MALFUNCTIONING POSTGASTRECTOMY STOMA—Diagnosis and Treatment

Individualization in the treatment of patients with malfunctioning gastrojejunostomy stomas is paramount. Prompt surgical intervention in critically ill patients is necessary to save life.In the early postoperative phase, the use of barium studies is disappointing and very seldom gives information as to the actual site of the obstruction.In surgical treatment, operation directly upon the stoma should be avoided as much as possible. The release of small bowel obstruction, the reduction of intussusception or the correction of retraction of the jejunum through the mesocolon can be accomplished readily. Double or single jejunostomy for feeding and decompression are all that is necessary in cases in which no cause can be found for obstruction at or below the stoma.In a patient with peptic ulcer, the use of enteroenterostomy below the stoma is unphysiological and will predispose to gastrojejunal ulcer at a later date.     

Highly selective vagotomy for duodenal ulcer: do hypersecretors need antrectomy?

Two to five years after highly selective vagotomy (H.S.V.) for duodenal ulcer the results were similar in patients with high preoperative maximal acid outputs and those with lower acid outputs. Pain of ulcer type was experienced at some time by 6% of patients from each group, but it was mild and transient in some. No patients had recurrent ulceration at endoscopy or laparotomy, while incidence of individual symptoms was about equal in the two groups. Hence H.S.V. is adequate surgical treatment for patients with both duodenal ulceration and high levels of acid secretion. Antrectomy in such patients is not necessary provided that the incidence of incomplete vagotomy can be kept low.     

Deaths from peptic ulceration.

Deaths due to peptic ulceration can be prevented only by curing the ulcer and preventing the ulcer diathesis permanently by either medical or surgical means. Recurrence of ulcers after drug treatment is a major problem, so continuous treatment is often necessary, but there is no evidence that this decreases mortality. Surgery is the only means of permanently removing the ulcer diathesis in most patients, and subsequent mortality is low. A reasonable balance has to be achieved between the two kinds of treatment to prevent most deaths from peptic ulcer.     

Gastrointestinal complications of renal transplantation. 1. The upper gastrointestinal tract.

In 95 consecutive cases of cavaderic renal transplantation followed up for 1 to 83 months (mean 23.1 months) 17 complications developed in the upper gastrointestinal tract of 15 patients; these included duodenal ulcer in 12 and gastric ulcer, esophagitis, hemorrhagic gastritis, small-bowel obstruction and small-bowel perforation in 1 each. The occurrence of a complication was not related to the patient''s age, sex, blood group or use of cigarettes or alcohol, the duration of hemodialysis before transplantation, the tissue match or the number of infusions of immunosuppressive medication. One patient died of the complication. The peptic ulcers that developed after transplantation were successfully managed conservatively in 69% of cases. Since surgical treatment in patients whose immune response has been suppressed is associated with an increased frequency of complications such as disruption of suture lines, it is preferable to reserve it for those in whom complications develop that are unresponsive to conservative measures.     

Effect of Helicobacter pylori eradication on peptic ulcer disease complicated with outlet obstruction

Background. At present, the prevalence of Helicobacter pylori ( H. pylori ) in complicated peptic ulcer and the effect of H. pylori eradication on complicated peptic ulcer have not been fully established. In this study, we report the prevalence of H. pylori in peptic ulcer patients complicated with gastric outlet obstruction, effectiveness of oral eradication therapy on these patients, and their long-term follow up.
Patients and Methods. Ten consecutive patients presenting with clinically and endoscopically significant obstructed peptic ulcers were included in this study. During each endoscopy, seven gastric biopsy specimens were obtained and analyzed for H. pylori colonization.
Results. The antral mucosal biopsy specimens were positive for H. pylori in nine patients. H. pylori infection was eradicated and complete ulcer healing was observed in all patients. The mean follow-up period was 14 (7–24) months. One patient had duodenal perforation and underwent surgical intervention following medical treatment, despite the eradication of H. pylori. Ulcer recurrence was noted in two (22.2%) of nine patients, and in one of them the recurrent ulcer was complicated with obstruction (11.1%). The mean time to ulcer recurrence was 17 months (range, 10–24 months). The biopsies and CLOtests were H. pylori negative at the time of ulcer or erosion recurrence in two patients.
Conclusion. We suggest that H. pylori eradication may improve the resolution in obstructive ulcer cases with colonization.     

