Amram Ayalon

Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial.

ObjectiveTo assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. Summary Background DataMechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. However, in cases of penetrating colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not prepared. MethodsPatients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. ResultsThree hundred eighty patients were included in the study, 187 in group A and 193 in group B. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. Colo-colonic or colorectal anastomosis was performed in 63% of the patients in group A and 66% in group B. There was no difference in the rate of surgical infectious complications between the two groups. The overall infectious complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%, respectively. ConclusionsThese results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.

Surgical aspects of gastrointestinal persimmon phytobezoar treatment

One hundred thirteen patients presented with gastrointestinal complications due to persimmon phytobezoars during a 3 year period. One hundred three patients had a history of persimmon ingestion. One hundred five patients had undergone previous gastric operation for duodenal ulcer, one patient underwent highly selective vagotomy, and seven patients had not undergone previous operation. An elevated temperature, leukocytosis, and decreased bowel sounds were typical early clinical manifestations of small bowel obstruction by persimmon phytobezoars. In 13 patients, gastric bezoars were found, in 20 patients, gastric and intestinal bezoars, and in 80 patients, intestinal bezoars. One hundred patients were treated surgically. In 14 of the 20 patients with concomitant gastric and intestinal phytobezoars, extraction of the bezoars was achieved by gastrotomy. Of the remaining six patients, it was achieved by intraoperative milking of the gastric bezoar into the small bowel in two patients and by conservative treatment in four patients. Of the 100 patients who presented with small bowel obstruction, 60 were treated by milking of the bezoar into the large bowel, 34 by enterotomy, and 6 by conservative therapy with intravenous fluids, gastric suction, and a water-soluble contrast meal. Small bowel resection of a gangrenous segment was necessary in two patients. Two patients died after operation because of sepsis and respiratory complications. Eleven of the 13 patients in whom postoperative wound infection developed underwent gastrotomy or enterotomy. We conclude that the treatment of choice of intestinal obstruction due to persimmon phytobezoars is milking of the bezoar into the large bowel without enterotomy. Preoperative or operative endoscopy should be performed in patients presenting with complications of gastrointestinal phytobezoars. Patients who have undergone gastric operation should be warned against the risk of persimmon ingestion.

Laparoscopic colectomy without mechanical bowel preparation

BackgroundMechanical bowel preparation prior to colorectal surgery may reduce infectious complications, facilitate tumor localization, and allow intraoperative colonoscopy, if required. However, recent data suggest that mechanical bowel preparation may not facilitate a reduction in infectious complications. During laparoscopic colectomy, manual palpation is blunt, thereby potentially compromising tumor localization. The aim of this study was to assess the utility of mechanical bowel preparation in laparoscopic colectomy.Materials and methodsA retrospective medical record review of all patients who underwent laparoscopic colectomy was performed. Patients were divided into two groups: those who had preoperative mechanical bowel preparation (Group A) or those who did not (Group B). All relevant perioperative data were reviewed and compared.ResultsTwo hundred patients underwent laparoscopic colectomy; 68 (34%) were in Group A and 132 (66%) were in Group B. Sixteen (8%) patients required intraoperative colonoscopy for localization and were evenly distributed between the two groups. The incidence of conversion to laparotomy was slightly higher in Group B (14 vs 9%) due to difficult localization in some cases; however, this difference did not reach statistical significance. Furthermore, there was no significant difference in the postoperative complication rate between the two groups. Specifically, an anastomotic leak and a wound infection were recorded in 4 and 12% of patients in Group A compared to 3 and 17% in Group B, respectively.ConclusionsLaparoscopic colectomy may be safely performed without preoperative mechanical bowel preparation, although difficult localization may lead to a slightly higher conversion rate. Appropriate patient selection for laparoscopic colectomy without mechanical bowel preparation is essential. Furthermore, bowel preparation should be considered in cases of small and nonpalpable lesions.

Closure of Laparoscopic Trocar Site Wounds with Cyanoacrylate Tissue Glue: A Simple Technical Solution

Cyanoacrylate-based tissue glue has been widely used for many years around the world, and was recently approved for use in the United States, mainly for skin cuts and lacerations. Other applications were described, in different surgical situations. Although ideal for small, clean incisions, its use in laparoscopic surgery is currently limited. Over a year period, 100 patients with more 250 trocar site wounds had their wounds glued using histoacryl. Infection rate was extremely low (one case), and partial dehiscence of the wound happened in two patients, where wound edge approximation was not optimal. Cosmetic results were excellent and patient satisfaction was high, as no sutures had to be removed. Glue application is easy and quick, with no risk of needle sticks, and it is a viable option for laparoscopic wound closure.

