Clinicopathologic characteristics and prognosis of synchronous multifocal gastric carcinomas

Background

We sought to define differences between multifocal and solitary gastric carcinoma to decrease the risk of missing a cancer while resecting another more evident carcinoma.

Methods

We retrospectively examined clinicopathologic characteristics of multifocal gastric carcinoma including anatomic distribution and postoperative survival.

Results

Multifocal gastric carcinoma was seen more frequently when patients were older and when the largest tumor was small and at an early stage. More than half of accessory lesions were located near the main tumor. No significant difference in postoperative survival was seen between patients with multifocal and solitary carcinoma, whether early or advanced.

Conclusions

The entire stomach should be examined carefully before and during resection, especially when local or endoscopic surgery is performed.     

Single-incision laparoscopic surgery in children: initial single-center experience

Background

In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures.

Method

A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010.

Results

There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients.

Conclusion

This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.     

Clinicopathologic assessment of prenatally diagnosed lung diseases

Purpose

To investigate the clinical features and pathologic diagnosis of prenatally diagnosed lung diseases.

Materials and Methods

The medical records of 28 fetuses with prenatally diagnosed lung diseases were reviewed with regard to perinatal courses, ultrasonographic measurement of the lesion volume ratio, and the histopathology of lung tissue.

Results

Of the 23 fetuses with a prenatal diagnosis of congenital cystic adenomatoid malformation (CCAM), 4 required an emergency lobectomy (1 prenatally and 3 postnatally), whereas the other 14 showed uneventful courses after birth. The pathologic diagnosis of the resected lungs included CCAM (n = 4), lobar emphysema (n = 2), intralobar sequestration (n = 2), and bronchial atresia (n = 1). The peak value of the lesion volume ratio was significantly higher in the CCAM cases that required urgent surgery than in the non-CCAM cases (2.29 ± 0.46 vs 1.20 ± 0.21, P < .001). The ratio decreased after the 25th to the 30th week to less than 1.0 in the 5 non-CCAM cases, but remained higher than 2.0 in the 4 CCAM cases. Prenatally diagnosed extralobar pulmonary sequestration caused massive pleural effusion requiring a fetal intervention in 4 of the 5 fetuses.

Conclusions

The prenatally diagnosed lung lesions include various kinds of pulmonary diseases. Regardless of the diseases, sequential ultrasonographic assessment may predict perinatal risks.     

Thoracoscopic versus open resection of congenital lung lesions: a case-matched study

Purpose

The purpose of the study was to compare the outcomes in children undergoing thoracoscopic versus open resection of congenital lung lesions.

Methods

Retrospective review of 12 consecutive children (<3 years of age) undergoing thoracoscopic resection of a congenital lung lesion between 2004 and 2005 was performed. Intraoperative and early postoperative results were compared with randomly selected age- and sex-matched (2:1) patients undergoing thoracotomy between 2000 and 2005.

Results

Twelve children underwent thoracoscopic resection and were compared with 24 that underwent thoracotomy. Seventy five percent of the lesions in both groups were congenital cystic adenomatoid malformations. There were no major intraoperative complications. Two thoracoscopic procedures were converted to a thoracotomy. Perioperative outcomes including operative time, length of stay, duration and volume of chest tube drainage, and dose and duration of intravenous opioids were similar for the procedures. However, children undergoing thoracoscopic procedures were less likely (odds ratio = 0.07) to have received adjunctive regional anesthesia. Overall morbidity was 33% thoracoscopic and 25% open (P = .70).

Conclusion

Thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions. Examination of long-term advantages of the thoracoscopic approach such as decreased risk of chest wall deformity and scoliosis and improved cosmesis will require longer follow-up.     

Routine use of a SILASTIC spring-loaded silo for infants with gastroschisis: a multicenter randomized controlled trial

Background

Retrospective studies have suggested that routine use of a preformed silo for infants with gastroschisis may be associated with improved outcomes. We performed a prospective multicenter randomized controlled trial to test this hypothesis.

Methods

Eligible infants were randomized to (1) routine bedside placement of a preformed Silastic spring-loaded silo, with gradual reduction and elective abdominal wall closure, or (2) primary closure.