Surgical Management of Regional Enteritis

The present-day concepts concerning the surgical management of regional enteritis are reviewed and the multitude of problems that may arise in surgical treatment are discussed. The primary treatment of regional enteritis remains medical. Surgical intervention is necessary only for the complications of intractability, obstruction, fistula, abscess formation, anal and rectal complications, massive hemorrhage and perforation. To ensure the best possible results, medical treatment should continue after surgery. A perfect operation for this disease does not exist. Operations for regional enteritis can now be performed with a mortality rate of less than 2%, and although the recurrence rate following surgery averages approximately 30%, the disease is well controlled in the majority of patients with medical and/or surgical treatment.     

Helicobacter pylori infection and perforated peptic ulcer prevalence of the infection and role of antimicrobial treatment

Although the role of Helicobacter pylori infection on noncomplicated peptic ulcer disease has been definitively established, the precise relationship between the organism and complicated ulcer has hardly been studied. The mean prevalence of H. pylori infection in patients with perforated peptic ulcer is of only about 65-70%, which contrasts with the almost 90-100% figure reported in noncomplicated ulcer disease. However, H. pylori infection rates in various studies range markedly from 0% to 100%, suggesting that differences in variables as number and type of diagnostic methods used to diagnose H. pylori infection, or frequency of nonsteroidal anti-inflammatory drug intake, may be responsible for the low prevalence reported in some studies. Recurrent ulcer disease after peptic ulcer perforation mainly occurs in patients with H. pylori infection, which suggests that the microorganism plays an important role in this complication. All patients with perforated peptic ulcer should be treated by simple closure of the perforation and with therapy aimed at healing of the ulcer and eradicating the H. pylori infection, as disappearance of the organism prevents, or at least decreases, ulcer recurrence and ulcer perforation in patients with H. pylori-associated perforated ulcers after simple closure. Therefore, H. pylori eradicating treatment should be started during the immediate postoperative period. The patients with intractable recurrent symptoms of peptic ulcer despite adequate medical treatment, but without H. pylori infection (e.g. a patient using nonsteroidal anti-inflammatory drugs), is probably the only remaining indication for elective definitive surgical treatment of peptic ulcer disease.     

Therapy and prevention of gastric ulcer.

After establishing the benign nature of a gastric ulcer, the treatment is primarily medical. This medical therapy is aimed to alleviate symptoms, to heal the ulcer and to prevent relapses. Based on the history of non-steroidal anti-inflammatory drugs (NSAIDs) and the Helicobacter pylori-status, gastric ulcer patients can be divided into four categories (1) H. pylori positive plus NSAID-use, (2) H. pylori positive without NSAID use, (3) NSAID use with negative H. pylori-status, (4) Negative H. pylori-status and no NSAID use. Patients taking NSAIDs should stop this therapy if possible. Patients with gastric H. pylori infection should be treated by a regimen of a proton pump inhibitor with at least two appropriate antibiotics. This treatment will result in early alleviation of symptoms, rapid healing of the ulcer and prophylaxis of ulcer relapse. In patients with gastric ulcer who cannot stop NSAIDs, maintenance therapy with prostaglandins or potent antisecretory drugs should be considered. The few patients with gastric ulcer who do not take NSAIDs and do not have gastric H. pylori infection should be treated by antisecretory drugs, and they should be carefully followed endoscopically to exclude malignant (carcinoma, lymphoma) or non-peptic (Crohn''s disease) disease. All patients with gastric ulcer should be re-endoscoped to verify complete ulcer healing. Surgery may be considered in gastric ulcer patients with complications, in those with severe dysplasia of the gastric mucosa, and in those who are not able or willing to take the medication.     

