Pancreatic injury after thoracoabdominal aortic occlusion in a porcine model.

BACKGROUND: The aim of this study was to investigate pancreatic injury after 45 min of thoracoabdominal aortic occlusion in a porcine model. METHODS: Twenty-four pigs were used. Six pigs underwent sham operation and 18 intravascular balloon thoracoabdominal aortic occlusions for 45 min. The animals were randomly killed at 12, 48 and 120 h after reperfusion. After killing, all pancreata were examined macroscopically for any signs of acute pancreatitis, whereas gland specimens were harvested for histological study to evaluate pancreatic injury (haematoxylin and eosin staining) and acinar cell apoptosis (Terminal deoxynucleotidyl transferase mediated dUTP Nick-End Labelling staining). RESULTS: Pancreatic injury severity score was mildly increased in terms of oedematous features at 12 h after reperfusion, but normalized to sham levels by the second day and thereafter. Necrotic injury was not statistically significant at any time point. Acinar cell apoptotic index was mildly increased at 12 and 48 h, but showed a tendency to decrease towards sham levels by the fifth day. One animal developed acute pancreatitis. CONCLUSION: Acute pancreatitis is unlikely to occur after 45 min of thoracoabdominal aortic occlusion. However, an early, mild oedematous and apoptotic injury that occurs subclinically seems to be a constant event. This injury might have clinical significance when combined with pre-existent pancreatic pathologies.

A new simplified one port laparoscopic technique of peritoneal dialysis catheter placement with intra-abdominal fixation.

BACKGROUND: Various laparoscopic techniques have been described for the insertion of peritoneal dialysis catheters. However, most use 3 to 4 ports, thus multiplying the potential risk for abdominal wall complications (hemorrhage, hernia, leaking). METHODS: A Tenckhoff catheter was placed laparoscopically, using just 1 port, in 13 consecutive patients with end-stage renal failure. All catheters were fixed in the abdominal cavity with no additional ports for this purpose. RESULTS: After a follow-up of 76 patient-months, all catheters are working properly. There were no postoperative wall hemorrhages, early leaking, or hernias. There was 1 case of catheter migration and 2 cases of late leaking in 2 patients in total, due to severe constipation. There were no exit site or tunnel infections. One episode of peritonitis was successfully treated with antibiotics. CONCLUSION: The simplicity and the rapidity of the method justifies serious consideration for its use as the standard Tenckhoff catheter placement.

Impact of spleen preservation in patients with gastric cancer.

BACKGROUND: Resection of the spleen en bloc with the stomach for gastric cancer is still widely performed for a curative resection (R0), but the presence of the spleen may have a favorable effect on recurrence control and survival. The hypothesis that the spleen suppresses tumor growth from minimal residual disease in the critical early postsurgical period and reduces the risk of recurrent disease was tested. PATIENTS AND METHODS: Patients were included who underwent gastrectomy, with or without splenectomy, for gastric adenocarcinoma. Standardized, strongly-defined criteria were used to accurately stratify patients, who had an extended (D2) lymph node dissection, into the curative and non-curative resection groups. Limited, D1 resection confounds appropriate R-stratification and thus D1 patients were excluded. Prospectively-defined primary endpoints were early (within two years) and overall recurrence and death from any cause and secondary endpoints were postsurgical risks (morbidity, mortality) and metastases to the splenic hilum nodes. RESULTS: Overall survival for the total population studied (n = 202) was better for preservation-versus-resection of the spleen among R0 patients (p = 0.0001), but not for those with non-curative resection (p = 0.42). For the R0 D2 group of patients, preservation (n = 59) over resection (n = 67) of the spleen, there was no significant difference in in-hospital postoperative morbidity or mortality (3.4% vs. 0%). At a median follow-up of 112 months, significantly the preservation of the spleen, lowered the risks of early recurrence (HR, 0.33; 95% CI, 0.16 to 0.69; p = 0.003) and death from any cause (p = 0.009) after adjustment analysis. Since at baseline there was a significant imbalance of tumor stage in favor of the spleen-preservation group, we conducted a stage-stratified subgroup analysis. This treatment effect remained consistent in the subgroup analyses according to nodal and serosal status, while in multivariate analysis preservation of the spleen was an independent predictor of outcome. An overestimation of the risk for residual disease in the splenic hilum nodes in the case of spleen preservation was obtained in 94% of splenectomized patients. CONCLUSION: Our findings indicate that preservation of the spleen may be associated with a reduced risk of early and overall recurrence translated into a better survival in patients receiving curative surgery for gastric cancer. A large randomized trial is needed to confirm this finding. Indications for splenectomy are few, being limited to those patients with advanced proximal cancers.