Results

There were 27 infants in each group. There was no significant difference between groups with respect to age, weight, sex, Apgar scores, prenatal diagnosis, or mode of delivery. The total number of days on the ventilator was lower in the spring-loaded silo group, although it did not reach statistical significance (3.2 vs 5.3, P = .07). There was no significant difference between groups with respect to length of time on total parenteral nutrition, length of stay, or incidence of sepsis and necrotizing enterocolitis.

Conclusion

Routine use of a preformed silo was associated with similar outcomes to primary closure for infants with gastroschisis but with a strong trend toward fewer days on the ventilator. Use of a preformed silo has the advantage of permitting definitive abdominal wall closure in a more elective setting.     

Establishment of an Ex Vivo Lung Perfusion Model Using Non-Heart-Beating Large Pigs

Background

Functional evaluation of potentially damaged lungs donated after cardiac death is crucial for widespread clinical transplantation. To date, the mean weight of animals used in studies of ex vivo lung perfusion (EVLP) has been 60 kg; however, in the clinical setting, donor weight may be greater.

Objective

To investigate EVLP using lungs from large pigs (mean weight, 115 kg) to simulate human adult lungs donated after cardiac death.

Materials and Methods

Five heart-lung blocks were obtained at 20 minutes after death at the slaughterhouse. The lungs were flushed and preserved on ice for 6 hours before being connected to an ex vivo lung circuit, and were perfused for at least 2 hours.

Results

In all cases, perfusion was sustained for at least 2 hours. Mean (SEM) final flow rate was 4.9 (0.1) L/min, pulmonary artery pressure was 14.8 (1.7) mm Hg, and oxygen tension/fraction of inspired oxygen was 518.0 (18.0) mm Hg. The shunt fraction was 20.5% (4.0%). Histologic analysis demonstrated no significant pulmonary edema at the end of perfusion.

Conclusion

We successfully completed EVLP using lungs from large pigs.     

The Delorme repair for full-thickness rectal prolapse: a retrospective review

Background

The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse.

Methods

Consecutive patients were identified from a surgical database and evaluated by chart review.

Results

Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19-49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications.

Conclusions

Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.     

Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Extent of small bowel resection does not influence the magnitude of intestinal adaptation in the mouse

Purpose

The magnitude of intestinal adaptation is considered to correlate with the extent of small bowel resection (SBR). However, this association has never been tested in mice. We sought to test the hypothesis that a greater SBR will induce a greater adaptation response.

Methods

C57/B6 mice underwent 50% SBR, 75% SBR, or sham operation and were killed on postoperative day 7. The magnitude of adaptation was compared between 50% SBR and 75% SBR as changes in villus height, crypt depth, as well as rates of apoptosis and proliferation.

Results

Seventy-five percent SBR led to decreased survival and increased weight loss compared with 50% SBR. The remnant ileum of both 50% SBR and 75% SBR displayed similar crypt expansion, enhanced villi, and increased apoptotic indices. Proliferation rates increased after 50% and 75% SBR equally.

Conclusion

Models of resection greater than 50% in mice result in greater morbidity and mortality and do not magnify the adaptation response to massive SBR. The use of more extreme resection models does not appear to provide added benefit for investigating mechanisms of intestinal adaptation.     

Primary surgery for oropharyngeal cancer

Objective

The development of new techniques for transoral resection has led to a renewed interest in primary surgical treatment of oropharyngeal squamous cell cancer (SCCA). We reviewed our experience with primary surgery for oropharyngeal SCCA to identify factors associated with survival.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Patients who underwent primary surgical treatment of oropharyngeal SCCA from 1985 to 2002 were analyzed. Patients who failed nonoperative treatment or had distant metastases at presentation were excluded.

Results

A total of 105 patients met study criteria. The majority of patients (91%) had advanced stage disease (III/IV). All patients received postoperative radiation; chemotherapy was used in eight patients. Five-year disease-free survival was 83 percent for stage I, 67 percent for stage II, 56 percent for stage III, and 43 percent for stage IV disease. Crude local control rates were 94 percent for T1 disease, 90 percent for T2 disease, 81 percent for T3 disease, and 80 percent for T4 disease; crude regional control rates were 100 percent for N0 disease, 90 percent for N1 disease, 84 percent for N2 disease, and 82 percent for N3 disease. Cox proportional hazards models revealed that nodal stage (hazard ratio [HR] 2.3, P = 0.02) and black race (HR 2.6, P = 0.004) were the only significant predictors of disease-free survival.

