Intracorporeal colorectal anastomosis following laparoscopic left colon resection

BACKGROUND: The aim of this study was to assess the impact of an intracorporeal double-stapled colorectal anastomosis upon the outcome of laparoscopic left colon resection. METHODS: Fifty-four selected patients underwent elective laparoscopic left colon resection for benign disease. Once resection was completed, a 33-mm suprapubic port allowed insertion of the anvil of a circular stapler into the colon, which was closed by a handsewn purse-string suture using the T-needle technique. The circular stapler was passed transanally to perform a double-stapled anastomosis. Specimens were delivered in a plastic bag via the suprapubic port. RESULTS: There were no deaths. Minor intraoperative and postoperative complications occurred in 3.7% and 9.2% of the patients, respectively. Median operating time was 125 min (range 80-210 min). Complete proximal and distal doughnuts were obtained in all patients and anastomoses were all methylene blue tight. Median hospital stay was 4 (range 3-7) days. CONCLUSIONS: Fashioning double-stapled colorectal anastomoses intracorporeally is feasable and safe.     

Dilatation of the left colon with a Foley catheter: an aid to staple anastomosis

Balloon dilatation of the left colon using a Foley catheter was performed in 26 patients prior to staple anastomosis. A 28-mm stapler was then used in six (23%) patients, a 29-mm in seven (27%), a 31-mm in eleven (42%) and a 33-mm in two (8%). Two anastomoses failed (7.9%) and one patient developed local recurrence. None of the remainder developed a symptomatic stricture. Flexible sigmoidoscopy was performed on 18 patients at least 3 months after surgery, revealing that one (5.5%) had developed an asymptomatic stricture. A 28-mm stapler had been used in this case. This technique of dilating the left colon with a Foley catheter is a useful aid to staple anastomosis in large bowel surgery.     

Intraoperative irrigation of the colon to permit primary anastomosis

A technique is described which permits intraoperative application of antegrade bowel irrigation to clear the obstructed or loaded colon of faeces with minimal risk of contamination. The procedure extends the indications for safe primary anastomosis in surgery of the left colon.     

The exteriorized anastomosis: its role in surgery of the colon

Sixty-one patients (59, trauma; two, nontrauma) have been managed at Detroit General Hospital from 1972 to 1976 utilizing an exteriorized colon anastomosis. Healing of the anastomosis was present in 42 (70%) of the patients, and 37 (62%) avoided colostomy. Our experience with this procedure has demonstrated that it is a safe, reliable adjunct to be used in colon surgery when primary intraperitoneal repair is not desirable, that the added operating time (20 to 30 minutes) will not be deleterious to the patient, that the lesion is at least 18 cm above the peritoneal reflection, and that the likelihood of a prolonged septic postoperative course is not high.     

Subtotal colectomy with primary ileocolonic anastomosis for obstructing carcinoma of the left colon: valid option for elderly high risk patients

During a period of 4 years, 20 patients with obstructing carcinoma of the left colon were treated by subtotal colectomy with primary ileocolonic anastomosis. Thirteen patients (65%) were 65 years of age or older. All patients presented to the emergency room with large bowel obstruction. Twelve patients (age > 65) suffered other systemic diseases (chronic obstructive pulmonary disease, ischemic heart disease, morbid obesity), placing them in a high risk category. The mortality rate was 5% (1/20), 7.6% if only high risk patients are considered. The one-stage procedure in the treatment of obstructing carcinoma of the left colon offers the patient a number of advantages over stage intervention elimination of colostomy, namely removal of occult lesions in the resected colon, shorter hospitalization and low morbidity and mortality. We found this procedure to be a valid option also in the elderly (> 65) high risk patient. Metastatic disease in our view is not a contraindication, since the elimination of colostomy will improve the quality of life of these patients.     

