Amos Vromen

Water-soluble contrast material has no therapeutic effect on postoperative small-bowel obstruction: Results of a prospective, randomized clinical trial

BACKGROUND Hyperosmotic water-soluble contrast materials have been fo und to be helpful diagnostic tools in postoperative small-bowel obstruction (POSBO); however, their therapeutic value remains controversial. PATIENTS AND METHODS A prospective, randomized clinical study was conducted to examine the use of meglumine ioxitalamate as a supplement to the standard conservative treatment of POSBO. Patients with POSBO (n = 50) suitable for a conservative approach were randomized to receive standard conservative treatment with (n = 25) or without (n = 25) the addition of 100 mL of meglumine ioxitalamate via the nasogastric tube (patients with diffuse carcinomatosis and early POSBO were excluded). Both groups were compared for resolution of obstruction, need for surgical relief of obstruction, and complications. RESULTS Seven (14%) patients required surgery: 3 in the contrast material group and 4 in the control group (P = not significant [NA]. Resolution of symptoms was achieved in nonsurgical patients within an average of 25.7 hours in the contrast material group and 28.7 hours in the control group (P = NS). There was no mortality in this study. In 2 (4%) patients (1 in each group), strangulated bowel was found during surgery, but only the 1 (2%) patient in the contrast material group required bowel resection. No difference was found in the length of hospital stay or rate of complications. There were no complications that could be attributed to the use of the contrast material itself. CONCLUSIONS Although water-soluble contrast material is a safe and useful diagnostic tool, it offers no advantage as a supplement to the usual conservative treatment of POSBO.

Laparoscopic-modified Nissen fundoplication in children with familial dysautonomia

Children with familial dysautonomia (FD) often require an antireflux operation and gastrostomy to prevent the detrimental effects of aspirated gastric juice on the lungs and to facilitate liquid feeding. The aim of this study was to examine whether a laparoscopic procedure in such patients is as safe and effective as the traditional open technique. The data for all pediatric patients who underwent a laparoscopic antireflux procedure for familial dysautonomia were reviewed and compared with those the last pediatric patients with FD who were operated upon using the open technique, before the introduction of the laparoscopic procedure. Of the 61 children who underwent an antireflux procedure for FD (1978-1996), 13 were operated on laparoscopically. The authors found that the postoperative course of these patients was less complicated than that of patients who had the traditional laparotomy procedure. There was no need for mechanical ventilation during the postoperative course, and there were no respiratory complications. The mean hospitalization period was significantly shorter (7.9 days v 13.2 days). There were no complications attributable to laparoscopy, and the antireflux procedure has been effective in all patients (short-term follow-up). The authors conclude that laparoscopic procedures that include a modified Nissen fundoplication, gastrostomy, and appendectomy are feasible and as safe as conventional surgery for the treatment of FD in children. It appears that this approach has fewer complications than laparotomy, might reduce the need for postoperative mechanical ventilation, and is associated with a shorter postoperative stay.

Truncating Mutation in the Nitric Oxide Synthase 1 Gene Is Associated With Infantile Achalasia

Nitric oxide is thought to have a role in the pathogenesis of achalasia. We performed a genetic analysis of 2 siblings with infant-onset achalasia. Exome analysis revealed that they were homozygous for a premature stop codon in the gene encoding nitric oxide synthase 1. Kinetic analyses and molecular modeling showed that the truncated protein product has defects in folding, nitric oxide production, and binding of cofactors. Heller myotomy had no effect in these patients, but sildenafil therapy increased their ability to drink. The finding recapitulates the previously reported phenotype of nitric oxide synthase 1-deficient mice, which have achalasia. Nitric oxide signaling appears to be involved in the pathogenesis of achalasia in humans.

Laparoscopic Nissen fundoplication in children under 2 years of age

AbstractBackground: Antireflux operations have been recommended for infants and children suffering from complications related to gastroesophageal reflux (GER). In recent years, the laparoscopic approach has been used increasingly for antireflux surgery in adult patients. This is our initial experience with Nissen fundoplication in infants and children under 2 years of age. Patients: We operated on 11 patients weighing between 3.0 and 10.0 kg. The main indications for surgery were GER-induced aspiration pneumonia and failure to thrive, in spite of intensive conservative treatment. All patients except one had an associated neurological abnormality, including six patients with familial dysautonomia. Results: All attempted operations were completed successfully laparoscopically, with only a few postoperative complications and acceptable short-term results. The clinical considerations and technical aspects unique to this specific group of patients are discussed. Conclusion: Laparoscopic Nissen fundoplication is feasible, safe, and effective, even in very small babies.