Conclusion

Primary surgical treatment of oropharyngeal SCCA is effective in achieving excellent locoregional control and permits deintensification of adjuvant therapy, even in patients with advanced stage disease. Nodal status and race are the primary determinants of disease-free survival. These data provide useful information for counseling and treatment planning.     

Balloon-occluded retrograde transvenous obliteration performed in a pediatric patient with isolated gastric fundal varices

Background

For giant gastric varices in association with portal hypertension, endoscopic treatment often is difficult. Although balloon-occluded retrograde transvenous obliteration (B-RTO) has been performed successfully in adult cirrhotic patients, there has been no report in pediatric patients.

Methods

A 10-year-old girl with biliary atresia (BA) who had been free of jaundice after hepatic portoenterostomy was detected to have isolated gastric fundal varices by routine endoscopy. They gradually enlarged up to 4 cm in diameter, showing a tense appearance, so prophylactic treatment was conducted. Magnetic resonance angiography showed the blood flow of the varices mainly drained by a large gastrorenal shunt. A balloon catheter was introduced into the gastrorenal shunt via the femoral vein and was inflated to occlude the outflow of the varices. Five percent ethanolamine oleate was injected into the varices, and the outflow occlusion was kept for more than 30 minutes. Extensive thrombosis was achieved by an additional embolotherapy after 17 months. Throughout the course, the patient has been doing well without bleeding or worsening of the liver function tests.

Conclusions

B-RTO for isolated gastric fundal varices has been performed safely in a pediatric patient and seems effective in reducing the variceal size and tension.     

The ratio between metastatic and examined lymph nodes is an independent prognostic factor for patients with resectable middle and distal bile duct carcinoma

Background

The lymph node ratio, defined as the ratio between the number of lymph node metastasis and the total number of lymph nodes examined, has been reported to be an important prognostic factor in other gastrointestinal carcinomas except middle and distal bile duct carcinomas.

Methods

Between 1991 and 2004, 62 consecutive patients who underwent surgery for middle and distal bile duct carcinoma were retrospectively analyzed concerning prognostic factors.

Results

The median number of lymph nodes examined was 12 (range 5 to 38). The overall 5-year survival rates of patients with lymph node ratio of 0, lymph node ratio of 0 to .2, and lymph node ratio >.2 were 62%, 41%, and 0%, respectively. A multivariate analysis revealed that a lymph node ratio >.2 and perineural invasion were independent predictive factors for survival.

Conclusions

Lymph node ratio >.2 is an important factor to predict survival after resected middle and distal bile duct carcinoma.     

Is congenital lobar emphysema a surgical disease?

Background

The management of congenital lobar emphysema has traditionally been surgical. Because of increased use of imaging, this lesion is frequently found in asymptomatic and mildly symptomatic children, prompting us to adopt a more conservative approach to these children.

Methods

All children with congenital lobar emphysema presenting between 1995 and 2002 were included. Medical records, imaging files, and pathology reports were reviewed.

Results

Twenty children (0-17 years) were identified. Eight were diagnosed antenatally. Fourteen were managed without surgery. Of the 11 symptomatic children, 6 showed spontaneous improvement.

Conclusions

The favorable outcome of both asymptomatic and mildly symptomatic children suggests that a nonoperative approach should be considered in these patients.     

Utilidad de la tomografía computarizada para el diagnóstico de lesiones intestinales y mesentéricas en el trauma abdominal cerrado

Background

The frequency of bowel and mesenteric injuries is increasing. They are difficult to diagnose and delays in their diagnosis leads to a significantly increased morbidity and mortality. The aim of this study is to evaluate the usefulness of the computed tomography (CT) in the detection of blunt bowel and mesenteric injuries.

Method

Between January 2000 and October 2007, 79 patients with blunt abdominal trauma (60 men and 19 women) were included in our study. They underwent laparotomy after performing the abdominal CT. The CT findings were compared with the findings at laparotomy in order to determine the accuracy of the CT in the detection of bowel and mesenteric injuries.

Results

For the detection of bowel and mesenteric injuries we obtained for the CT: Sensitivity=84.2%, Specificity=75.6%, Positive Predictive Value =76.2%, Negative Predictive Value =83.8%, Positive Probability Value=3.45 and Negative Probability Value =0.21. Accuracy: 79.7%.

Conclusion

The abdominal CT is suitable for detecting bowel and mesenteric injuries following blunt abdominal trauma.     