Primary anastomosis of the trachea: management and pitfalls

The potentiating activity of SG-86[N-(2-hydroxyethyl)nicotinamide], a denitrated metabolite of nicorandil, on the adenosine-induced vasodepression was compared with that of nicorandil in anesthetized rats. Single bolus i.v. adenosine (3-100 micrograms/kg) produced dose-dependent reductions of blood pressure, accompanied by slight decreases (except for 100 micrograms/kg) in heart rate. The adenosine-induced vasodepression was significantly enhanced during i.v. infusion of either SG-86 (100 micrograms/kg per min) as well as nicorandil (10 micrograms/kg per min). The enhancement of adenosine action by them did not occur in the presence of glibenclamide (20 mg/kg i.v.). Single bolus i.v. injections of SG-86 (0.3-30 mg/kg), except for 30 mg/kg, which caused a glibenclamide-sensitive decrease by about 5-10 mmHg in mean arterial blood pressure, had no effects on blood pressure and heart rate, whereas those of nicorandil (30-300 micrograms/kg) elicited overt reduction of blood pressure, accompanied by decreases in heart rate. The present results revealed that SG-86, like nicorandil, significantly enhanced the vasodepressor response to adenosine, probably in part through KATP channel activation, and that the activity of SG-86 was about 10 times less potent than that of nicorandil.     

Laparoscopic intracorporeal anastomosis in the colon using the biofragmentable anastomotic ring--an animal study

The authors report about surgical treatment of herpes simplex encephalitis, although conservative management of this disease is the method of choice in the first place. They draw a lesson from this case that certain cases of large space occupying lesions of infectious origin leading to brain stem compression may require surgical management, even if they customary treatment is conservative.     

Monoclonal antibodies in the treatment of steroid-resistant acute graft-versus-host disease

Acute graft-versus-host disease (GVHD) remains the major obstacle for successful allogeneic bone marrow transplantation (BMT). The frequency of grade II or higher acute GVHD ranges from 30-50% in human leukocyte antigen (HLA)-matched sibling transplants and 50-80% in HLA-matched unrelated transplants. The mortality and morbidity associated with this complication are substantial. Corticosteroid and polyclonal antibodies such as antithymocyte globulin (ATG) have had little success in treating the disease; however, advances have been made in hybridoma technology and understanding its immunopathophysiology. Based on these new insights, monoclonal antibodies, either murine or "humanized," were tested as rescue treatment for acute GVHD in human trials. Complete response rates ranged from 20-40%, with relapse occurring often. Side effects consisted of constitutional symptoms such as fever, chills, hypotension, thrombocytopenia, and leukopenia. Limitations of monoclonal antibody treatment included low response rate and patient survival, high relapse rate, risk of infectious complication, and leukemic relapse. Future study should focus not only on improved side effects and efficacy of monoclonal antibodies but also on better patient survival.     

Primary resection with antegrade colonic irrigation and peritoneal lavage versus subtotal colectomy in the management of obstructed left colon cancer

Between 1980 and 1996 122 patients with acutely obstructed resectable carcinomas of the colon and rectum were treated in our hospital. Ninety-four has undergone one stage operation of immediate resection and primary anastomosis without proximal colostomy. Intraoperative colonic irrigation was performed in 34 patients, subtotal/total colectomy in 30 patients, right hemicolectomy in 30 patients. There were 2.3 and 1 operative deaths, respectively. The average hospital stay for the survivors was 19.8 days in the primary resection and anastomosis group, and 41.0 days in staged operation group. Concerning the possibility of multiple lesions the authors recommend subtotal/total colectomy except for tumours localized in the sigma where they apply total colectomy only when the proximal part of the colon is necrotized or filled with solid stool.     

