Colitis Cystica Profunda of the Hepatic Flexure: A Case Report.

A 72-year-old woman with a prior sigmoid resection for colon cancer underwent a right hemicolectomy after a colonoscopy revealed a mass in the hepatic flexure. A preoperative biopsy at colonoscopy showed tubulovillous dysplasia with high-grade neoplasm. The final specimen pathology revealed benign mucosal elements with mucin pools consistent with colitis cystica profunda (CCP). CCP is a benign lesion; no further treatment was necessary after resection. To our knowledge, this is the first reported case of CCP in the right colon, presenting atypically in the hepatic flexure. This case report brings to light the difficulty and importance of making an accurate diagnosis of CCP.

Intracorporeal and extracorporeal anastomosis for robotic-assisted and laparoscopic right colectomy: short-term outcomes of a multi-center prospective trial.

BACKGROUND: Studies to date show contrasting conclusions when comparing intracorporeal and extracorporeal anastomoses for minimally invasive right colectomy. Large multi-center prospective studies comparing perioperative outcomes between these two techniques are needed. The purpose of this study was to compare intracorporeal and extracorporeal anastomoses outcomes for robotic assisted and laparoscopic right colectomy. METHODS: Multi-center, prospective, observational study of patients with malignant or benign disease scheduled for laparoscopic or robotic-assisted right colectomy. Outcomes included conversion rate, gastrointestinal recovery, and complication rates. RESULTS: There were 280 patients: 156 in the robotic assisted and laparoscopic intracorporeal anastomosis (IA) group and 124 in the robotic assisted and laparoscopic extracorporeal anastomosis (EA) group. The EA group was older (mean age 67 vs. 65 years, p = 0.05) and had fewer white (81% vs. 90%, p = 0.05) and Hispanic (2% vs. 12%, p = 0.003) patients. The EA group had more patients with comorbidities (82% vs. 72%, p = 0.04) while there was no significant difference in individual comorbidities between groups. IA was associated with fewer conversions to open and hand-assisted laparoscopic approaches (p = 0.007), shorter extraction site incision length (4.9 vs. 6.2 cm; p ≤ 0.0001), and longer operative time (156.9 vs. 118.2 min). Postoperatively, patients with IA had shorter time to first flatus, (1.5 vs. 1.8 days; p ≤ 0.0001), time to first bowel movement (1.6 vs. 2.0 days; p = 0.0005), time to resume soft/regular diet (29.0 vs. 37.5 h; p = 0.0014), and shorter length of hospital stay (median, 3 vs. 4 days; p ≤ 0.0001). Postoperative complication rates were comparable between groups. CONCLUSION: In this prospective, multi-center study of minimally invasive right colectomy across 20 institutions, IA was associated with significant improvements in conversion rates, return of bowel function, and shorter hospital stay, as well as significantly longer operative times compared to EA. These data validate current efforts to increase training and adoption of the IA technique for minimally invasive right colectomy.

Nanoliposomal Delivery of MicroRNA-203 Suppresses Migration of Triple-Negative Breast Cancer through Distinct Target Suppression.

Triple-negative breast cancers affect thousands of women in the United States and disproportionately drive mortality from breast cancer. MicroRNAs are small, non-coding RNAs that negatively regulate gene expression post-transcriptionally by inhibiting target mRNA translation or by promoting mRNA degradation. We have identified that miRNA-203, silenced by epithelial-mesenchymal transition (EMT), is a tumor suppressor and can promote differentiation of breast cancer stem cells. In this study, we tested the ability of liposomal delivery of miR-203 to reverse aspects of breast cancer pathogenesis using breast cancer and EMT cell lines. We show that translationally relevant methods for increasing miR-203 abundance within a target tissue affects cellular properties associated with cancer progression. While stable miR-203 expression suppresses LASP1 and survivin, nanoliposomal delivery suppresses BMI1, indicating that suppression of distinct mRNA target profiles can lead to loss of cancer cell migration.

Engineered aluminum nanoparticle induces mitochondrial deformation and is predicated on cell phenotype.

