Cystic fibrosis transmembrane conductance regulator modulates enteric cholinergic activities and is abnormally expressed in the enteric ganglia of patients with slow transit constipation.

BACKGROUND: Cystic fibrosis transmembrane conductance regulator (CFTR) was recently found in the enteric nervous system, where its role is unclear. We aimed to identify which enteric neuronal structures express CFTR, whether CFTR modulates enteric neurotransmission and if altered CFTR expression is associated with slow transit constipation (STC). METHODS: Immunofluorescence double labeling was performed to localize CFTR with various neuronal and glial cell markers in the human colon. The immunoreactivity (IR) of CFTR and choline acetyltransferase (ChAT) on myenteric plexus of control and STC colon was quantitatively analyzed. In control colonic muscle strips, electrical field stimulation (EFS) evoked contractile responses and the release of acetylcholine (ACh) was measured in the presence of the CFTR channel inhibitor, CFTR(inh)-172. RESULTS: CFTR-IR was densely localized to myenteric ganglia, where it was co-localized with neuronal markers HuC/D and ß-tubulin, and glial marker S-100 but little with glial fibrillary acidic protein. Vesicular ACh transport was almost exclusively co-localized with CFTR, but neurons expressing nitric oxide synthase were CFTR negative. Significant reductions of CFTR-IR (P < 0.01) and ChAT-IR (P < 0.05) were observed on myenteric ganglia of STC compared to control. Pre-treatment of colonic muscle strips with CFTR(inh)-172 (10 µM) significantly inhibited EFS-evoked contractile responses (P < 0.01) and ACh release (P < 0.05). CONCLUSIONS: Co-localization of CFTR-IR with cholinergic markers, inhibition of EFS-induced colonic muscle contractility and ACh release by CFTR(inh)-172 suggest that CFTR modulates enteric cholinergic neurotransmission. The downregulation of CFTR and ChAT in myenteric ganglia of STC correlated with the impaired contractile responses to EFS.

Patient compliance with surveillance colonoscopy: patient factors and the use of a graded recall system.

BACKGROUND: Surveillance colonoscopy allows for the early detection and improved treatment outcomes in colorectal neoplasms but compliance rates and factors require further investigation. METHODS: This is a retrospective cohort study examining 816 patients recalled for surveillance colonoscopy at an Australian colorectal practice over a 6-month period. Primary outcome was compliance with colonoscopy within 12 months of recall. The secondary outcome of this study was to identify factors affecting compliance including patient factors and the practices' graded recall system. RESULTS: A total of 715 patients (87.6%) were compliant with recall requests for repeat colonoscopy. Significantly higher compliance rates were noted with a personal history of adenomatous polyps (90.9% versus 85.6%, P = 0.025). Those with private insurance or Department of Veterans Affairs were more likely to be compliant than those publicly funded (89.0% versus 93.3% versus 79.0%, P = 0.007). No statistically significant difference in compliance was shown with a personal history of colorectal cancer, diverticular disease, perianal disease, National Health and Medical Research Council risk category, gender, time associated with the practice or the clinician. There was a significant positive correlation between the number of letters sent and compliance with recall, with 61.8% being compliant after a single letter, and a final cumulative compliance after five letters of 87.6% (R = 0.882, P = 0.048). CONCLUSION: A graded recall system can achieve compliance rates as high as 87.6% compared to a single letter only achieving 61.8% compliance. A history of adenomatous polyps and insurance status were the only factors shown to result in higher recall compliance.

Single visit surgery for pediatric ambulatory surgical procedures: a satisfaction and cost analysis.

BACKGROUND: Single visit surgery (SVS) consists of same-day pre-operative assessment and operation with telephone post-operative follow-up. This reduces family time commitment to 1 hospital trip rather than 2-3. We began SVS for ambulatory patients with clear surgical indications in 2013. We sought to determine family satisfaction, cost savings to families, and institutional financial feasibility of SVS. METHODS: SVS patients were compared to age/case matched conventional surgery (CS) patients. Satisfaction was assessed by post-operative telephone survey. Family costs were calculated as the sum of lost revenue (based on median income) and transportation costs ($0.50/mile). RESULTS: Satisfaction was high in both groups (98% for SVS vs. 93% for CS; p=0.27). 40% of CS families indicated that they would have preferred SVS, whereas no SVS families indicated preference for the CS option (p<0.001). Distance from the hospital did not correlate with satisfaction. Estimated cost savings for an SVS family was $188. Reimbursement, hospital and physician charges, and day-of-surgery cancellation rates were similar. CONCLUSIONS: SVS provides substantial cost savings to families while maintaining patient satisfaction and equivalent institutional reimbursement. SVS is an effective approach to low-risk ambulatory surgical procedures that is less disruptive to families, facilitates access to pediatric surgical care, and reduces resource utilization. TYPE OF STUDY: Cost Effectiveness Study. LEVEL OF EVIDENCE: Level II.

