (controls, 48%; GERD, 41%) nor cardia inflammation (controls, 41%; GERD, 40%) differed between groups. All 11 controls and 22 of 23 patients with GERD (96%) and cardia inflammation had H. pylori infection. Esophagitis was more common among GERD patients (33%) than controls (7%; P = 0.01). Cardia intestinal metaplasia was more common among controls (22%) than GERD patients (3%; P = 0.01); all had cardia inflammation, 7 had H. pylori infection, and 6 had metaplasia elsewhere in the stomach. CONCLUSIONS: The prevalence of cardia inflammation is similar in patients with and without GERD and is associated with H. pylori infection (P < 0.001). Cardia intestinal metaplasia is associated with H. pylori-related cardia inflammation (P = 0.01) and intestinal metaplasia elsewhere in the stomach, indicating that it is distinct from Barrett's esophagus.     

Closed Brock operation for an infant case of double outlet right ventricle with pulmonary atresia

Venous drainage patterns of the stomach were studied in 30 golden hamsters (Mesocricetus auratus) and in 30 guinea pigs (Cavia aperea f. porcellus). In golden hamsters the most frequent group had a v. gastroepiploica dextra (85.6% of cases). The v. gastroepiploica sinistra was found in 63.3% of cases. In the second group, the venous drainage pattern was without a v. gastroepiploica dextra (13.3% of cases). The only constant venous channel from the stomach was the v. gastrica sinistra. Other veins draining the stomach were vv. gastricae (tributaries of the v. lienalis) and interorgan venous anastomoses with neighbouring organs. A venous arch along the curvatura ventriculi major was not observed in any of the cases. In the guinea pig, the first group with a v. gastroepiploica dextra accounted for 90.0% of cases while the second group without this vein represented 10.0% of cases. The only constant venous channel was, once again, the v. gastrica sinistra. Other veins of the stomach were similar to those in the golden hamster. A venous arch along the curvatura ventriculi major was found in 76.6% of cases. Some differences in the venous pattern between the two animal species can be explained by zoological differences in these mammals. The results obtained also stimulate interest in the study of possible variations in venous patterns of the stomach in man.     

Stomach cancer complicated by perforation of the tumor

Operations were performed on 27 patients with perforative gastric tumor. The author believes that resection of the stomach as a planned operation after suturing the tumor is hopeless since the state of the patient within the interval fails to improve while the tumor becomes inoperable. Patients with the fourth stage of the disease in all circumstances have indications for suturing the tumor only.     

Capsaicin-resistant vagal afferent fibers in the rat gastrointestinal tract: anatomical identification and functional integrity

The presence and distribution of vagal fibers and terminals throughout esophagus and gastrointestinal tract that could be anterogradely labeled by nodose ganglion tracer injections was quantitatively assessed in capsaicin- and vehicle-pretreated adult rats, in order to identify the capsaicin-resistant population. Up to 90% of the intraganglionic laminar endings (IGLEs), in the myenteric plexus of the esophagus, and 70-90% in the stomach, as well as 57% of the intramuscular endings or arrays (IMAs) in the fundic stomach survived the capsaicin treatment, while in the upper small intestine only few and in the lower small intestine, the cecum and colon, virtually no IGLEs survived capsaicin treatment. Intramucosal terminals were not assessed. Furthermore, gastric balloon distension-induced c-Fos expression in the dorsal vagal complex was not significantly decreased in capsaicin-treated rats. It is concluded that among primary vagal afferents there is a capsaicin-resistant population that primarily innervates the esophagus and upper gastrointestinal tract, and a capsaicin-sensitive population that innervates mainly the lower tract. At least vagal gastric tension-sensitive afferents also seems to be functionally intact in that they may be capable of synaptically activating second-order neurons in the brainstem.     

Pain from herpes zoster and postherpetic neuralgia

Under observation there were 82 patients operated on for ulcer disease of the stomach and duodenum. Dissemination of the mucosa with Helicobacter pylori (HP) was studied by means of using the urease test. Before the operation the positive result of the study was obtained in 73 patients (89%). In 1-6 months after the operation the HP infection was found in 29 patients (39.7%). The HP persistence retained in 39.7% of the patients subjected to resection of the stomach in spite of the preoperative treatment including De-nol and Metronidazole. Post-resectional reflux-gastritis and anastomositis were more pronounced in HP carriers. The antireflux variants of anastomoses (transversal, terminolateral gastroduodenal anastomosis and gastrojejunal anastomosis by Roux) were followed by much less HP persistence and less frequent cases of anastomositis and gastritis of the gastric stump.     