The main role of mitochondria is to generate the energy necessary for the cell to survive and adapt to different environmental stresses. Energy demand varies depending on the phenotype of the cell. To efficiently meet metabolic demands, mitochondria require a specific proton homeostasis and defined membrane structures to facilitate adenosine triphosphate production. This homeostatic environment is constantly challenged as mitochondria are a major target for damage after exposure to environmental contaminants. Here we report changes in mitochondrial structure profiles in different cell types using electron microscopy in response to particle stress exposure in three different representative lung cell types. Endpoint analyses include nanoparticle intracellular uptake; quantitation of mitochondrial size, shape, and ultrastructure; and confirmation of autophagosome formation. Results show that low-dose aluminum nanoparticles exposure (1 ppm; 1 µg/mL; 1.6 × 1 0-7 µg/cell)) to primary and asthma cells incurred significant mitochondrial deformation and increases in mitophagy, while cancer cells exhibited only slight changes in mitochondrial morphology and an increase in lipid body formation. These results show low-dose aluminum nanoparticle exposure induces subtle changes in the mitochondria of specific lung cells that can be quantified with microscopy techniques. Furthermore, within the lung, cell type by the nature of origin (i.e. primary vs. cancer vs. asthma) dictates mitochondrial morphology, metabolic health, and the metabolic stress response of the cell.

Silver Nanoparticles Agglomerate Intracellularly Depending on the Stabilizing Agent: Implications for Nanomedicine Efficacy.

Engineered nanoparticles are utilized as drug delivery carriers in modern medicine due to their high surface area and tailorable surface functionality. After in vivo administration, nanoparticles distribute and interact with biomolecules, such as polar proteins in serum, lipid membranes in cells, and high ionic conditions during digestion. Electrostatic forces and steric hindrances in a nanoparticle population are disturbed and particles agglomerate in biological fluids. Little is known about the stability of nanoparticles in relation to particle surface charge. Here, we compared three different surface-stabilized silver nanoparticles (50 nm) for intracellular agglomeration in human hepatocellular carcinoma cells (HepG2). Nanoparticles stabilized with branched polyethyleneimine conferred a positive surface charge, particles stabilized with lipoic acid conferred a negative surface charge, and particles stabilized with polyethylene glycol conferred a neutral surface charge. Particles were incubated in fetal bovine serum, simulated lung surfactant fluid, and simulated stomach digestion fluid. Each nanoparticle system was characterized via microscopic (transmission electron, fluorescence, and enhanced darkfield) and spectroscopic (hyperspectral, dynamic light scattering, and ultraviolet-visible absorption) techniques. Results showed that nanoparticle transformation included cellular internalization, agglomeration, and degradation and that these changes were dependent upon surface charge and incubation matrix. Hyperspectral analyses showed that positively charged silver nanoparticles red-shifted in spectral analysis after transformations, whereas negatively charged silver nanoparticles blue-shifted. Neutrally charged silver nanoparticles did not demonstrate significant spectral shifts. Spectral shifting indicates de-stabilization in particle suspension, which directly affects agglomeration intracellularly. These characteristics are translatable to critical quality attributes and can be exploited when developing nano-carriers for nanomedicine.

Robotic-Assisted and Laparoscopic Sigmoid Resection.

BACKGROUND AND OBJECTIVES: Published comparisons of minimally invasive approaches to colon surgery are limited. The objective of the current study is to compare the effectiveness of robotic-assisted and laparoscopic sigmoid resection. METHODS: A multicenter retrospective comparative analysis of perioperative outcomes from consecutive robotic-assisted and laparoscopic sigmoid resections performed between 2010 and 2015 by six general and colorectal surgeons, who are experienced in both robotic-assisted and laparoscopic surgical techniques and who had >50 annual case volumes for each approach. Baseline characteristics and surgical risk factors between the two groups were balanced using a propensity score methodology with inverse probability of treatment weighting. Mean standardized differences were reported, and in all instances, a p-value < 0.05 was considered statistically significant. RESULTS: Three hundred thirty-six cases (robotic-assisted, n = 211; laparoscopic, n = 125) met eligibility criteria and were included in the study. Following weighting, patient demographics and baseline characteristics were comparable between the robotic-assisted (n = 344) and laparoscopic (n = 349) groups. The laparoscopic group was associated with shorter operating room and surgical times. The robotic-assisted group had lower estimated blood loss and shorter time to first flatus compared to the laparoscopic group. Rates of complications post discharge to 30 d tended to be lower for the RA group: 5.1% vs 8.6% [p = 0.0657]. The RA group also had lower rates of readmissions and reoperations: 4% vs 8% [p = 0.029] and 0.5% vs 5.1% [p = 0.0003], respectively. CONCLUSIONS: Robotic-assisted sigmoid colon resection is clinically effective and provides a minimally invasive alternative to the laparoscopic approach with improved intraoperative and postoperative outcomes for colorectal patients.

