Case report: Renal infarction by paradoxical embolism through the patent foramen ovale as an unusual cause of post-operative abdominal pain after sleeve gastrectomy.

50-year-old female presented with abdominal pain 9days post sleeve gastrectomy and was found to have acute renal infarction caused by paradoxical emboli through patent foramen ovale (PFO) as a cause of the renal infarction. Renal infarctions caused by paradoxical embolism are rare and have not been previously reported following surgery, bariatric surgery in particular. This report describes presentation, work up and management of a patient with renal infarct following bariatric surgery.

The Modified Early Warning Score (MEWS): an instant physiological prognostic indicator of poor outcome in acute pancreatitis.

CONTEXT: The Modified Early Warning Score (MEWS) is a bedside scoring system that is non-invasive, simple and repeatable to reflect dynamic changes in physiological state. OBJECTIVE: This study aims to assess accuracy of MEWS and determine an optimal MEWS value in predicting severity in acute pancreatitis (AP). METHODS: A prospective database of consecutive admissions with AP to a single institution was analysed to determine value of MEWS in identifying severe acute pancreatitis (SAP) and predicting poor outcome. Receiver operator curves (ROC) were used to determine optimal accuracy. Sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) were calculated for the optimal MEWS values obtained. RESULTS: One-hundred and 42 patients with AP were included. The optimal highest MEWS per 24 hours period (hMEWS) and mean MEWS per 24 hour period (mMEWS) in predicting SAP as determined by ROC were 2.5 and 1.625 respectively; with hMEWS ≥3 and mMEWS >1 utilised in this cohort as MEWS scores are whole numbers. On admission, sensitivity, specificity, NPV, PPV, and accuracy of hMEWS ≥3 was 95.5%, 90.8%, 99.0%, 65.6% and 92.0%; and for mMWES >1 was 95.5%, 87.5%, 99.0%, 58.3% and 88.7%, both superior than the Imrie score: 31.5%, 92.1%, 88.9%, 40.0% and 83.5%. The accuracy of hMEWS ≥3 and mMEWS >1 increased over the subsequent 72 hours (days 0-2) from 92 to 96%, and 89% to 94%, respectively. CONCLUSIONS: MEWS provides a novel, easy, instant, repeatable, reliable prognostic score that may be superior to existing scoring systems. A larger cohort is required to validate these findings.

Clinical utility of anti-p53 auto-antibody: systematic review and focus on colorectal cancer.

Mutation of the p53 gene is a key event in the carcinogenesis of many different types of tumours. These can occur throughout the length of the p53 gene. Anti-p53 auto-antibodies are commonly produced in response to these p53 mutations. This review firstly describes the various mechanisms of p53 dysfunction and their association with subsequent carcinogenesis. Following this, the mechanisms of induction of anti-p53 auto-antibody production are shown, with various hypotheses for the discrepancies between the presence of p53 mutation and the presence/absence of anti-p53 auto-antibodies. A systematic review was performed with a descriptive summary of key findings of each anti-p53 auto-antibody study in all cancers published in the last 30 years. Using this, the cumulative frequency of anti-p53 auto-antibody in each cancer type is calculated and then compared with the incidence of p53 mutation in each cancer to provide the largest sample calculation and correlation between mutation and anti-p53 auto-antibody published to date. Finally, the review focuses on the data of anti-p53 auto-antibody in colorectal cancer studies, and discusses future strategies including the potentially promising role using anti-p53 auto-antibody presence in screening and surveillance.

Caution in using a unique technique of banded revision gastric bypass: Successful endosopic and surgical management of a rare complication.

INTRODUCTION: Revision surgery is increasingly performed as result of the increase in primary bariatric procedures. We describe a new technique of revision Roux-en-Y gastric bypass (RYGB) acombining stapled gastroenterostomy with fixed band placement. We report two cases of unique complications and its successful endoscopic and surgical management. PRESENTATION OF CASE: Two out of twenty patients undergoing this revision RYGB procedure presented with gastric outlet obstruction due to band erosion within 10 weeks. Endoscopic band retrieval was successful in the first patient but the second patient required surgical removal. DISCUSSION: We report the new complication of band erosion in 10% patients using a unique revision RYGB technique combining restriction of the gastric outlet and band placement. We advise using one or the other technique but not both in combination. Surgeons need to be aware of this as erosion which occurs early due to close proximity of band with fresh staple line. We report successful endoscopic and surgical management. CONCLUSION: Revision surgery using this technique predisposes to bande erosion, presenting as gastric outlet obstruction. Endoscopic management should be attempted prior to surgical removal.