Sclerotherapy for splenic cysts in children.

BACKGROUND: Sclerotherapy has been described as a treatment option for nonparasitic pediatric splenic cysts; however, there are limited data on its long-term effectiveness. METHODS: We performed a retrospective review and prospective follow-up imaging study of children treated for nonparasitic splenic cysts at our institution during 2006-2015. Included patients had International Classification of Disease, Ninth Revision, Clinical Modification diagnosis code 289.59 or 759.0 and underwent either sclerotherapy or a partial splenic operation (partial splenectomy, cyst excision, or marsupialization). Charts were reviewed for demographics, imaging, treatments, and complications. Identified patients were contacted and asked to return for splenic ultrasonography. RESULTS: Six surgical patients and 19 sclerotherapy patients were identified. Sclerotherapy patients underwent a median of four treatments with a decrease in the size of the cyst or complete ablation in 89.5% (17/19). Of the two patients who underwent unsuccessful sclerotherapy, one patient had sclerotherapy with sotradecol and ethanol for eight treatments, developed infection, and underwent total splenectomy. The other patient did not improve with sclerotherapy and underwent partial splenectomy. Nine patients (eight patients treated with sclerotherapy and one patient treated with partial splenectomy) were successfully contacted and underwent follow-up imaging at a median follow-up of 2.4 y since last treatment. Of the eight patients treated with sclerotherapy, four patients remained cyst-free, three had small residual asymptomatic cysts stable in size, and one developed a recurrent small asymptomatic cyst; the patient treated with surgery had no recurrence. CONCLUSIONS: Sclerotherapy appears to be an effective and durable alternative treatment for children with splenic cysts.

Patients exposed to diagnostic head and neck radiation for the management of shunted hydrocephalus have a significant risk of developing thyroid nodules.

PURPOSE: External radiation to the head and neck can lead to an increased incidence of thyroid nodules. We investigated whether patients requiring repeated head and neck imaging for the management of shunted hydrocephalus had a higher incidence of ultrasound-detected thyroid nodules compared to reports of comparable age. METHODS: Patients treated at our institution for shunted hydrocephalus from 1990 to 2003 were contacted. Enroled patients underwent a thyroid ultrasound. Demographic data and radiation exposure history were obtained retrospectively. RESULTS: Thyroid nodules were identified sonographically in 15/112 patients (13.6 %). Patients with thyroid nodules were older (mean 24.3 ± 7.6 years) than those without (mean 18.4 ± 8.0 years) (p = 0.005). Those with a detectable thyroid nodule had a longer follow up time compared to those who did not (mean 21.9 ± 5.5 vs. 15.1 ± 7 years, respectively) (p = 0.018). CONCLUSION: Patients with shunted hydrocephalus are exposed to substantial head and neck radiation from diagnostic imaging and have a higher incidence of thyroid nodules detected by ultrasonography. These patients should be provided ongoing surveillance for detection of thyroid nodules and the possibility of malignancy.

A Rare Cause of Postoperative Abdominal Pain in a Spinal Fusion Patient.

We present the case of a 12-year-old girl who underwent an uncomplicated posterior spinal fusion with instrumentation for scoliosis and who later developed nausea, emesis, and abdominal pain. We discuss the epidemiology, prevalence, anatomic findings, symptoms, diagnostic tests, and clinical management, including nonsurgical and surgical therapies, of superior mesenteric artery syndrome (SMAS), a rare condition. Over a 2-week period, the patient developed an uncommon type of bowel obstruction likely related to her initial thin body habitus, correction of her deformity, and weight loss after surgery. The patient returned to the operating room for placement of a Stamm gastrostomy feeding tube with insertion of a transgastric-jejunal (G-J) feeding tube. The patient had the G-J feeding tube in place for approximately 6 weeks to augment her enteral nutrition. As she gained weight, her duodenal emptying improved, and she gradually transitioned to normal oral intake. She has done well since the G-J feeding tube was removed. Posterior spinal fusion for adolescent idiopathic scoliosis is a relatively common procedure, and SMAS is a rare condition. However, in the case of an asthenic adolescent with postoperative weight loss, intestinal obstruction can develop. When planning operative spinal correction in scoliosis patients who have a low body mass index at the time of surgery and who have increased thoracic stiffness, be alert for signs and symptoms of SMAS. This rare complication can develop, and timely diagnosis and medical management will decrease morbidity and shorten the length of time needed for nutritional rehabilitation.

Plasma TIMP-1 and CEA as Markers for Detection of Primary Colorectal Cancer: A Prospective Validation Study Including Symptomatic and Non-symptomatic Individuals.

