Bowel Function and Hysterectomy – A Review

Hysterectomy is the most common major gynecological operation performed in the United Kingdom and in the United States. As the operation disrupts the innervation and the intimate anatomical relationship of the pelvic organs such as the bowel and the bladder, function of these organs may be affected. Frequently women date the onset of their bowel symptoms to the time of hysterectomy, though there is no scientific evidence to support causation. Although so frequently performed little is understood of the true incidence of bowel dysfunction after a hysterectomy or the pathophysiology behind it.     

Small Bowel Adenocarcinoma: Understaged and Undertreated?

Background  

Primary small bowel adenocarcinoma (SBA) is a rare, chemoresistant tumor with an aggressive clinical nature. Surgery is the mainstay of therapy, but the extent of lymph node (LN) recovery necessary for optimal care of jejunoileal SBA is unknown.     

Fournier’s gangrene: Exists and it is still lethal

Background: Fournier’s gangrene is an aggressive form of necrotizing fascitis of the perineal, perianal or genital regions, caused by a polymicrobial infection that includes virulent organisms. Patients and methods: Eleven cases of Fournier’s gangrene were treated in our department during the last 20 years. Portals of entry were ischiorectal abscess, perirectal abscesses, scrotal abscess and trauma in the perianal area. The documents were analyzed according to clinical and epidemiologic patterns. Results: We dispensed systemic chemotherapy with broad-spectrum antibiotics, and performed surgical debridement for all patients. In addition, one patient was treated by local use of 100% oxygen, with excellent results in wound healing. All patients made a full recovery, except one who died of sepsis. Conclusion: These cases are presented with some notes underlying the reasons for the persisting incidence and mortality of this disease.     

Primary omental gangrene mimicking appendicular perforation peritonitis—A case report

IntroductionPrimary omental torsion is a rare cause of acute abdomen in adults and presents with variable signs and symptoms. Establishing a preoperative diagnosis may be difficult in the emergency setting. It is rarely diagnosed preoperatively as it mimics common surgical emergencies such as acute appendicitis, appendicular perforation, acute cholecystitis and perforated peptic ulcers and can lead to the clinical deterioration of patient if missedPresentation of caseA 47 years old male was taken to the operating room with a diagnosis of appendicular perforation peritonitis and during surgery was found to have a primary omental gangrene with pyoperitoneum, for which omentectomy and peritoneal lavage was performed.DiscussionTorsion of the omentum is a condition in which the organ twists on its long axis to such an extent that its vascularity is compromised. Omental torsion can be primary (idiopathic) or secondary, depending on an underlying cause. Primary omental torsion was first described by Eitel in 1899. However, very few cases have been reported. Our case was a rare case presenting with omental gangrene with pyoperitoneum mimicking appendicular perforation peritonitis.ConclusionPrimary omental torsion is a rare diagnosis. A high index of clinical suspicion is required for a preoperative diagnosis. In doubtful cases a CT scan may be helpful. Surgical excision of the omentum remains the treatment of choice; however, conservative management may be attempted in an uncomplicated omental torsion.     

Short Bowel Syndrome: An Uncommon Clinical Entity and a Therapeutic Challenge—Our Experience and Review of Literature

Short bowel syndrome (SBS), one of the commonest types of intestinal failure, usually secondary to extensive bowel resection, traditionally has been associated with a high mortality rate and hence a big challenge for the treating surgeons. It requires comprehensive clinical care to minimise the morbidities and mortality associated with the condition. We report a retrospective review of a series of seven patients with SBS, who presented at our surgical emergency within a period of 1 year and their outcome so as to encourage others in managing such a challenge with more positive mindsets. A retrospective analysis of seven patients with SBS admitted from January 2014 to January 2015 with a follow-up of 1 year has been done in terms of their demographic characteristics, underlying pathology and clinical outcome. A rising incidence of SBS in the younger age group (71.4%) has been observed in this analysis. Majority of patients (57.1%) had mesenteric ischemia as the underlying cause followed by each case of small bowel volvulus, internal herniation and blunt trauma abdomen. A discharge rate of 71.4% and mortality rate of 28.5% were observed. With this analysis, we believe that SBS is no more an uncommon condition. A structured clinical approach, timely surgical intervention and multidisciplinary postoperative management are essential for managing such frail patients to achieve best possible results. This will encourage others in managing such a critically challenged condition with a more positive approach and thus beneficial for both the patients and the treating surgeon.     

