Matrix metalloproteinase-9 expression correlated with tumor response in patients with locally advanced rectal cancer undergoing preoperative chemoradiotherapy

PURPOSE: To analyze whether the expression of matrix metalloproteinases (MMPs) and their tissue inhibitors are associated with tumor response to preoperative chemoradiotherapy in rectal cancer patients. METHODS AND MATERIALS: Forty-four patients who had undergone preoperative chemoradiotherapy were evaluated retrospectively. Treatment consisted of pelvic radiotherapy and two cycles of 5-fluorouracil plus leucovorin. Surgery was performed 6-8 weeks later. MMP-2, MMP-9, and tissue inhibitors of metalloproteinase-1 and -2 expression was analyzed by immunohistochemistry of the preradiation biopsy and surgical specimens. The intensity and extent of staining were evaluated separately, and a final score was calculated by multiplying the two scores. The primary endpoint was the correlation of expression with tumor response, with the secondary endpoint the effect of chemoradiotherapy on the expression. RESULTS: Preoperative treatment resulted in downstaging in 20 patients (45%) and no clinical response in 24 (55%). The pathologic tumor response was complete in 11 patients (25%), partial in 23 (52%), and none in 10 (23%). Positive MMP-9 staining was observed in 20 tumors (45%) and was associated with the clinical nodal stage (p = 0.035) and the pathologic and clinical response (p < 0.0001). The staining status of the other markers was associated with neither stage nor response. The overall pathologic response rate was 25% in MMP-9-positive patients vs. 52% in MMP-9-negative patients (p = 0.001). None of the 11 patients with pathologic complete remission was MMP-9 positive. CONCLUSIONS: Matrix metalloproteinase-9 expression correlated with a poor tumor response to preoperative chemoradiotherapy in rectal carcinoma patients.     

Live donor liver transplantation for acute liver failure

BACKGROUND: Acute liver failure (ALF) carries a high mortality unless urgent orthotopic liver transplantation (OLT) is performed on time. Live donors are utilized to treat this irreversible condition first in pediatric cases and then in adults. Herein, we aimed to report our experience with live donors for ALF in a country of a deceased donor organ donation rate is only 1.5 per million people. METHODS: Among the 245 live donor liver transplantations (LDLT) performed from June 1999 to December 2005, 14 of them (6%) were performed for ALF in 8 pediatric and 6 adult cases. Right lobes were harvested for the adult cases whereas left lateral segments were harvested for pediatric cases, except one child transplanted with a right lobe graft. The etiology of the disease was; acute hepatitis B in four cases, hepatitis A in three cases, Wilson disease two cases, autoimmune hepatitis in two cases, and was unknown in three cases. RESULTS: Three-year graft and patient survival is 79% for these series. Five of the six adult patients and six of the eight pediatric cases survived after transplantation. There was not any donor mortality or major morbidity. CONCLUSIONS: LDLT offers a safe and effective modality of treatment for ALF for both pediatric and adult patients to overcome the problem of organ shortage especially in countries where the chance of receiving an organ from a deceased donor is low.     

Tubularized incised plate for mid shaft and proximal hypospadias repair

PURPOSE: We report outcomes from tubularized incised plate repair of mid shaft and proximal hypospadias by a single surgeon. MATERIALS AND METHODS: Chart review of all patients undergoing mid shaft and proximal hypospadias was performed. Those with tubularized incised plate were divided into 2 groups for mid shaft and proximal repairs. Group 1 underwent single layer urethroplasty using chromic catgut suture, while group 2 underwent 2-layer polyglactin subepithelial closure. All patients had a dartos barrier flap, while spongioplasty was also done in group 2 when possible. RESULTS: A total of 30 patients underwent mid shaft repairs, while 35 had more proximal defects. Complication rates for mid shaft repairs did not differ between the 2 groups, and averaged 13%. However, complications in mid shaft vs proximal repairs (37%) were significantly different (p = 0.04). Overall complications (53% vs 25%) and incidence of fistulas (33% vs 10%) decreased in proximal repairs from group 1 to 2. CONCLUSIONS: Tubularized incised plate repair was applicable for all mid shaft hypospadias cases and for those more proximal cases when ventral curvature could be straightened without plate transection and the incised plate was grossly supple. Outcomes were improved using 2-layer subepithelial tubularization of the neourethra. Results of mid shaft vs proximal hypospadias repairs are significantly different and should be reported separately.     

Inflammatory abdominal aortic aneurysm: predictors of long-term outcome in a case-control study

