Successful colonoscopic decompression of colon after development of an early postoperative obstruction at the stapled anastomosis after an anterior colectomy and early chemotherapy: a case report

A case report describing the successful colonoscopic decompression and catheter drainage of an early postoperative large bowel obstruction caused by swelling at the stapled anastomosis after the initiation of chemotherapy. Our case illustrates that colonoscopy can be successful in managing early postoperative bowel obstruction secondary to swelling at the stapled colonic anastomosis.     

Long-term results of the Cox-Maze III procedure for persistent atrial fibrillation associated with rheumatic mitral valve disease: 10-year experience.

OBJECTIVE: We evaluated the long-term results of the Cox-Maze III procedure (CM-III) for persistent atrial fibrillation (AF) associated with rheumatic mitral valve (MV) disease. METHODS: We analyzed 127 patients who underwent the CM-III combined with a rheumatic MV procedure between 1994 and 2004. In-hospital mortalities were excluded from the study. RESULTS: There were 10 late deaths and the mean follow-up duration was 7.1+/-2.8 years (range, 13 months to 11.5 years). Normal sinus rhythm was restored in 88.2% (112/127) after the CM-III. Right atrial contractility was demonstrable in 100% (112/112) and left atrial contractility in 68.8% (77/112) of the patients restored to sinus rhythm. Fifteen patients never regained sinus rhythm after the CM-III (AF treatment failure). Permanent pacemakers were implanted in 4.7% (6/127) of the patients during the follow-up. Late recurrence of AF developed in 34 of 112 patients at 44+/-27 months postoperatively, and sinus rhythm was restored in 29 of 34 patients by administration of an antiarrhythmic medication. Independent risk factors for late AF recurrence were longer duration of AF (>60 months) (odds ratio (OR)=2.758, p=0.025), increased left atrial size (OR=1.113, p=0.004). Freedom from AF recurrence was 93% at 1-year, 82% at 3 years, 71% at 5 years, and 63% at 7 years. Risk factors for AF treatment failure were longer duration of AF (>60 months) (p<0.001) and increased patient age (p=0.030). A higher prevalence of significant late tricuspid regurgitation was observed in patients with AF treatment failure and those with late AF recurrence. CONCLUSIONS: The CM-III for persistent AF associated with rheumatic MV disease demonstrated a progressively decreased cure rate during the follow-up period. Early surgical therapy, aggressive left atrial reduction, and correction of tricuspid regurgitation at the time of surgery may increase the long-term success rate.     

Vascular trauma: endovascular management and techniques

Endoluminal treatments have traditionally been restricted to a radiology suite, where an interventional radiologist is required. For this reason, this technology has had limited utility for trauma patients who have moderate to severe injuries. Now that vascular surgeons have incorporated endovascular techniques into their practice, the operating room is a radiology suite, and the surgeon is the interventionalist. Endovascular techniques provide an opportunity to improve trauma care by either temporizing a life-threatening injury or serving as the primary treatment. Using endovascular adjuncts does not preclude standard open surgery, nor does it prohibit an immediate or delayed surgical repair.     

CD151 Overexpression is Associated with Poor Prognosis in Patients with pT3 Gastric Cancer

Introduction

CD151, a transmembrane protein of the tetraspanin family, is implicated in the regulation of cell-substrate adhesion and cell migration. Overexpression of CD151 has been reported in several cancers and controls MET-dependent neoplastic growth by enhancing receptor signaling. However, association of CD151 overexpression with MET or tumor progression has not been reported in gastric cancer.

Materials and Methods

We conducted immunohistochemical analysis of CD151 overexpression in 491 pT3 gastric carcinomas and analyzed the relationship with MET overexpression and prognostic significance.

Results

CD151 was highly expressed in 119 gastric carcinomas (24.2 %) and was significantly associated with higher pN stages. Patients with CD151-positive gastric cancer showed shorter overall (p = 0.003) and disease-free survival (p = 0.001) compared with patients with CD151-negative gastric carcinoma. CD151 overexpression was an independent prognostic factor for overall survival [hazard ration (HR) 1.335; 95 % CI 1.005–1.775; p = 0.046] and disease-free survival (HR 1.903; 95 % CI 1.348–2.685; p < 0.001). Co-overexpression of CD151 and MET was observed in 30 (6.1 %) gastric cancers and was more frequent in advanced pN stages than in other groups. Moreover, co-overexpression of CD151 and MET was a strong independent prognostic factor for overall survival (HR 3.163; 95 % CI 1.958–5.108; p < 0.001) and disease-free survival (HR 3.834; 95 % CI 2.145–6.852; p < 0.001).

Conclusion

CD151 overexpression is an independent prognostic factor and could be a potential molecular therapeutic target in patients with advanced gastric cancers. Further studies are needed to establish the biological significance of CD151/MET co-overexpression and the potential of targeting both molecules as a therapeutic strategy.     