Ferrate(VI) pretreatment before disinfection: An effective approach to controlling unsaturated and aromatic halo-disinfection byproducts in chlorinated and chloraminated drinking waters.

Disinfection is an essential process of drinking water treatment to eliminate harmful pathogens, but it generates potentially toxic disinfection byproducts (DBPs). Ferrate (FeO42-, Fe(VI)) was used to pre-oxidize natural organic matter (NOM, the precursor of DBPs) in source water to control DBP formation in subsequent chlorine or chloramine disinfection. Currently, it is unclear how Fe(VI) changes the structure of NOM, and no information details the effect of Fe(VI) pretreatment on the aromatic DBPs or the speciation of overall DBPs generated in subsequent disinfection of drinking water. In the present paper, Fe(VI) was applied to pretreat simulated source water samples at a Fe(VI) to dissolved organic carbon mole ratio of 1:1 at pH 8.0. 13C nuclear magnetic resonance spectroscopy was newly employed to characterize NOM in simulated source waters with and without Fe(VI) treatment, and it was demonstrated that Fe(VI) converted unsaturated aromatic C functional groups in NOM to saturated aliphatic ones. High-resolution mass spectrometry (HRMS) and high performance liquid chromatography/triple quadrupole MS were applied to analyze the DBPs generated in chlorination and chloramination of the source waters with and without Fe(VI) pretreatment. It was confirmed that Fe(VI) pretreatment followed by chlorination (or chloramination), generated DBPs containing less unsaturated, halogenated, and aromatic moieties than chlorination (or chloramination) without pretreatment by Fe(VI). Finally, the cytotoxicity of disinfected drinking water samples were assessed with the human epithelial colorectal adenocarcinoma Caco-2 cell line (a model of the intestinal barrier for ingested toxicants), and the results show that Fe(VI) pretreatment detoxified the chlorinated and chloraminated drinking waters.

Robotic-assisted ventral and incisional hernia repair with hernia defect closure and intraperitoneal onlay mesh (IPOM) experience.

BACKGROUND: The most common technique described for robotic ventral hernia repair (RVHR) is intraperitoneal onlay mesh (IPOM). With the evolution of robotics, advanced techniques including retro rectus mesh reinforcement, and component separation are being popularized. However, these procedures require more dissection, and longer operative times. In this study we reviewed our experience with robotic ventral/incisional hernia repair (RVHR) with hernia defect closure (HDC) and IPOM. METHODS: Retrospective chart review and follow-up of 31 consecutive cases of ventral/incisional hernia treated between August 2011 and December 2018. Demographics, operative times, blood loss, length of stay (LOS), hernia size, location, and type, mesh size and type, recurrence, conversion to open ventral hernia repair (OVHR) and complications including bleeding, seroma formation and infection were analyzed. RESULTS: Mean age was 63.9 years old, with median BMI of 31.24 kg/m2. Median hernia area was 17 cm2. Mean operating time was 142.61 min (SD 59.79). Mean LOS was 1.46 days (range 1-5), with 48% being outpatient, and overnight stay in 32% for pain control. Conversion was necessary in 12.9% cases. Complication rate was 3% for enterotomy. Recurrence was 14.81% after a mean follow-up of 26.96 months. There was significant association of recurrence with COPD history (P = 0.0215) and multiple hernia defects (P = 0.0376). CONCLUSION: Our recurrence rate (14.81%) compares favorably to those reported in literature (16.7%) for LVHR with HDC and IPOM. Our experience also indicates that IPOM is associated with satisfactory outcomes, low conversion and complications rates, and short LOS.

Synthesis and characterization of nanometer-sized liposomes for encapsulation and microRNA transfer to breast cancer cells.