Removal of Circulating Gastrin and Cholecystokinin into the Lumen of the Small Intestine

This study was undertaken to investigate the mechanism by which the small intestine removes circulating gastrin and cholecystokinin (CCK). A 100-cm (acute study, 10 dogs) or a 50-cm (chronic study, 5 dogs) segment of midjejunum was excluded in all 15 dogs. The excluded loop was perfused with 0.1 M phosphate buffer (pH 7.4), which was constantly recirculated by a peristaltic pump. It the acute control study (5 dogs), gastrin concentrations in the intestinal perfusate were increased gradually to a level of 320 +/- 49 pg/ml at 90 min (i.e., 7.6 +/- 0.9 times higher than serum gastrin levels). In the antrectomy group (5 dogs), perfusate gastrin concentrations were greatly decreased after antrectomy, in consonance with the decrease in serum gastrin concentrations. In the chronic study (5 dogs), perfusate gastrin concentrations were significantly increased after food stimulation, in consonance with the increase in serum gastrin concentrations. CCK was also released into the bowel lumen in considerable amounts basally and after endogenous release. Although one cannot exclude the possibility that a considerable amount of gastrin or CCK in the lumen may originate from the bowel segment, this study shows that the small bowel removes gastrin and CCK from the circulation by their secretion into the bowel lumen. Loss of this mechanism might partially explain the rise in gastrin levels that is observed in some patients after extensive small bowel resections.

Direct effect of bombesin on isolated gastric mucosa

Abstract The stimulatory effect of bombesin on gastric acid secretion has been assumed to be mediated by the release of gastrin. We report here that bombesin also has a direct effect on isolated bullfrog fundic mucosa mounted in Ussing chambers. It stimulates acid secretion and produces a transient increase in electric conductance and in short circuit current.

Does luminal gastrin stimulate gastric acid secretion

The effects of pentagastrin on acid secretion, short circuit current, electrical conductance and potential difference were determined in isolated bullfrog fundic mucosa. Biologically active luminal pentagastrin had no effect on gastric mucosa, even at a concentration 100 times higher than that necessary for stimulation of the mucosa from the serosal side. It is concluded that luminal gastrin does not appear to have a physiologic role in gastric secretory processes.

Bedside laparoscopy in the ICU: report of four cases.

BACKGROUND Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties. PATIENTS AND METHODS We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four. RESULTS The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later. CONCLUSION Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

Sweet’s Syndrome in Association with Ulcerative Colitis and Dyserythropoietic Anemia

infiltrate of the papillary dermis without leukocytoklastic vasculitis, compatible with the diagnosis of Sweet’s syndrome. She was treated with systemic steroids with rapid symptomatic improvement. The steroid dose was gradually tapered. Her medical history was significant for anemia for 7 years, worsening in conjunction with any concomitant disease, and occasionally requiring blood transfusions. Based on clinical features and bone marrow aspiration, hematologic work up suggested the diagnosis of congenital dyserythropoietic anemia. The patient developed diffuse abdominal pain the day following her admission. Abdominal CT scan indicated severe pancolitis and free fluid within the abdominal cavity. Conservative treatment with broadspectrum antibiotics, intravenous hydration, and bowel rest was initiated. However, within 48 h she developed worsening abdominal pain, signs of peritoneal irritation, tachypnea, and tachycardia. The patient was taken to the operating room emergently and the entire colon was found to be severely inflamed and thickened with 2 microperforations. The small bowel appeared normal throughout its length. Total abdominal colectomy with Hartmann’s pouch, which was closed at the upper rectum, and an ileostomy were performed. Dear Sir, Sweet’s syndrome is a rare autoimmune condition which manifests as red or brown painful skin lesions, most commonly in the upper extremities, face and neck. The mainstay of treatment involves high doses of systemic steroids, usually resulting in rapid resolution of symptoms [1] . Rare cases of Crohn’s disease and ulcerative colitis associated with Sweet’s syndrome have been reported in the literature [2] . This letter reports a nontypical presentation of inflammatory bowel disease (IBD), most probably ulcerative colitis, wherein Sweet’s syndrome as well as severe anemia preceded an unusual intestinal manifestation of IBD.

Late Regeneration of Infarcted Small Bowel Mucosa: A Case Report

Ischemic injury of the small bowel may recover after revascularization, provided that full-thickness infarction did not occur. Animal studies showed that if the mucosal crypts remain viable, rapid mucosal restitution occurs hours after injury. The treatment of transmucosal infarction that does not extend to full wall thickness, however, was not investigated thoroughly. The patient presented had a mesenteric event leading to resection of about half of his small bowel. The unresected segment had severe ischemic injury, which seemed to cause transmucosal, but not transmural, infarction. Imaging of the remaining small bowel revealed a seromuscular layer denuded of mucosa. The ischemic damage was too deep to allow rapid regeneration, and the patient had short-bowel syndrome. A year later, during operation for stricture complications, new mucosa covered parts of the small-bowel surface, encouraging the surgeon to elect a conservative approach. Sixteen months after the injury, normal mucosa covered the entire small bowel, and enteral feeding resumed successfully. This report shows that infarcted small-bowel mucosa may regenerate even months after injury.