Intraductal papillary mucinous neoplasms of the pancreas: an updated experience

OBJECTIVE: To update the authors' experience with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. BACKGROUND DATA: IPMNs are intraductal mucin-producing cystic neoplasms of the pancreas with clear malignant potential. Since the authors' 2001 report, the number of IPMNs resected at our institution has more than doubled, providing an opportunity to define the clinical features of this distinct neoplasm. METHODS: All patients undergoing pancreatic resection for an IPMN at the Johns Hopkins Hospital between January 1987 and March 2003 were evaluated. Noninvasive IPMNs were classified as "adenoma," "borderline," or "carcinoma-in situ" (CIS) depending on the degree of dysplasia within the specimen. Invasive cancers were classified as tubular, colloid, mixed, or anaplastic types. Pathology was retrospectively reviewed to identify main-duct or branch-duct origin of the tumors. Long-term overall survival for patients having IPMNs with invasive cancer was compared with those patients having IPMNs without an invasive component. RESULTS: Between January 1987 and March 2003, inclusive, 136 pancreatic resections were performed for patients with IPMNs, with 78 resections performed since January 2001. The mean age of the patients was 66.8 +/- 1.1 years, with 57% being male and 89% white. Pancreaticoduodenectomy was performed in 71% of patients, total pancreatectomy in 15%, distal pancreatectomy in 12%, and central pancreatic resection in 2%. IPMNs without evidence of invasive cancer were identified in 62% (n = 84) of patients (17% adenoma, 28% borderline, or 55% CIS). The remaining 38% (n = 52) of patients had IPMNs with associated invasive cancer (60% tubular, 27% colloid, 7% mixed, and 6% anaplastic). The mean age of patients with IPMN adenoma was 63.2 years, 66.7 years for those with borderline/CIS IPMNs, and 68.1 years for those with invasive cancer (P = 0.08, adenomas vs. invasive cancer). In those patients with invasive cancers, 15% had invasive cancer at the final surgical margin, 23% had IPMN without invasive cancer at the margin, and 54% had lymph node metastases. Residual IPMN was identified at the neck or uncinate margin in 24% of patients with noninvasive IPMNs. The overall 5-year survival for patients having IPMNs without invasive cancer was 77% (several deaths secondary to metachronous invasive cancer), compared with 43% in those patients with an invasive component (P < 0.0001). There were no differences in survival when comparing adenomas, borderline neoplasms, and CIS. Similarly, there were no statistically significant differences in survival when comparing branch-duct, main-duct, and combined variants; however, the branch-duct variants were more often noninvasive. For those patients with invasive IPMNs, 2-year survival was 40% when margins were positive for invasive cancer or for IPMN without invasive cancer, and 60% when margins were tumor-free (P = 0.15). Those patients with colloid carcinomas (n = 14) had improved survival compared with those with tubular carcinomas (n = 31), with 5-year survival rates of 83% and 24%, respectively. IPMN recurrences and deaths from cancer occurred in patients with both invasive and noninvasive IPMNs at initial resection. CONCLUSIONS: IPMNs continue to be recognized with increasing frequency. Five-year survival for those patients following resection of IPMNs with invasive cancer (43%) is improved compared with those patients with resected pancreatic ductal adenocarcinoma in the absence of IPMN (averages 15%-25%). Survival following resection of IPMNs without invasive cancer (regardless of degree of dyplasia) is good, but recurrent disease in the residual pancreas suggests that long-term surveillance is critical. Based on the age at resection data, there appears to be a 5-year lag time from IPMN adenoma (63.2 years) to invasive cancer (68.1 years).     

The fate of the rectal segment after diversion of the fecal stream in Crohn's disease: its implications for surgical management

Diverting the fecal stream has been considered to benefit the course of Crohn's disease. Clinical signs and symptoms have not, however, been distinguished previously from the objective inflammatory changes in the distal segment. We reviewed the course of 16 consecutive patients with Crohn's disease in whom sigmoidoscopy showed normal mucosa at the time of diversion and who underwent an ileostomy or colostomy, the rectal segment being left in place. As early as 3 months after diversion, all 16 patients showed progressive friability, ulceration, and exudation in the retained rectum. Stricture occurred in four and lead to abdominoperineal resection in three. Four of eight patients with only moderate inflammation on sigmoidoscopy underwent reanastomosis which was followed by a return to a normal-appearing rectal mucosa. The rectal segment inflammed after diversion rarely shows the histological characteristics of Crohn's disease when resected. This leads us to suspect that the disorder of nonspecific "diversion colitis" might account for this phenomenon entirely, or at least it may accelerate the Crohn's disease process. Continuity of the intestinal tract should be maintained in the course of Crohn's disease surgery if feasible. If a diversion is clinically warranted, reanastomosis should be considered as early as possible despite progressive inflammation of the rectal mucosa.     

