Extragastrointestinal stromal tumour of the lesser omentum: A case report and literature review.

INTRODUCTION: Extragastrointestinal stromal tumours (EGISTs) are very uncommon compared to their gastrointestinal counterparts. Most of them originate from the intestinal mesentery and the omentum. CASE REPORT: A 70 year-old Caucasian woman presented with a bulky abdominal mass which on laparotomy was found to originate from the lesser omentum and was completely resected. Histological examination revealed spindle cells with severe pleomorphism and high mitotic activity. Immunohistochemically, the tumour cells showed strong positivity for c-kit (CD117), DOG-1 and human haematopoietic progenitor cell antigen (CD34). An exon 11 deleterious mutation was identified and thus regular dosing of 400mg imatinib mesylate was initiated. DISCUSSION: There have been only a few previous reports of EGISTs arising in the lesser omentum. Although EGISTs seem to have morphological and immunohistochemical similarities with GISTs, their pathogenesis, incidence, genetic background and prognosis are not completely known because they are extremely rare. It is strongly believed that such tumours originate from cells, which have similar pathological characteristics and biological behaviour as the intestinal cells of Cajal. In most series of EGISTs, a female predominance, a greater size and a higher mitotic index than GISTs were observed. CONCLUSION: EGISTs are very rare mesenchymal tumours which originate from cells outside the gastrointestinal tract and tend to have a more aggressive biological behaviour than their GI counterparts. Complete surgical resection is the most effective treatment associated with the use of imatinib in the presence of adverse prognostic factors. In any case a strict follow-up is necessary due to high recurrence rates.

Fluorine-18 fluorodeoxyglucose positron emission tomography in the preoperative staging of thoracic oesophageal and gastro-oesophageal junction cancer: a prospective study.

BACKGROUND: The pre-operative staging in oesophageal cancer is often challenging and underestimation of the extent of the disease may lead to unnecessary surgery. AIM: To audit the use and assess the value of fluorine-18 fluorodeoxyglucose positron emission tomography ((18)F FDG-PET) as a staging tool for thoracic oesophageal and gastro-oesophageal junction (GOJ) cancers in our oncological surgical practice. PATIENTS AND METHODS: Over a 3 year period, between 2002 and 2004, 134 patients with thoracic oesophageal or GOJ cancer were referred to our unit for treatment. The standard preoperative staging investigation in all cases was CT (thorax, abdomen and pelvis). A preoperative FDG-PET scan was further requested in 22 patients. The case notes of all the patients that underwent a FDG-PET scan were reviewed and compared with the preoperative imaging, the operative findings and the histopathology of the resected tumours. RESULTS: Eighteen men and 4 women with a median age of 65 (range 43-79) years were studied. After FDG-PET, 13 out of 22 patients (59%) were deemed suitable for tumour resection. Twelve of the 13 patients were fit to undergo surgery. At laparotomy, 2 of those (17%) were found inoperable due to widespread disease. The sensitivity of CT versus FDG-PET to detect infiltrated lymph nodes was 29% (95% CI: 3-70) versus 71% (95% CI: 29-96) (P=0.0412), whereas both tests had 67% specificity (95% CI: 9-99) in detecting lymph nodes. The sensitivity and the specificity of CT versus FDG-PET to detect distant organ metastases (M1b) were 33% (95% CI: 4-77) and 88% (95% CI: 47-99) versus 50% (95% CI: 6-93) and 100% (95% CI: 69-100), respectively (P>0.05). The FDG-PET regarding the N and M status differed from the CT in 11 patients and led to modification of the planned management in 5 of them. CONCLUSIONS: FDG-PET is more accurate than CT in defining N and M status. It can result in a reduction of unnecessary surgery in a significant number of patients. The combined PET-CT scan as a single imaging modality is expected to further improve diagnostic accuracy of FDG-PET.

What is the difference between proximal and total gastrectomy regarding postoperative bile reflux into the oesophagus?

