Small bowel evisceration after abdominal hysterectomy with open vaginal cuff technique: A case report.

Key Clinical Message: Vaginal cuff dehiscence post-hysterectomy is rare yet significant. Early recognition and prompt surgical intervention are crucial to prevent complications like bowel infarction. Consider second-look laparotomy in cases of uncertain bowel viability. Abstract: Vaginal cuff dehiscence (VCD) is a rare but potentially life-threatening complication following a hysterectomy characterized by the separation of the vaginal vault. This condition, which may result in vaginal evisceration (VE), presents a significant risk of pelvic contents, particularly the small bowel, protruding into the vagina. Early diagnosis and prompt surgical intervention are paramount to prevent severe complications, including bowel infarction, obstruction, and peritonitis. Although VCD and VE are rare, they require urgent surgical management to avoid adverse outcomes. We reported a case of small bowel evisceration in a woman with a history of total abdominal hysterectomy 6 months ago. VCD and VE are very rare but life-threatening complications of hysterectomy. Discussing the symptoms with patients who have multiple risk factors is crucial to avoid severe sequels following hysterectomy. Based on our experience, performing a second-look laparotomy is a reliable approach to ensure the viability of the intestinal loop. However, it will likely increase the risk of infection.

Iatrogenic injuries of the extrahepatic biliary system.

BACKGROUND: Iatrogenic traumatic extrahepatic biliary tract injuries though rarely occur; they can lead to exceedingly morbid complications. The aim of this study was to evaluate the management strategies and outcomes of patients presented with iatrogenic bile duct injuries. METHODS: This is a retrospective study. Over 19 y, 124 patients were managed for iatrogenic biliary injuries at our institution. The data related to the etiology of biliary tract injury, symptoms of injury, laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, hospitalization time, and postoperative complications were reviewed. RESULTS: The main clinical presentations were jaundice or recurrent cholangitis in 64 (51.61%) patients, followed by bile peritonitis in 34 (56.67%) and biliary fistula in 26 (43.33%) patients. Only in 23 (18.54%) cases, the injury was recognized intraoperatively. The most frequent surgical procedure was open cholecystectomy in 81 (65.32%) of 124 patients. The remaining patients were operated on laparoscopically. Good results were achieved in 99 of 101 patients with direct suture repair including hepaticojejunostomy, choledocoduodenostomy, and choledochocholedochostomy (98.02% success rate) at the first attempt. Three cases (2.97%) of biliary strictures after direct suture technique and four (3.96%) cases of postoperative mortalities were detected. The mortality rate was mostly affected by male gender, advanced age, and existence of bile peritonitis. Totally, 111 (89.52%) patients are still alive with a mean follow-up time of 78 ± 38 (2-230) mo. CONCLUSIONS: Biliary injuries can be sometimes life-threatening complications. A successful repair may provide patients with a lifelong relief from symptoms, whereas a failed repair may result in recurrent biliary obstruction, reoperation, and even death.

Early Post Operative Enteral Versus Parenteral Feeding after Esophageal Cancer Surgery.

INTRODUCTION: The incidence of malnutrition in hospitalized patients is reported to be high. In particular, patients with esophageal cancer are prone to malnutrition, due to preoperative digestive system dysfunctions and short-term non-oral feeding postoperatively. Selection of an appropriate method for feeding in the postoperative period is important in these patients. MATERIALS AND METHODS: In this randomized clinical trial, 40 patients with esophageal cancer who had undergone esophagectomy between September 2008 and October 2009 were randomly assigned into either enteral feeding or parenteral feeding groups, with the same calorie intake in each group. The level of serum total protein, albumin, prealbumin, transferrin, C3, C4 and hs-C-reactive protein (hs-CRP), as well as the rate of surgical complications, restoration of bowel movements and cost was assessed in each group. RESULTS: Our results showed that there was no significant difference between the groups in terms of serum albumin, prealbumin or transferrin. However, C3 and C4 levels were significantly higher in the enteral feeding group compared with the parenteral group, while hs-CRP level was significantly lower in the enteral feeding group. Bowel movements were restored sooner and costs of treatment were lower in the enteral group. Postoperative complications did not differ significantly between the groups. There was one death in the parenteral group 10 days after surgery due to myocardial infarction. CONCLUSION: The results of our study showed that enteral feeding can be used effectively in the first days after surgery, with few early complications and similar nutritional outcomes compared with the parenteral method. Enteral feeding was associated with reduced inflammation and was associated with an improvement in immunological responses, quicker return of bowel movements, and reduced costs in comparison with parenteral feeding.

An unusual case of recurrent gastric cancer long after the first gastrectomy due to adenocarcinoma.

