The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour.

AIM: The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib. METHOD: The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment. RESULTS: Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant. CONCLUSION: Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

The lienorenal ligament and the tail of the pancreas: a surgical anatomical study.

Only brief descriptions of the lienorenal ligament and the anatomical relationship between the tail of the pancreas and the hilus of the spleen have been reported in the literature. The anatomical variations in this region are of significant surgical importance. The lienorenal ligament was studied in 37 anatomical specimens. A classification of its variations is presented, and clinical-surgical applications are discussed.

Intraoperative internal spermatic vein phlebography in the subfertile male with varicocele.

Intraoperative internal spermatic vein phlebography was performed in 20 subfertile patients with a varicocele; 10 patients with varicoceles and left-sided indirect inguinal hernias without fertility problems served as controls. Phlebography was carried out during surgery with the patient supine and in a 45 degree anti-Trendelenburg position to stimulate an "erect" posture. In all 25 patients with a varicocele, valvular insufficiency was demonstrated at the renal-spermatic vein junction. When visualized, the position of the left adrenal vein in all instances was medial to or opposite the renal-internal spermatic vein confluence. This observation, reinforced by simultaneous determinations of cortisol levels in the internal spermatic and antecubital veins, practically excluded the validity of the theory of adrenal hormonal suppression of testicular tissues. In 40% of subfertile patients with a varicocele, double internal spermatic veins and reflux to the distended external spermatic (cremasteric) venous plexus were demonstrated. In no instance were such phenomena observed in the control groups. The not-infrequent failure of operative correction of varicocele seems to relate directly to such overlooked pathology. Broad clinical application of operative phlebography, especially in recurrent, persistent, or clinically advanced cases, will detect such anomalies and should reduce significantly the operative failures in the surgical correction of varicocele.

PIP: Intraoperative internal spermatic vein phlebography was performed on 20 subfertile patients with a varicocele; 5 infertile patients with varicoceles; and on 5 patients with left-sided indirect inguinal hernias without fertility problems who served as controls. Phlebography was carried out during surgery with the patient supine and in a 45 degree anti-Trendelenburg position to simulate an "erect" posture. In all 25 patients with varicocele, valvular insufficiency was demonstrated at the renal-spermatic vein junction. When visualized, the position of the left adrenal vein in all instances was medial to or opposite the renal-internal spermatic vein confluence. This observation, reinforced by simultaneous determinations of cortisol levels in the internal spermatic and antecubital veins, practically excluded the validity of the theory of adrenal hormonal suppression of testicular tissues. In 40% of subfertile patients with a varicocele, double internal spermatic veins and reflux to the distended external spermatic (cremasteric) venous plexus were demonstrated. No such phenomena were observed in the control groups. The not-infrequent failure of operative correction of varicocele seems to relate directly to overlooked pathology. Broad clinical applications of operative phlebography, especially in recurrent, persistent, or clinically advanced cases, will detect such anomalies and should reduce significantly the operative failure in the surgical correction of varicocele. Likewise, through the use of this technique, therapeutic results of high ligation of the spermatic vein may be substantially improved.

Right-sided varicocele associated with situs inversus.

In the overwhelming majority of cases, varicocele appears in the left scrotum, the reason being the anatomical dissimilarity of the two sides. In patients with right-sided or bilateral varicocele, further investigation to rule out a retroperitoneal pathology, especially neoplastic, is indicated. On rare occasions, however, a vascular anomaly as the underlying pathology must be considered. A patient is presented with a complete situs inversus accompanied by a right-sided varicocele. Intraoperative right internal spermatic phlebography revealed that this vein drained into the right renal vein, and valvular incompetence at their confluence was the etiology of the disease. Intraoperative internal spermatic phlebography in patients with right-sided or bilateral varicoceles is recommended as the simplest and safest means to demonstrate the etiology of this disease.

Varicocele and left renal vein compression.

Several current theories concerning the possible etiology of varicocele are critically reviewed. The possibility of arterial compression of the left renal vein, probably by the superior mesenteric artery is elaborated upon. Since direct experimentation is impossible because of the exclusively human character of this disease, a "triple indirect approach" is adopted. Three differently directed studies are conducted: intraoperative antegrade spermatic phlebography visualizing the left renal vein, anatomic dissection of the left renal vascular pedicle, and intraoperative marking of the superior mesenteric artery and the left renal vein for in vivo studies of their relationships. Because the outcomes of these three pathways converge and focus on the superior mesenteric artery compression of the left renal vein, it is concluded that this is a probable contributing mechanism in the etiology of varicocele.

Spermatic vein ligation in varicocele: prognosis and associated male and female infertility factors.