Obstructions des canaux éjaculateurs: diagnostic et traitements

The management of male factor infertility has been frustrated by the large group of men with idiopathic infertility in whom treatment options have been limited to either empiric medical thrapy,orassisted reproductive technologies or donor insemination. Therefore, the identification of reversible causes of infertility in these patients is extremely attractive to couples and physicians. Recent reports suggest that partial ejaculatory duct obstruction may be responsible for infertility in some men previously labelled as having idiopathic infertility. Complete ejaculatory duct obstruction is suspected in azoospermic or severely oligospermic patients with low ejaculate volume (less than 1 ml), absence of sperm from the post-ejaculatory urine, normal endocrine studies and normal testis size. Demonstration of dilatation of the seminal vesicles and/or ejaculatory ducts by transrectal ultrasonography is diagnostic of ejaculatory duct obstruction in patients with the afore-mentioned clinical features. However, in the absence of definitive transrectal ultrasonography findings, vasography remains the gold standard for the diagnosis of ejaculatory duct obstruction. Ejaculatory duct obstruction is diagnosed in approximately 5% of azoospermic infertile men and is treated by transurethral incision of the ducts. After the surgical procedure semen parameters can improve and pregnancies have been initiated. Although, the patient must be informed that surgical therapy can also fail and can be associated with significant complications.     

Safer gastrectomy; 100 consecutive cases without mortality

Duodenal stump disruption accompanied by fatal peritonitis is the complication most to be feared following gastrectomy and anastomosis by any one of the Billroth II modifications. While many explanations of this complication have been presented and many means devised to prevent it, by far the most frequent cause is distention of the proximal duodenum because of obstruction at the stoma due to kinks, angulations or postoperative edema.A supplemental report is made on a disintegrating T-tube designed to facilitate gastroenteric anastomosis, insure patency of the stoma and make impossible obstruction of the proximal loop. This report covers 100 consecutive instances in which the disintegrating tube was used and emphasizes the favorable postoperative course usually experienced by the patients.     

SAFER GASTRECTOMY—100 Consecutive Cases Without Mortality

Duodenal stump disruption accompanied by fatal peritonitis is the complication most to be feared following gastrectomy and anastomosis by any one of the Billroth II modifications.While many explanations of this complication have been presented and many means devised to prevent it, by far the most frequent cause is distention of the proximal duodenum because of obstruction at the stoma due to kinks, angulations or postoperative edema.A supplemental report is made on a disintegrating T-tube designed to facilitate gastroenteric anastomosis, insure patency of the stoma and make impossible obstruction of the proximal loop.This report covers 100 consecutive instances in which the disintegrating tube was used and emphasizes the favorable postoperative course usually experienced by the patients.     

Psychometric Properties of the Participation Scale among Former Buruli Ulcer Patients in Ghana and Benin

Background

Buruli ulcer is a stigmatising disease treated with antibiotics and wound care, and sometimes surgical intervention is necessary. Permanent limitations in daily activities are a common long term consequence. It is unknown to what extent patients perceive problems in participation in social activities. The psychometric properties of the Participation Scale used in other disabling diseases, such as leprosy, was assessed for use in former Buruli ulcer patients.

Methods

Former Buruli ulcer patients in Ghana and Benin, their relatives, and healthy community controls were interviewed using the Participation Scale, Buruli Ulcer Functional Limitation Score, and the Explanatory Model Interview Catalogue to measure stigma. The Participation Scale was tested for the following psychometric properties: discrimination, floor and ceiling effects, internal consistency, inter-item correlation, item-total correlation and construct validity.

Results

In total 386 participants (143 former Buruli ulcer patients with their relatives (137) and 106 community controls) were included in the study. The Participation Scale displayed good discrimination between former Buruli ulcer patients and healthy community controls. No floor and ceiling effects were found. Internal consistency (Cronbach''s alpha) was 0.88. In Ghana, mean inter-item correlation of 0.29 and item-total correlations ranging from 0.10 to 0.69 were found while in Benin, a mean inter-item correlation of 0.28 was reported with item-total correlations ranging from −0.08 to 0.79. With respect to construct validity, 4 out of 6 hypotheses were not rejected, though correlations between various constructs differed between countries.

Conclusion

The results indicate the Participation Scale has acceptable psychometric properties and can be used for Buruli ulcer patients in Ghana and Benin. Future studies can use this Participation Scale to evaluate the long term restrictions in participation in daily social activities of former BU patients.     

Management of pressure sores in a specialty center. A reappraisal.