Selecting a specific pre- or postoperative adjuvant therapy for individual patients with operable gastric cancer.

Although the very high locoregional recurrence rates reported with limited D0/D1 surgery can be reduced with extended D2 gastrectomy for operable gastric cancer, overall relapse and survival rates remain poor and can only be improved with adequate perioperative adjuvant treatment. However, despite intensive research, no regimen has been established as standard. Meta-analyses have demonstrated a marginal survival benefit with adjuvant chemotherapy. Two recent large randomized trials for operable gastric cancer, the MAGIC trial and the INT-0116 trial, provide evidence that some patients may benefit from perioperative chemotherapy and chemoradiation, respectively. However, while both trials suggest an overall survival benefit with adjuvant treatment, they don't provide the harm-benefit ratio for specific subsets of patients wih different extent of surgery (D1 or D2) and tumor stage (early [T1,2]/advanced [T3,4]). This lack of evidence complicates current therapeutic adjuvant decisions. Estimating the risk of local and distant recurrence (high, moderate or low) after D1 or D2 surgery in various tumor stages and the expected harm-benefit ratio, the authors provide useful information for decisions on adjuvant chemotherapy with or withour radiotherapy in individual patients. Research on newer cytotoxic and targeted agents may improve treatment efficacy. Simultaneously, advances with microarray-based gene-expression profiling signatures may improve individualized treatment decisions. However, the validation and translation of these genomic classifiers as biomarkers into a completed 'bench-to-bedside' cycle for tailoring treatment to individuals is a major challenge and limits inflated expectations.

Management of synchronous abdominal aortic aneurysm and complicating colorectal cancer.

Concomitant management of synchronous abdominal aortic aneurysm (AAA) and colorectal cancer (CRC) is mandatory in cases in which both entities are life threatening for the patient. The endovascular aneurysm repair (EVAR) method can contribute toward concomitant management by offering the avoidance of an otherwise threatening vascular graft infection. We present a case of a complicating CRC and a synchronous AAA, which were successfully treated at the same hospitalization. The AAA was treated first by EVAR, and the colon resection followed 3 days later. The patient's postoperative course was uneventful. EVAR, if the standard criteria are met, could comprise an alternative and reliable solution for treating concomitant AAA and CRC even in the acute setting.

Carotid endarterectomy with bovine pericardium patch angioplasty: mid-term results.

The objective of this study was to assess the efficacy of bovine pericardium (BP) as a patch material in carotid endarterectomy (CEA) in terms of peri- and postoperative complications and the incidence of recurrent stenosis. During a 4-year period, 148 CEAs were performed in 138 consecutive patients. The study group included elective, emergency, and combined with cardiac operation CEAs in both symptomatic and asymptomatic carotid artery disease patients. Patch angioplasty using the BP followed the standard CEA in all patients. Postoperative follow-up included clinical examination and periodical color duplex scans at 3, 6, and 12 months and yearly thereafter. Surgical outcome was evaluated by the operation-related parameters, early and late mortality and morbidity rates, and the incidence of recurrent stenosis. All CEAs were performed without any unfavorable event. In the early postoperative period, there were no deaths and the morbidity consisted of transient cranial nerve paresis (4.7%) in seven patients and two ipsilateral strokes (1.4%). During the follow-up period, three patients (2%) developed significant carotid restenosis, though they remain asymptomatic, while there were no deaths related to the CEA. Patch angioplasty of the carotid artery using BP showed unwittingly early and mid-term surgical outcome. Our results demonstrate the BP to be a suitable patch material for routine use in carotid surgery.

Evolution of spinal cord injury in a porcine model of prolonged aortic occlusion.

