Simultaneous or sequential combined living donor-intestine transplantation in children

BACKGROUND: Since the report of the first successful living donor combined liver-intestine transplant in pediatric patients, three other cases have been performed. In this article, we describe surgical technique, outcome, and propose a broader application of this procedure using deceased donors. PATIENTS: Four children of mean age 15.5 months (11-24 months) and weight 9.5 kg (8-10.9 kg) affected by end-stage liver and intestinal failure underwent living donor combined liver-intestine transplant with a left lateral liver and a distal segment of jejunum. In one case, the organs were transplanted simultaneously and in three in staged procedures. In all cases the liver transplant was performed first. The intestine was always transplanted with systemic venous drainage. The biliary anastomosis was a duct-to-duct, a biliodigestive, or a combined one according to the biliary anatomy of the liver graft. The abdomen was routinely closed with a Vicryl mesh followed by a skin graft. A loop graft ileostomy was fashioned for protocol biopsies and taken down within 3 months. RESULTS: One intestine was lost to generalized ischemia. The child was promptly retransplanted with another living donor graft. All children are alive and well at an average follow-up of 30 months (18-54 months). CONCLUSIONS: Living donor combined liver-intestine transplant can be performed successfully with excellent early outcome. The in situ splitting technique here described can be applied to obtain grafts for small children from appropriate adult deceased donors.     

Treatment of Bone Tumors

In this article, the authors summarize the state of the art and future potential in the management of Osteosarcoma, Ewing's sarcoma, and Chondrosarcoma. They cover systemic therapy, surgical therapy, and radiotherapy, along with targeted therapies to inhibit signal transduction pathways. They discuss staging and the role of imaging evaluation to provide an overview of bone tumor treatment. Images presenting pathologic-radiologic correlations are included.     

The incidence and patterns of pulmonary artery involvement in Takayasu's arteritis

The pulmonary arterial anatomy in 44 patients with Takayasu's arteritis was examined by intravenous digital subtraction angiography (IV-DSA) on an outpatient basis using centrally delivered, small-volume, bolus injections of an ionic, water soluble contrast medium. Diagnostic pulmonary angiograms were obtained in 42 patients (95.4%) without complication. Angiographically evident pulmonary arterial involvement was seen in six patients (14.3%). The pulmonary involvement was not suspected clinically in any patient and the chest radiographs were abnormal in only two patients (33%). The angiographic spectrum of systemic arterial involvement was the same irrespective of the presence or absence of pulmonary arterial involvement. The pulmonary arterial pressures were measured in two patients with abnormal pulmonary angiograms and were found normal. Follow up IV-DSA in one of these patients 16 months after immuno-suppressive therapy showed no change in the pulmonary angiographic picture.     

Mutagenic activity of gastric fluid from chewers of tobacco with lime

Although tobacco chewing is strongly associated with a highrisk of oral and upper alimentary tract cancers, the natureof mutagenic exposure among users has not been clearly defined.In this study, tobacco-specific and mutagenic exposure of chewersof tobacco with lime was evaluated by analysis of gastric fluid(GF). The pH, nitrite and cotinine levels of GF samples fromchewers and non-chewers were determined and the samples weretested for mutagenicity in the Ames Sahnonella/microsome assayusing Salmonella typhimurium strains TA98, TA100 and TA102.Cotinine was not detected in GF from non-chewers while the levelsranged between 0.4–13.64 µg/ml in samples from chewers;however, the mean pH values (3.8 ± 0.4 versus 2.8 ±0.3) and nitrite levels (29.40 ± 1.51 versus 27.39 ±0.83 µM) were similar in both groups. While all GF samplesfrom non-chewers were non-mutagenic, samples from chewers weredirectly mutagenic or upon nitrosatlon to all the three testerstrains and to TA102 strain in the presence of S9. Experimentsusing scavengers of reactive oxygen species (ROS) showed thatmannitol and benzoate abolished the mutagenic response of TA102,indicating that ROS are principally responsible for oxidativedamage. The findings provide specific information regardingthe mutagenic exposure among tobacco chewers and suggest thattobacco chewing may be an important risk factor in the developmentof gastric cancer.     