Primary treatment of left coronary artery diseases by percutaneous implantation of stents

Left main coronary artery (LM) stenting has only been reported in bail-out situations or absolute contraindications so surgery. The authors report the immediate and midterm results of primary Palmaz-Schatz stent implantation in two young patients without contraindication to surgery. The first patient, 58 year-old, was admitted for unstable angina in October 1994. Coronary angiography showed an isolated severe ostial lesion of the LM. After conferring with the surgical team which remained on stand-by, angioplasty and stent implantation were performed with excellent results, no complications and no restenosis on angiographic controls at 3 and 12 months. The patient remained asymptomatic 24 months later. The second patient, 38 year-old, was admitted in June 1995 for unstable angina, and coronary angiography showed a severe isolated stenosis in the middle of a long and wide LM. Primary coronary stenting was also performed with excellent results, no complication and no restenosis on angiographic controls at 4 and 8 months. This patient was still asymptomatic 16 months after stenting. These excellent immediate and medium-term results are encouraging and suggest that this form of treatment might be extended to patients with an isolated whether primary LM stent implantation could become a suitable alternative to surgery in the future.     

Primary malignant fibrous histiocytoma of the descending colon

We herein present the case of a 50-year-old woman with malignant fibrous histiocytoma arising from the descending colon and localizing in the colonic wall. Malignant fibrous histiocytoma of the large bowel is a very rare tumor. A total of 18 cases, including our case, have been reported in the world medical literature so far and we also reviewed these cases. In our case, combined adjuvant chemotherapy was administered after a complete resection had been performed. No clinical signs of local recurrence or distant metastasis were found at 7 years after the operation.     

Pulmonary vascular disease complicating the Blalock-Taussig anastomosis

Comparative pharmacologists solidly trained in the principles of modern pharmacology, comparative biology, and comparative medicine are needed in various facets of drug research. Although this type of training would ideally be obtained in the professional medical environment of a veterinary college, the discipline of pharmacology has been neglected in these schools and must be upgraded by staffing and funding before quality training programs can be established. An interim solution would be to offer postgraduate training in comparative pharmacology and medicine at selected veterinary schools. Trainees would be recruited from pharmacology centers of excellence in medical or pharmacy schools. We assume that some of these trainees wound join veterinary school faculties and eventually establish quality Ph.DTRAINING PROGRAMS IN COMPARATIVE PHARMACOLOGY AT THEIR INSTITUTIONS. Comparative pharmacologists trained in these pre- or postdoctoral programs would be valuable additions to any team responsible for evaluating the safety and efficacy of drugs or chemicals in man or animals.     

Total laparoscopic ultrasonic colon dissection: is the colonic anastomosis safe?

Harvesting split-thickness skin grafts from the abdomen is difficult when using a conventional hand dermatome. In this study, pneumoperitoneum was created in 10 patients before skin grafts were taken. No complications arose from the insufflation, and the conventional dermatome was then easy to use. Pneumoperitoneum provides more abdominal surface area, allowing the surgeon to harvest a greater number of larger, more uniform grafts during a single procedure, even when working near an anatomical protuberance.     

Primary diffusely infiltrative adenocarcinoma of the colon and rectum

In this study, patient opinion on oral rehabilitation by means of Br?nemark implants was investigated. All patients were referred to a periodontal clinic for implant installation and treated by one and the same operator. Prosthetic restorations were performed by dentists, who had no previous experience with prostheses on implants, but had completed a postgraduate training course. Patient opinion was obtained through questionnaires, pertaining to satisfaction and oral function. A comparison was made between pre-implant situation, short-term (< 4 months) and long-term functioning (3 years) with the implant-restorative rehabilitation. In total, 61 patients participated in the study; 23 received a full lower arch bridge and 18 a full upper arch bridge, while 20 patients got partial bridges. Of 298 installed implants, 7 failed at abutment connection (2.3%) and 1 during the 3-year follow-up interval (0.3%). The study results indicated that a great majority of patients were very satisfied with the treatment. Comfort with eating, aesthetics, phonetics and overall satisfaction improved significantly and nearly all patients said that they would undergo the treatment again or recommend it to others. Patients experienced their implants as "natural" teeth. The conclusion is that rehabilitation ad modum Br?nemark, even in the hands of non-specialized dentists, can be of high quality, improving oral function and satisfying the needs and demands of patients.     