Decreased density of ganglia and neurons in the myenteric plexus of familial dysautonomia patients

BACKGROUND Familial dysautonomia (FD) is a hereditary disease of the autonomic and sensory nervous system. A prominent manifestation of FD is gastrointestinal dyscoordination, which contributes to the morbidity and mortality in FD. AIM As the myenteric plexus is an essential factor in gastrointestinal motility control, we compared its morphology in appendices of FD patients and controls. METHODS Appendices from FD patients (N=19) were obtained during surgery of fundoplication and gastrostomy; normal appendices (N=17) were obtained from patients suspected to suffer from acute appendicitis, in whom, however, the appendix was found to be normal. Specimens were stained histochemically for NADPH diaphorase (NADPH-d) and in a blinded manner examined under a light microscope for seven morphologic parameters: ganglionic density, neuronal density, ganglionic area, number of stained neurons per ganglion, nerve bundle width, ratio between nervous tissue area and total area, and neuronal area. RESULTS Ganglionic density was 10.13 per mm(2) in controls versus 5.01 per mm(2) in FD (p<0.05). Neuronal density was 70.12 per mm(2) in controls, compared with 22.09 per mm(2) in FD (p<0.01). The other parameters were not different between the two groups. CONCLUSION Densities of myenteric ganglia and neurons of FD patients were significantly lower than in controls. This deficiency may contribute to the pathogenesis of FD gastroenteropathy.

Horner Syndrome: A Rare Complication of Internal Jugular Vein Cannulation

Percutaneous cannulation of the internal jugular vein is a widely used and accepted method for central venous cannulation, used for parenteral alimentation, fluid administration, and measurement of pressures. A multitude of complications associated with this procedure have been described. Horner syndrome as a rare complication of internal jugular vein cannulation is presented.

Hyponasality Caused by Retronasopharyngeal Air as a Symptom of Pneumomediastinum

During a 6-month period we encountered five patients with acute hyponasality as a presentation of pneumomediastinum (Table 1). All were male, ranging in age from 16 to 74 years. Three patients had spontaneous pneumomediastinum, and two patients had posttraumatic pneumothorax and pneumomediastinum. Two patients had spontaneous pneumomediastinum caused by asthma and respiratory infection. In one case it was the result of a ruptured pulmonary bleb. Chest pain was present in four patients, and shortness of breath was present in three patients. Pneumothorax was Hyponasality caused by retronasopharyngeal air as a symptom of pneumomediastinum

Pentoxifylline and thalidomide fail to reduce hepatic steatosis during total parenteral nutrition and bowel rest in the rat.

BACKGROUND We suggested that the continuous translocation of endotoxin from Gram-negative bacterial overgrowth during bowel rest and total parenteral nutrition (TPN) causes the release of tumor necrosis factor (TNF), resulting in liver damage and hepatic dysfunction. Because TPN-induced hepatic steatosis was significantly reduced by the monoclonal antibodies against TNF, we attempted a more clinically applicable approach using pentoxifylline and thalidomide. METHODS A control group (group I) fed rat chow and four groups of rats receiving TPN were studied. Group II received TPN only; group III, TPN and 100 mg/kg/d pentoxifylline; group IV, TPN and 200 mg/kg/d pentoxifylline; and group V, TPN and 5 mg/kg/d thalidomide. On day 7, total liver fat was determined. RESULTS Bowel rest and TPN resulted in a significant (p < .0005) increase in liver fat content that was unaltered by either pentoxifylline or thalidomide. CONCLUSIONS Our results show no role for pentoxifylline or thalidomide in reducing TPN-associated hepatic steatosis.

Amyand's hernia with perforated appendicitis in a premature infant.

We present a case of Amyand’s hernia with perforated appendicitis in a premature infant. The favorable outcome compared to perforated abdominal appendicitis is discussed. Despite its rarity, this diagnosis should be considered in the differential diagnosis of a scrotal mass in premature infants.

Pentazocine Reduces Cholinergic Responses in the Guinea-Pig Extrahepatic Biliary Tract by a Non-Opiate Mechanism

The mechanical responses of the guinea-pig gallbladder and common bile duct to pentazocine were measured in vitro. At concentrations of 1 microM or higher, pentazocine reduced the responses of the gallbladder and common bile duct to electrical stimulation and to carbachol. This antagonism was not blocked by naloxone and appears to be due to an atropine-like action of pentazocine. At concentrations of 5 microM or higher pentazocine induced gallbladder contraction which was naloxone-insensitive. Both effects were not affected by tetrodotoxin and appear to be due to direct action on the muscle. The antimuscarinic activity of pentazocine should be taken into consideration when this opioid is administered experimentally or clinically.