Leptin receptor expression in neoplastic and normal ovarian and endometrial tissue.

PURPOSE: The objective of this study was to investigate the expression of leptin receptors in benign and malignant tumors of the ovaries and endometrium and its association with body mass index (BMI). METHODS: Histological uterine and ovarian samples of normal and neoplastic tissue from 35 patients aged 37-72 years were examined for the expression of leptin receptors with the method of RT-PCR. T. RESULTS: A BMI > 30 was correlated with increased expression of leptin receptors. Both Ra and Rb receptors were expressed in normal and neoplastic tissues. A statistically significant difference in leptin receptor expression was detected between normal and neoplastic tissue, with expression being around 5-fold higher in neoplatic tissue. CONCLUSION: Endometrial neoplasms and long leptin isoform receptor expression were associated with an increased BMI. A role of long isoform in endometrial carcinogenesis is proposed.

The fat content of small primary breast cancer interferes with radiofrequency-induced thermal ablation.

BACKGROUND: Radiofrequency (RF) thermal ablation is a minimally invasive technique of local mass elimination with variable efficiency. METHODS: Ten patients with small primary breast cancer diagnosed preoperatively by core needle biopsy were ablated percutaneously by an RF (Radionics Cool-tip) device operating on impedance control mode. The percent fat-containing area was calculated in each slide of a total of 47 slides introduced to IQ materials software image analysis. RESULTS: Seven of 10 tumors with tumor diameter less than 2.8 cm and fat content less than 12.47% were totally ablated (score 3). One of 10 with 3 cm tumor diameter and 5.45% fat content showed an intermediate degree of ablated tissue (score 2), and the last 2 with 2 cm and 2.2 cm tumor diameter and more than 19.74% tumor fat content were minimally ablated (score 1). Our present exploratory study on 10 patients suggests dependence of the degree of thermal damage on tumor fat content. CONCLUSIONS: We conclude that the fat content of small primary breast cancer could serve as a 'heat sink' and should be considered as a preventing factor of complete local tumor destruction by RF thermal ablation.

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh.

OBJECTIVES: Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty. METHODS: In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19-88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients' records were retrospectively reviewed for the purpose of this study. RESULTS: Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6-44 months postoperatively. CONCLUSION: From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.

Late-onset deep mesh infection after inguinal hernia repair.

BACKGROUND: Groin sepsis requiring mesh removal is said to be a rare complication of tension-free inguinal hernioplasty. Furthermore, late-onset deep-seated prosthetic infection seems to be an unexpected complication. The aim of this study was to report our experience on late mesh infection occurring years after open hernia repair. METHODS: Between 1998 and 2005, 1,452 patients (954 men), median age 64 years (range 19-89) underwent groin hernioplasty using a tension-free polypropylene mesh technique. Five patients (0.35%) appeared with late mesh infection (between 2 and 4.5 years postoperatively). The patients' records were retrospectively reviewed for the purpose of this study. Antibiotic prophylaxis had been given in the five patients, while none of them had a prior history of wound infection. RESULTS: The patients were re-operated and the meshes were removed. Pus was found in three patients and Staphylococcus aureus was isolated in one. There was no hernia recurrence and none of the patients had chronic groin pain for a period of 6-44 months postoperatively. CONCLUSION: From the results of this study, it appears that late-onset deep-seated prosthetic mesh infection is an important complication which has been rarely reported upon. Its true incidence is yet to be established. Late graft infection does not seem to correlate to neither the administration or not of antibiotic prophylaxis, nor to the presence or not of previous superficial wound infection. Furthermore, graft infection does not seem to correlate to neither the type of mesh inserted, nor to the fixation material. With the increasing use of synthetic materials for primary and recurrent hernia repair, the number of patients presenting with late mesh infections is likely to increase.

The role of antibiotic prophylaxis in elective tension-free mesh inguinal hernia repair: results of a single-centre prospective randomised trial.