BACKGROUND: Spinal cord injury and subsequent paraplegia remains an unpredictable and devastating complication of thoracoabdominal aortic surgery. The aim of this study was to investigate spinal cord injury due to prolonged thoracoabdominal aortic occlusion. MATERIALS AND METHODS: We used a highly reproducible porcine model of 45-min thoracoabdominal aortic occlusion, which was accomplished by two balloon occlusion catheters. Neurological evaluation after the end of experiment was performed by an independent observer according to the Tarlov scale. The lower thoracic and lumbar spinal cords were harvested at 10, 48, and 120 h (n = 6 animals per time point) and examined histologically with hematoxylin and eosin (H&E) stain and TUNEL method. Tarlov scores, number of neurons, and the grade of inflammation were analyzed. RESULTS: H&E staining revealed reduction in the number of motor neurons which occurred in two phases (between 0 and 10 h and between 48 and 120 h of reperfusion), as well as development of inflammation in spinal cord sections during the reperfusion period, reaching a peak at 48 h. TUNEL reaction was negative for apoptotic neurons at any time point. CONCLUSIONS: In this porcine model, we demonstrated that, after 45 min of thoracoabdominal aortic occlusion, motor neuron death seems to occur in two phases (immediate and delayed). Inflammation was a subsequent event of transient prolonged spinal cord ischemia and possibly a major contributor of delayed neuronal death. Using TUNEL straining we found no evidence of neuronal apoptosis at any time point of reperfusion.

Rectal Epstein-Barr virus-positive Hodgkin's lymphoma in a patient with Crohn's disease: case report and review of the literature.

We present the case of a 35-year-old man with Crohn's disease diagnosed at the age of 27, several months after an operation for small-bowel adenocarcinoma. Seven years after the adenocarcinoma diagnosis, the patient presented with severe continuous anal pain and diarrhea. In parallel with antibiotic administration, the patient was given treatment with Infliximab, but without clinical symptom amelioration. Sigmoidoscopy and subsequent biopsies from an ulcerated rectal area supported the diagnosis of Epstein-Barr virus-positive (EBV+) primary Hodgkin's lymphoma. Infliximab administration was immediately discontinued and the patient underwent oncological follow-up and began a course of chemotherapy. Only a few cases with primary gastrointestinal Hodgkin's lymphoma in Crohn's disease patients have so far been reported, including a variety of scenarios on the causal relationship including disease duration, presence of EBV, long-term immunosuppressive treatment and, recently, anti-TNFalpha administration.

Perspectives in the treatment of gastric cancer.

The overall 5-year survival of patients with gastric cancer is only 23% in the US compared with 60% in Japan. For Western patients, detecting the disease earlier and applying treatment quality control could substantially improve clinical outcome. For the treatment of gastric cancer, complete tumor resection, whenever feasible, is the standard treatment. Resection of the primary tumor (partial or total gastrectomy) is based on standardized criteria of the tumor, such as location, stage, histology, and surgical margins. The extent of regional lymphadenectomy required, however, has been a matter of considerable debate. Emerging evidence from the latest randomized controlled trials show that extended (D2) lymphadenectomy is safe and able to cure 20% of patients with N2-disease compared with 0% treated with limited D1 dissection, provided that the optimal surgical technique is used. Estimates suggest that this N2-specific subgroup advantage reflects a potential absolute overall survival benefit of 3-6%. Postoperative decisions about adjuvant chemotherapy and radiotherapy are based on pathologic staging, the extent of surgery performed (D0/D1 vs D2/D3) and the risk-benefit ratio. Recurrence-risk and mortality-risk reduction is achievable with a carefully planned relapse-prevention guided therapeutic strategy. Patient-related factors (tumor features and expected recurrence-risk magnitude) and treatment-related factors (surgical experience, adjuvant treatment risk-benefit ratio) should be considered on an individual basis. In future, genomic-based approaches will help to provide a more personalized therapeutic approach and improve patient outcome.

Factors increasing local recurrence in breast-conserving surgery.

From 20-year follow-up results of two pioneering randomized controlled trials demonstrating equal survival after mastectomy and breast-conservation therapy, recent high-quality, evidence-based clinical practice recommendations have been made. Breast-conservation therapy undoubtedly represents substantial progress for a better quality of life for women with early-stage breast cancer. However, lumpectomy is associated with a substantial proportion, approximately 10-20%, of local recurrence in long-term follow-up studies even after accounting for postoperative radiotherapy. Risk factors for local failure include margin status, young age and an extensive intraductal component. Young age and family history strongly suggest the need for genetic testing before initiation of treatment. Women with BRCA1 or BRCA2 mutations should be informed about the increased risk of contralateral breast cancer and ipsilateral failure after breast-conservation therapy. Bilateral mastectomy should also be offered as a treatment option. There is controversy over whether current effective adjuvant treatment, including chemotherapy and endocrine therapy, beyond appropriate local treatment as surgery and radiotherapy, can improve local control. Instead of debate over whether an ipsilateral tumor after breast-conservation therapy is local recurrence or a new primary cancer by analyzing conflicting data lacking strong evidence, efforts should be focused on reducing this risk irrespective of origin. Selecting women for breast-conservation therapy and achieving margin control can reduce ipsilateral failures.