Introduction: The use of liposomes as a drug delivery carrier (DDC) for the treatment of various diseases, especially cancer, is rapidly increasing, requiring more stringent synthesis, formulation, and preservation techniques to bolster safety and efficacy. Liposomes otherwise referred to as phospholipid vesicles are self-assembled colloidal particles. When formed in either the micrometer or nanometer size range, they are ideal candidates as DDC because of their biological availability, performance, activity, and compatibility. Defining and addressing the critical quality attributes (CQAs) along the pharmaceutical production scale will enable a higher level of quality control for reproducibility. More specifically, understanding the CQAs of nanoliposomes that dictate its homogeneity and stability has the potential to widen applications in biomedical science. Methods: To this end, we designed a study that aimed to define synthesis, characterization, formulation (encapsulation), preservation, and cargo delivery and trafficking as the major components within a target product profile for nanoliposomes. A series of synthetic schemes were employed to measure physicochemical properties relevant to nanomaterial drug product development, including concentration gradients, probe versus bath sonication, and storage temperature measured by microscopy (electron and light) and dynamic light scattering. Results: Concentration was found to be a vital CQA as reducing concentrations resulted in nanometer-sized liposomes of <350 nm. Liposomes were loaded with microRNA and fluorescence spectroscopy was used to determine loading efficacy and stability over time. Lyophilization was used to create a dry powder formulation that was then assessed for stability for 6 months. Lastly, breast cancer cell lines were used to ensure efficacy of microRNA delivery and localization. Conclusion: We conclude that microRNA can be loaded into nanometer-sized liposomes, preserved for months in a dried form, and maintain encapsulation after extended time periods in storage.

Refining In Vitro Toxicity Models: Comparing Baseline Characteristics of Lung Cell Types.

There is an ever-evolving need in the field of in vitro toxicology to improve the quality of experimental design, ie, from ill-defined cell cultures to well-characterized cytotoxicological models. This evolution is especially important as environmental health scientists begin to rely more heavily on cell culture models in pulmonary toxicology studies. The research presented in this study analyzes the differences and similarities of cells derived from two different depths of the human lung with varying phenotypes. We compared cell cycle and antioxidant-related mRNA and protein concentrations of primary, transformed, and cancer-derived cell lines from the upper and lower airways. In all, six of the most commonly used cell lines reported in in vitro toxicology research papers were included in this study (ie, PTBE, BEAS-2B, A549, PSAE, Met-5A, and Calu-3). Comparison of cell characteristics was accomplished through molecular biology (q-PCR, ELISA, and flow cytometry) and microscopy (phase and fluorescence) techniques as well as cellular oxidative stress endpoint analyses. After comparing the responses of each cell type using statistical analyses, results confirmed significant differences in background levels of cell cycle regulators, inherent antioxidant capacity, pro-inflammatory status, and differential toxicological responses. The analyzed data improve our understanding of the cell characteristics, and in turn, aids in more accurate interpretation of toxicological results. Our conclusions suggest that in vitro toxicology studies should include a detailed cell characterization component in published papers.

Advantages of Robotic Right Colectomy With Intracorporeal Anastomosis.

Through retrospective review of consecutive charts, we compare the short-term and long-term clinical outcomes after robotic-assisted right colectomy with intracorporeal anastomosis (RIA) (n=89) and laparoscopic right colectomy with extracorporeal anastomosis (LEA) (n=135). Cohorts were similar in demographic characteristics, comorbidities, pathology, and perioperative outcomes (conversion, days to flatus and bowel movement, and length of hospitalization). The RIA cohort experienced statistically significant: less blood loss, shorter incision lengths, and longer specimen lengths than the LEA cohort. Operative times were significantly longer for the RIA group. No incisional hernias occurred in the RIA group, whereas the LEA group had 5 incisional hernias; mean follow-up was 33 and 30 months, respectively. RIA is effective and safe and provides some clinical advantages. Future studies may show that, in obese and other technically challenging patients, RIA facilitates resection of a longer, consistent specimen with less mesentery trauma that can be extracted through smaller incisions.

Characterizing the Nano-Bio Interface Using Microscopic Techniques: Imaging the Cell System is Just as Important as Imaging the Nanoparticle System.