BACKGROUND/AIM: The combination of plasma tissue inhibitor of metalloproteinases-1 (1) and CEA has been shown to have utility in early detection of colorectal cancer (2). A prospective study was performed to validate previous findings. PATIENTS AND METHODS: Individuals undergoing large bowel endoscopy were prospectively included (N=1965). Baseline data and co-morbidity were recorded. The primary end-point was the detection of CRC. Plasma was obtained before endoscopy and TIMP-1 and CEA levels were determined using an automated analysis platform when all samples were collected. RESULTS: CRC was detected in 32 individuals, 24 with colonic cancer (CC) and 8 with rectal cancer (RC). Other findings were 265 with adenomas and 889 with non-neoplastic pathology. The biomarker levels were elevated in plasma from patients with CRC, but also from patients with various co-morbidities compared to individuals without any findings at endoscopy. Univariate analysis demonstrated that both markers were significant predictors of CRC. The odds ratios (OR) for an elevated TIMP-1 level for the detection of CRC was 6.2 [95% confidence interval (CI)=3.1-13.0, p<0.0001] and for an elevated CEA level was 2.4 (95% CI=1.9-2.9, p<0.0001). A subset analysis with CC as the end-point showed an OR for TIMP-1 of 7.0 (95% CI=3.2-15.3, p<0.0001). Multivariable analysis including TIMP-1, CEA and age resulted in an OR for TIMP-1 of 2.0 (95% CI=0.7-5.2, p=0.078) and for CEA the OR was 2.2 (95% CI=1.8-2.8, p<0.0001). CONCLUSION: This prospective study validates a previous study testing the detection of CRC based on TIMP-1 and CEA levels (3).

Inverse expression of prostaglandin E2-related enzymes highlights differences between diverticulitis and inflammatory bowel disease.

BACKGROUND: Prostaglandin E2 (PGE2) is the dominant prostaglandin in the colon and is associated with colonic inflammation. PGE2 levels are regulated not only by cyclooxygenases (COX-1 and COX-2) but also by 15-hydroxyprostaglandin dehydrogenase (15-PGDH), the major PGE2-degrading enzyme. Information about the involvement of 15-PGDH in colonic inflammation is sparse. AIM: We thus aimed to determine the gene expression and immunoreactivity (IR) of COX-1, COX-2, and 15-PGDH in colonic mucosa from patients with diverse inflammatory disorders: ulcerative colitis (UC), Crohn's disease (CD), and acute diverticular disease (DD). METHODS: RNA from human colonic mucosa was extracted and assessed for gene expression by real-time PCR. Intact colon sections were processed for immunohistochemistry with immunostaining of the mucosal areas quantified using ImageJ. RESULTS: In colonic mucosa of both UC and CD, COX-2 mRNA and COX-2-IR were significantly increased, whereas 15-PGDH mRNA and 15-PGDH-IR were significantly reduced. In macroscopically undamaged acute DD mucosa, the opposite findings were seen: for both gene expression and immunoreactivity, there was a significant downregulation of COX-2 and upregulation of 15-PGDH. COX-1 mRNA and COX-1-IR remained unchanged in all diseases. CONCLUSIONS: Our study for the first time demonstrated differential expression of the PGE2-related enzymes COX-2 and 15-PGDH in colonic mucosa from UC, CD, and acute DD. The reduction of 15-PGDH in IBD provides an additional mechanism for PGE2 increase in IBD. With respect to DD, alterations of PGE2-related enzymes suggest that a low PGE2 level may precede the onset of inflammation, thus providing new insight into the pathogenesis of DD.

Xanthogranulomatous appendicitis in a child: report of a case and review of the literature.

Xanthogranulomatous inflammation is a well-described inflammatory process, which may involve any organ but is most frequently encountered in the gall bladder and the kidney. There are rare reports of xanthogranulomatous appendicitis (XA) in the adult population, but only one brief mention of such a diagnosis in a child. In this report, we describe the case of an 11-year-old boy who presented with clinical signs and symptoms of acute appendicitis necessitating appendectomy. Upon microscopic examination, the appendix showed the typical features of XA. To the best of our knowledge, this is the first well-described case XA in a noninterval appendix in a child. We also reviewed the limited medical literature on the subject.

Synchronous resection of colorectal primary cancer and liver metastases.

BACKGROUND: Patients with synchronous colorectal liver metastases are thought to have a less favorable prognosis than those with colorectal cancer alone. Surgical treatment options are controversial, be it synchronous resection or staged resection. This study compared the clinical, perioperative, disease-free survival (DFS), and overall survival (OS) results of patients undergoing synchronous resection versus staged resection. METHODS: An observational cohort study of 103 patients with synchronous colorectal liver metastases was performed. All data were collected prospectively. Clinical, perioperative, DFS, and OS results of patients undergoing synchronous resection (group I, n = 73) and staged resection (group II, n = 30) were compared. RESULTS: More patients in group I had poorly differentiated colorectal cancer, bilobar liver metastases, more than three liver metastases, < or =4 cm liver metastases, and shorter hospital stays than patients in group II. There were no significant statistically differences in DFS and OS between the two groups. The median DFS of groups I and II were 28 and 26 months, respectively (p = 0.585). The median OS of groups I and II were 37 and 36 months, respectively (p = 0.900). CONCLUSIONS: Synchronous resection achieved DFSs and OSs similar to those seen after staged resection while avoiding a second major operation.

