Ventricular septal fistula formation due to infectious endocarditis in a hemodialysis patient with aortic valve replacement

We report a case of infectious endocarditis in a 77-year-old woman who was undergoing maintenance hemodialysis therapy, and who was also having a prosthetic aortic valve replacement. The disease resulted from a local skin infection at the needle puncture site of the arteriovenous fistula. Ampicillin-resistant Staphylococcus aureus was the causal organism. Surgical treatment could not be performed because of associated intracranial hemorrhage due to septic embolism. In spite of intensive treatment with several antibiotics, a ventricular septal abscess just beneath the prosthetic aortic valve progressed to form a ventricular septal fistula. The resultant intracardiac left-to-right shunt led to refractory congestive heart failure. The patient finally died of heart failure. The formation of a ventricular septal fistula is considered to be a rare and extraordinary complication of infectious endocarditis in a hemodialysis patient with aortic valve replacement. Received: July 25, 2001 / Accepted: November 3, 2001     

An Unusual Complication of Vesical Stones

The author reports a complicated recurrence of genital tract fistula. The initial vesicovaginal fistula resulted from obstructed labor, which was subsequently surgically managed without success. The patient had a recurrent vesicovaginal fistula that was formed by the erosion of vesical stones through the anterior endopelvic fascia into the vagina. The stones eventually eroded into the rectum, resulting in the formation of a complex vesicovaginal and rectovaginal fistula.     

Self-expandable metallic stents in the treatment of post-esophagogastrostomy/post-esophagoenterostomy fistula

Esophageus or gaster resection in patients with malignant disease is still a treatment of choice. It is obvious that each surgical procedure in these patients carries some possibility of complications. Esophageo-gastric or esophageo-jejuno anastomosis has a 4-27% frequency of fistula occurrence. All these result in 65% mortality in cases of poorer prognosis. The aim of this paper is not to present all types of complications but to objectively analyse the usefulness of the covered stent placement in the treatment of anastomotic fistulas. We present six patients who were treated for postoperative fistula of esophageo-gastric anastomosis (1 case) or esophageo-jejuno anastomosis (5 cases). All patients were treated with stapler suture for digestive tract reconstruction after malignancy removal during the primary surgical procedure. Signs and symptoms of suture leak between 5-8 days post-surgery were observed. Conservative therapy was not effective. Thus a new method of treatment was employed - covered stent placement. The procedure was performed under X-ray control. In all treated patients there was change for the better and quick reduction of secretion from the fistulas was observed. All patients were discharged from the department after several days and all had survived at 30 days follow-up. Covered esophageal stent placement seems to be a safe and promising method of treatment for patients with anastomotic fistula which significantly reduces mortality and improves quality of live. Our experiences confirms that of other investigators.     

Pancreatic cancer–Palliative therapy: surgery (bypass/resection)

Objective: We compare the outcome of palliative pancreaticoduodenectomy and palliative surgical bypass in patients with advanced pancreatic carcinoma in our hospital. Recent published related articles are also reviewed. Methods: A respective analysis was performed comparing the perioperative parameters and outcome of 20 patients who underwent pancreaticoduodenectomy with a gross suspected cancer residue and 30 patients who underwent a surgical bypass, all of the patients were diagnosed as in advanced stages intra-operatively. Results: The two groups were comparable with patient characteristics, including age, gender, initial symptoms and concomitant major organ diseases. Tumors are similar in size and intra-operatively diagnosed as in advanced stages in both groups. All of the patients in the resection group were microscopically proved having cancer residue. One postoperative mortality occurred in the resection group (5%), zero in the bypass group (P > 0.05). Overall complications were significantly higher in the resection group (30% vs. 0, P < 0.01), including 2 patients developed Acute Respiratory Distress Syndrome (ARDS), zero in the bypass group (P < 0.01); hemorrhage and transfusions in the resection group were much more than that in the bypass group (P < 0.05). Hospital stay after resection was significantly longer than bypass (20 vs. 12 days, P < 0.01). Hospital fee after resection was 4 times more than after bypass (median 61.500 vs. 15. 300 yuan, P < 0.01). Survival was significantly longer after resection (median 12.2 vs. 7.1 months, P < 0.01). Conclusion: Our results show that palliative resection in advanced pancreatic carcinoma lengthens the survival time of the patients, but this is paid for significantly higher complications than bypass.     