The rapid growth of nanotechnology and its industries has elevated the need to understand the risks associated with handling, using, and disposing of nanomaterials. These risks can be assessed through exposure measurement and hazard identification. One of the common challenges associated with quantifying nanomaterials in products, waste, humans, or the environment is the lack of tools available to measure concentration. The ability of refined tools and techniques to qualitatively detect nanoparticles in complex matrices has been demonstrated. For biological and ecological tests systems, dose can be represented as initial concentration in the applied matrix, concentration administered during the route of exposure, concentration at the target organ, and intake concentration at the cellular level. Each of these concentration measurements requires different sets of tools to perform accurate analyses. Advances in microscopy techniques provide new opportunities for reporting observations occurring at the interaction of a nanoparticle with a biomolecular entity of similar size within a biological test(s) system. This protocol outlines the steps to image nanomaterials within cell-based systems. © 2017 by John Wiley & Sons, Inc.

Robotic right colectomy with intracorporeal anastomosis: experience with 52 consecutive cases.

BACKGROUND: In laparoscopic right hemicolectomy (LRC), extracorporeal or intracorporeal (ICA) anastomosis can be performed. Several authors have suggested advantages to ICA. This study reports our transition to and our experience with robotic right colectomy (RRC) with ICA. MATERIALS AND METHODS: From June 2009 to September 2012 we performed 58 consecutive RRCs, of which 52 were with ICA. Data were prospectively stored and retrospectively reviewed. RESULTS: Twenty-eight female and 30 male patients with a mean age of 71.6 ± 8.3 years (range, 52-89 years) were studied. Indications for surgery included adenocarcinoma (n=30), adenoma (n=20), diverticulitis (n=1), and Crohn's disease (n=1). For RRC with ICA (n=52), mean operative time (OT) was 193.2 ± 42.2 minutes (range, 123-239 minutes). Mean estimated blood loss (EBL) was 47.8 ± 59.5 mL (range, 5-300 mL). Mean length of hospital stay (LOS) was 3.7 ± 3.2 days (range, 1-21 days). Mean extraction-site incision size was 4.61 ± 0.78 cm (range, 2.5-6.5 cm). Mean lymph node harvest was 20.7 ± 8.2 (range, 6-40). Mean specimen length was 18.9 ± 7.2 cm (range 10-37). No intraoperative complications, conversions, or 30-day mortality occurred. Nine postoperative complications (19.1%) occurred, with one anastomotic leak (1.7%). For LRC with ICA as reported in the literature, OT ranges from 136 to 190 minutes, EBL ranges from 0 to 500 mL, median LOS ranges from 3 to 5 days, complication rates range from 6% to 15%, with ileus <22%, and conversion rates are <5%. CONCLUSIONS: RRC with ICA is safe and feasible. OTs and outcomes compare favorably with those published in the literature for LRC with ICA. The robot may facilitate transition to ICA, and if future studies confirm advantages of ICA, the role of RRC may gain importance.

Self-expanding metallic stents for palliation and as a bridge to minimally invasive surgery in colorectal obstruction.

BACKGROUND AND OBJECTIVES: Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. Emergency procedures had an associated mortality rate of 10% to 30%. This encouraged development of other options, most notably self-expanding metallic stents. The primary endpoint of this study to is to report our group's experience. METHODS: We performed a retrospective review of 37 patients who underwent self-expanding metallic stent placement for colorectal obstruction between July 2000 and May 2012. Data collected were age, comorbidities, diagnosis, intent of intervention (palliative vs bridge to surgery), complications, and follow-up. RESULTS: The study comprised 21 men (56.76%) and 16 women (43.24%), with a mean age of 67 years. The intent of the procedure was definitive treatment in 22 patients (59.46%) and bridge to surgery in 15 (40.54%). The highest technical success rate was at the rectosigmoid junction (100%). The causes of technical failure were inability of the guidewire to traverse the stricture and bowel perforation related to stenting. The mean follow-up period was 9.67 months. Pain and constipation were the most common postprocedure complications. DISCUSSION: The use of a self-expanding metallic stent has been shown to be effective for palliation of malignant obstruction. It is associated with a lower incidence of intensive care unit admission, shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Laparoscopic or robotic surgery can then be performed in an elective setting on a prepared bowel. Therefore the patient benefits from advantages of the combination of 2 minimally invasive procedures in a nonemergent situation. Further large-scale prospective studies are necessary.

Laparoscopic versus robotic right colectomy: a single surgeon's experience.

