Robotic complete mesocolic excision for transverse colon cancer can be performed with a morbidity profile similar to that of conventional laparoscopic colectomy.

BACKGROUND: In minimally invasive surgery, complete mesocolic excision (CME) for transverse colon cancer is challenging; thus, non-CME resections are commonly preferred when laparoscopy is used. Robotic technology has been developed to reduce the limitations of laparoscopy. The aim of our study was to evaluate whether robotic CME for transverse colon cancer can be performed with short-term outcomes similar to those of laparoscopic conventional colectomy (CC). METHODS: A retrospective review of 118 consecutive patients having robotic CME or laparoscopic CC for transverse colon cancer in two specialized centers between May 2011 and September 2018 was performed. Perioperative 30-day outcomes of the two procedures were compared. RESULTS: There were 38 and 80 patients in the robotic CME group and laparoscopic CC group, respectively. The groups were comparable regarding preoperative characteristics. Intraoperative results were similar, including blood loss (median 50 vs 25 ml), complications (5.3% vs 3.8%), and conversions (none vs 7.5%). The rate of intracorporeal anastomosis was significantly higher (86.8% vs 20.0%), mean operative time was longer (325.0 ± 123.2 vs 159.3 ± 56.1 min (p < 0.001), and the mean number of harvested lymph nodes was higher in the robotic CME group (46.1 ± 22.2 vs 39.1 ± 17.8, p = 0.047). There were only minor differences in length of hospital stay (7.2 ± 3.1 vs 7.9 ± 4.0 days), anastomotic leak (none vs 2.6%), bleeding (none vs 1.3%), surgical site infections (10.5% vs 12.5%), and reoperations (2.6% vs 6.3%). CONCLUSIONS: Robotic CME can be performed with a similar morbidity profile as laparoscopic CC for transverse colon cancer along with a higher rate of intracorporeal anastomosis, and higher number of lymph nodes retrieved, but longer operative times.

The da Vinci Xi system for robotic total/subtotal colectomy vs. conventional laparoscopy: short-term outcomes.

BACKGROUND: The aim of this study was to evaluate the feasibility of robotic total/subtotal colectomy procedures with the Xi robot and to compare its short-term outcomes with those of conventional laparoscopy. METHODS: Between October 2010 and September 2018, consecutive patients with colonic neoplasia, inflammatory bowel disease, familial adenomatous polyposis or colonic inertia who underwent elective robotic or laparoscopic total/subtotal abdominal colectomy at two specialized centers in Turkey were included. Data on perioperative characteristics and 30-day outcomes were compared between the two approaches. RESULTS: There were a total of 82 patients: 26 and 56 patients in the robotic and laparoscopic group, respectively (54 men and 28 women, mean age 54.7 ± 17.4 years). The groups were comparable regarding preoperative characteristics. All the robotic procedures were completed with a single positioning of the robot. Estimated blood loss (median, 150 vs 200 ml), conversions (0% vs 14.3%), and complications (0% vs 7.1%) were similar but operative time was significantly longer in the robotic group (median, 350 vs 230 min, p < 0.001). No difference was detected in the length of hospital stay (7.9 ± 5.7 vs 9.5 ± 6.0 days, p = 0.08), anastomotic leak (3.8% vs 8.3%), ileus (15.4% vs 19.6%), septic complications, reoperations (7.7% vs 12.5%), and readmissions (19.2% vs 12.5%). The number of harvested lymph nodes in the subgroup of cancer patients was significantly higher in the robotic group (median, 66 vs 50, p = 0.01). CONCLUSIONS: In total/subtotal colectomy procedures, the robotic approach with the da Vinci Xi platform is feasible, safe, and associated with short-term outcomes similar to laparoscopy but longer operative times and a higher number of retrieved lymph nodes.

Serum uric acid as a surrogate marker of favorable response to bevacizumab treatment in patients with metastatic colon cancer.