Establishment of a Porcine Model for Lobar Lung Auto-Transplantation

Objective

The aim of this study was to develop a porcine model of left single lung auto-transplantation.

Methods

Eighteen 50-kg male domestic pigs underwent left pneumonectomy and lobar lung auto-transplantation (left lower lobe). Each animal was allocated to a perfusion protocol during surgery: group I, cold saline (n = 6); group II, cold heparin (n = 6); and group III, cold Euro-Collins (n = 6). We measured changes of partial pressure of oxygen in pulmonary vein blood (PvO₂), partial pressure of carbon dioxide in pulmonary vein blood (PvCO₂), lung compliance, and mean pulmonary artery pressure.

Results

The postoperative survival rate was 100%. PvO₂, PvCO₂, mean pulmonary artery pressure, and lung compliance of the left lower lobe showed a significant difference between the saline and the heparin groups or the Euro-Collins group (P < .05), whereas there was no significant difference between the heparin and the Euro-Collins groups.

Conclusion

Compared with other species, humans and pigs show remarkable anatomical and physiological similarity. It is useful experimental animal model to evaluate pulmonary function and grafting protocols following lobar lung transplantation.     

Contemporary outcomes of open thoracic aortic surgery in a veteran population: do risk models exaggerate mortality?

Background

We evaluated contemporary outcomes of open thoracic aortic surgery at a Veterans Affairs (VA) medical center affiliated with a major academic aortic program and examined the predictive value of 2 established cardiac risk models.

Methods

We retrospectively reviewed all open thoracic aortic operations performed between April 1998 and April 2008 (n = 100). Both the EuroSCORE and the VA Continuous Improvement in Cardiac Surgery Program (CICSP) scores were evaluated.

Results

Procedures included ascending aortic repair (n = 74, 15 with arch repair), descending thoracic repair (n = 11, 1 with arch repair), and thoracoabdominal aortic repair (n = 15). Emergency surgery was necessary in 15 cases, and 19 procedures were reoperations. The patients' logistic EuroSCORE and the CICSP scores were similar (18.7% and 18.2%, respectively), but both scores significantly exceeded the observed operative mortality rate (8.0%, P = .008).

Conclusions

Good outcomes can be achieved when thoracic aortic surgery is performed at an experienced VA center. The cardiac risk models we examined overpredicted operative mortality.     

Prospective clinical and functional results of combined rectal and urogynecologic surgery in complex pelvic floor disorders

Background

The aim of this prospective study was to evaluate the results of combined rectal and urogynecologic surgery in women with associated obstructed defecation, urinary incontinence, or genital prolapse.

Methods

One hundred forty-two selected patients with obstructed defecation in isolation or associated with urinary incontinence, enterocele, or genital prolapse were consecutively operated on by stapled transanal rectal resection alone or associated with transobturator tape, vaginal repair of the enterocele, or vaginal hysterectomy, respectively, and followed up by clinical controls and defecography.

Results

At 2 years, all symptom, quality-of-life, and defecographic parameters had significantly improved in all groups (P < .001). The association with hysterectomy showed higher risk for severe complications, longer operative time, hospital stay, and time of inability (P < .001). Recurrence of urinary incontinence was observed in 3 of 24 patients, while 2 of 21 showed residual vaginal prolapse.

Conclusion

The combination of rectal and urogynecologic surgery is effective, with higher morbidity in the association with vaginal hysterectomy. Randomized trials comparing surgery in 1 and more stages and longer follow-up are necessary for a definitive conclusion.     

Pancreatoduodenectomy using a no-touch isolation technique

Background

Pancreatoduodenectomy is the only effective treatment for cancers of the periampullary region. Because surgeons usually grasp tumors during pancreatoduodenectomy, this procedure may increase the risk of squeezing and shedding the cancer cells into the portal vein, retroperitoneum, and/or peritoneal cavity. In an effort to overcome these problems, we have developed a surgical technique for no-touch pancreatoduodenectomy.

Methods

From March 2005 through May 2008, 42 patients have been operated on following this technique. Resected margins were microscopically analyzed.

Results

We describe a technique for pancreatoduodenectomy using a no-touch isolation technique. We resect cancers with wrapping them within Gerota's fascia and transect the retroperitoneal margin along the right surface of the superior mesenteric artery and abdominal aorta without grasping tumors.

Conclusions

No-touch pancreatoduodenectomy has many potential advantages that merit further investigation in future randomized controlled trials.