Transdural anastomosis in a juvenile form of moyamoya disease

INTRODUCTION: Moya-Moya disease has a low prevalence and world-wide distribution, with greater incidence in the first 5 years of life (juvenile form) or in the third decade (adult form). Stenosis of the intracranial portion of the internal carotid artery leads to secondary establishment of intracranial compensating anastamoses at different levels (leptomeninges, basal ganglia and transdural). We present the case of a 7 year old boy who presented clinically with choreiform movements and later had a cerebral infarct. On angio-MR and MR studies we observed the typical smoky image together with development of additional compensatory transdural anastomoses from the superficial temporal and ophthalmic arteries to the anterior and middle cerebral arteries.     

Primary angioplasty is elective reperfusion therapy in the treatment of acute myocardial infarction. Arguments in favor

Thrombolytic treatment has demonstrated its efficacy on acute myocardial infarction. However, it cannot be used in a significant number of patients and it doesn't achieve adequate reperfusion in a great percentage of cases. Primary angioplasty, a treatment which can be used in the majority of acute myocardial infarction patients, obtains artery patency in more than 90% of cases, with a better perfusion in the infarct territory and fewer reocclusion rates compared to thrombolysis. Consequently, primary angioplasty is associated with a lower mortality rate, and a lower incidence of recurrent ischemia and hemorrhagic stroke during hospitalization. Coronary artery stents and new antiplatelet agents have improved the short-term and mid-term results of primary angioplasty. Currently, when the facilities and trained personal are available, primary angioplasty should be the treatment of choice in acute myocardial infarction.     

Emergency treatment of wounds of the colon

Colonic wounds vary greatly in their severity and the number of concomitantly injured organs. Relatively few colonic wounds are single; these can usually be treated by primary repair. The approach to colonic wounds generally must be selective and take into account the degree of associated shock,contamination, and surrounding tissue damage. Judicious application of the wide variety of technical approaches available today has increased the incidence of primary repair to over 50% and has reduced mortality to 10% to 15%.     

Hemodynamic evaluation in acute myocardial infarct. Application to the treatment of contractile insufficiency syndromes of the left ventricle

Even though the coronary care units have reduced to a minimum the mortality due to arrhythmias, the syndromes of left ventricular failure are responsible for the greatest part of hospital deaths in patients with acute myocardial infarction. The poor results depend upon the extensive destruction of left ventricular mass. The management in these cases should be directed to improve the performance of viable muscle as well as to preserve thejeopardized ischemic myocardium that is potentially viable. These goals may be adequately pursued by continuous hemodynamic characterization of left ventricular function. The experience of the Coronary Care Unit of the Instituto Nacional de Cardiología de México in the study of 30 of these patients is presented. Hemodynamic evaluations were performed by means of a Swan-Ganz catheter and cardiac output determinations by the thermodilution technique. The studies may be performed with a minimum of risk. Central venous pressure measurements do not adequately indicate the status of the left ventricle. Its function may be evaluated by the use of end diastolic pulmonary artery pressure which reflects, quite accurately, the left ventricular filling pressure in these patients. Continuous hemodynamic monitorization facilitates the proper manipulation of the determinants of ventricular performance (preload, afterload, cardiac rate and contractility) and permits an attempt to improve the balance between available oxygen and myocardial oxygen requirements. Hemodynamic studies and ventricular function curves are presented in selected patients with acute myocardial infarction. The mortality due to left ventricular failure and cardiogenic shock in patients with acute myocardial infarction remains extremely high. However, it is only through the early recognition by continuous hemodynamic monitorization and the aggressive management of the patient with incipient left ventricular failure that the number of survivors may be increased.     

Sigmoidovesicocutaneous fistula complicating diverticular disease of the colon

A sixty-six year old diabetic male had a draining sinus tract from the lateral portion of a fourteen year old left herniorrhaphy scar. The diagnosis of sigmoidovesicocutaneous fistula was confirmed by a sinogram and the patient was treated in one stage with left hemicolectomy and resection of the fistula site from the dome of the bladder. To our knowledge this is the first report of a sigmoidovesicocutaneous fistula.