Hernia repair is one of the so-called clean operations. Many surgeons, however, use antibiotics, especially in the mesh repair era, without strong evidence to support this policy. We conducted a single-centre prospective randomised trial with a view to clarify this issue on a scientific basis. From January 2000 all patients undergoing elective inguinal hernia repair using a tension-free polypropylene mesh technique, provided they fulfilled predetermined criteria, were randomised to have a single dose of amoxicillin and clavoulanic acid or placebo in a double-blind manner. The main end point was to detect any difference in infectious complication rates - with specific interest to wound infection rates - between the two groups. Between January 2000 and June 2004, 386 patients entered the study (364 men and 22 women, median age 63 years, range 15-90 years) and were randomised to have antibiotic prophylaxis (group A, n = 193) or placebo (group B, n = 193). The two groups were comparable regarding demographic data. In total, 19 (5%) cases with infectious complications were detected. Fourteen of these were wound infections (3.7%). There were five cases of wound infection in group A and nine in group B (p = 0.4, Fisher's exact test). All wound infections were treated with antibiotics. The wound was opened in some cases. Mesh removal was not required in any of the cases. From the results of this study it does not appear that antibiotic prophylaxis offers any benefits in the elective mesh inguinal hernia repair.

Laparoscopic cholecystectomy under spinal anesthesia: a pilot study.

BACKGROUND: Regional anesthesia has not been used as the sole anesthetic procedure other than in the scenario of a patient at high risk to undergo laparoscopic cholecystectomy with CO2 pneumoperitoneum under general anesthesia. METHODS: Fifteen ASA grade I or II patients underwent laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under spinal anesthesia. Intraoperative parameters, postoperative pain and recovery in general, as well as patient satisfaction at follow-up were prospectively recorded in a pilot study to assess the feasibility and safety of the procedure. RESULTS: All operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score 4 h postoperatively was 1.5 (range, 0-5), at 8 h it was 1 (range, 0-6), and at 24 h it was 1 (range, 0-4). All patients were discharged after 24 h. Follow-up 2 weeks postoperatively showed all but one patient to be satisfied and strongly recommending the anesthetic procedure. CONCLUSION: Laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and at least an equally good recovery as with general anesthesia.

Local treatment of a loop colostomy prolapse with a linear stapler.

Stomal prolapse is considered to be a common complication especially following loop colostomies. A variety of methods has been reported for the management of this condition, with many of them requiring extensive reconstruction of the stoma under anesthesia. We report a simple and fast technique for the local correction of the prolapse under minor sedation. A linear stapler device was applied for the amputation and reconstruction of the prolapse stoma at the desired level.

Perianal abscesses due to ingested foreign bodies.

Four cases of perianal abscesses due to foreign bodies (FBs) impacted in the anal canal are reported. The clinical presentation mimics common causes of acute anal pain. Digital rectal examination under local or general anaesthesia and/or proctoscopy can establish the diagnosis, but may miss the presence of an FB. Incision and drainage of the abscess along with removal of the FB results in immediate pain relief and long-term cure. Impacted FBs must not be overlooked as an unusual cause of perianal abscess.

Electrocoagulation: an alternative palliative treatment for rectal cancer.

BACKGROUND: We present our experience with palliative transanal electrocoagulation therapy (TEC) for rectal cancer. METHODS: Eight patients with biopsy-proven localised low rectal adenocarcinoma were treated with palliative TEC. Inclusion criteria were: high risk patients with anal adenocarcinoma less than 3 cm in diameter, localised less than 7 cm from the anal verge, limited to the rectal wall. Under local anaesthesia all patients underwent TEC using the traditional cautery. RESULTS: No mortality and morbidity was found. Four patients required a second procedure and one patient had a third session . Two patients died within 2 years from distal metastasis. The remaining six patients are alive and free of local recurrence (follow-up 9 months to 4 years). CONCLUSIONS: In poor surgical candidates, palliative TEC of rectal adenocarcinoma may have a role as an alternative to radical surgical treatment.

Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: a multicenter study.