There is increased interest in robotic techniques for colon resection, but the role of robotics in colorectal surgery has not yet been defined. The purpose of this study was to compare our recent experience with robotic right colectomy to that with laparoscopic right colectomy. From November 2008 to June 2011, a total of 47 consecutive patients underwent elective, right colectomy: 25 laparoscopic right colectomies (LRC) and 22 robotic right colectomies (RRC). All procedures in this study were performed by a single, board-certified colon and rectal surgeon (H.J.L.). Main outcomes recorded included conversion rate, operative time (OT), estimated blood loss (EBL), length of extraction sites, length of stay (LOS), and complications. Data studied were prospectively recorded in a database and were retrospectively reviewed. Mean OT for LRC was 107 ± 36.7 min (median 98, range 48-207) and for RRC was 189.1 ± 38.1 min (median 185, range 123-288, P < 0.001). Mean total operating room time (TORT) for LRC was 158.6 ± 38.1 min (median 149, range 104-274) and for RRC was 258.3 ± 40.9 (median 251, range 182-372, P < 0.001). The tendency lines for both OT and TORT decreased over time for RRC. EBL for LRC was 70.2 ± 52.9 ml (median 50, range 10-200) and for RRC was 60.8 ± 71.3 ml (median 40, range 10-300, P = 0.037). The mean extraction site length for the laparoscopic group was 5.3 ± 1.3 cm (median 5, range 4-11) and for the robotic group was 4.6 ± 0.7 cm (median 4.5, range 3.5-6, p = 0.008). LOS was similar for both groups, as were complications. No cases were converted to open. No leaks occurred and there was no 30-day mortality. RRC is safe and feasible, with similar outcomes to LRC. Operative times were longer for RRC; however, they compare favorably with times for LRC published in the literature. Extraction site length and EBL were less for RRC. However, further study is necessary to demonstrate the clinical relevance of these findings. We are optimistic that OT and TORT will continue to improve.

Use of surgisis mesh in laparoscopic repair of hiatal hernias.

BACKGROUND: Breakdown of the crural closure is a frequent reason for failure of antireflux surgical procedures. This retrospective study aimed to determine the effectiveness of using absorbable mesh in preventing recurrence of hiatal hernia after posterior cruroplasty. DESIGN: Comparative retrospective analysis. METHOD: The charts of 220 adults who underwent antireflux surgery with posterior cruroplasty between 1997 and 2005 were retrospectively reviewed. Patients were divided into 2 groups: posterior cruroplasty+absorbable mesh reinforcement (n=127) and posterior cruroplasty alone (n=93). Symptomatic outcome was assessed by telephone interview in 92 patients (72%) in the mesh group at a median of 3.2 years postoperatively and 59 patients (63%) in the no mesh group of men studied at a median of 3.8 years postoperatively. MAIN OUTCOME MEASURES: Incidence of recurrence and persistent symptoms. RESULTS: In the mesh group, 74/92 (80%) patients remained asymptomatic at a median of 3.2 years postoperatively. Of these patients, 31 underwent either an upper endoscopy or an upper gastrointestinal (UGI) series; none had recurrence of hiatal hernia. Of the 18 symptomatic patients, 13 underwent an upper endoscopy or an UGI series to determine the etiology of symptoms; 3 recurrences were confirmed for a 3.3% overall proven recurrence rate. In the no mesh group, 26/59 (44%) patients were symptomatic. Of these, 18 underwent either an upper endoscopy or an UGI series. Recurrence of hernia was confirmed in 12 patients for a 20% overall proven recurrence rate. There were no instances of mesh infection or erosion. CONCLUSIONS: Symptomatic recurrence rates of hiatal hernia after antireflux surgery vary. Recurrence of a hiatal hernia may or may not lead to symptoms. This retrospective analysis demonstrates that absorbable mesh is safe and may lead to a significant reduction in the incidence of symptomatic recurrent hiatal hernia.

Laparoscopic management as the initial treatment of acute small bowel obstruction.