Bevacizumab is a monoclonal antibody which is a vascular endothelial growth factor inhibitor. It obscures vascularization of tumor tissue and damages intratumoral microcirculation. The damaged intratumoral microcirculation leads to tissue hypoxia and results in increase of uric acid level. The main aim of our study was to investigate the relationship between uric acid change and response to bevacizumab therapy. This study included a total of 158 patients with metastatic colorectal cancer who had received bevacizumab therapy. The number of male patients was 100 (63.3 %) while female patients number was 58 (37.7 %). The median age was 61 (29-83). There was relationship between increase of uric acid level of third month uric acid level and stable disease (p < 0.001). There was a significant overall survival increased in the group with increased uric acid level (p < 0.001). The decline of CEA level was related to uric acid level (p < 0.022). In conclusion, this study is the first showing significant increases of serum uric acid in patients with metastatic colorectal cancer who favorably responded to chemotherapy with bevacizumab. But further studies are justified to test whether monitoring uric acid levels might predict clinical outcomes of patients with metastatic colorectal cancer.

How and how much do endoscopy professionals protect themselves against infection?

PURPOSE: It is aimed to identify, the educations given to professionals working in endoscopy units against infectious risks during the endoscopic procedures and awareness of professionals for protection from these infections. MATERIAL AND METHOD: After obtaining the required ethic committee permissions, 50 physicians and 34 nurses, working in the endoscopy units of three university and one training and research hospital, were included in this study. A survey with 37 questions, prepared in accordance with the literature was applied to the participating endoscopist (E) and endoscopy nurses (EN). SPSS (Statistical Package for Social Sciences) for Windows 16.0 program was used for statistical evaluation of the obtained data. FINDINGS: Forty-four (52%) of the subjects were female and 40 (48%) were male, and their average age was 39 (±6.82) years. When trainings on endoscopy of E and EN were evaluated, it was found that 44% (n = 37) of them precise an endoscopy course on endoscopy training, %56 (n = 47) received no training and they learned through master/apprentice system. Furthermore, it was found that 65% (n = 55) of the E and EN received no training on universal precautions procedures, infection and risks endoscopic procedures and only 35% (n = 29) received a specific course or on-the-job training. Nevertheless, rates of wearing protective gowns and gloves were high both for E and EN; but rate of other precautions such as wearing mask, using special gloves and face shields were found to be low. It was found that the rate of "receiving an education on endoscopy" for E was significantly higher than that of EN (p < 0001). The rate of reporting emergency situations such as contact with blood/body fluids or percutaneous injuries and the rate of taking universal precautions of EN who received an education, was statistically higher than that of EN who did not (p < 0.001 and p < 0008). RESULTS: As a result of our investigation, it was determined that the endoscopists and endoscopy nurses did not effectively apply the universal precautions against infectious risks faced during endoscopic procedures and did not receive the basic trainings. The professionals who received training were more responsive for this issue. According to our results, organizing continuous training programs through endoscopy professionals is necessary to provide the universal precautions of avoiding exposure to blood and body fluids.

Do different abdominal incision techniques play a role in wound complications in patients operated on for gastrointestinal malignancies ? "Scalpel vs. electrocautery".

BACKGROUND: Despite the studies of animals that demonstrate better wound healing after abdominal incisions with the use of a scalpel rather than electocautery, clinical experience does not confirm these findings. The purpose of this study was to compare the early postoperative and late-term wound complication rates between the scalpel and electrocautery in patients with gastrointestinal malignancies undergoing midline abdominal incisions. METHODS: Patients undergoing midline abdominal incisions for gastrointestinal malignancies were randomly divided into two groups according to the method used to perform the incisions: scalpel or electrocautery. Complications were investigated, diagnosed and compared in the early postoperative and late-term follow-up periods. The independent samples, chi-square, and Student's t tests were used for statistical analysis. RESULTS: Two hundred and eighteen patients were included to this study, of whom 97 (44.5%) were in the scalpel group and 121 (55.5%) in the electrocautery group. Both groups were similar with respect to their demographic, operative and postoperative characteristics. The analysis revealed no significant statistical differences in consideration of the incidences of either wound infection in the early postoperative period or incisional hernia in the late-term follow-up period between these two study groups (p > 0.05). CONCLUSIONS: Scalpel and electrocautery are similar in terms of early postoperative and late-term wound complications when used to perform midline abdominal incisions. Therefore, the choice of method remains a matter of the surgeon's preference.