BACKGROUND: Although the use of stapling devices in elective colon surgery has been shown to be as safe as handsewn techniques, there have been concerns about their safety in emergency trauma surgery. The purpose of this study was to compare stapled with handsewn colonic anastomosis following penetrating trauma. METHODS: This was a prospective multicenter study and included patients who underwent colon resection and anastomosis following penetrating trauma. Multivariate logistic regression analysis was used to identify independent risk factors for abdominal complications and compare outcomes between stapled and handsewn repairs. RESULTS: Two hundred seven patients underwent colon resection and primary anastomosis. In 128 patients (61.8%) the anastomosis was performed with handsewing and in the remaining 79 (38.2%) with stapling devices. There were no colon-related deaths and the overall incidence of colon-related abdominal complications was 22.7% (26.6% in the stapled group and 20.3% in the handsewn group, p = 0.30). The incidence of anastomotic leak was 6.3% in the stapled group and 7.8% in the handsewn group (p = 0.69). Multivariate analysis adjusting for blood transfusions, fecal contamination, and type of antibiotic prophylaxis showed that the adjusted odds ratio (OR) of complications in the stapled group was 0.83 (95% CI, 0.38-1.74, p = 0.63). In a second multivariate analysis adjusting for blood transfusions, hypotension, fecal contamination, Penetrating Abdominal Trauma Index, and preoperative delays the adjusted OR in the stapled group was 0.99 (95% CI, 0.46-2.11, p = 0.99). CONCLUSION: The results of this study suggest that the method of anastomosis following colon resection for penetrating trauma does not affect the incidence of abdominal complications and the choice should be surgeon's preference.

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study.

BACKGROUND: The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS: Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION: The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Glutathione-linked enzymes in benign and malignant oesophageal tissue.

Oxyradicals are involved in multiple mutational events and can contribute to the conversion of healthy cells to cancer cells. Glutathione (GSH) and the GSH-replenishing enzymes keep the antioxidant status of normal cells at a level where they can avert oxyradical derived mutations. The aim of this study was to determine whether in cancer cells the GSH-replenishing, GSH antioxidant and GSH-depleting enzymes were not at appropriate levels and therefore not able to protect cancer cells adequately against oxyradical-induced mutations. Cancer of the oesophagus was chosen since it is the most common gastrointestinal malignancy in South African Blacks. Biopsies and blood from 31 patients with cancer of the oesophagus and 29 non-cancer patients were assessed for these enzymes. The mean activity of the antioxidant and depleting enzyme GSH-peroxidase was elevated significantly by twofold in the cancer tissue compared to normal tissue. However, the activity of the replenishing enzyme GSSG-reductase and the level of the depleting enzyme GSH-s-transferase P1-isoenzyme were significantly reduced by 23% and 33% respectively. As in a previous paper we found that GSH was depleted and gamma-glutamine transpeptidase was diminished in oesophageal cancer. There can be two reasons for GSH depletion. Firstly, elevated GSH-peroxidase will use more GSH in an attempt to cope with the excessive production of oxyradicals as revealed by elevated lipid peroxidation; this was, as shown by us before, elevated sixfold in oesophageal cancer. Secondly, if little replenishment of GSH occurred the level of GSH would become lower. This was confirmed by our findings that the activities of the replenishing enzymes were significantly diminished in oesophageal cancer tissue. Contrary to what was expected, the other depleting enzyme GSH-s-transferase P1 was not elevated in cancer tissue but was significantly lower. However, in the blood of the same patients it was significantly elevated. An explanation for this phenomenon is that, although the production of GST-P1 was enhanced in cancer, it did not show because it was rapidly extruded into the blood by an unknown mechanism operational only in cancer cells.

Laparoscopic inguinal hernia repair by an intraperitoneal onlay mesh technique using expanded PTFE: a prospective study.