BACKGROUND: Tumours of the oesophagogastric junction and the gastric cardia can be treated either with proximal or with total gastrectomy. Reflux of bile and other duodenal contents into the oesophagus following proximal gastrectomy has generally been considered worse than reflux after total gastrectomy. The aim of the present study was to test this assumption given that there is limited literature regarding objective evaluation of the postoperative duodeno-oesophageal reflux. PATIENTS AND METHODS: We carried out bilirubin monitoring with the ambulatory spectrophotometer Bilitec 2000 in two groups of patients and in one group of healthy volunteers matched in age and sex. The proximal gastrectomy group consisted of 8 patients who underwent proximal gastrectomy and an end-to-side oesophagogastrostomy without pyloric drainage procedure. The total gastrectomy group consisted of 11 patients who underwent total gastrectomy and Roux-en-Y reconstruction with a 50-cm-long jejunal limb. The control group consisted of 8 healthy volunteers. In all cases, an absorption value of 0.14 was used as the threshold for reflux episodes. RESULTS: The median fraction of time that bilirubin absorbance was >0.14 in the proximal versus total gastrectomy group was 47.4 and 13.4%, respectively (p = 0.02). The difference between the two groups was significant in the supine position (p = 0.03), whilst the upright position, meal and postprandial periods were not found to have significant difference. Likewise, no significant difference was found in the number of reflux episodes. The median fraction of time in the proximal gastrectomy group compared with controls was 47.4 versus 3.95% (p < 0.001), whilst in the total gastrectomy group compared with controls, it was 13.4 versus 3.95% (p > 0.05). The number of reflux episodes in the proximal gastrectomy group compared with controls was 74 versus 21 (p = 0.02), whilst in the total gastrectomy group compared with controls, it was 103 versus 21 (p > 0.05). CONCLUSIONS: Total gastrectomy with Roux-en-Y reconstruction reduces the time of oesophageal exposure to duodenal juices as compared with proximal gastrectomy. This effect seems to be more prominent in the supine position.

Tube pharyngostomy: a simple method for prolonged intubation of the foregut following oesophagogastric surgery.

Tube pharyngostomy involves the percutaneous passage of a tube through the pharynx as an alternative to nasogastric intubation. We use this method for upper gastrointestinal decompression after oesophagectomies and total gastrectomies where prolonged intubation of the foregut is anticipated. It is simple to perform and very well tolerated as compared to a nasogastric tube. The pharyngostomy tube can also be used for enteral feeding. We present here the technique in detail and our experience with 67 procedures over the last 6 years where only few minor complications were encountered. We also review the literature for previous reports of pharyngostomy.

Endoscopic palliation of malignant dysphagia: a challenging task in inoperable oesophageal cancer.

BACKGROUND: The main goal when managing patients with inoperable oesophageal cancer is to restore and maintain their oral nutrition. The aim of the present study was to assess the value of endoscopic palliation of dysphagia in patients with oesophageal cancer, who either due to advanced stage of the disease or co-morbidity are not suitable for surgery. PATIENTS AND METHODS: All the endoscopic palliative procedures performed over a 5-year period in our unit were retrospectively reviewed. Dilatation and insertion of self-expandable metal stents (SEMS) were mainly used for tight circumferential strictures whilst ablation with Nd-YAG laser was used for exophytic lesions. All procedures were performed under sedation. RESULTS: Overall 249 palliative procedures were performed in 59 men and 40 women, with a median age of 73 years (range 35-93). The median number of sessions per patient was 2 (range 1-13 sessions). Palliation involved laser ablation alone in 24%, stent insertion alone in 22% and dilatation alone in 13% of the patients. In 41% of the patients, a combination of the above palliative techniques was applied. A total of 45 SEMS were inserted. One third of the patients did not receive any other palliative treatment, whilst the rest received chemotherapy, radiotherapy or chemoradiotherapy. Swallowing was maintained in all patients up to death. Four oesophageal perforations were encountered; two were fatal whilst the other two were successfully treated with covered stent insertion and conservative treatment. The median survival from diagnosis was 10.5 months (range 0.5-83 months) and the median survival from 1st palliation was 5 months (range 0.5-68.5 months). CONCLUSION: Endoscopic interventions are effective and relatively safe palliative modalities for patients with oesophageal cancer. It is possible to adequately palliate almost all cases of malignant dysphagia. This is achieved by expertise in combination treatment.

Outcome of treatment of primary and recurrent pilonidal sinuses with the Limberg flap.

BACKGROUND: Surgical treatment of pilonidal sinus disease has a significant morbidity and recurrence rate. The rhomboid flap of Limberg is a transposition flap that has been advocated for treatment of this condition. We present our experience with the Limberg technique for both primary and recurrent pilonidal sinuses. PATIENTS AND METHODS: In a three-year period, 25 patients with chronic pilonidal sinus disease were treated with this method. Twelve patients had recurrent disease and were previously treated with other types of surgery. The sinuses were excised in a rhomboid fashion and the defect closed using a transposition flap designed to obliterate the midline cleft. Patients were treated with prophylactic antibiotics and the wound drained with a vacuum drain. RESULTS: Median post-operative hospital stay was four days. There were four (16%) wound complications. The mean follow-up period was 20 months. There was a single recurrence (4%) of a pilonidal sinus, which required further surgical excision. CONCLUSIONS: Despite the risk of wound complications, this method is particularly useful for complex sinuses with extended tracts where radical excision leaves a large defect. It is also suitable for cases where simpler operations have failed and carries a low risk for recurrence.