BACKGROUND: Inflammatory abdominal aortic aneurysms (AAAs) are relatively rare clinical entities. The aim of this study is to ascertain the risk factors in patients with inflammatory AAAs and clarify which feature plays a role in determining the long-term outcome in these patients. METHODS: Between 1990 and 1997, 238 patients underwent surgery for an AAA at our institution, 17 (7.1%) of whom had the diagnosis of inflammatory type AAA. This group was matched in a case-control fashion to a group of 35 patients with similar characteristics of age, gender, and preoperative risk factors who were operated on for a noninflammatory AAA. All available clinical, pathologic, and postoperative variables were retrospectively reviewed, and the 2 groups were compared. In the inflammatory group, risk factor analysis was performed for poor outcome. RESULTS: All operations were performed through a standard transperitoneal median laparotomy. The 2 groups did not differ significantly in terms of clinical characteristics and preoperative risk factors Patients with inflammatory AAAs were significantly more symptomatic (100% vs 31%, P = .03) and had larger aneurysm size on admission (8.2 +/- 1.2 cm vs 6.1 +/- 0.4 cm, P = .04). In inflammatory AAAs, preoperative erythrocyte sedimentation rate was found to be significantly elevated (mean, 48 +/- 14 mm/h vs 8 +/- 3 mm/h, P = .01). Surgical morbidity and mortality rates did not differ between 2 groups. The intensive care unit and hospital stay periods were similar in both groups (2.2 days vs 1.8 days, P = .25, and 9.2 days vs 8.1 days, P = .35). Eight-year survival rates of inflammatory and noninflammatory groups were 60% and 74%, respectively (P = .01). Results from Cox proportional hazards model analysis showed that a high sedimentation rate after surgical intervention (P = .02), cardiovascular disease (P = .01), postoperative persisting fibrosis with ureteral entrapment (P = .01), and postoperative chronic renal failure (P = .02) were independent risk factors for death. Other surgical variables did not prove to be risk factors for long-term mortality. CONCLUSIONS: Although the preoperative characteristics may differ in patients with inflammatory type AAAs, they can be treated today with low morbidity and mortality rates. However, inflammatory process may continue postoperatively because of unknown reasons, and the study documented that persisting, postoperative inflammatory process with or without retroperitoneal fibrosis may place a patient at high risk for poor outcome. This is important information for the long-term management of these patients, and we believe that their follow-up protocols should be more comprehensive to further improve their long-term survival rates.     

Uterine preservation and vaginal reconstruction in a patient with congenital vaginal agenesis presenting with cyclic menouria

Herein we report the case of a patient with primary amenorrhea and cyclic menouria. The patient was a 20-year-old woman with primary amenorrhea and inability to achieve sexual intercourse. Clinical examination revealed normally developed labia majora and minora, clitoris, and external urethral orifice, but no vaginal opening. A mature female pubic hair pattern was present, and axillary hair development was normal. Breasts were normally developed. Abdominopelvic magnetic resonance imaging demonstrated a remnant upper vagina and unicornuate uterus filled with fluid, and left-sided renal agenesis. Intraoperatively, a congenital vesicouterine fistulous tract was observed. The fistulous tract was completely resected. Vaginal reconstruction using a sigmoid colon pedicled flap was performed. The proximal part of the neovagina was connected to the remnant cervix, and a Foley catheter was left in the uterine cavity for 7 days to prevent obstruction. The patient has been menstruating regularly since the operation. Menouria might be an early sign of congenital vesicouterine fistula. Resection of the fistulous tract with uterine preservation might be considered in patients with vaginal agenesis.     

Echocardiographic features of patients with paroxysmal atrial fibrillation

Background. There are several risk factors for the initiation of paroxysmal atrial fibrillation (PAF) and the underlying mechanisms are multifactorial. Our study aims to explore the echocardiographic parameters that can identify in patients with PAF compared to normal subjects. Methods. Eighty consecutive patients who were with PAF detected by 24-h Holter monitoring (HM) were assigned in our study. The control group (n = 80) consisted individuals with no PAF on HM. Indication for HM was palpitations at rest. All patients underwent routine echocardiographic evaluation. Patients with aortic and mitral stenosis, hyperthyroidism, and hypothyroidism were excluded from the study. Comprehensive clinical data were collected. Results. Mean age of the patients with PAF was 63 ± 11 years and of those 42% were male subjects. There was no difference in the prevalence of hypertension in both groups. Mean left ventricular ejection fraction (LVEF) was 57 ± 15% in PAF group and 64 ± 2% in control subjects (p < 0.001). Mean values of left atrial (LA) diameter for PAF and control groups were 3.7 ± 0.6 cm vs. 3.1 ± 0.4 cm (p < 0.001), respectively. Patients with PAF had more severe valve insufficiency, higher values of mean pulmonary artery systolic pressures (PAP) (29 ± 10 mmHg vs. 25 ± 2 mmHg, respectively; p = 0.001) and deteriorated MV inflow velocities (E:A ratio 0.9 ± 0.4 vs. 1.1 ± 0.3, respectively; p = 0.008) when compared to control group. In multivariate logistic regression analysis, LA diameter predicted the development of PAF after adjusted for age and gender. Conclusion. Our results indicate that LA diameter predicts the development of PAF.     

Serum neuron-specific enolase as a predictor of short-term outcome and its correlation with Glasgow Coma Scale in traumatic brain injury

Elevated serum neuron-specific enolase levels are correlated with brain cell damage. Low scores according to Glasgow Coma Scale are also considered as serious poor prognostic factor. The aims of the study were to investigate whether there is a correlation between the two measurements in patients with traumatic brain injury and whether serum neuron-specific enolase levels have potential as a screening test to predict outcome. A total of 169 consecutive patients with traumatic brain injury admitted to our clinic between 2002 and 2005 are included in this study. Those patients, who had any major health problem before trauma, were excluded from the study. However, patients with isolated head injury were included in the study. Serial serum neuron-specific enolase concentrations taken at the first 2, 24, and 48 h after traumatic brain injury were analyzed. A computed tomography was performed on each patient on admission. Their Glasgow Coma Scale scores were recorded serially. The relationship between Glasgow Coma Scale scores and the serum neuron-specific enolase levels were assessed by statistical methods. There was a significant negative correlation between the serum neuron-specific enolase levels and Glasgow Coma Scale scores. The levels of neuron-specific enolase were significantly higher in the patients who died in 30 days after trauma and whose scores were lower than or equal to 8 points in Glasgow Coma Scale. Although there are several serious limitations of the use of neuron-specific enolase as a biomarker in traumatic brain injury (i.e., hypoperfusion, extracranial trauma, bleeding, liver, or kidney damage also increase the level of neuron-specific enolase), its concentrations may be useful as a practical and helpful screening test to identify neurotrauma patients who are at increased risk and may provide supplementary estimation with radiological and clinical findings.