Cases reported "Digestive System Diseases"

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1/8. Effective treatment of rumination with Nissen fundoplication.

    Rumination is a syndrome characterized by the effortless regurgitation of recently ingested food. It has been linked to severe medical and psychosocial conditions including malnutrition, aspiration pneumonia, and complete social withdrawal. psychotherapy, the current treatment modality for rumination, may improve symptoms but requires significant motivation and is rarely curative. We hypothesized that a complete fundoplication would eliminate, or at least impair, the ability to regurgitate gastric contents through the esophagogastric junction. We performed a Nissen fundoplication in five patients with a classic history of rumination. In all cases, symptoms had been resistant to medical and psychiatric intervention prior to fundoplication. Formal preoperative testing included esophageal manometry, 24-hour pH monitoring, endoscopy, and upper gastrointestinal barium swallow studies. All patients reported their primary symptom to be effortless recurrent postprandial regurgitation for 1 to 2 hours after meals consistent with rumination. Four (80%) of the five patients had low resting lower esophageal sphincter pressures with evidence of gastroesophageal reflux disease on 24-hour pH monitoring. All patients reported complete cessation of ruminating behavior after Nissen fundoplication. We report, for the first time, complete elimination of rumination symptoms after a Nissen fundoplication. Although further trials are needed to confirm our results, we recommend considering a Nissen fundoplication for treatment of rumination refractory to behavioral and medical interventions.
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ranking = 1
keywords = operative
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2/8. Annular pancreas in the adult: two case reports and review of more than a century of literature.

    This paper brings the diagnosis and treatment of this interesting yet infrequent condition to contemporary standards through an assessment of past literature and a re-evaluation of the problem in view of technological advances. Two cases of annular pancreas are cited with a review of the last 183 years of literature. Only 100 cases, however, were reported in enough detail to examine outcomes in general and to arrive at a reasonable conclusion in terms of recommendations for diagnosis and operative intervention in adult annular pancreas. Two observations are brought to light. Despite all present diagnostic tools including endoscopic retrograde cholangiopancreatography diagnosis at best is made in only 60 per cent of patients preoperatively. Intraoperative expertise remains the best diagnostic modality available to date. Enteroenterostomy seems to be the intervention of choice for a multitude of anatomic and physiologic reasons and with a wide array of surgical options available when additional factors need to be addressed.
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ranking = 3
keywords = operative
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3/8. Extraperitoneal endometriosis with catamenial pneumothoraces: a review of the literature.

    OBJECTIVE: To present a case of recurrent catamenial pneumothorax and diaphragmatic endometriosis that was managed thoracoscopically. A review of the literature is also presented. methods: A-28-year-old woman presented with bloody stools, chronic constipation, and chest pain. A review of systems was positive for monthly chest pain associated with her menses. A preoperative chest x-ray revealed a right pneumothorax. colonoscopy revealed biopsy proven endometriosis of the sigmoid colon. A pelvic computed tomography scan revealed bilateral complex, cystic and solid adenexal lesions. RESULTS: A right thoracoscopy was performed. A lesion on the right hemidiaphragm was excised and confirmed to be endometriosis. A wedge section of lung tissue containing a bleb was resected and also contained endometriosis. Three months later, the patient underwent laparoscopic excision of her pelvic endometriosis, including a low anterior rectal resection. Five months later, she presented again with right-sided chest pain. A thoracoscopic right total pleurectomy was performed for recurrent pneumothorax. CONCLUSION: Pullmonary endometriosis may present as chest pain, shortness of breath, or hemoptysis associated with menstrual cycles. This case emphasizes the importance of a careful review of systems in patients with known endometriosis. Management now includes an endoscopic alternative and all of its known benefits.
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keywords = operative
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4/8. Management and long-term follow-up of patients with types III and IV laryngotracheoesophageal clefts.