Extent of Primary Breast Cancer Surgery: Standards and Individualized Concepts

Surgery is still a main therapeutic option in breast cancer treatment. Nowadays, methods of resection and reconstruction vary according to different tumors and patients. This review presents and discusses standards of care and arising questions on how radical primary breast cancer surgery should be according to different clinical situations. In most early breast cancer patients, breast conservation is the method of choice. The discussion on resection margins is still controversial as different studies show conflicting results. Modified radical mastectomy is the standard in locally advanced breast cancer patients, although there are different promising approaches to spare skin or even the nipple-areola complex. A sentinel node biopsy is the standard of care in clinically node-negative invasive breast cancer patients, whereas the significance of axillary lymphonodectomy seems to be questioned through a number of different findings. Although there are interesting findings to modify surgical approaches in very young or elderly breast cancer patients, it will always be an individualized approach if we do not adhere to current guidelines. Up to date, there are no special surgical procedures in BRCA mutation carriers or patients of high-risk families.     

Medical Malpractice Reform: The Role of Alternative Dispute Resolution

Background  

Alternative dispute resolution (ADR) refers to techniques used to resolve conflicts without going to the courtroom. As healthcare and malpractice costs continue to rise, there is growing interest in tactics such as early apology, mediation, and arbitration in the medical arena.     

Androgen and estrogen receptors in the human corpus cavernosum penis: immunohistochemical and cell culture results

Despite the central and peripheral effects of androgens on the nervous system, the local effects of androgens in the corpus cavernosum penis and their importance for erectile function is still unclear. In this study corpus cavernosum biopsies of eight adult potent patients, aged 19–63 years, undergoing penile deviation surgery (group A) and 12 patients undergoing male-to-female transsexual surgery (group B) were immunostained for nuclear androgen and estrogen-alpha receptors. Additionally, primary corpus cavernosum endothelial cell cultures were obtained from six transsexual patients and exposed to testosterone, dihydrotestosterone, estradiol and progesterone likewise for 7 days. Total cell count was performed and cell metabolic activity was measured by a tetrazolium salt-based assay. Androgen and estrogen-alpha receptors were detected in stromal as well as in endothelial cells. Of all cell nuclei, 74.9% (SD 16.4) in group A and 63.5% (SD 17.1) in group B were positively stained for androgen receptors. The respective percentage of estrogen receptors was 11% (SD 9.5) and 21.2% (SD 12.6). An age-dependent difference in receptor distribution was not observed in either group. In the cell culture system only cultures exposed to testosterone and dihydrotestosterone showed a dose-dependent increase of cell metabolic activity compared to the cultures supplemented with estradiol and progesterone. The significant and age-independent high androgen and low estrogen-alpha receptor distribution found in both groups suggests a possible peripheral effect of androgens at the level of the corpus cavernosum penis in adult humans. This is supported by the observed effect of testosterone and dihydrotestosterone on cell count and endothelial cell metabolism in our cell culture system. The role of estrogens remains unclear.     

MRI visible Fe<Subscript>3</Subscript>O<Subscript>4</Subscript> polypropylene mesh: 3D reconstruction of spatial relation to bony pelvis and neurovascular structures

Introduction and hypothesis

To demonstrate mesh magnetic resonance imaging (MRI) visibility in living women, the feasibility of reconstructing the full mesh course in 3D, and to document its spatial relationship to pelvic anatomical structures.

Methods

This is a proof of concept study of three patients from a prospective multi-center trial evaluating women with anterior vaginal mesh repair using a MRI-visible Fe₃O₄ polypropylene implant for pelvic floor reconstruction. High-resolution sagittal T2-weighted (T2w) sequences, transverse T1-weighted (T1w) FLASH 2D, and transverse T1w FLASH 3D sequences were performed to evaluate Fe₃O₄ polypropylene mesh MRI visibility and overall post-surgical pelvic anatomy 3 months after reconstructive surgery. Full mesh course in addition to important pelvic structures were reconstructed using the 3D Slicer® software program based on T1w and T2w MRI.

Results

Three women with POP-Q grade III cystoceles were successfully treated with a partially absorbable MRI-visible anterior vaginal mesh with six fixation arms and showed no recurrent cystocele at the 3-month follow-up examination. The course of mesh in the pelvis was visible on MRI in all three women. The mesh body and arms could be reconstructed allowing visualization of the full course of the mesh in relationship to important pelvic structures such as the obturator or pudendal vessel nerve bundles in 3D.

Conclusions

The use of MRI-visible Fe₃O₄ polypropylene meshes in combination with post-surgical 3D reconstruction of the mesh and adjacent structures is feasible suggesting that it might be a useful tool for evaluating mesh complications more precisely and a valuable interactive feedback tool for surgeons and mesh design engineers.