Bowel, bladder and sexual function in women undergoing laparoscopic posterior compartment repair in the presence of apical or anterior compartment dysfunction.

OBJECTIVE: The aim of the study was to analyse the functional outcome of women undergoing a laparoscopic posterior compartment repair in the presence of anterior or apical compartment dysfunction. DESIGN: Prospective cohort study. METHODS: Forty women, median age 65 years (41-78), with symptoms of genital prolapse 31 (78%), urinary dysfunction 32 (80%) and bowel dysfunction 40 (100%), underwent laparoscopic posterior compartment repair in conjunction with an anterior compartment repair. Pre-operative and postoperative bowel and bladder function was prospectively assessed with a Wexner continence score, Vienna constipation score and a urinary dysfunction score. Twenty-eight (70%) and 24 patients (60%) had pre-operative urodynamics and anorectal manometry. Post-operatively all women were also assessed with a Watt's sexual dysfunction score and a linear analogue patient satisfaction score. Twelve women (30%) had postoperative anal manometry. RESULTS: At 20 months median follow-up, 30 (97%), 20 (62%) and 12 (31%) women reported improvement in their prolapse, urinary and bowel symptoms, respectively. Post-operatively, one woman reported denovo faecal incontinence, four worsening obstructive defecation and three denovo urinary dysfunction. Nine women (35%) reported denovo dyspareunia. The mean time to clinical deterioration following surgery was 11 months. Bowel function improvement was the only factor to significantly correlate with postoperative patient satisfaction. CONCLUSION: The functional outcome of laparoscopic posterior compartment repair in the presence of anterior compartment dysfunction is disappointing. Preoperative counselling is important to ensure that patients have reasonable and realistic expectations from repair surgery, and an understanding that anatomical improvement might not be followed by long-term functional improvement.

Sutureless intestinal plication.

BACKGROUND: Adhesions form between damaged mesothelial surfaces and can cause recurrent small bowel obstruction. Repeat laparotomies may be required in some cases, which can be associated with significant morbidities. METHODS: A technique is described for plication of the small bowel in an orderly manner with the use of two silicone indwelling urinary catheters. CONCLUSIONS: This plication technique, a modification of the Noble and Childs-Phillips operations, is effective, safe, quick and cost-effective.

Picoprep-3 is a superior colonoscopy preparation to Fleet: a randomized, controlled trial comparing the two bowel preparations.

PURPOSE: Bowel preparations for colonoscopy have to balance the demand for adequate cleansing action of the bowel and patient acceptability. There has been no study comparing Picoprep-3 (sodium picosulfate), a relatively new product, to Fleet (sodium phosphate), a well-studied and widely used preparation. This study was designed to compare the efficacy and patient tolerance of these two bowel preparations for colonoscopy. METHODS: A randomized, single-blinded, prospective trial was conducted. A total of 400 consecutive patients presenting for elective colonoscopy at St George Private Hospital during a 20-week period were randomly assigned to receive Picoprep-3 or Fleet. Patients were asked to record the effects of the preparation, noting tolerability, taste, and side effects. Two hundred patients were assigned to the Picoprep-3 group and 200 to the Fleet group. Surgeons were blinded to the preparation used and rated the quality of the bowel preparation on a scale of 1 to 5 (1 being the optimal score). RESULTS: Picoprep-3 was found to be better tolerated (P < 0.0001) and better tasting (P < 0.0001) than Fleet. Patients in the Picoprep-3 group reported significantly less nausea (P < 0.001), vomiting (P < 0.004), dizziness (P < 0.01), abdominal pains (P = 0.0005), and thirst (P < 0.0001) associated with the preparation. There was no significant difference in visualization of the colon between the two groups as judged by the two colonoscopists (P = 0.06). CONCLUSIONS: Colonoscopy preparation with Picoprep-3 has similar efficacy but superior taste and tolerability compared with Fleet. Picoprep-3 caused less adverse side effects in the study population.

Use of endoscopic titanium stapler in rectal anastomotic stricture.

A quick and effective technique is described here for the treatment of rectal anastomotic stricture. It consisted of cutting the stricture using the Ethicon 35-mm Endoscopic Titanium Stapler. A patient was treated here as a day-surgery case. Good functional and anatomic results were achieved on follow-up.