Spinal intradural primary germ cell tumour—review of literature and case report

Background  Primary spinal cord germ cell tumour is a rare tumour. We herein review the tumour characteristics, associated risk factors, treatment policy, and patterns of failure of primary intradural germ cell tumour. Method  We conducted a PUBMED search using a combination of keywords such as “spinal germ cell tumor,” “germinoma,” “extradural,” “intradural,” “intramedullary,” “extramedullary,” and identified 19 cases of primary spinal germ cell tumour. Clinical features, pathologic characteristics, and treatment details of these patients including status at follow-up were noted from respective case reports. We also describe a case of a young Indian patient of intradural extramedullary germ cell tumour treated with a combination of surgery, chemotherapy, and radiotherapy. Findings  The median age at presentation was 24 years. The most common location of the tumour was thoracic (40%). β-HCG overproduction was noted in 40% of the patients. Most patients were treated with a combination of surgery, radiation therapy, and systemic chemotherapy. Median follow-up was 16.5 months. Recurrence was observed in 10% of the patients, all in β-HCG over-producing tumours. The illustrative case was a 28-year male, presenting with pain in lower back and both lower limbs for 2 months. Magnetic resonance imaging spine showed an inhomogeneous hyperintense soft tissue mass at L₂-L₄ spinal level. He was treated with complete surgical excision and four cycles of chemotherapy with BEP regimen following a histological diagnosis of non-seminomatous germ cell tumour. Palliative irradiation to the lumbar spine was given on progression at 3 months. The patient eventually succumbed to his condition, due to compressive transverse myelitis possibly due to cervical cord metastasis. Conclusion  Limited surgery followed by upfront radiation therapy and adjuvant chemotherapy is the optimal management of this rare group of tumour. Omission of radiation therapy from the treatment armamentarium might engender local recurrence and spinal dissemination at first failure.     

Is stromal microinvasion in primary mucinous ovarian tumors with "mucin granuloma" true invasion?

Stromal microinvasion has been recently described in ovarian mucinous borderline tumors (MBTs), leading to proposals for new classifications, including a category of MBTs with stromal microinvasion. This study was conducted to test the validity of this belief. To determine whether stromal microinvasion can be distinguishable from extruded neoplastic epithelium from an adjacent ruptured gland, particularly if accompanied by a mucin granuloma (MG) on hematoxylin and eosin (H&E)-stained sections, we compared the histopathologic features of 138 primary ovarian mucinous tumors, consisting of 81 MBTs, 37 MBTs with stromal microinvasion, 11 intraglandular carcinomas, 2 with microinvasive foci, and 7 mucinous adenocarcinomas with extensive stromal invasion. Immunohistochemical analysis for cytokeratin was performed in 72 cases. Of 77 cases containing MGs, 52% contained "microinvasive foci," consisting of individually scattered epithelial or irregular glandular components in the intervening stroma, as determined by H&E staining. Of the 37 negative cases on H&E, cytokeratin reactivity was detected in 15 additional cases with epithelial/glandular components. Therefore, "stromal microinvasion" can be missed on H&E. All patients with MBT with or without microinvasive foci and localized intraglandular carcinoma with or without microinvasive foci had stage I tumors; none died of tumor-related causes during the follow-up period. Tumor-related deaths were identified only in 5 patients with extensive stromal invasion. This study suggests that some cases of stromal microinvasion in stage I MBTs not accompanied by high grade nuclear atypia represent mucocele-like stromal reaction to ruptured mucinous glands rather than true stromal invasion because isolated tumor cells were exclusively confined to the boundary of MGs and devoid of obvious cellular atypia, and no patient with stromal microinvasion died of tumor-related causes.     