A surgical approach to anogenital Buschke Loewenstein tumours (giant condyloma acuminata).

BACKGROUND: Condyloma acuminata are anogenital warts caused by human papillomavirus (HPV). Neglected giant peri-anal condyloma acuminata (Buschke Loewenstein Tumours) require major surgical procedures. This report reflects our experience concerning the aggressive surgical approach to this rarely presented type of condyloma acuminata. METHODS: The medical records of five patients, who had been surgically treated following the diagnosis of giant perianal condyloma acuminata between April, 1996 and September, 2003 were reviewed and evaluated retrospectively. Full thickness tumour and skin excisions were performed followed by delayed split thickness skin graftings in all patients. RESULTS: Five patients (3 men, 2 women) who suffered from giant condyloma acuminata lesions obliterating the anal canal were evaluated. The mean age was 36.5 years (range: 24-52). All patients underwent total surgical excisions. The wounds were left open for secondary healing, and following a mean time period of 35 days, split thickness skin graftings were performed. The histopathologic examinations of the specimens of these five patients did not reveal any malignant transformations. No recurrences were detected at the end of a mean follow-up period of 22 months and all patients were considered to be disease-free at the end of their long-term 5-year follow-up periods. CONCLUSIONS: Peri-anal condyloma acuminatum is usually a benign disease, but may grow locally to an excessive extent, developing into a Buschke Loewenstein Tumour, and may cause serious peri-anal hygiene problems. Even though the incidence of malignant transformation is rare, there is always a risk of this complication occurring. Transmission of the disease to other sexual partners is another point of concern. Therefore, this disease must be treated aggressively with total surgical excision. The results of our surgical treatment methods are satisfactory.

Perioperative GMCSF limits the proangiogenic plasma protein changes associated with colorectal cancer resection.

AIMS: Colorectal resection (CR) increases plasma VEGF levels which may promote residual tumor growth. This study assessed the effect of perioperative GMCSF on plasma levels of sVEGFR1, Ang-1 and Ang-2 and also the impact of post-GMCSF plasma on in vitro endothelial cell (EC) growth and invasion. Ang-2 increases while sVEGFR1 and Ang-1 impede angiogenesis. METHODS: Fifty-nine CR cancer patients were randomized to 7 perioperative doses of GMCSF or saline for 3days prior and 4days after CR. Blood samples were taken pre-drug (PreRx) and on several postoperative days (POD). Protein levels were assessed and PreRx and POD 5 plasma added to EC cultures after which branch point formation (ECBPF) and invasion (ECI) were measured. RESULTS: sVEGFR1 levels were significantly higher on POD 1 and POD 5 in both groups but the GMCSF POD 5 level was twice the control value (p=0.002). Ang-2 levels were higher on PODs 1 and 5 in both groups (p<0.05) but the control POD 5 value (vs. GMCSF) was greater (p=0.03). Ang-1 decreases were noted in all (p=not significant, ns). The control group POD 5 ECBPF was 35.8% greater than Pre Rx (p=0.001) while the GMCSF result was 18.0% lower (p=ns); the control POD 5 median percent change from baseline was greater than the GMCSF result(p=0.008). The POD 5 ECI was +12.2% for the control group vs. baseline (p=ns) and -17.2% for the GMCSF group (p=ns): the control median percent change was greater than in the GMCSF group(p=0.045). CONCLUSION: CR-related plasma changes are proangiogenic (>Ang-2) and anti-angiogenic (>sVEGFR1); the net effect is promotion of in vitro ECBPF. GMCSF limits the proangiogenic changes (higher POD 5 sVEGFR1 levels and lower Ang-2 elevations, lower POD 5 ECBPF and ECI). The clinical import of these effects is unclear; perioperative GMCSF has anti-angiogenic plasma effects that may limit tumor growth. Further investigation is warranted.

