Efficacy of anterior, posterior and total fundoplication in an experimental model

BACKGROUND: This study examined the effect of different types of laparoscopic fundoplication on an incompetent lower oesophageal sphincter to test their effectiveness at preventing gastro-oesophageal reflux in the early postoperative period. METHODS: An experimental porcine model was used. Initial oesophageal myotomy ensured an incompetent lower oesophageal sphincter with free reflux of 'intragastric fluid'. Anterior, posterior or total fundoplication was then performed laparoscopically in 15 laboratory pigs (five in each group). Fundoplication competence and efficacy were determined 2 weeks after laparoscopic antireflux surgery by inflating the stomach with liquid through a gastrostomy cannula. Some animals were also studied at 4 and 6 weeks. Lower oesophageal sphincter pressure was determined using a water-perfused oesophageal manometry catheter incorporating a Dent sleeve. RESULTS: All three types of fundoplication produced similar increases in postoperative resting lower oesophageal sphincter pressure and restored adequate competence to the gastro-oesophageal junction. CONCLUSION: All three variants of laparoscopic fundoplication restore gastro-oesophageal competence in the early postoperative period.     

Gelatinase B and A expression after laser in situ keratomileusis and photorefractive keratectomy

OBJECTIVE: To compare the expression of gelatinases in the corneal epithelium and stroma after laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). METHODS: Rabbit eyes were treated with LASIK (n=11), PRK (n=12), or corneal flap construction (n=12); 4 eyes served as unwounded controls. Zymography was performed on the central epithelium and the stroma 1, 3, and 7 days after surgery to determine the expression of gelatinases. RESULTS: Epithelial expression of gelatinase B in the LASIK group (0%-25%) was lower than that in the PRK group at all time points (50%-100%) and was identical to the corneal flap group. Stromal expression of gelatinases A and B was similar after LASIK and PRK, but was minimal after corneal flap construction at all time points. Epithelial expression of gelatinase A was similar for the first 3 days after LASIK and PRK but not thereafter. CONCLUSIONS: Gelatinase B epithelial expression was up-regulated after PRK but not after LASIK. Gelatinase B stromal expression was up-regulated after both procedures. CLINICAL RELEVANCE: Differences in wound healing and subepithelial scarring after these 2 procedures may be related to gelatinase B.     

Primary nonampullary/periampullary adenocarcinoma of the duodenum

Primary duodenal adenocarcinoma not involving the ampullary region is rare. Our aim was to review the outcome of these patients and determine the factors that affect survival. We performed a retrospective review of all patients with primary, nonampullary duodenal adenocarcinoma at the Cleveland Clinic Foundation from January 1986 through December 1996. Twenty-six patients with primary, nonampullary duodenal malignancies were identified. There were 16 adenocarcinomas, 3 gastrinomas, 3 stromal tumors, 3 leiomyosarcomas, and 1 carcinoid tumor. Patients with adenocarcinoma had symptoms present an average of 6.1 months. Tumors were identified by upper gastrointestinal contrast study and esophagogastroduodenoscopy in 90 per cent and 87 per cent of patients, respectively. Twelve of 13 (93%) cancers found in the third or fourth portion of the duodenum were adenocarcinomas. Seven of the 16 adenocarcinomas were resectable on exploration. Those that were contained within the serosa have not recurred (mean, 6 years); one of the two patients with locally invasive adenocarcinoma remains disease free. The average survival for patients with unresectable disease was 6.7 months. The 5-year survival rates were: all adenocarcinoma, 38 per cent; resectable, 86 per cent; and unresectable, 0 per cent. All patients presenting with weight loss or obstructive symptoms died of disease; those with melena survived long term. Patients with tumors other than adenocarcinoma had a 90 per cent 5-year survival. We conclude that patients typically present with a long history of symptoms. Distal duodenal malignancies are most frequently adenocarcinomas. Upper gastrointestinal contrast study or endoscopy is often diagnostic. Patients with weight loss and/or obstructive symptoms had invasive disease and a morbid prognosis. Aggressive surgery is warranted, and most with resectable disease (86%) had long-term survival.     

Synthesis and conformational analysis of a novel type of spin labelled bicyclonucleoside based on a tetrahydrofurano[2,3-c]pyrrolidine sugar skeleton

Bicyclonucleosides bearing a 5-deoxy-5-N-hydroxyamino-3,N5-(1,1-ethano)-beta-D-furanosyl sugar moiety (15-18) have been prepared by glycosidation of the corresponding bicyclosugars obtained via an intramolecular reverse Cope elimination. The configuration of the asymmetric carbon of the 1,1-ethano bridge is the most important factor directing the conformation of the N-hydroxypyrrolidine ring and its invertomers ratio as shown by variable temperature H NMR experiments.     

Cardiac natriuretic peptides for diagnosis and risk stratification in heart failure: influences of left ventricular dysfunction and coronary artery disease on cardiac hormonal activation

BACKGROUND: Cardiac natriuretic peptides are activated in heart failure. However, their diagnostic and prognostic values have not been compared under the routine conditions of an outpatient practice. METHODS: We studied the diagnostic and prognostic value of plasma N- and C-terminal peptides of the atrial natriuretic factor prohormone (N-proANF and ANF respectively) and brain natriuretic peptide (BNP) to evaluate the severity of congestive heart failure (CHF) as reflected by the New York Heart Association (NYHA) classification and to predict its 2-year mortality. Peripheral plasma concentrations of the three natriuretic peptides were measured in 27 normal subjects (CTR), in 32 patients with coronary artery disease (CAD) and normal left ventricular ejection fraction and in 101 patients with chronic CHF in functional classes I and II (n = 61) or III and IV (n = 40). RESULTS: Plasma concentrations of the three peptides increased in the presence of CHF in relation to its severity (P < 0.01). BNP was unable to distinguish CTR from CAD, just as ANF could not differentiate CAD from CHF I-II; only N-proANF displayed a significant and continuous increase from CTR to CAD, CHF I-II and III-IV. Receiver-operating characteristic curves showed better evaluation of the degree of CHF by BNP than by ANF or ejection fraction (P < 0.05). Assessment of the 2-year prognosis revealed that N-proANF and BNP were the best independent predictors of outcome after the NYHA classification. These peptides identify a very high-mortality group. CONCLUSION: Plasma N-proANF and BNP concentrations are good indicators of the severity and prognosis of CHF in an outpatient practice. CAD does not stimulate BNP as long as ventricular dysfunction is not present, although increased N-proANF levels in this setting suggest an early humoral activation.     

Squamous cell carcinoma arising from a nonhealing wound and osteomyelitis treated with Mohs micrographic surgery: a case study

The treatment of choice for squamous cell carcinoma arising from chronic ulcer at the lower extremity has traditionally been amputation. Recently, Mohs micrographic surgery has been used as a limb-saving option in selected patients. One of these patients, a 69 year-old white male, presented with a two-year history of a progressive non-healing would and osteomyelitis. A four-month history of an enlarging mass within the ulcer suggested squamous cell carcinoma, which was confirmed by biopsies. The patient was treated with Mohs micrographic surgery for local eradication of the tumor, intravenous antibiotics, and skin grafting.