Pretreatment effect of adenosine on activation of NF—κB and level of TNF—α during myocardial ischemia and reperfusion in rats

Ithasbeenshownthatischemiaandreperfusion(I/R)increasecytokinelevelsincludingTNF α ,IL 1,IL 6 ,IL 8,IF γ ,andintercellularadhesionmolecule 1(ICAM 1)inthemyocardium .1TNF αandIL 6arethoughttobeimportantintheprogressionofmyocardialdysfunction .2 AdenosineinhibitsmyocardialTNF αproductionin postischenmicrat ,reduceshumanmyocardialinjuryafterI/R ,3anddecreasesLipopolysaccharide (LPS )inducedcardiacandmacrophageTNF a production .4 However ,themolecularmechanismsofadenosineinthedown …     

Laparoscopic Surgery for Inflammatory Bowel Disease—The Experience in China

ABSTRACT

Background: The incidence of inflammatory bowel disease (IBD) has risen rapidly in China over the last 15 years. Increasing numbers of people with IBD require surgery during their lifetime, but few reports of IBD in Eastern populations have been described to date. The aim of this study was to assess the short-term effects of the laparoscopic surgery for IBD in Chinese patients. Materials and methods: From February 2010 to March 2012, 35 patients with IBD underwent laparoscopic operations and the clinical data obtained for these patients were reviewed. Results: Patients with Crohn's disease (CD) (N = 21) and ulcerative colitis (UC) (N = 14) underwent laparoscopic surgery. In the CD group, the mean age was 37.4 years. Two patients (9.5%) required conversion to an open procedure. The median length of postoperative hospitalization was 9 (7–40) days. Overall morbidity was 26.3% and no patients required re-operation. In the UC group, the mean age was 55.2 years. The conversion rate was 14.3% (2/14). The median time to regular diet was 4 (3–10) days and the median length of postoperative hospitalization was 8 (7–25) days. Four patients developed postoperative complications and one patient developed ileostomy retraction requiring urgent operative intervention to rebuild the stoma. Conclusions: Laparoscopic surgery in patients with IBD can be accomplished safely and with reasonable operative times, conversion rates and morbidity rates. The main advantages of the laparoscopic approach are rapid recovery, improved cosmesis, less postoperative pain, and patient satisfaction.     

Is Radical Bowel Cancer Resection Under Local Anaesthesia and Sedation Feasible?

Some patients with bowel cancer have significant comorbidities, making them unfit for major surgery under general anaesthesia. However, treatment without surgery offers no possibility of cure, and furthermore, symptom control may be poor. We investigated the possibility of performing these resections under local anaesthesia in patients with a slim body habitus in a cohort of patients rejected for general anaesthesia. Eight patients (4 M, 4 F) aged 77–89 were included in this study. All had significant comorbidities and were deemed unfit for general anaesthesia by the consultant anaesthetist in charge of pre assessing high-risk patients. All patients had undergone a thorough assessment, which included P-POSSUM scoring. The recruited patients underwent a careful and fully informed consenting process, leading to standard cancer resections. These resections occurred between 2005 and 2012, under combined local anaesthesia and sedation. The operations undertaken were four right hemicolectomies (for caecal cancer), two Hartmann’s procedures (for sigmoid cancer), one Hartmann’s procedure with en bloc small bowel resection (for sigmoid cancer invading small bowel) and one transverse colectomy (for mid transverse colon cancer). Seven patients survived radical surgery without complications, although one died from an unrelated cause 8 months after surgery. One of these surviving patients subsequently underwent CABG and further bowel surgery under GA 2 years later for a metachronous sigmoid cancer. There was one postoperative death due to cardiogenic shock on the third postoperative day. Radical cancer resections under local anaesthesia are feasible in suitably selected high-risk patients with acceptable mortality and comparable medium- to long-term results.     

Small Bowel Adenocarcinoma – Report of Two Cases and Review of Literature

Although accounting for 90 % of the intestinal surface area, small bowel adenocarcinomas are not common. The majority of these lesions are incidentally detected during laparotomy for intestinal obstruction or perforation. The symptoms associated with these lesions are not very specific and preoperative diagnosis is rare. We report two cases of jejunal adenocarcinomas detected in patients undergoing laparotomy for acute abdomen and review the literature for small bowel adenocarcinomas.     

Multiple primary malignancies involving colorectal cancer—clinical characteristics and prognosis with reference to surveillance

Background/aim  

The purpose of this study was to investigate clinically useful information for effective screening for synchronous and metachronous second primary cancers and to suggest potential surveillance tool.