OBJECTIVES: We prospectively evaluated our experience with laparoscopic management of acute small bowel obstruction (SBO). METHODS: The study group included all patients requiring surgical intervention based on complete mechanical SBO by clinical assessment or who had failed conservative management. Patients with malignant causes were excluded. Experienced laparoscopic surgeons performed all operations. RESULTS: Between January 1998 to January 2003, 61 patients required operative intervention for acute SBO. Causes included adhesions, internal hernia, incarcerated incisional hernia, and inflammatory bowel disease. Laparoscopic techniques (LAP) alone were successfully used to complete 41 cases (67%). Twenty patients (33%) were converted (CONV) to either mini-laparotomy [7 patients (35%)] or standard midline laparotomy [13 patients (65%)]. A single band was identified in 25 patients (41%). Complications occurred in both groups. CONCLUSIONS: We believe all patients requiring surgery in the setting of acute small bowel obstruction should undergo a laparoscopic approach initially. By specifically identifying those patients with a single band as the cause of obstruction, a significant number of patients will be spared a large laparotomy incision. Conversion should not be viewed as failure, but rather, a sometimes necessary step in the optimal management of these patients.

Penetrating injuries of the subclavian artery.

BACKGROUND: Penetrating injuries of the subclavian artery occurs infrequently but represent a surgical challenge. We reviewed our experience with penetrating injury of the subclavian artery and identify factors that influenced morbidity and mortality. METHODS: A retrospective review was performed on 54 consecutive patients who sustained penetrating injury to the subclavian artery during a 10-year period. RESULTS: The causes of injuries were gunshot wounds in 46 patients (85%), stab wounds in 5 patients (9%), and shotgun wounds in 3 patients (6%). The overall mortality was 39%. Operative management of the subclavian artery injury included primary repair in 38 patients, interposition grafting in 13 patients, and ligation in 3 patients. The most common associated injury was subclavian vein (44%) followed by brachial plexus (31%). Predictors of survivability include mechanism of penetrating injuries, hemodynamic status of patients on arrival, and three or more associated injuries involving other structures. Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors. CONCLUSIONS: Penetrating injuries of the subclavian artery are associated with high morbidity and mortality. Multiple concomitant injuries, unstable vital signs upon presentation, and gun shot injuries greatly increase mortality.

Long-term survival after laparoscopic colon resection for cancer: complete five-year follow-up.

PURPOSE: The role of laparoscopic surgery in the cure of colorectal cancer is controversial. The aim of this study was to evaluate long-term survival after curative, laparoscopic resection of colorectal cancer. Specifically, we wanted to review those patients who now had complete five-year follow-up. METHODS: One hundred two consecutive patients (March 1991 to March 1996) underwent laparoscopic colon resections for cancer at one institution and now have complete five-year survival data. Charts were retrospectively reviewed and results compared with conventional surgery, i.e., open colectomy at our institution, and with the National Cancer Data Base during a similar time period. RESULTS: Fifty-nine male and 43 female patients with an average age of 70 (range, 34-92) years made up the study. Complications occurred in 23 percent of patients, and one patient died (1 percent). Forty-four laparoscopic right colectomies, 2 transverse colectomies, 36 laparoscopic left or sigmoid colectomies, 15 laparoscopic low anterior resections, and 5 laparoscopic abdominoperineal resections were performed. The average number of lymph nodes harvested was 6.6 +/- 0.61 (range, 0-22). Eight cases (7.8 percent) were "converted to open"; i.e., the typical 6-cm extraction site was lengthened to complete mobilization, devascularization, resection, or anastomosis, or a separate incision was required to complete the procedure. There was one extraction-site recurrence and one port-site recurrence; both occurred before the routine use of plastic-sleeve wound protection. The mean follow-up for laparoscopic colon resection patients was 64.4 +/- 2.8 (range, 1-111) months. According to the TNM classification system, 27 patients had Stage I cancer, 37 had Stage II, 23 had Stage III, and 15 had Stage IV. Similar five-year survival rates for laparoscopic and conventional surgery for cancer were noted. The five-year relative survival rates in the laparoscopic colon resection group were 73 percent for Stage I, 61 percent for Stage II, 55 percent for Stage III, and 0 percent for Stage IV. The five-year relative survival rates for the open colectomy and National Cancer Data Base groups were 75 and 70 percent, respectively, for Stage I, 65 and 60 percent for Stage II, 46 and 44 percent for Stage III, and 11 and 7 percent for Stage IV. CONCLUSIONS: Laparoscopic colon resection for cancer is safe and feasible in a private setting. Our data suggest that long-term survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery. Prospective, randomized trials presently under way will likely confirm these results.