Repeat surgical bowel lengthening with the STEP procedure

BACKGROUND: Feasibility of repeat lengthening has been demonstrated in animals, but in humans, none of the three clinical case reports have achieved enteral autonomy after secondary lengthening with serial transverse enteroplasty (STEP). PATIENTS AND METHODS: Institutional Review Board approved retrospective review of a single center series of repeat intestinal lengthening after prior Bianchi lengthening or STEP. Outcome measures examined include patient survival, weaning from parenteral nutrition, and need for intestinal transplantation. RESULTS: Repeat lengthening with STEP was performed 16 times in 14 patients including 2 adults and 7 male patients after prior Bianchi (n=7) and prior STEP (n=7). Median time after initial lengthening to reSTEP was 12 months (2 months-15 years). Median remnant bowel length before initial lengthening was 35 cm (15-110), before reSTEP was 56.5 cm (27-100) and final length after reSTEP was 90 cm (39-120). Survival is 100% with a median follow-up of 14.5 months (1-65 months). Discontinuation of parenteral nutrition (PN) after reSTEP was achieved in 6 of 14 (43%) patients at a median of 3 months (0.5-13 months) after reSTEP. Intestinal transplant salvage was performed in four patients at 7, 9, 13 months, and 4.6 years, respectively, after reSTEP. All four of those undergoing intestinal transplantation have also subsequently discontinued PN. CONCLUSIONS: Repeat lengthening is technically feasible after either of the available surgical lengthening procedures (Bianchi and STEP). In the stable patient, who is unable to wean from PN, repeat lengthening led to discontinuation of TPN in almost half of these carefully selected patients and does not preclude intestinal transplantation.     

Short Bowel Syndrome After Continence-Preserving Procedures

The short bowel syndrome (SBS) can result from a variety of conditions, including postoperative complications and malignancy. Continence-preserving operations are generally performed for either ulcerative colitis (UC) or familial polyposis (FAP). These procedures can be associated with high morbidity and the potential for future malignancy. Our aim was to determine the causes and consequences of SBS in patients undergoing these procedures. Twenty-four patients (12 men and 12 women) 18 to 64 years of age were identified with SBS after continence-preserving procedures. Eighteen had pelvic procedures, and six had continent ileostomies. All SBS patients had a proximal ostomy. Remnant length measured <60 cm in five patients, 60–120 cm in ten patients, and >120 cm in nine patients. Overall 13 patients required long-term PN. Four FAP patients with desmoid tumors died. One patient with UC underwent intestinal transplant and expired. Follow-up ranges from 6 to 192 months. Overall 14 patients had UC, nine had FAP, and one had functional disease. Eight patients with an initial diagnosis of UC had subsequent Crohn’s disease necessitating further resection and pouch excision. Eight patients (five with UC, two FAP, and one with functional disease) had postoperative complications, including obstruction or mesenteric ischemia requiring resections. One UC patient developed adenocarcinoma in a continent ileostomy. Seven of the nine FAP patients required resection for desmoid tumors. Six of these underwent resection alone. Three died at 10, 11, and 13 months after SBS from liver failure and sepsis while awaiting transplant. One patient has recurrent desmoid at 30 months, another is alive and well at 48 months, and the other patient, who was not a transplant candidate, died from an unrelated cardiac operation at 23 months. A single patient underwent resection with simultaneous multivisceral transplantation. SBS can develop after continence-preserving procedures. This occurs with inflammatory bowel disease when unsuspected Crohn’s disease is present or complications occur. SBS related to desmoid tumors has a poor prognosis in patients undergoing resection alone. A more aggressive approach to intestinal transplantation in these patients may be warranted.     

Diabetes and sexual dysfunction: results from the Olmsted County study of urinary symptoms and health status among men

PURPOSE: We examined the association of diabetes and domains of sexual dysfunction in a population based sample of men residing in Olmsted County, Minnesota. MATERIALS AND METHODS: A cohort of 2,115 white men 40 to 79 years old as of January 1, 1990 was randomly selected from the Olmsted County population. Men who had a history of prostate or bladder surgery, urethral surgery or stricture, or medical or other neurological condition that could affect normal urinary function were excluded from analysis. Diabetes itself was not used as an exclusionary criterion, although those with end stage organ failure as a result of diabetes were excluded. A previously validated male sexual function index was included in the questionnaires administrated to the cohort in 1996, which consisted of 11 questions on the 5 sexual function domains of sexual drive, erectile function, ejaculatory function, sexual problem assessment and sexual satisfaction. The baseline questionnaire also included whether they had ever been diagnosed by a physician as having diabetes. Only men with regular sexual partners were included. RESULTS: Individuals with diabetes at baseline had significantly greater dysfunction in all 5 sexual function domains. In multivariate adjusted analyses diabetes was significantly associated with all sexual dysfunction domains. The associations remained significant after adjusting for numerous predictors of sexual dysfunction. CONCLUSIONS: The presence of diabetes at baseline was significantly associated not only with erectile dysfunction but with all aspects of sexual dysfunction, including sexual drive, ejaculatory function, sexual problems and sexual satisfaction in this population based sample of men residing in Olmsted County.     

