Small Bowel Obstruction.

Small bowel obstruction (SBO) remains a common problem for surgeons and nonsurgeons alike. Management of SBO has shifted from primarily being surgical to a nonoperative approach, which can be attributed to a multitude of reasons, including better understanding of the pathophysiology of SBO, the advent of laparoscopy, and improvement in diagnostic imaging. But given the nature of SBO, the need for surgical consultation continues to remain a necessity. This article will review the etiology, diagnosis, and management of SBO.

Perianal basosquamous carcinoma treated with radiation therapy, a case report.

Background: Perianal basal cell carcinoma (BCC) is very rare and estimated to account for 0.08% of all BCC and 0.02% of all anorectal neoplasms. Perianal lesions are more likely to be squamous cell carcinoma (SCC) as BCC usually develops on areas of skin exposed to ultraviolet (UV) light such as the face and arms. Proper diagnosis with the assistance of immunohistochemistry (IHC) stains to distinguish the two entities can help inform the suitable course of treatment. Case Description: Our case is an 82-year-old male with a history of cutaneous BCC on the arms and trunk presenting with a symptomatic perianal lesion. Initial biopsy demonstrated BCC with subsequent IHC studies differentiating from basaloid SCC. Standard treatment includes wide local excision (WLE) but given his poor performance status, radiation only was recommended. He was successfully treated and tolerated 30 Gy in 5 daily fractions. Conclusions: Radiation only is a unique and feasible non-surgical treatment for basosquamous carcinoma of the anus.

The use of intra-abdominal tissue expansion for the management of giant omphaloceles: review of literature and a case report.

Giant omphaloceles present a reconstructive challenge in planning, management, and eventual closure of the abdominal wall defect. The goal of reconstruction is to recreate a functional abdominal wall domain and return the extra-anatomically placed viscera into the peritoneal cavity in a safe manner. Traditionally, placement of tissue expanders has been in the subcutaneous and intramuscular planes. Recently, however, there have been reports of intra-abdominal placement of expanders. We present a detailed review of the literature regarding the use of tissue expanders in the management of giant omphaloceles with specific emphasis on the intra-abdominal technique of placement. We also present a case report with the longest follow-up till date in which the patient underwent staged reduction using the intra-abdominal approach. Initial reports of this modality are promising both as a primary strategy and in patients in whom conventional techniques have failed. Results from our review of literature and case report suggest that this technique appears to be durable and effective with successful functional and cosmetic outcomes.

Relationship between obstructive sleep apnea severity and brain activation during a sustained attention task.

STUDY OBJECTIVES: The objectives of this study were to (1) characterize cognitive and cerebral correlates of attention and response speed in patients with obstructive sleep apnea (OSA) and (2) assess the association of performance and brain activation with measures of OSA severity. DESIGN: Patients with OSA and controls were compared on performance and brain activation during a sustained attention task. The association of reaction time and brain activation with apnea-hypopnea index, nocturnal hypoxia, and arousals was assessed. SETTING: Functional magnetic resonance imaging was conducted while participants performed a Go-No-Go task. The 'Go' trials of the Go-No-Go task were used to index attention processing. PARTICIPANTS: Fourteen patients with OSA and 14 normal control subjects with equivalent age, body mass index, blood pressure, and education. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Patients with OSA showed decreased brain activation in cingulate, frontal, and parietal regions typically involved in attention tasks, compared with control subjects. Within the patients with OSA, increasing arousal index, but not desaturation index, was associated with slower mean reaction time and with decreased brain activation in areas involved in arousal and attention, response selection, motor response, and decision making. The apnea-hypopnea index, by itself, was not associated with changes in cerebral response. CONCLUSIONS: Patients with OSA showed decreased brain activation compared with control subjects during an attention task. The association of arousal index (but not hypoxia) with slow reaction times and brain activation suggests that alertness and reaction times show greater correlations with measures of sleep disruption than with measures of hypoxia.

Short-term outcomes in children undergoing restorative proctocolectomy with ileal-pouch anal anastomosis.

INTRODUCTION: Patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) commonly undergo restorative proctocolectomy with ileal-pouch anal anastomosis (RP-IPAA). We sought to describe patient characteristics and postoperative outcomes in this patient population. METHODS: Using the National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who were 6-18years old who underwent RP-IPAA for FAP or UC were identified. Postoperative morbidity, including reoperation and readmission were quantified. Associations between preoperative characteristics and postoperative outcomes were analyzed. RESULTS: A total of 260 children met the inclusion criteria, of which 56.2% had UC. Most cases were performed laparoscopically (58.1%), and the operative time was longer with a laparoscopic versus open approach (326 [257-408] versus 281 [216-391] minutes, p=0.02). The overall morbidity was 11.5%, and there were high reoperation and readmission rates (12.7% and 21.5%, respectively). On bivariate analysis, preoperative steroid use was associated with reoperation (22.5% versus 10.9%, p=0.04). On multivariable regression analysis, obesity was independently associated with reoperation (odds ratio: 3.34 [95% confidence intervals: 1.08-10.38], p=0.04). CONCLUSIONS: Children who undergo RP-IPAA have high rates of overall morbidity, reoperation, and readmission. Obesity was independently associated with reoperation. This data can be used by practitioners in the preoperative setting to better counsel families and establish expectations for the postoperative setting. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

The Heat-Stable Enterotoxin Receptor, Guanylyl Cyclase C, as a Pharmacological Target in Colorectal Cancer Immunotherapy: A Bench-to-Bedside Current Report.

Cancer immunotherapy is becoming a routine treatment modality in the oncology clinic, in spite of the fact that it is a relatively nascent field. The challenge in developing effective immunotherapeutics is the identification of target molecules that promote anti-tumor efficacy across the patient population while sparing healthy tissue from damaging autoimmunity. The intestinally restricted receptor guanylyl cyclase C (GUCY2C) is a target that has been investigated for the treatment of colorectal cancer and numerous animal, and clinical studies have demonstrated both efficacy and safety. Here, we describe the current state of GUCY2C-directed cancer immunotherapy and the future directions of this work.

Guanylate cyclase C as a target for prevention, detection, and therapy in colorectal cancer.

INTRODUCTION: Colorectal cancer remains the second leading cause of cancer death in the United States, and new strategies to prevent, detect, and treat the disease are needed. The receptor, guanylate cyclase C (GUCY2C), a tumor suppressor expressed by the intestinal epithelium, has emerged as a promising target. Areas covered: This review outlines the role of GUCY2C in tumorigenesis, and steps to translate GUCY2C-targeting schemes to the clinic. Endogenous GUCY2C-activating ligands disappear early in tumorigenesis, silencing its signaling axis and enabling transformation. Pre-clinical models support GUCY2C ligand supplementation as a novel disease prevention paradigm. With the recent FDA approval of the GUCY2C ligand, linaclotide, and two more synthetic ligands in the pipeline, this strategy can be tested in human trials. In addition to primary tumor prevention, we also review immunotherapies targeting GUCY2C expressed by metastatic lesions, and platforms using GUCY2C as a biomarker for detection and patient staging. Expert commentary: Results of the first GUCY2C targeting schemes in patients will become available in the coming years. The identification of GUCY2C ligand loss as a requirement for colorectal tumorigenesis has the potential to change the treatment paradigm from an irreversible disease of genetic mutation, to a treatable disease of ligand insufficiency.