Mucinous adenocarcinoma arising from chronic perianal fistula

Perianal mucinous adenocarcinoma is a rare tumour which may be associated with long‐standing chronic perianal sepsis. Early diagnosis is challenging and is based on a high index of clinical suspicion and specific histological features. Definitive treatment is surgical, in the form of an abdomino‐perineal resection. We hereby describe a case of a perianal mucinous adenocarcinoma arising from long‐standing recurrent perianal fistula and complement this with a brief review of the literature pertaining in particular to the management of this condition.     

柯里拉京对人胰腺癌Bxpc-3细胞抑制作用的初步研究

目的 观察柯里拉京(Corilagin)对人胰腺癌Bxpc-3细胞的抑制作用。方法 采用MTT法和流式细胞仪技术。结果 Corilagin显著抑制了Bxpc-3细胞的增殖，且呈时间-剂量依赖性；流式细胞仪分析结果显示，Corilagin主要作用于细胞周期的S期，同时也作用于G2-M期。并且有凋亡峰出现。结论 Corilagin可有效抑制Bxpc-3细胞增殖，阻滞细胞于S期和诱导凋亡可能是其作用机制之一。     

Preparation of protected peptidyl thioester intermediates for native chemical ligation by Nα‐9‐fluorenylmethoxycarbonyl (Fmoc) chemistry: considerations of side‐chain and backbone anchoring strategies,and compatible protection for N‐terminal cysteine*,†

Abstract: Native chemical ligation has proven to be a powerful method for the synthesis of small proteins and the semisynthesis of larger ones. The essential synthetic intermediates, which are C‐terminal peptide thioesters, cannot survive the repetitive piperidine deprotection steps of N^α‐9‐fluorenylmethoxycarbonyl (Fmoc) chemistry. Therefore, peptide scientists who prefer to not use N^α‐t‐butyloxycarbonyl (Boc) chemistry need to adopt more esoteric strategies and tactics in order to integrate ligation approaches with Fmoc chemistry. In the present work, side‐chain and backbone anchoring strategies have been used to prepare the required suitably (partially) protected and/or activated peptide intermediates spanning the length of bovine pancreatic trypsin inhibitor (BPTI). Three separate strategies for managing the critical N‐terminal cysteine residue have been developed: (i) incorporation of N^α‐9‐fluorenylmethoxycarbonyl‐S‐(N‐methyl‐N‐phenylcarbamoyl)sulfenylcysteine [Fmoc‐Cys(Snm)‐OH], allowing creation of an otherwise fully protected resin‐bound intermediate with N‐terminal free Cys; (ii) incorporation of N^α‐9‐fluorenylmethoxycarbonyl‐S‐triphenylmethylcysteine [Fmoc‐Cys(Trt)‐OH], generating a stable Fmoc‐Cys(H)‐peptide upon acidolytic cleavage; and (iii) incorporation of N^α‐t‐butyloxycarbonyl‐S‐fluorenylmethylcysteine [Boc‐Cys(Fm)‐OH], generating a stable H‐Cys(Fm)‐peptide upon cleavage. In separate stages of these strategies, thioesters are established at the C‐termini by selective deprotection and coupling steps carried out while peptides remain bound to the supports. Pilot native chemical ligations were pursued directly on‐resin, as well as in solution after cleavage/purification.     

Rhinolith: An unusual presentation

A case of rhinolith in a 60 years old male prsenting with palatal performation is, presented alongwith a brief discussion on the pathogenesis and treatment.     