Vasectomy management in Morecambe Bay NHS Trust.

INTRODUCTION: Vasectomy is a common method of contraception in the UK. However, there is a wide variation in management protocols. The aim of the present study was to identify differences within the hospitals of Morecambe Bay NHS Trust and to recommend a uniform practice. PATIENTS AND METHODS: Retrospective case notes review of 395 vasectomy procedures performed within the Morecambe Bay NHS Trust in a 1-year period. RESULTS: Inconsistency was found with regards to the anaesthetic technique, the vas histology request and the timing of the semen analysis. The non-compliance rate for postvasectomy semen analysis was 33.4%. The complication and failure rates were 4.04% and 0.51%, respectively. Motile sperm (n = 4) was submitted at an average time of 8 weeks' postvasectomy. In half of those cases, vasectomy proved unsuccessful. Immotile sperm (n = 41) was submitted at an average time of 9.5 weeks and, in 80% of those men, semen cleared at an average time of 15.5 weeks' postvasectomy. An azoospermic (n = 285) sample was submitted at an average time of 10.5 weeks. Eleven of those men submitted a second sample with immotile sperm at an average time of 12 weeks' postvasectomy and that was eventually clear at 18 weeks in the majority of cases. CONCLUSIONS: A uniform vasectomy practice should include vasectomy under local anaesthesia if possible, no vas histology and a request for a single sample at 12 weeks. If this is clear, vasectomy should be considered successful. If any sperm are present, then a further sample should be requested at 16 weeks' postvasectomy. Immotile sperm at that time should not justify any further samples and a 'special clearance' should be issued to those men.

Sclerosing encapsulating peritonitis secondary to CAPD: the effect of fibrotic debridement on further dialysis.

BACKGROUND: Sclerosing peritonitis (SCP) is a complication of continuous ambulatory peritoneal dialysis (CAPD) and is characterized by progressive fibrosis of the peritoneum. Entrapment of the intestine in a fibrous sac resulting in complete intestinal obstruction is called sclerosing-encapsulating peritonitis (SEP) and represents the most severe form of the disease. Various reports have been pessimistic regarding the surgical outcome when SEP has caused complete intestinal obstruction. Continuation of CAPD after laparotomy is generally considered not feasible. The aim of this article is to present our experience in the surgical management of SEP and, in particular, in the postoperative continuation of CAPD. MATERIAL AND METHODS: Seventeen consecutive patients with SCP among 175 patients undergoing CAPD during a period of 14 years in a single Unit were retrospectively reviewed. Two groups of patients were recognized. The SCP group included 9 patients with incomplete intestinal obstruction that were treated with single peritoneal catheter removal and switching to haemodialysis. The SEP group included 8 patients with complete obstruction that necessitated laparotomy for surgical debridement of the fibrotic tissue and release of the intestinal loops. RESULTS: Switching to haemodialysis improved the majority of the group of patients. In 2 of the SEP group of patients (early in the series), where enterectomy was inevitable, performance of an intestinal anastomosis resulted in leakage with subsequent fatal outcome. Two of the SEP group of patients were transferred to haemodialysis after the laparotomy. In the remaining 4 SEP patients (50%), exposure of a significant portion of active peritoneal surface was achieved - called "neoperitonization"-and allowed effective continuation of peritoneal dialysis for an average duration of 16 months (range 1-32). CONCLUSIONS: In patients with SEP, careful release of the intestinal loops avoiding enterectomies and even inadvertent intestinal wounds is mandatory. Continuation of peritoneal dialysis after meticulous debridement and removal of the fibrotic tissue is possible and may be effective. To the best of our knowledge, there have not been previously reported cases of continuations of CAPD after laparotomy for SEP.

Perforation of a gastric tube peptic ulcer into the thoracic aorta.

We present a case of a 52-year-old male patient who died from massive hematemesis as a result of perforation of a benign peptic ulcer into the descending thoracic aorta, 1 year after esophagectomy for esophageal cancer and gastric tube interposition. We also review the literature for mechanisms of ulceration in intrathoracic gastric grafts and for complications of such ulcers.