    BACKGROUND: Laryngotracheoesophageal cleft (LTEC) is a rare congenital anomaly that occurs when the trachea and esophagus fail to separate during fetal development. The 2 most severe forms of LTEC are type III, with extension of the cleft from the larynx to the carina, and type IV, with extension of the cleft into one or both mainstem bronchi. methods: Over the past 25 years, we have accumulated an experience caring for 9 patients with severe LTEC, including 4 with type III and 5 with type IV. RESULTS: morbidity and mortality from severe LTEC often result from aspiration and chronic lung disease. patients with types III (1/4) and IV (5/5) LTEC have an extremely high incidence of microgastria with a shortened esophagus for which fundoplication is ineffective. Because gastric feeding often does not initially increase stomach volume and may cause severe aspiration, we suggest early gastric division with later reconstruction of intestinal continuity in patients with microgastria. Postoperative tracheoesophageal fistulas have occurred in 6 of 9 patients. CONCLUSIONS: Generous interposition of vascularized tissue with a multiple-layer closure has helped to prevent further recurrences. Postoperative tracheomalacia may be managed with continuous positive airway pressure and may require customized endotracheal tubes. Evaluation of respiratory and digestive function, school performance, and quality of life for the surviving patients is described.
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ranking = 2
keywords = operative
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5/8. Endoscopic examination for fistula.

    In 15 postoperative fistula cases, we performed endoscopic examination (fistuloscopy) and studied the clinical significance. The inside of the fistula was easily observed after irrigation with physiological saline. The drain was extubated in 6 cases in which cavities without abscesses were recognized. In a case of pancreatic fistula, the fistula was temporarily closed using fibrin glue. Re-operation was performed in a case in which recurrence of cancer was recognized by biopsy. On the other hand, in 9 cases in which cavities with abscesses were recognized, foreign bodies, such as suture threads, which were sources of infections were removed. Moreover, the drain was removed to the effective site, and the fistula then irrigated repeatedly. Consequently, with the exception of a death due to cancer and a case complicated by osteomyelitis, the fistula was closed in all cases. Fistuloscopy is a safe and easy technique. In addition, the method, which is less stressful for the patient, is considered to be effective for the examination and treatment of fistulas.
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ranking = 1
keywords = operative
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6/8. Wound amylase levels as an early indicator of orocutaneous fistulae.

    The formation of an orocutaneous fistula following ablative head and neck surgery is a common complication. Early fistula detection could permit prompt management, hopefully preventing further wound breakdowns. Amylase is quantitatively the most prominent enzyme in saliva. This study prospectively evaluated whether the amylase content of wound drainage could predict the formation of an orocutaneous fistula earlier than clinically evident. patients undergoing procedures that required postoperative wound drainage represented the study population. Baseline serum and salivary amylase determinations were obtained. The drainage was assayed for amylase content twice daily. Wound amylase values were then correlated with the patient's clinical course. Results showed wound amylase had a downward trend in uncomplicated postoperative courses. An upward trend of wound amylase was correlated with early fistulization. No pattern was identified in patients with delayed fistulae.
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ranking = 2
keywords = operative
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7/8. Studies on the causes of deaths from esophageal carcinoma.

    statistics on the causes for deaths of 638 patients operated on in our department for resection of cancer of the intrathoracic esophagus (squamous cell carcinoma) during the period from 1959-1979 showed that the major causes for direct operative deaths were pyothorax, pulmonary complications, failure of the sutures, and postoperative hemorrhage. Among operation survivors, recurrence was the most frequent cause of death, responsible for the deaths of as many as 80% of less-than-five year survivors; and recurrence in the cervical, supraclavicular fossa, and superior mediastinal lymph nodes and that in the other organs were the frequent causes for the deaths of two- to three-year survivors. Pulmonary complications were the causes for the deaths of 50%, and recurrence for the deaths of 30% of five- to ten-year survivors. recurrence in the digestive organs other than the esophagus and cardiovascular diseases were the frequent causes for the deaths of more-than ten-year survivors, while none of these survivors died of recurrence.
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ranking = 2
keywords = operative
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8/8. Neurovascular morbidity from the lithotomy position.

    The lithotomy position is used in pediatric surgery when it is necessary to have simultaneous access to the abdomen and perineum. At the authors' institution, after a prolonged period in the lithotomy position, significant lower limb complications developed in four patients. Two patients with Hirschsprung's disease underwent a redo Duhamel procedure, one had an anorectal leiomyoma excised, and one had an ileoanal anastomosis for ulcerative colitis. sciatic nerve injury developed in two patients and deep venous thrombosis and bilateral compartment syndrome resulting in myonecrosis developed in one each. There is an association between operations that require prolonged lithotomy position and the development of postoperative neurovascular complications. By placing the child in the lithotomy position only when access to the perineum is required, these significant injuries may be avoided.
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ranking = 1
keywords = operative
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