The postgastrectomy recurrence rate is as high as 30-65%, with 5-year overall survival rates of <20%. Local recurrence is very common which occurs in 38-45% of cases. The most common sites of locoregional recurrence are the gastric remnant at the anastomosis, the gastric bed, and the regional nodes. The recurrence may occur as early and late events after gastrectomy. Most recurrences are early, within three years of surgery. Numerous studies reported the late recurrences, but most of them having a survival time of less than ten years. This report elucidates a case of recurrent gastric cancer after 24 years postoperatively.

Quantitative analysis of TEM-8 and CEA tumor markers indicating free tumor cells in the peripheral blood of colorectal cancer patients.

BACKGROUND: Colorectal cancer (CRC) remains the third most common cancer in the world. Approximately in 50 percent of patients, metastatic disease is a major cause of death. Therefore, early diagnosis of CRC is crucial for a successful outcome. For the detection of circulating cancer cells, this study applied a sensitive method that employed specific tumor markers for early detection. METHODS: A total of 80 blood samples from 40 CRC patients and 40 age-matched healthy controls were collected for the study. The circulating mRNA levels of two CRC tumor markers, tumor endothelial marker 8 (TEM-8) and carcinoembryogenic antigen (CEA) were evaluated using an absolute quantitative real-time PCR assay in a Stratagene Mx-3000P real-time PCR system. GAPDH was used as the endogenous control. RESULTS: TEM-8 and CEA were primarily detected more in the CRC patients rather than in the controls: 22/40 vs 9/40, p=0.009 and 30/40 vs 11/40, p=0.00054, respectively. In the CRC patients, the mRNA level of these markers was significantly higher in comparison to the normal controls (p=0.018 and 0.01). The overall sensitivity of this panel was 65% with a specificity of 75%. Statistical analysis for demographic variants did not reach significant values. CONCLUSIONS: TEM-8 and CEA markers were detected more frequently and in significantly higher levels in the blood samples of patients compared with samples from age-matched healthy controls. The copy number of CEA and TEM-8 mRNA, as detected by a real-time quantitative PCR, appears to be a promising marker for evaluating the risk of tumor spread.

Soluble Fas might serve as a diagnostic tool for gastric adenocarcinoma.

BACKGROUND: Fas (Apo-1/CD95) and its specific ligand (FasL) are key elements in apoptosis. They have been studied in different malignancies but there are few published studies about the soluble forms of these markers (i.e. sFas/sFasL) in gastric cancer. We have compared the serum levels of sFas/sFasL in gastric adenocarcinoma patients and cases with pre-neoplastic lesions as potential markers for early diagnosis, and investigated their relation with clinicopathological characteristics. METHODS: Fifty-nine newly-diagnosed cases of gastric adenocarcinoma who had undergone gastrectomy, along with 62 endoscopically- and histologically-confirmed non-cancer individuals were enrolled in this study. sFas/sFasL serum levels were detected by Enzyme Linked Immunosurbent Assay. RESULTS: Mean serum sFas level was significantly higher in gastric cancer patients than in control group (305.97 +/- 63.71 (pg/ml) vs. 92.98 +/- 4.95 (pg/ml), P < 0.001); while the mean serum level of sFasL was lower in patients with gastric adenocarcinoma (0.138 +/- 0.04 (pg/ml) vs. 0.150 +/- 0.02 (pg/ml), P < 0.001). Mean serum levels of sFas/sFasL were significantly different in both intestinal/diffuse and cardiac/non-cardiac subtypes when compared to the control group (P < 0.001). There was an increase in the serum level of sFas from the first steps of pre-neoplastic lesions to gastric adenocarcinoma (P < 0.001). Patients who had no lymph node involvement (N0) showed significantly higher serum levels of sFas compared to others (P = 0.044). CONCLUSIONS: Production of sFas may play a critical role in the carcinogenesis of intestinal-type gastric cancer. sFas serum level may serve as a non-invasive tool for early diagnosis of gastric cancer.

Induction of cytotoxic T lymphocytes primed with tumor RNA-loaded dendritic cells in esophageal squamous cell carcinoma: preliminary step for DC vaccine design.

BACKGROUND: Dendritic cells (DC) are potent antigen presenting cells with the ability to prime naïve T cells and convert them to cytotoxic T-lymphocytes (CTL). We evaluated the capability of autologous DCs transfected with total tumor and normal RNA to induce cytotoxic CTL as the preliminary step to design a DC-based vaccine in the esophageal squamous cell carcinoma (ESCC). METHODS: Monocytes-derived DCs were electroporated with either total tumor RNA or normal RNA. T cells were then primed with tumor RNA transfected DCs and lytic effects of the generated CTL were measured with Cytotoxicity assay and IFN-gamma Release Elispot assay. RESULTS: Cytotoxicity was induced against DCs loaded with tumoral RNA (%24.8 +/- 5.2 SEM) while in normal RNA-loaded DCs, it was minimal (%6.1 +/- 2.4 SEM) and significantly lower (p < 0.05). INF-gamma secretion was more than 2-folds higher in tumoral RNA-loaded DCs when compared with normal RNA-loaded DCs (p < 0.05). CONCLUSION: Electroporating DCs with tumor RNA generated tumor antigen presenting cells which in turn enhanced cytotoxic effects of the T cells against ESCC. This may be a useful autologous ex vivo screening tool for confirming the lytic effects of primed T cells on tumors and evaluate probable further adverse effects on noncancerous tissues. These data provide crucial preliminary information to establish a total tumor RNA-pulsed DC vaccine therapy of ESCC.