The fertility outcome of 129 spermatic vein ligations with good postoperative anatomic results is analyzed. For each couple, specific attention was also directed to other infertility factors. The study analyzes four groups: group I, 55 patients with varicocele only; group II, 16 patients with varicocele and prostatovesiculitis; group III, 16 patients with varicocele and a severe degree of testicular failure; and group IV, 42 patients with a varicocele only and associated female infertility factors. In each group, the pregnancy rate within 6 to 24 months after the operation was recorded. The control subjects were 36 patients with varicocele only who had declined or postponed intervention for 6 months. The best results were obtained in group I. Sperm motility improved following ligation and was associated with a greater percentage of pregnancies within a shorter period: 51% and 62% within 6 and 12 months, respectively, as compared with the control group (14% within 6 months). The prostatic disease required additional treatment for a longer period, but results similar to those of group I were eventually obtained (50% pregnancy rate). With testicular failure or female infertility factors, the prognosis worsened (31% overall pregnancy rate).

Richter's hernia--a surgical pitfall.

BACKGROUND: Although Richter's hernia was first described in 1598, little attention has been given to this topic in recent literature. The diagnosis of Richter's hernia is difficult because of the innocuous development of signs and symptoms and it is associated with a high mortality rate. Awareness of this relatively rare surgical entity is important. STUDY DESIGN: Of 350 patients with incarcerated hernias who underwent operation between 1977 and 1994 at the Department of Surgery "A," Assaf Harofeh Medical Center, 14 had strangulated Richter's hernia. A retrospective study was carried out in order to characterize the clinical manifestations of Richter's hernia and to assess preoperative delay, hospital stay, and complication and mortality rates. A comparison study was made with matched patients with strangulated hernias of non-Richter's type. Differences in morbidity and mortality rates, preoperative delay, and hospital stay of patients with Richter's hernias and the comparison group were evaluated. RESULTS: Of 14 patients with Richter's hernia, seven underwent intestinal resection. The hernia most commonly occurred at the femoral and inguinal sites. Compared with patients with other hernias, patients with Richter's hernias had greater preoperative delay, rate of bowel resection, length of hospital stay, and postoperative morbidity and mortality rates. CONCLUSIONS: Early operative intervention is the mainstay of successful management of Richter's hernia and awareness of this disease and its misleading clinical presentation is of utmost importance.

Peritoneal encapsulation in childhood. Case report, embryologic analysis, and review of literature.

The first reported case of peritoneal encapsulation causing mechanical small bowel obstruction in a child is described. So far, only seven asymptomatic adult patients with this anomaly have been reported on. The embryogenetic basis is discussed. Methods of operative recognition and surgical management are suggested.

Anterior rectus sheath repair for inguinal hernia.

Fifty-four patients over the age of 40, with direct inguinal hernias were studied. Thirty-two of them underwent operation with the anterior rectus sheath flap, and 22 patients in whom the hernias were repaired by the method described by Bassini served as the control group. We could not demonstrate any significant difference between the two groups in regard to length of hospital stay, complications, and recurrence rate. There was only one recurrence in the rectus flap group. Anterior rectus sheath repair proved to be easy to perform and comfortable for the patient.

Duodenal necrosis as the presenting manifestation of polyarteritis nodosa.

Polyarteritis nodosa involves necrotising vasculitis of small and medium-sized arteries. Multiple organ systems are involved. A non-specific and slow course of disease is common. Gastrointestinal involvement is characterised by abdominal pain, nausea and vomiting. Bowel infarction and perforation, cholecystitis and hepatic infarction are well known complications. However, bowel infarction as the presenting symptom of the disease is rare. The case of a 20-year-old male with necrosis of the duodenum heralding polyarteritis nodosa is reported. The patient made a slow recovery after extensive abdominal surgery and a stormy course. The postoperative management and treatment of polyarteritis nodosa are discussed. A high index of suspicion and prompt multidisciplinary approach are needed in order to improve survival in these rare but potentially fatal conditions.

Intra-operative ultrasonography as a routine screening procedure in biliary surgery.

Intra-operative cholangiography and ultrasonography were compared in screening for unsuspected common bile duct stones. In 57 consecutive patients both procedures were performed, and in 60 only ultrasonography was used. Although the study was conducted during the initial self-teaching period (regarding ultrasonography) the results show an advantage of this relatively new diagnostic technique. The false positive rate was lower and consequently the predictive value of a positive test was higher for intraoperative ultrasonography. The main benefit would thus be a lower rate of negative common bile duct explorations. Our early results suggest that the general surgeon would need only a short adaptation period to this imaging modality, which would seem to be a valuable alternative to intra-operative cholangiography.