Hormone Responses to an Acute Bout of Low Intensity Blood Flow Restricted Resistance Exercise in College-Aged Females

The purpose of this study was to determine whether the acute hormone response to exercise differed between low intensity blood flow restricted resistance exercise and traditional high-intensity resistance exercise in college-aged women. A total of 13 healthy women (aged 18-25 yrs), who were taking oral contraceptives, volunteered for this randomized crossover study. Subjects performed a session of low intensity blood flow restricted resistance exercise (BFR) (20% of 1-RM, 1 set 30 reps, 2 sets 15 reps) and a session of traditional high intensity resistance exercise without blood flow restriction (HI) (3 sets of 10 repetitions at 80% of 1-RM) on separate days. Fasting serum cortisol and growth hormone (GH) and blood lactate responses were measured in the morning pre and post exercise sessions. GH (Change: HI: 6.34 ± 1.72; BFR: 4.22 ± 1.40 ng·mL^-1) and cortisol (Change: HI: 4.46 ± 1.53; BFR: 8.10 ± 2.30 ug·dL^-1) significantly (p < 0.05) increased immediately post exercise for both protocols compared to baseline and there were no significant differences between the protocols for these responses. In contrast, blood lactate levels (HI: 7.35 ± 0.45; BFR: 4.02 ± 0.33 mmol·L^-1) and ratings of perceived exertion were significantly (p < 0.01) higher for the HI protocol. In conclusion, acute BFR restricted resistance exercise stimulated similar increases in anabolic and catabolic hormone responses in young women.

Key Points

• Growth hormone and cortisol levels significantly increased after a single bout of low intensity blood flow restricted resistance exercise in young women.
• There were no significant differences in hormone responses between the low intensity blood flow restricted protocol and the traditional high intensity higher total workload protocol.
• Low intensity blood flow restricted resistance exercise provides a sufficient stimulus to elicit anabolic and catabolic hormone responses in young women.

Key Words: Growth Hormone, Cortisol, blood flow restriction     

Tacrolimus dose requirements in African‐American and Caucasian kidney transplant recipients on mycophenolate and prednisone

Racial differences among kidney transplant recipients may impact the total daily tacrolimus dose required to achieve therapeutic tacrolimus concentrations. Previous studies suggest that African Americans require higher doses to achieve similar therapeutic drug concentrations compared with Caucasians. Data were collected on a total of 147 de novo kidney transplant recipients. Tacrolimus total daily dose (TDD) requirements (mg/kg/d) and tacrolimus concentrations were retrospectively reviewed at discharge and at days 30, 60, and 90 after transplant. TDD requirements in African‐American and Caucasian patients were 0.14 mg/kg/d and 0.11 mg/kg/d, respectively (p = 0.005), at day 30. TDD requirements at day of hospital discharge and days 60 and 90 following transplant were significantly higher in African‐American patients vs. Caucasian patients, with similar tacrolimus concentrations at all time points. This study suggests that when compared to Caucasians, African Americans require significantly higher TDD of tacrolimus to achieve similar tacrolimus concentrations. These findings provide transplant clinicians with a sense of certainty to more rapidly titrate daily tacrolimus doses in African‐American patients to achieve therapeutic concentrations.     

ER and PR Immunohistochemistry and HER2 FISH versus Oncotype DX: Implications for Breast Cancer Treatment

Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor (HER2) concordance between immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH), and Oncotype DX, a commercially available RT‐PCR‐based assay which recently began reporting biomarker results was assessed. ER concordance was 98.9% (262/265), Pearson correlation coefficient (r) = 0.42, and Spearman's rank correlation (ρ) = 0.25. Positive percent agreement for ER was 98.9% (262/265). One patient with discordant ER results was not offered hormone therapy based on the preferential use of Oncotype DX. PR was concordant in 91.3% (242/265), r = 0.80, ρ = 0.75, and Cohen's kappa (κ) = 0.63. Positive percent agreement for PR was 90.5% (218/241) and negative percent agreement was 100% (24/24). HER2 concordance was 99.2% (245/247), r = 0.35, ρ = 0.28, and κ = 0.12. Positive percent agreement for HER2 was 0% (0/2) and negative percent agreement was 100% (245/245). Of the three FISH HER2‐amplified cases, two were negative and one was equivocal, and all FISH HER2‐equivocal cases (n = 3) were negative by Oncotype DX. Patients that were FISH HER2‐amplified, Oncotype DX HER2‐negative did not receive trastuzumab. Although our results demonstrated high concordance between IHC and Oncotype DX for ER and PR, our data showed poor positive percent agreement for HER2. Compared to FISH, Oncotype DX does not identify HER2‐positive breast carcinomas. The preferential use of Oncotype DX biomarker results over IHC and FISH is discouraged.     