Prevalence of chest wall deformities in a large sample of Iranian children aged 7-14 years.

OBJECTIVE: Pectus excavatum (PE) and pectus carinatum (PC) are two common chest deformities. We investigated the prevalence of chest wall deformities including PE and PC in Iranian population. METHODS: 25587 children and adolescents aged 7-14 years consisting of 13586 (53.1%) males and 12001 (46.9%) females were studied using cluster-stratified sampling method. Screening was clinical and based on descriptive findings. Suspected subjects with chest wall deformity were referred to the expert surgeon to confirm the diagnosis. FINDINGS: The prevalence of chest deformities in our population was 204 (1.03%). The mean age of subjects was 10.2±3.0 years. Of these subjects 124 (0.49%) [74 (54%) males and 50 (42%) females)] had PE and 80 (0.31%) [58 (72.5%) males and 22 (17.5%) females)] had PC. CONCLUSION: The prevalence of PE seems to be very high in Iran. Special attention must be paid to diagnose and treat this problem in our population.

How long the lymphoscintigraphy imaging should be continued for sentinel lymph node mapping?

OBJECTIVE: We assessed the need for delayed lymphoscintigraphy imaging for sentinel lymph node (SLN) biopsy in stage I and II breast cancer patients using intradermal injection of (99m)Tc-antimony sulfide colloid. METHOD: Seventy-five patients with early-stage breast cancer were included in our study. Periareolar intradermal injections of 0.5 mCi/0.2 mL (99m)Tc-antimony sulfide colloid was used for the patients without previous excisional biopsy (45 patients). Two intradermal injection of 0.5 mCi/0.2 mL (99m)Tc-antimony sulfide colloid was used on each side of the dermal incision in patients with the history of excisional biopsy (30 patients). Anterior and lateral static images were taken at 2 min. If SLN was not visualized, delayed imaging at 5, 10, 30, 60, 90, 150, and 180 min was done (till the visualization of the SLN or 180 min). SLN was performed by the combination of gamma probe and blue dye during surgery. RESULTS: Sentinel lymph node detection rate was 96% (72/75). SLNs were detected on the immediate (2 min) images in 55 (73.33%) patients. In the remaining patients, the SLNs were detected first on the 5-, 10-, and 30-min images in 10 (13/33%), 5 (6.66%), and 2 (2.66%) patients, respectively. In three patients (4%), SLN was not detected by lymphoscintigraphy even on 180-min images. During surgery, SLN was not detected in these three patients either. CONCLUSION: Considering the rapid flow of (99m)Tc-antimony sulfide colloid in our study, lymphoscintigraphy imaging can be completed in the nuclear medicine department without any delay in sending the patient back to the surgery department. Thirty minutes after radiotracer injection seems to be the optimal time for lymphoscintigraphy and delayed imaging beyond 30 min would not be necessary.

Overexpression and interactions of interleukin-10, transforming growth factor beta, and vascular endothelial growth factor in esophageal squamous cell carcinoma.

BACKGROUND: Sharing the role of immune suppression, interleukin-10 (IL-10), transforming growth factor beta (TGF-beta), and vascular endothelial growth factor (VEGF) are critical genes in several aspects of tumorigenesis. To elucidate the role of these cytokines in esophageal squamous cell carcinoma (ESCC), their relative mRNA expression in tumoral tissue compared with corresponding tumor-free tissue was evaluated. METHODS: A total of 49 patients with histologically confirmed ESCC were included in the study prior to any therapeutic interventions. Quantitative analysis of the mRNA expression was performed by real-time reverse transcription-polymerase chain reaction and the clinicopathologic associations were assessed. RESULTS: The mRNA of IL-10, VEGF, and TGF-beta was frequently overexpressed in 53.2%, 44.9%, and 37.5% of ESCC patients, respectively. TGF-beta was significantly co-expressed with IL-10 and with VEGF. Although VEGF was not independently associated with increased tumor size (p = 0.065), concomitant overexpression of VEGF with TGF-beta was significantly correlated with increased size of the tumor (p < 0.05). CONCLUSIONS: Overexpression of IL-10, TGF-beta, and VEGF plays an important role in ESCC and consequently leads to the frequent event of immune evasion in ESCC. TGF-beta is concomitantly overexpressed with IL-10 and with VEGF in ESCC. A stimulatory signal from TGF-beta to VEGF is necessary for VEGF to promote tumor progression.