Fournier's gangrene: diagnostic approach and therapeutic challenge.

OBJECTIVE: To identify the prognostic variables and to assess the role of aggressive management in patients with Fournier's gangrene. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 11 patients (9 men and 2 women) with Fournier's gangrene admitted between April 1986 and December 2000. INTERVENTIONS: Early aggressive debridements. MAIN OUTCOME MEASURES: Postoperative course, hospital stay, outcome, morbidity, and mortality. RESULTS: The mean age was 65 years (range 17-90) and the mean (SD) duration of hospital stay was 35 (8) days (range 8-62). The aetiology was identified in 8 patients and idiopathic in 3. Predisposing factors (diabetes, n = 4; heart failure, agranulocytosis, and alcohol misuse, n = 1 each) were identified in 6 patients. All patients except one had raised serum glucose concentrations and low serum albumin values. On admission the white cell count was >15 x 10(9)/L in 10, serum sodium <135 mmol/L, mean (SD) serum creatinine 124 (27) micromol/L, and C-reactive protein >150 mg/L was found in all patients. 3/9 male patients required partial excision of the scrotum. Temporary faecal diversion was done for 3 patients. A mean of 3 aggressive repeated debridements (range: 3-6) were required. Nine patients survived and two patients died. CONCLUSION: Rapid and accurate diagnosis remains the key to achieving a successful outcome. Abnormal laboratory variables on admission may suggest the diagnosis. Early, repeated, aggressive debridement is essential for a successful outcome.

Aortobipopliteal bypass grafting for in situ replacement of infected aortobifemoral prosthesis.

Conventional treatment of an infected aortobifemoral graft includes total graft excision and ex situ bypass grafting, but has been associated with significant perioperative morbidity and mortality. Additionally, the presence of infection in the groin makes limb revascularization problematic. There is increasing evidence that in situ replacement of an infected graft can achieve promising results in selected patients. We present a case of an aortobifemoral graft infection, affecting both the groin as well as the entire pelvis. The patient underwent successful in situ graft replacement with a new aortobipopliteal prosthesis via an alternative extraperitoneal route.

Prognostic significance of the deleted in colorectal cancer gene protein expression in high-risk resected gastric carcinoma.

The deleted in colorectal cancer (DCC) gene is a candidate tumor suppressor gene that may be associated with differentiation and proliferation of normal cells. Loss of heterozygosity (LOH) of 18q, where the gene is located, and absence of DCC protein expression have been associated with worse prognosis in certain subgroups of patients with colorectal adenocarcinoma. We studied the prognostic significance of loss-of-protein expression in 66 patients with resected gastric cancer with a high probability of relapse (T3, T4, N+). The DCC protein was detected with immunohistochemistry using an anti-DCC monoclonal antibody on paraffin-embedded sections. The DCC protein expression was present in 51 cases (77.3%) and absent in 15 cases (22.7%). Poorly differentiated and signet ring carcinomas had significantly lower expression than more differentiated tumors (p < 0.05) as did diffuse-type tumors compared to intestinal and mixed (p < 0.01). There was no correlation with proliferation rate, estimated immunohistochemically using an anti-proliferating cell nuclear antigen (PCNA) monoclonal antibody. Absence of DCC protein was an independent favorable prognostic factor (median survival 57 months vs. 18 months, p = 0.0176). The DCC protein expression was correlated with relapse site: all patients with distant metastases were positive for DCC staining, while one-third of patients with local/peritoneal relapse were negative (p < 0.01). In conclusion, DCC protein expression seems to be a significant prognostic factor in high-risk resected gastric cancer. Our results support previous data associating the DCC gene with differentiation and indicate that this gene may play a role in the metastatic potential of these tumors. These findings need to be confirmed by future larger studies.