We report a study on the surgical management of 145 pressure sores in 115 patients treated in a spinal cord injury center. There is a definite trend toward better education of these patients, who do not develop their first pressure sores until years following the injury. When the patient comes in for an ulcer, he is usually healthy and the ulcer is small and clean. In such instances the ulcer can be excised and closed, preferably with a myocutaneous flap, and the patient can usually begin sitting by the 21st post-operative day. In the ideal setting he may be discharged to his home on a custom-fitted (for pressure) cushion within 4 to 5 weeks, without increasing the risk of recurrence. Prophylaxis for the future is, probably, the most essential part of the treatment.     

Stasis Gastric Ulcer: A Complication of Duodenal Ulcer

A causal relation between gastric stasis and gastric ulceration is suggested by the literature reviewed. In obstructive duodenal ulcer disease it is important to know that a concomitant gastric ulcer may be present and causing the symptoms. In combined ulcers, symptoms are more severe and treatment is more difficult.A clinical study of 60 cases of stasis gastric ulcer associated with chronic duodenal ulcer disease is presented. Twenty-six of these patients with gastric ulcers were bleeding at the time of their admission. The mortality rate was at least twice that for solitary ulcer. Early warning symptoms of stasis were fatigue, anorexia, fullness and weight loss; vomiting was a late manifestation. X-ray findings were often inaccurate; evidence of retention was reported in only 21. Gastric residue measurements were particularly useful in showing gastric retention.Since the basic disease in combined ulcers is the duodenal lesion, surgical treatment is primarily that for duodenal ulcer.     

Operative mortality and postoperative morbidity of highly selective vagotomy.

In a world-wide survey of the results of 5539 highly selective vagotomies (HSVs) performed electively for duodenal ulcer the operative mortality was found to be 0-3%. This was lower than that found in collected series after either vagotomy with drainage (0-8%) or gastric resection with or without vagotomy (over 1%). Necrosis of the lesser curvature occurred in 10 patients (0-2%) after HSV and caused death in 5(0-1%). Such necrosis is probably ischaemic in origin. Hence reperitonealisation of the raw area on the lesser curvature and prompt laparotomy if the patient develops signs of peritonitis might lower the mortality still further. Three deaths were due to pulmonary embolism, one to mesenteric vascular occlusion, and four to myocardial infarction; such deaths might be reduced by the prophylactic use of low-dose heparin. Persisting gastric stasis requiring drainage occurred in only 0-1% of the patients in the early postoperative period and in 0-6% of the patients later. Hence drainage procedures, which produce side effects such as early dumping, bilious vomiting, and diiarrhoea, could be abandoned if the mean incidence of recurrent ulceration after HSV remains close to its present level. HSV is probably the safest operation for duodenal ulcer because the alimentary tract is not opened and there is no anastomosis, suture line, or stoma.     

Reconstruction of the lacrimal excretory system.

Primary surgical repair of the lacrimal drainage apparatus may not be feasible in patients with maxillofacial injuries involving extensive structural damage. If secondary restoration of the tear duct is not possible, reconstruction of an aberrant passage then will be necessary for tear drainage. Although the Pyrex conjunctivorhinostomy has been considered to be the most effective modality of treatment in managing patients with tear-duct dysfunction, this procedure can be plagued with problems of tube dislodgment, infection, and cicatricial tract obliteration. The patients are, furthermore, required to wear the device for the remainder of their lives. Autologous material is therefore best suited for reconstructing a conduit. A medially based mucosal flap fashioned in the lower palpebral conjunctiva, 5 mm in anteroposterior dimension and 15 mm in horizontal length, can be used to form a conduit. This is then sutured to a flap mobilized from the nasal cavity, the lacrimal sac, or the maxillary antrum. In the past 15 years, a total of 24 fistulous tracts utilizing this technique were reconstructed in 20 patients with tear-duct obstruction. The experience accumulated from managing this group of patients forms the basis of this report.     