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in children and adolescents: experience in a single institution.

INTRODUCTION: Experience in the use of endoscopic retrograde cholangiopancreatography (ERCP) for the investigation and treatment of pancreaticobiliary disorders is relatively limited in children. This report reviews the experience in a single institution with pediatric ERCPs and documents the indications, success rate, diagnostic and therapeutic yields, complications, and the impact on patient management. PATIENTS AND METHODS: The data of all consecutive patients aged < or = 18 years who underwent ERCP procedures between the years 1997 and 2007 were retrospectively identified through a computer database search. The database prospectively recorded the indications, findings, therapies, and complications. RESULTS: During the study period, 32 ERCP procedures were performed in 28 children with a median age of 13 (range 8 - 18) years. ERCPs were performed for biliary pathology in 21 (75 %) and for pancreatic pathology in 7 (25 %) patients. The most common biliary indications were suspected choledocholithiasis and postoperative bile leaks. Hydatid disease was the most common diagnosis that yielded bile leaks. The pancreatic indications were recurrent pancreatitis and traumatic pancreatic duct disruption. Cannulation of the desired duct was successful in all procedures. An endoscopic sphincterotomy, stone/sludge removal or a stent placement was performed in 20 (63 %) procedures. According to the long-term follow-up, avoidance from any further surgical interventions was achieved in 11 (65 %) children, in whom ERCP was undertaken as a therapeutic intervention. The complication rate was 6 % with the development of mild self-resolving pancreatitis in one patient and stent occlusion in another. CONCLUSIONS: ERCP in the pediatric population has a high success rate, both as a diagnostic tool and for therapeutic interventions, provided it is performed by experienced endoscopists. The delicate delineation of the anatomy by ERCP and its therapeutic potential make it absolutely superior to other less invasive tools such as magnetic resonance cholangiopancreatography.

Persistent elevation of plasma vascular endothelial growth factor levels during the first month after minimally invasive colorectal resection.

BACKGROUND: Elevations of plasma vascular endothelial growth factor (VEGF) have been noted early after colorectal resection. The duration of this increase is unknown. Because VEGF is a potent promoter of angiogenesis, which is critical to tumor growth, a sustained increase in blood VEGF levels after surgery may stimulate the growth of residual metastases early after surgery. This preliminary study aimed to determine VEGF levels during the first month after colorectal resection. METHODS: Patients from three prospective studies that had late postoperative blood samples available comprised the study population. Demographic, perioperative, pathologic, and complication data were collected. Plasma samples were obtained preoperatively for all patients: on postoperative day (POD) 1 for most patients and at varying time points thereafter during the first month after surgery and beyond. Levels of VEGF were determined via enzyme-linked immunoassay (ELISA) and compared using Wilcoxon's matched pairs test. Because the numbers of specimens beyond POD 5 were limited, samples from 7-day time blocks were bundled and averaged to permit statistical analysis. RESULTS: A total of 49 patients with cancer and 30 patients with benign indications, all of whom underwent minimally invasive colorectal resection, were assessed separately. With regard to the patients with cancer, the median preoperative plasma value was 150 pg/ml, and the peak postoperative median value for the POD 14 to 20 time block was 611.1 pg/ml. Furthermore, compared with the preoperative results, significant VEGF elevations were noted on POD 3 as well as during week 2 (POD 7-13), week 3 (POD 14-20), and week 4 (POD 21-27) (p < 0.05 for each). With regard to the benign patients, the median preoperative VEGF level was 112 pg/ml, and the peak postoperative value, 286 pg/ml, was noted during postoperative week 2. Significant elevations were noted on POD 3, and for weeks 2 and 3 as well as for POD 28 and later. Between 63% and 89% of the patients at each time point beyond POD 5 had elevated VEGF levels. CONCLUSION: This preliminary study demonstrates that after minimally invasive colorectal resection for cancer, median VEGF levels are significantly elevated on POD 3 and remain increased for as long as 4 weeks. Significant elevations in a similar pattern also were noted for the benign patients. However, the baseline and postoperative median values were lower. The clinical impact from increased blood levels of VEGF is uncertain. It is possible that the growth of residual tumor deposits may be stimulated early after surgery. These results warrant a larger study as well as endothelial cell in vitro assays to determine whether postoperative plasma stimulates proliferation and invasion.

