Synchronous cecal and sigmoid volvulus

Volvulus is a rare cause of intestinal obstruction in the U.S. Sigmoid colon volvulus is the most frequent, followed by cecal volvulus. The simultaneous occurrence of cecal and sigmoid colon volvulus is extremely unusual. We are reporting what to our knowledge is the third case.     

A Prospective,Multicenter, Clinical Trial Evaluating the Safety and Effectiveness of the Cerene Device to Treat Heavy Menstrual Bleeding

Study ObjectiveTo evaluate the safety and effectiveness of a novel cryoablation device (Cerene Cryotherapy Device, Channel Medsystems, Emeryville, CA) in premenopausal women with heavy menstrual bleeding owing to benign causes.DesignA prospective, multi-center, single-arm, open label, non-randomized study.SettingAt 11 academic and private practices in North America: 8 clinic sites in the United States, and 3 outpatient hospital sites (1 in Mexico and 2 in Canada).PatientsA total of 242 subjects comprise the intent-to-treat population. Subject demographics were similar to other published endometrial ablation studies performed.InterventionsSubjects were treated with a single-use disposable cryoablation device (Cerene) which delivers a 2.5-minute treatment to the endometrium. Analgesia and local anesthesia were administered per investigator discretion; intravenous sedation was used in only 3% of subjects and no general anesthesia was used.Measurements and Main ResultsThere were no device or procedure-related serious adverse events, nor unanticipated adverse device effects. Cerene cryoablation was effective in reducing menstrual blood loss, which was measured by pictorial blood loss assessment chart (PBLAC) score. Mean score dropped from 360.6 at pretreatment (±332.1) to 51 at 12 months posttreatment (±64.1), with 81% of 230 evaluable subjects reporting a PBLAC score of ≤75 and 85% of evaluable subjects reporting a PBLAC score of ≤ 100. The median pain rating was ≤2 (mild) throughout the treatment. Of 223 subjects that underwent hysteroscopic evaluation at 12 months, the uterine cavity was visualized in 220 subjects. Quality of life improved with 90% of reporting subjects indicating satisfied or very satisfied at month 12.ConclusionThis study demonstrated that Cerene cryoablation is safe and effective, offering the benefits of reduced menstrual blood loss with limited use of pain medication, high patient tolerability, quality of life improvement, and preserved access to the uterine cavity.     

Treatment of fistula-in-ano using a porcine small intestinal submucosa anal fistula plug

Background

Porcine small intestinal submucosa (SIS) is a bioprosthetic collagen material used in the management of various surgical conditions, especially hernia repairs. We studied the effectiveness of porcine SIS Bioprosthetic plug (Surgisis AFP^®, Cook Biotech Inc., West Lafayette, IN, USA) in the treatment of fistula-in-ano.

Methods

A prospective multi-institutional study was conducted on 73 patients with anorectal fistulas of differing etiologies. All plugs were inserted in the operating room under anesthesia in patients with preoperative bowel preparation. Regular follow-up was scheduled at 2 weeks, 3, 6, and 12 months. The primary end point was complete closure of the fistula and cessation of drainage over the follow-up period. Seventy-eight AFPs were inserted in 73 patients (28 women and 45 men). Rectovaginal fistulas were excluded. Crohn’s disease accounted for 11 % (8/73) of the patients. Seventy-three percent of patients (n = 53) had primary fistulas whereas 27 % (N = 20) had recurrent fistulas.

Results

The plug extrusion (fallout) rate was 9 % (7/78). There was no difference in closure rates between primary and recurrent fistulas (primary = 20/53 = 38 % and recurrent 8/20 = 40 %). The overall patient success rate was 38 % (28/73) and the plug success rate was 39.5 % when plug fallouts were eliminated. The fistulas in four out of eight patients with Crohn’s disease closed (50 %). There were no intraoperative complications. There were four postoperative abscesses (4/73; 5 %).

Conclusions

Use of AFP^® for treatment of fistula-in-ano is safe and modestly effective in reasonable long-term (15 months) follow-up. This sphincter conserving procedure should be included in the armamentarium of surgeons in the management of transsphincteric or suprasphincteric fistulas.     