This prospective trial was initiated to assess laparoscopic inguinal hernia repairs by an intraabdominal intraperitoneal onlay mesh (IPOM) technique. An IPOM method utilizing 10 x 7.5-cm expanded polytef (PTFE) patches was used to repair 52 inguinal hernias in 50 patients. There were two patients with bilateral defects. Fourteen were direct and 38 were indirect hernias. There was one patient with bladder perforation, one with strangulation of the small bowel that entered the sac of a recurrent defect, and five patients with other minor complications. There were two recurrences. The follow-up period ranged from 7 to 31 months. The operating time ranged from 35 to 180 min and was 35-60 min in 40 patients. The postoperative pain was minimal in 40 patients. Our conclusions are as follows: This IPOM method was less time consuming in theater time than other laparoscopic methods. There was minimal postoperative pain in the majority of cases. The hospital stay was shorter in comparison with the standardized stay for conventional methods. The case with recurrence and strangulation raises some questions as to the safety of this method. Hospital costs of conventional herniorrhaphies were lower (63%) than those of this laparoscopic method.

Comparison of the effects of the interposition of 'narrow' cycloperistaltic v. antiperistaltic segments on fluid perfusion through isolated loops of jejunum.

Experimental studies in dogs showed a delaying action of the cycloperistaltic (C-P) segment when interposed in isolated loops of jejunum ('narrow' C-P segments) and between stomach and duodenum after Billroth I gastrectomies ('wide' C-P segments). This study was designed to establish whether there were any differences in the delaying action on the passage of perfused fluids between isolated loops of jejunum with C-P and antiperistaltic (A-P) segments interposed. The latter is the surgical technique that is currently considered the gold standard for such actions. Two isolated segments of jejunum with the ends exteriorised as jejunostomies (Thiry-Vella (T-V) loops) were created in each of 4 dogs. Towards the end of one, a C-P segment with a diameter 70% that of the jejunum ('narrow' C-P segment) was interposed. Towards the end of the other, a reversed A-P segment was interposed. Fluid containing 14C-labelled polyethylene glycol was infused at a rate of 4 ml/min through all the 8 loops (4 dogs) for 1 hour (6 experiments per dog). Descriptive statistics (means and standard errors) show that no obvious differences in volume of output, absorption and pooling existed between T-V loops with 'narrow' C-P and A-P segments. The delaying effect in the passage of fluids of the C-P segment, shown in previous experiments, does not appear to be superior to that of the A-P segment. This statement is made with some reservation as the number of animals involved was relatively small and analytical statistics could not be used.

Audit of acute appendicitis in a black South African population.

This is a prospective study of 212 black South African patients operated on with a pre-operative diagnosis of acute appendicitis. There were 143 male and 69 female patients. Forty-four patients had normal appendices and 122 non-perforated and 46 perforated acute appendices. The appendix was normal in 12 male and 32 female patients. Most presenting signs had a high positive predictive value but few had a high negative predictive value. There was no significant difference in the systemic response between perforated and non-perforated groups. Delay in presentation accounted for the majority of perforated appendices, while there was no causal relationship between in-hospital observation and perforation. The complication rate was higher and hospital stay longer in the perforated group. We concluded that the presentation and clinical course of acute appendicitis in the population of black South Africans catered to by our hospital is not very different from that in the white population elsewhere in the world.

Gunshot arterial injuries to the groin: comparison of iliac and femoral injuries.

In a prospective study of 69 patients with gunshot arterial injuries to the groin, there were 18 patients with iliac and 51 with femoral artery injuries. In the former group, the majority of patients were admitted with gross physiological derangement that did not respond to pre-operative resuscitation, so were taken directly to theatre. There was a 39 per cent peri-operative mortality. A prompt operation is mandatory to improve the chances of survival of patients with this injury. In the latter group all patients responded to pre-operative resuscitation and in the great majority, the diagnosis was established by the presence of 'hard' signs of arterial injury alone. There was a 4 per cent amputation rate and no mortality.

Interposition of 'wide' cycloperistaltic segments into isolated segments of jejunum--influence on fluid perfusion.

Two isolated jejunal segments (Thiry-Vella (T-V) loops) were created in 7 dogs. One contained a 'wide' cycloperistaltic (C-P) segment while the other, acting as a control, did not. The C-P segment had the same diameter as the jejunum. Fluid perfusion experiments showed that there were no changes in the volume of output, absorption and pooling of the fluid in the T-V loops containing the 'wide' C-P segment. This was in contrast with significant changes shown in earlier experiments using 'narrow' C-P segments.