Insulin-like growth factor binding protein-3 inhibits colitis-induced carcinogenesis.

PURPOSE: Chronic inflammation in the setting of inflammatory bowel disease is thought to result in altered epithelial cell growth regulation and ultimately carcinogenesis. This loss in cell growth regulation may be partially caused by a decrease in circulating intact insulin-like growth factor binding protein-3 (IFGB-3) as a result of chronic inflammation. This study evaluates the effect of IFGB-3 on carcinogenesis in the setting of colitis. METHODS: A previously described animal model for colitis-induced carcinogenesis was used. Colitis was induced in both wild-type and IFGB-3 transgenic CD1 mice with a one-week oral exposure to dextran sodium sulfate (2 percent in drinking water). All mice received a single intraperitoneal administration (10 mg/kg body weight) of a genotoxic colonic carcinogen, azoxymethane. At Week 20, the animals were killed and their colons were excised. The colons were examined by a pathologist under blinded conditions. Criteria assessed included the severity of colitis, number of aberrant crypt foci per mouse colon, incidence of colonic adenomas, and mean size of colonic adenomas. RESULTS: A total of 20 mice (10 in each group) were included in the study. The severity of colitis was not significantly different between the two groups (mean colitis score wild-type = 13.2; IFGB-3 transgenic = 11; P = not significant). The average number of aberrant crypt foci per colon was significantly lower in the IFGB-3 transgenic mice compared with the wild-type mice (1.5 +/- 1.4 vs. 4.5 +/- 2.7, respectively; P < 0.0001). The number of adenomas per colon was significantly lower in IFGB-3 transgenic group (1.2 +/- 1.8) compared with the wild-type mice (3.7 +/- 2.7; P = 0.005). In addition the average size of adenomas was significantly smaller in IFGB-3 transgenic mice (1.4 +/- 1.3 mm) compared with the wild-type mice (2.6 +/- 2 mm; P = 0.013). CONCLUSIONS: IFGB-3 significantly reduces the development of colonic tumors and precursor lesions in the setting of induced murine colitis. It is possible that the loss of IFGB-3 as a result of chronic inflammation may be associated with an increased rate of carcinogenesis in the inflammatory bowel disease setting. Although further studies are necessary, in theory, inhibiting the depletion of IFGB-3 or replacement of IFGB-3 may serve as a novel treatment strategy to prevent the development of colitis-induced carcinogenesis.

Perioperative sargramostim (recombinant human GM-CSF) induces an increase in the level of soluble VEGFR1 in colon cancer patients undergoing minimally invasive surgery.