Haematemesis and Melaena,with Special Reference to Factors Influencing the Outcome

In a study of 2,149 emergency admissions because of haematemesis or melaena during a 15-year period, the sex ratio, age distribution, and main diagnostic groups showed no major change. Various factors affected the prognosis, such as the age of the patient, the underlying diagnosis, a low blood pressure on arrival at hospital, gross anaemia on arrival there, and the pattern of bleeding after admission. The fatality rate remained virtually constant throughout the period studied in spite of changes in diagnostic methods and management. There was a changing pattern in the type of operation performed in the treatment of bleeding peptic ulcer. Vagotomy combined with a drainage procedure and with a direct surgical attack on the bleeding point became more widely used at the expense of Polya or Billroth I partial gastrectomy and gave the best results. It is at first paradoxical that improved surgical results should not be reflected in a general improvement in the fatality rate, but this finding can be explained by the smaller proportion of patients treated by emergency surgery in the later years of the period studied. It is concluded that emergency surgery should be performed more frequently and that vagotomy plus drainage is the operation of choice in the peptic ulcer group.     

COMPLICATIONS FOLLOWING SUBTOTAL GASTRECTOMY

Four hundred consecutive cases in which subtotal gastrectomy was done for duodenal and gastric ulcer were reviewed. The mortality rate was 3.5 per cent. There were 57 complications, an incidence of 14 per cent. Of the fatal complications, duodenal stump disruption was the most common and serious—11 cases and 7 deaths. The other fatal complications included various types of obstruction, pulmonary embolus, hemorrhagic pancreatitis and separation of the abdominal incision. Of the nonfatal complications, obstruction of the stoma, anastomotic bleeding, pneumonia, venous thrombosis and wound infection were the most common.Catheter duodenostomy is helpful in the closure of a difficult duodenal stump. Where this was done in the present series there were no fatalities.Electrolyte balance, correction of protein deficiencies, blood replacement and the judicious use of antibiotics are important prophylactic factors against postoperative complications.     

Congenital nasal pyriform aperture stenosis: diagnosis and treatment

Congenital nasal pyriform aperture stenosis is an unusual form of nasal airway obstruction in the neonate. Pediatric plastic surgeons are often involved in the management of these children and should recognize this condition and know the treatment options. Fifteen cases of children with congenital nasal pyriform aperture stenosis were reviewed for presentation of the disorder, management, and effectiveness of treatment, making it the largest series to date. There were nine male patients and six female patients in the series. They all experienced varying degrees of nasal obstruction at birth and were managed on the basis of the severity of their symptoms. Twelve patients were treated surgically in the first year of life, with a mean age at operation of 97 days (range, 3 to 362 days). Two patients required surgical intervention during their teenage years (age, 14 and 18 years) because of persistent symptoms, and one patient (age, 2 years) with mild symptoms was managed medically. Associated craniofacial anomalies were present in six cases (40 percent). Surgical enlargement of the pyriform aperture was successfully performed through an upper buccal sulcus incision in 14 patients. Preoperative symptoms of upper airway obstruction were improved in all patients at an average follow-up of 2.4 years (range, 1 month to 5 years). Congenital nasal pyriform aperture stenosis varies in presentation and severity, occurring either as an isolated congenital anomaly or in association with developmental craniofacial anomalies. It can be effectively managed by surgical enlargement of the pyriform aperture without significant recurrence or long-term morbidity.     

Flap surgery to cover olecranon pressure ulcers in spinal cord injury patients

In the quadriplegic patient, the periolecranon region is subjected to continuous and permanent mechanical shearing and pressure forces. As the sensation of this region is partially impaired secondary to the level of the spinal cord injury, this anatomical area is prone to develop bursitis and then a chronic open draining wound. This type of wound is refractory to conservative measures. Surgical closure of this functional area can represent a challenge to the plastic and reconstructive surgeon because not all of the surgical options available are suitable for spinal cord injury patients. Therefore, we describe our clinical experience, which consists of seven patients with traumatic complete quadriplegia treated between 1989 and 1998 (all patients were male) who presented with an open olecranon ulcer, septic bursitis, or aseptic bursitis, and who underwent surgical closure by direct closure, local arm fasciocutaneous flap, or cross-chest flap to cover the periolecranon soft-tissue defects. The follow-up period ranged from 3 months to 8 years (mean, 44 months). All types of flaps achieved wound closure without losing range of motion at the elbow; however, at 10 to 12 months after surgery, an olecranon pressure ulcer or septic bursitis recurred in three of seven patients. These three patients required surgical revision. The local fasciocutaneous rotational flap was found to be effective for closing periolecranon soft-tissue defects and can be reused in instances of recurrence. Patient education is essential to prevent re-ulceration in that functional area in the spinal cord injury patient.