Controversies in Acral Lentiginous Melanoma

BACKGROUND: Acral lentiginous melanoma (ALM) is a subtype of melanoma initially described only two and half decades ago, but well-recognized by dermatologists today. However, several areas of controversy surround this entity. OBJECTIVE: The primary aims of this article are to review the literature, highlight recent advances, and review some of the ongoing controversies in ALM. METHODS: A review of the English language literature was performed. RESULTS: Controversy continues to surround ALM, particularly in regard to diagnostic histologic and clinical criteria. This leads to difficulties when reviewing studies that evaluate the epidemiology, etiology, and prognosis of ALM. CONCLUSION: Progress in understanding ALM requires the development of standardized diagnostic criteria.     

Acute kidney injury following implementation of an enhanced recovery after surgery (ERAS) protocol in colorectal surgery

Purpose

Fluid management within Enhanced Recovery After Surgery (ERAS) protocols is designed to maintain a euvolemic state avoiding the negative sequelae of hypervolemia or hypovolemia. We sought to determine the effect of a recent ERAS protocol implementation on kidney function and on the incidence of postoperative acute kidney injury (AKI).

Methods

A total of 132 elective colorectal resections performed using our ERAS protocol were compared to a propensity-matched group prior to ERAS implementation. Fluid balance, urine output, creatinine, and blood urea nitrogen (BUN) were recorded for all patients, and the incidence of AKI was determined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.

Results

Implementation of our ERAS protocol decreased average postoperative length of hospital stay (5.5 vs 7.7 days, p <?0.0001) and time to return of bowel function (2.5 vs 4.1 days, p <?0.0001). The rate of postoperative AKI increased following implementation of the protocol (11.4 vs 2.3%, p <?0.0001). However, by the time of discharge, the average creatinine of ERAS patients who had experienced AKI had returned to their preoperative baseline values (p =?0.9037). Significant univariate predictors of AKI in ERAS patients were longer operative times (p <?0.01) and the diagnosis of diverticulitis (p <?0.01). Within our ERAS patients, AKI was associated with a prolonged postoperative length of hospital stay (p <?0.01).

Conclusions

Despite the proven benefits of the Enhanced Recovery After Surgery (ERAS) protocols, care should be taken during protocol implementation to monitor for and to prevent acute kidney injury.

     

Non Calcifying Type of Calcifying Epithelial Odontogenic Tumor: An Unusual Case Report with Special Emphasis on Histogenesis of Calcifications

Calcifying epithelial odontogenic tumour also known as Pindborg tumour, is a rare benign odontogenic neoplasm of locally aggressive behavior. It is thought to arise from the epithelial element of the enamel origin which are reminiscent of the cells in the stratum intermedium layer of enamel organ in tooth development. The tumour is characterized histologically by the presence of polygonal epithelial cells, calcifications and eosinophilic deposits resembling amyloid. Non-calcifying epithelial odontogenic tumours are very rare and unusual. Only five cases have been reported in the English literature till date. Here, we present an additional case of non calcifying type along with a review of previously reported cases. It has a much lower recurrence and malignant transformation rate.     

Association of coronary calcification with obstructive disease in coronary arteries in Indian patients

A total of 1150 consecutive patients (1052 males and 98 females; age 51.2 +/- 10.1 years) with suspected coronary artery disease (Group I) were subjected to fluoroscopy for detection of coronary artery calcification (CAC) and coronary angiography. Another group (Group II) of 120 patients (95 males and 25 females; age 51.4 +/- 9.4 years) catheterized for cardiac diseases other than coronary artery disease (CAD) were subjected to the same protocol of fluoroscopy and coronary angiography to exclude incidental CAD in view of their age. CAC was present in 240 patients (20.0%) in Group I. Of these, 200 (83.4%) had triple-vessel disease (TVD); 20 (8.3%) had double-vessel disease (DVD); 19 (7.9%) had single-vessel disease (SVD); and 37 (15.4%) patients had left main coronary disease (LMCAD). Only one of these patients had insignificant CAD considered as "normal" coronary arteries (NC). Incidence of LMCAD, TVD, DVD, SVD, and NC in patients without CAC was 4.4%, 56.3%, 18.2%, 14.0%, and 11.5%, respectively. Incidence of CAC in patients with LMCAD, TVD, DVD, SVD, and NC was 48.1%, 28.1%, 10.8%, 13.0%, and 1.0% respectively. In Group II (n = 120), 24 patients (20%) had CAD, CAC was present in 5 patients with CAD (20.9%), and in two patients without CAD (2%). CAC is relatively uncommon in Indian CAD patients. Its presence, however, indicates severe multivessel disease.