Heart insufficiency in traumatic arteriovenous fistulas

Objective: To analyse the incidence, clinical presentation, and outcome of heart insufficiency in patients with chronic arteriovenous fistulas (AVF). Methodology: From 1991 to 2000 we treated 49 patients with traumatic AVF. The present study included 19 patients with AVF present for 6 months or longer, as it was presumed that these AVF will have an impact on cardiac overload. There were 16 male and three female patients with a mean age of 36 years (17–59). The time from injury to admission varied from 6 months to 33 years. Cardiological examination checked for dyspnoea and palpitation. ECG, chest X‐ray and ECHO‐cardiography were also performed. All AVF were deleted, magistral vessels reconstructed, non‐magistral obliterated, either surgically or by percutaneous embolization. Results: Mean follow up was 44.2 months (3–93). Serious heart insufficiency was seen in two patients only, with AVF in the subclavial vessels. Both suffered from serious heart disease prior to the therapeutic procedures that resulted in iatrogenic AVF, so it was difficult to connect heart insufficiency to the AVF alone. Despite surgical closure of AVF and intensive medical treatment, signs of heart insufficiency remained in both patients. Signs of cardiac overload were seen in six patients with long‐standing AVF in major vessels. Except for one patient who refused surgical closure of femoral AVF, the remaining five were symptom free for cardiac overload during the follow‐up period. Conclusion: In our series, heart insufficiency was an infrequent complication in long‐standing AVF, even when major vessels were involved.     

Curative Laparoscopic Resection for Pancreatic Neoplasms: A Critical Analysis from a Single Institution

Laparoscopic pancreatic surgery (LPS) has seen significant development but much of the knowledge refers to small and benign pancreatic tumors. This study aims to evaluate the feasibility, safety, and long-term outcome of the laparoscopic approach in patients with benign, premalignant, and overt malignant lesions of the pancreas. This study, currently, is the largest single center experience worldwide. One hundred twenty-three consecutive patients underwent laparoscopic pancreatic surgery from April 1998 to April 2007, 20 patients with cysts or pseudocysts for acute and chronic pancreatitis, laparoscopic pancreatic drainage was performed, and were excluded from the analysis. The 103 patients were divided based on preoperative diagnosis: group I, inflammatory tumors for chronic pancreatitis (eight patients); group II, cystic pancreatic neoplasms (29 patients); group III, intraductal papillary mucinous neoplasms (10 patients); group IV, neuroendocrine pancreatic tumors (NETs) (43 patients); and group V ductal adenocarcinoma (13 patients). The median tumor size was 5.3 cm. Pathologic data include R ₀ or R ₁ resection (transection margins on the specimen were inked). Perioperative data, postoperative complications, and resection modalities were compared using statistical analysis. Long-term outcomes were analysed by tumor recurrence and patient survival. The overall conversion rate was 7%. Laparoscopic distal pancreatic resection was performed in 82 patients (79.6%). Laparoscopic spleen-preserving distal pancreatectomy (Lap SPDP) was performed in 52 patients (63.7%), but with splenic vessels preservation in 22% and without splenic vessels preservation in 41.5%. Laparoscopic en-bloc splenopancreatectomy (Lap SxDP) was performed in 30 patients (36.6%) and laparoscopic enucleation (Lap En) in 20 patients (19.4%). There was no mortality. The overall complication rate was 25.2, 16.7, and 40% after Lap SPDP, Lap SxDP, and Lap En, respectively. The overall morbidity rate was significantly higher (p > 0.05) in the group of Lap SPDP without splenic vessels preservation comparing with Lap SPDP with splenic vessels preservation because of the occurrence of splenic complications (20.6%). The overall pancreatic fistulas was 7.7, 10, and 35% after Lap SPDP, Lap SxDP, and Lap En, respectively; the severity of fistula was significantly higher in the Lap En group (p > 0.05). The mean hospital stay was within 1 week in all groups, except in the group of ductal adenocarcinoma, which is 8 days. In this series, 27 patients (26.2%) had malignant disease. R ₀ resection was achieved in 90% of ductal adenocarcinoma and 100% for other malignant tumors. The median survival for ductal adenocarcinoma patients was 14 months. This series demonstrates that LPS is feasible and safe in benign-appearing and malignant lesions of the pancreas.