Morphologic analyses of proteoglycans in rabbit corneal scars

Ultrastructural localization of proteoglycans (PGs) in 1-week- to 2-year-old scar was determined by staining with cuprolinic blue dye (CBD) after specific enzymatic digestion of keratan sulfate (KS) glycosaminoglycans (GAGs) or chondroitin sulfate glycosaminoglycans (CSs). High critical electrolyte conditions were maintained for CBD-staining, specific for high-sulfated GAGs. Although KS was detected in the 1-week-old wound, no CBD-stained KS was seen in the anterior stroma adjacent to the wound. The CS was present throughout the 1-week-old wound and adjacent stroma, and PGs were biosynthetically 35SO4-labeled in normal stroma. Subsequently, radioactivity from labeled PGs in normal stroma adjacent to the wound moved into scar tissue during healing. Marked sensitivity of PGs to Chondroitinase ABC indicated an abundance of CS in 2-week-old scars. Punctate CBD-staining and immunohistochemical evidence suggested chemically altered KS is present in the 2-week-old anterior scar. The pattern of CBD-staining in 1- and 2-week scars, after chondroitinase treatment, suggested KS in the younger scar is similar to adult high-sulfated GAG, whereas KS in the 2-week scar contains primarily newly synthesized low-sulfated KS. The latter is consistent with previous immunochemical and biochemical analyses. Cytochemical and immunohistochemical evidence indicated that KS is not present in the 2-week-old posterior scar. By the week 8 of healing, CBD-stained KS was present throughout most of the scar, except along the posterior margin, consistent with earlier stages of healing. The CBD-stained structures in the first 8 weeks of healing were reminiscent of stained GAGs in normal developing cornea. This fetal-like CBD-staining pattern seen in scar, however, changed to that of the normal adult by the 2nd year of healing. The significance of these observations relate to our contention that healing adult cornea recapitulates some ontogenetic events of the normal cornea, and that the nonuniform distribution and chemical properties of GAGs in scar tissue are a function of the movement of existing proteoglycans and de novo synthesis of altered macromolecules.     

Immunohistochemistry of proteoglycans in human lamina cribrosa

Proteoglycans are macromolecular components of connective tissue, which are believed to have an important role in the organization of other extracellular matrix components and in the hydration and rigidity of tissue. Using antibodies to the heparan sulfate-, dermatan sulfate-, and keratan sulfate-proteoglycans core proteins, we used indirect immunofluorescence to determine the presence of these core proteins and to characterized their distribution in the lamina cribrosa of healthy human eyes of various ages. Findings with heparan sulfate-proteoglycan core proteins support the multilayered organization of basement membranes in the lamina cribrosa as proposed in previous reports. Dermatan sulfate-proteoglycan core protein results indicate colocalization with fibrillar collagen. Application of monoclonal antibodies to the glycosaminoglycan side chain disclosed an increasing predominance of chondroitin-4-sulfate over chondroitin-6-sulfate with age. This may indicate a decreasing water-holding capacity of the cribriform plates and suggest a decreasing ability to withstand pressure. This study attempts to identify the core proteins of proteoglycans in human lamina cribrosa and serves as a basis for study of glaucomatous eyes.     

Modifiers of exercise-induced S-T segment changes

Myocardial ischemia due to coronary atherosclerosis is the usual cause of exercise-induced S-T segment changes. A number of drugs, electrolyte alterations, and hemodynamic factors may accentuate or mask these changes. The clinician should keep this in mind during the electrocardiographic interpretation of exercise tests.     

Bladder pheochromocytoma with MR correlation

This case report demonstrates the utility of magnetic resonance in the diagnosis of pheochromocytomas in the urinary bladder.     

Hand-sewn versus stapled intestinal anastomoses in a chronically steroid-treated porcine model

Chronic steroid treatment is known to delay wound healing; however, there are no trials examining stapled intestinal anastomoses in subjects chronically treated with steroids. The current study compares mechanically stapled to manually sutured intestinal anastomoses in a steroid-treated porcine model. Twenty adult male pigs were treated with daily prednisolone (0.5 mg/kg IM) for 14 days. The pigs were divided between hand-sewn and stapled groups. All pigs underwent a laparotomy with construction of a jejunojejunostomy, an ileocecostomy, and a colocolostomy. Pigs were sacrificed on postoperative day 4. Bursting pressure, collagen content, and inflammatory scores were used to evaluate each anastomosis. Bursting pressure was greater for the hand-sewn group at the jejunojejunostomies only (1.52 vs 0.79 psi; P < 0.001). The collagen content and microscopic inflammatory scores were not significantly different at any location. The mean gross inflammatory score was greater for the hand-sewn colocolostomies only (5.20 vs 4.00; P < 0.01). Stapled ileocecostomies and colocolostomies appear to heal as well as hand-sewn anastomoses. This may not be true of the jejunojejunostomies as evidenced by the decreased bursting pressures. These data may provide evidence in support of the use of stapled anastomoses in steroid-treated patients.