INTRODUCTION: Experimentally, laparotomy is associated with increased tumor growth. In humans, abdominal surgery is associated with immunosuppression and elevated plasma VEGF levels that might stimulate tumor growth early after surgery. Avoidance of these surgery-related changes and their consequences may be advantageous. Granulocyte-macrophage colony stimulating factor (GMCSF) is a non-specific immune system up-regulator that has also been associated, experimentally, with increased release of soluble VEGF Receptor 1 (sVEGFR1) which is an endogenous inhibitor of VEGF. This study's purpose was to determine the impact of perioperatively administered recombinant human GMCSF (rhu-GMCSF) on both immune function and plasma sVEGFR1 levels in colorectal cancer patients. METHODS: This randomized placebo-controlled study included 36 colorectal cancer patients who underwent minimally invasive resection (17 GMCSF, 19 Placebo). Patients received 7 subcutaneous injections of either rhu-GMCSF, 125 microg/m2, or saline on preoperative days 3, 2 and 1 and on postoperative days (POD) 1, 2, 3 and 4. A number of immune parameters were followed and plasma levels of soluble VEGF Receptor 1 (sVEGFR1) and VEGF were determined. RESULTS: The total WBC, neutrophil, eosinophil, and monocyte counts were significantly higher after surgery in the GMCSF group; no differences were noted for the other immune parameters. In the GMCSF group, median plasma sVEGFR1 levels were significantly elevated on POD 1 (188.1 pg/ml), and on POD 5 (142.8 pg/ml) when compared to pre-GMCSF levels (0 pg/ml) (p-value<0.05 for all comparisons). In the placebo group, the POD5 median sVEGFR1 level (116.3 pg/ml) was elevated and of borderline significance (p=0.05) vs the pre-treatment result (0 pg/ml). Of note, both groups had significantly elevated median plasma VEGF levels on POD 5 (Control 435.7 pg/ml; GMCSF 385.3 pg/ml) when compared to their preoperative results (Control 183.3 pg/ml, p=0.0013; GMCSF 171.5 pg/ml, p=0.0055). CONCLUSIONS: Perioperative GMCSF was not associated with an immune function benefit in this study, however, such treatment leads to increased plasma sVEGFR1 levels. Colorectal resection, with or without GMCSF, was also associated with increased VEGF levels postoperatively. Increased plasma levels of sVEGFR1 after surgery might limit the pro-angiogenic tumor stimulatory effects of VEGF. Further study of GMCSF's impact on angiogenesis appears warranted.

Major surgical trauma induces proteolysis of insulin-like growth factor binding protein-3 in transgenic mice and is associated with a rapid increase in circulating levels of matrix metalloproteinase-9.

BACKGROUND: The authors previously demonstrated a significant decrease in plasma levels of intact insulin-like growth factor binding protein-3 (IGFBP-3) after major open but not after laparoscopic-assisted surgery in humans. They postulated that this decrease may have an effect on postoperative tumor growth. It also has been shown that plasma levels of matrix metalloproteinase-9 (MMP-9), a protease capable of degrading IGFBP-3, are transiently increased after open colectomy in humans. The authors aimed to develop an animal model that would allow further study of the effect that surgical trauma has on plasma levels IGFBP-3 and MMP-9. In addition, they set out to assess the concentration of MMP-9 in circulating monocytes before and after surgery. METHODS: The 30 mice included in this study were divided into three groups: sham laparotomy, carbon dioxide (CO2) pneumoperitoneum, and anesthesia control. All mice were IGFBP-3 transgenics (overexpressing human IGFBP-3) on a CD1 background. The mice were anesthetized using ketamine and xylazine. Blood was drawn retroorbitally 48 h before the procedure. The duration of the procedure was 30 min. The animals were killed 24 h postoperatively and blood was drawn. Intact IGFBP-3 levels were measured using a combination of Western blot analysis and enzyme-linked immunoassay (ELISA) at the two time points: before and after the operation. Plasma and peripheral blood mononuclear cell levels of MMP-9 were measured at each time point using zymography. Mononuclear cell lysates were used to determine intracellular MMP-9 levels. RESULTS: Plasma levels of intact IGFBP-3 were significantly lower than preoperative levels after sham laparotomy. A mean decrease of 76.6% was noted (p < 0.05). Zymography demonstrated significantly higher plasma MMP-9-related proteolytic activity than observed preoperatively after sham laparotomy (78.5 vs 42.3 Relative Units [RU]; p < 0.05). In the pneumoperitoneum group, no significant decrease was found between the pre- and postoperative levels of intact IGFBP-3. A nonsignificant increase in MMP-9 was noted after CO2 pneumoperitoneum (38 RU preoperatively vs. 46.4 RU postoperatively; p > 0.05). The anesthesia control group did not demonstrate a significant change in either circulating intact IGFBP-3 levels or MMP-9 levels. Mononuclear intracellular levels of MMP-9 were significantly lower after laparotomy than the preoperative levels (3 vs 37 RU). The postprocedure intracellular levels of MMP-9 were not significantly decreased in the pneumoperitoneum or anesthesia control group. CONCLUSION: Plasma levels of intact IGFBP-3, a cell growth regulating factor, were found to be decreased significantly after laparotomy. This decrease was not seen after pneumoperitoneum. Depletion of intact IGFBP-3 after laparotomy correlated with a rapid release of MMP-9 from mononuclear cells and an increase in circulating plasma MMP-9 levels. Matrix metalloproteinase-9 may play an important role in IGFBP-3 proteolysis after surgical trauma. Furthermore, circulating mononuclear cells are one source of MMP-9 after surgery. Finally, the model used reproduces events in humans after surgery, and thus should permit further study on the mechanism of IGFBP-3 proteolysis after surgical trauma.