The late results of the surgical treatment of perforated gastroduodenal ulcers in young people

The article is devoted to surgical treatment of perforating gastroduodenal ulcers. An investigation of remote results of palliative and radical interventions for the perforation of the stomach and duodenum in patients of young age has shown that recurrent ulcers after suturing the perforation take place in 67.2% of the people operated upon against 21% of those subjected to bilateral truncal subdiaphragmatic vagotomy with pyloroplasty. A conclusion is made that for perforating ulcers it is expedient to perform radical operative interventions as a bilateral truncal subdiaphragmatic vagotomy with pyloroplasty.     

"Cre"-ating mouse mutants-a meeting review on conditional mouse genetics

BACKGROUND: The antireflux capacity of various gastric fundoplications combines the creation of a valve (flapper or nipple) with recreation of a sharp cardioesophageal angle. Experimental comparison of valve competency and appropriate valve geometry is incomplete despite wide application of these techniques. Our primary aim was to compare the competency of several antireflux valves in explanted cadaver stomachs. Our secondary aim was to understand better the geometry of the gastric fundus in empty and full stomachs. METHODS: Stomachs with 6-8 cm of distal esophagus were harvested from 18 fresh cadavers. With the stomach empty, the greater and lesser curvature length and the transverse dimensions of the anterior and posterior surface of the stomach in the fundus, body, and antrum were measured. The pylorus was tied off over a catheter; the stomachs were inflated with water; and reflux occurred. Intragastric pressure was measured during inflation with a needle inserted in the side of the stomach. A clamp was then placed on the esophagus, and the stomach was inflated to a pressure of 10 mmHg. Gastric measurements were recalculated in the distended stomach. The stomachs were deflated, the clamp removed, and a 2-cm Nissen fundoplication as well as 270 degrees and 180 degrees posterior fundoplications were performed over a 60 Fr dilator. The stomachs were reinflated while the pressure was transduced. The inflation was stopped when reflux occurred or when the fundoplication disrupted. RESULTS: The stomachs expanded symmetrically when filled with water except for the fundus in which the anterior gastric wall lengthened by more than 100% and the posterior gastric wall lengthened by about 50%. In the untreated stomachs, reflux occurred at a pressure of 3.0 +/- 1.0 mmHg. After fundoplication, reflux never occurred, but the sutures pulled out of the stomach or esophagus at 28.6 +/- 16.8 mmHg. Posterior fundoplications refluxed water in several stomachs. CONCLUSIONS: When filled, the anterior fundus expands to a greater degree than the posterior fundus, offering more tissue for creation of floppy fundoplication. The "floppy" Nissen fundoplication is completely competent, suffering a degradation before allowing reflux. The posterior partial fundoplication is unpredictable in its competency.     

Delayed postoperative emptying after esophageal resection is dependent on the size of the gastric substitute

BACKGROUND: Delayed emptying of the gastric substitute is a common problem after resection and reconstruction of the esophagus. The occurrence of postoperative delayed gastric emptying in patients undergoing resection and reconstruction of the esophagus was studied with regard to the type and size of gastric substitute and the execution of a pyloroplasty. STUDY DESIGN: From 1983 to 1994, one hundred fifty-five patients underwent resection of the esophagus, with a hospital mortality rate of 7 percent. The inability to resume a diet of solid food within one week after a normal esophagography was defined as delayed gastric emptying. One hundred forty patients were studied; group 1, substitution with whole stomach with (1a, n = 9) and without (1b, n = 31) pyloroplasty; group 2, substitution with distal two-thirds stomach with (2a, n = 20) or without (2b, n = 45) pyloroplasty; and group 3, tubulized stomach without pyloroplasty (n = 35). RESULTS: Delayed gastric emptying was seen in 38 percent (15 of 40) of patients in group 1 (1a, 44 percent; 1b, 37 percent), in 14 percent (nine of 65) of patients in group 2 (1a, 10 percent; 2b, 15 percent), and in 3 percent (one of 35) of patients in group 3. The differences between patients in group 1 and group 2, and between patients in group 1 and group 3 were significantly different (p < 0.05). CONCLUSIONS: The type of gastric remnant used for reconstruction is an important determinant of postoperative gastric emptying. Pyloroplasty does not prevent delayed gastric emptying after esophageal substitution.