Graduated compression stockings (20-30 mmHg) do not compress leg veins in the standing position

BACKGROUND: Since graduated compression stockings (GCS) reduce the risk of deep venous thrombosis (DVT) in both hospital and ambulant patients, we checked the compressive efficiency of 20-30 mmHg GCS in the standing position. METHODS: In 30 volunteers (17 normal legs, 13 varicose legs), duplex ultrasound was used to measure the internal diameters of the long saphenous vein, posterior tibial veins, peroneal veins, and soleal veins in the lying and standing position and with and without 20-30 mmHg GCS. RESULTS: Graduated compression stockings effectively compressed both superficial and deep veins in supine individuals but not the superficial or the deep veins when standing. In the varicose leg, the stockings did not compress the long saphenous vein at the mid-calf level even when supine. In the varicose leg the long saphenous vein was constricted at the upper band of the stocking, which might explain why superficial venous thrombosis is more common when compression stockings are worn. CONCLUSIONS: In the standing position, GCS did not compress the deep or superficial veins of the calf.     

Portosystemic shunts in children: a 15-year experience

BACKGROUND: The role of portosystemic shunt (PSS) in children with portal hypertension has changed because of acceptance of liver transplantation and endoscopic hemostasis. We report our experience with PSS, mainly the distal splenorenal shunt, to define its role in the management of variceal bleeding. STUDY DESIGN: From 1987 to 2002, 20 children with variceal bleeding after endoscopic therapy underwent PSS. Patient and database records were reviewed. RESULTS: There were 14 boys and 6 girls; mean age was 11 years (range 3 to 18 years). Seventeen distal splenorenal and three mesocaval venous interposition shunts were performed. There was no operative mortality, 19 patients were alive at a median followup of 31 months (range 4 to 168 months) without evidence of recurrent gastrointestinal bleeding. One patient underwent transplantation 2 years after PSS and 1 patient died of hepatic failure while awaiting transplantation. The cause of portal hypertension was portal vein thrombosis (n = 13), biliary atresia (n = 3), congenital hepatic fibrosis (n = 2), hepatitis C cirrhosis (n = 1), and Budd-Chiari syndrome (n = 1). Eighteen children were Child-Turcotte-Pugh class A and the remaining two were class B. One patient had two episodes of hematemesis after PSS. Two patients had worsening ascites. One patient had mild encephalopathy and one patient had shunt stenosis requiring angioplasty. CONCLUSIONS: PSS is a safe and durable therapy for pediatric patients with portal hypertension. Liver transplantation should be reserved for children with poor synthetic function associated with variceal bleeding. PSS may also serve as a bridge to transplantation in patients with preserved hepatic function. PSS, in particular the distal splenorenal shunt, has produced excellent results. This experience challenges the need for alternative forms of portal decompression.     

Percutaneous nonvascular splenic intervention: a 10-year review

OBJECTIVE: We performed a retrospective review of our experiences with percutaneous splenic interventions to evaluate the safety and usefulness of these procedures. We examined both the success rate and the complication rate. MATERIALS AND METHODS: We used our electronic database to perform a retrospective analysis of patients treated from January 1990 to December 2000. Thirty-nine imaging-guided percutaneous splenic procedures were performed in 38 patients: 27 men and 11 women who ranged in age from 17 to 83 years (mean age, 56.5 years). For 28 procedures, sonographic guidance was used, and for 11, CT guidance was used. Procedures performed included splenic biopsy (n = 24), fluid aspiration (n = 8), and fluid drainage (n = 7). RESULTS: Splenic biopsy was successful in 91% of the procedures; fluid aspiration, in 100%; and fluid drainage, in 86%. The overall complication rate was 10.3%, with three patients requiring emergency splenectomy as a result of massive bleeding after the procedure. Two of these patients had previously unrecognized vascular tumors, and one had concomitant refractory thrombocytopenia. CONCLUSION: This study suggests that splenic biopsy can be performed safely and is of considerable value in diagnosis. Our findings also show that percutaneous catheter drainage of splenic abscesses is successful and that splenectomy should be reserved for failed percutaneous drainage. The complications that occur after procedures on vascular tumors emphasize the importance of requiring normal coagulation parameters before the procedure because the vascular nature of the lesion may be difficult to recognize on imaging before the procedure.