Altered plasma matrix metalloproteinase-9/tissue inhibitor of matrix [corrected] metalloproteinase-1 concentration during the early postoperative period in patients with colorectal cancer.

BACKGROUND: The authors have previously demonstrated that insulin-like growth factor binding protein-3 (IGFBP-3) is depleted in plasma for 1 to 3 days after major open surgery (OS), but not after laparoscopic surgery (LS). After surgery, IGFP-3 cleavage occurs rapidly and is likely attributable to altered plasma proteolytic activity. This study aimed to assess plasma proteolysis after both open and closed colorectal resection and, if possible, to identify a protease/protease inhibitor system affected by surgery. METHODS: Plasma from 88 patients with colorectal cancer (stages I-III) who underwent resection was obtained preoperatively (pre-OP) and on postoperative days (POD) 1 to 3. Plasma proteolytic activity was assessed via zymography. On the basis of the results, specific protease and protease inhibitor concentrations were next measured via enzyme-linked immunoassay (ELISA). Statistical analysis was performed using Wilcoxon's test. RESULTS: Early after surgery, zymography showed a predominant band representing a 92-kDa gelatinase corresponding to a proform of matrix metalloproteinase-9 (MMP-9), a protease known to cleave IGFBP-3. In OS patients, the mean concentration of plasma MMP-9 was significantly higher on POD 1 than at pre-OP (p < 0.003). On POD 2 and 3, no differences were noted. In the LS group, the mean levels of MMP-9 before and after surgery were comparable. The levels of a natural MMP-9 inhibitor, tissue inhibitor of metalloproteinase-1 (TIMP-1), also were measured. In the OS group, the level of TIMP-1 was significantly higher on POD 1 (p < 0.0003) and POD 2 (p < 0.01) and 3 (p < 0.01) than at pre-OP. In the LS group, a smaller but significant increase in TIMP-1 levels was found between the pre-OP sample and the POD 1 (p < 0.01) and POD 2 (p < 0.01) samples. No difference was noted on POD 3 (p = 0.1). CONCLUSIONS: Open surgery, but not laparoscopic surgery, is accompanied by a short-lived significant increase in MMP-9 levels, which likely accounts for the decrease in IGFBP-3 levels observed after OS. The transitory nature of MMP-9 imbalance may be attributable to the increase in TIMP-1 levels postoperatively.

A case of protrusion of an intraperitoneal chemotherapy catheter through rectum.

Bowel penetration of an intraperitoneal catheter occurred in a patient who had received a course of uncomplicated intraperitoneal chemotherapy for a persistent ovarian carcinoma. One month after the termination of chemotherapy, she presented with protrusion of a catheter through anus. At operation, the catheter was removed, the rectum was repaired primarily, and a cytoreductive surgery was performed.

Is it justified to obtain routine peritoneal fluid cultures during appendectomy in children?

Controversy exists regarding obtaining routine peritoneal cultures during appendectomy. The aim of the study was to determine the impact of obtaining routine peritoneal fluid cultures during appendectomy on the treatment and clinical outcome in children. The charts of 269 children who were operated with the diagnosis of appendicitis between January 1996 and January 2001 were reviewed. The microorganisms in peritoneal cultures, selection of antibiotics and clinical outcome were evaluated. Average age was 10.1+/-3.3 (range, 1 to 17 years) years with a male to female ratio of 1.7 (170/99). There were two groups of patients; Group 1: uncomplicated appendicitis (201/269=75%), and Group 2: complicated (perforated) appendicitis (49/269=18%). In the series, 19 patients were found to have a normal appendix in histopathological examination (7%). Cultures were obtained from 95 (35.3%) patients (group 1: 59/95, group 2: 36/95). In patients with uncomplicated appendicitis, 6.7% of the cultures (4/59) were positive while in group 2, the rate was 47.2% (17/36) ( p<0.05). Only in four patients who were in group 2, antibiotics were re-adjusted according to the cultures. Escherichia coli and Klebsiella pneumoniae were the most common microorganisms. There were no complications in group 1, while wound infection (18.3%) and intra-abdominal abscess (2%) were the two most common complications in group 2. Intra-operative peritoneal cultures during appendectomy do not add much to the treatment of children. Therefore, it is not necessary to get peritoneal swab cultures during the procedures, and empiric use of wide spectrum antibiotics when necessary is generally sufficient in the management of this group of children.

Primary pulmonary rhabdomyosarcoma arising within cystic adenomatoid malformation: a case report and review of the literature.

The current report describes a 13-month-old boy with primary pulmonary rhabdomyosarcoma (RMS) that originated within a congenital cystic adenomatoid malformation (CCAM). To the best of our knowledge, he is the youngest patient of all primary pulmonary RMS cases reported in the English-language literature. The tumor, localized in left upper lobe, was removed completely, and histologic examination showed embryonal subtype. Postoperative systemic chemotherapy was carried out. Recent evaluation 15 months after resection has not identified any residual or recurrent disease. Primary pulmonary RMS, although very rare in the pediatric age group, should be considered in young patients with solitary pulmonary masses and associated cystic lesions.

Askin tumors in children: a report of four cases.

Primary malignant tumors of the chest are rare in the pediatric age group. Askin tumor belongs to the peripheral primitive neuroectodermal tumor family, and typically involves the periosteum, soft tissue and extrapulmonary tissue of the thoracic wall. We report our ten years experience with four cases of this rare tumor.

Pilomatricoma in children: a prospective study.

Pilomatricoma is a skin appendage tumor that frequently involves the skin of the head, neck, and upper extremities in young children. In this prospective study, we present and discuss the characteristics of our patients with pilomatricoma. During the years 1984 to 1994, 15 children (9 girls and 6 boys) with pilomatricoma were admitted to our service. Their ages ranged from 3 to 13 years (mean age 9 years). All of the lesions of these patients were excised totally. On histopathologic examination, calcification was found in all of the specimens. No invasion or malignancy was observed by light microscopy. All patients have been followed up periodically by the same surgeons. Interestingly, we found two familial occurrences and four multiple occurrences. Although our series was too small for accurate statistical evaluation, multiple and familial occurrences of pilomatricoma (26.7% and 13.3%, respectively) were higher than in previously reported series.