The prognostic value of the neutrophil-lymphocyte ratio (NLR) in acute pancreatitis: identification of an optimal NLR.

INTRODUCTION: The neutrophil-lymphocyte ratio (NLR), calculated from the white cell differential count, provides a rapid indication of the extent of an inflammatory process. The aim of this study was to investigate the prognostic value of the NLR in acute pancreatitis (AP) and determine an optimal ratio for severity prediction. MATERIALS AND METHODS: NLRs were calculated on days 0, 1, and 2, and correlated with severity. Severity was defined using the Atlanta classification. RESULTS: One hundred forty-six consecutive patients managed were included, 22 with severe acute pancreatitis (SAP). NLR in SAP was significantly higher than in the favorable prognosis group on all 3 days (day 0, 15.5 vs. 10.5; day 1, 13.3 vs. 9.8; day 2, 10.8 vs. 7.6). The optimal cut-offs from ROC curves were 10.6 (day 0), 8.1 (day 1), and 4.8 (day 2) giving sensitivities of 63-90 %, specificities of 50-57 %, negative predictive value of 89.5-96.4 %, positive predictive values of 21.2-31.1 %, and accuracies of 57.7-60 %. CONCLUSIONS: Elevation of the NLR during the first 48 h of admission is significantly associated with severe acute pancreatitis and is an independent negative prognostic indicator in AP.

Missed presentation of Crohn's disease in a patient with a fistulating thigh abscess: a case report.

BACKGROUND: Musculoskeletal presentations of Crohn's disease are rare and they include psoas abscess, thigh abscesses and in extreme cases septic arthropathy. CASE PRESENTATION: Herein, we present a 53 year old gentleman with bilateral thigh fistulae discovered to be a new diagnoses of extra-intestinal Crohn's disease CONCLUSION: It is important to consider Crohn's disease in patients that present with unusual or persistent fistulae and to consider this essential when there are atypical organisms present.

Advances in radiotherapy in operable rectal cancer.

AIMS: Radiotherapy (RT) reduces local recurrence in rectal cancer but the optimal treatment schedule is unknown. Relevant questions in designing optimal therapy are set out. This review identifies evidence that influences current practice and shapes future trials in treatment of operable rectal cancer. METHODS: PubMed and MEDLINE search. RESULTS: RT reduces local recurrence and pre-operative treatment is superior to post-operative treatment. Longer interval to surgery and concurrent chemotherapy are associated with greater downstaging, although influence on sphincter preservation and survival is minimal. Short-course RT (SCRT) demonstrates lower recurrence, but with long-term dysfunction and minimal survival benefit. The role of SCRT should be re-evaluated to encompass new criteria/areas. CONCLUSION: SCRT should be used selectively rather than as a blanket treatment policy. SCRT compounds functional morbidity caused by mesorectal excision which may be excessive in some patient groups, especially early-stage rectal cancer or frail elderly patients. RT and local excision may be a feasible surgical alternative in these groups. Alternatively, SCRT and delayed surgery may be a future alternative to current long-course chemoradiotherapy. As survival is only marginally affected despite low local recurrence, future trials should aim to address metastatic disease. End points which incorporate function and quality of life must be used.

Preoperative serum vascular endothelial growth factor-a is a marker for subsequent recurrence in colorectal cancer patients.

PURPOSE: Serum vascular endothelial growth factor-A has been associated with stage of disease and prognosis in colorectal cancer. In this study, the clinical usefulness of preoperative serum vascular endothelial growth factor-A concentrations in the long-term follow-up of colorectal cancer patients was evaluated. METHODS: Serum vascular endothelial growth factor-A levels were determined by quantitative enzyme-linked immunosorbent assay in 93 patients prior to resection for colorectal cancer: node-negative (n = 41) and node-positive (n = 52). Median follow-up for patients without cancer death was 54 (interquartile range, 24-63.5) months. RESULTS: The median preoperative serum vascular endothelial growth factor-A level of these patients was 168 (interquartile range, 48-414) pg/ml. Seven patients had local recurrences with a median time of 6 (interquartile range, 4-12) months. Patients (n = 17) that developed metastasis had a median time of 17 (interquartile range, 7-42) months. Patients with local recurrence had significantly higher levels of serum vascular endothelial growth factor-A (P = 0.01). By classifying the patients into two groups, using the maximal chi-squared value of the Cox's regression based on our previous work, it was found that a serum vascular endothelial growth factor-A level >575 pg/ml is an independent prognostic factor for predicting tumor recurrence. CONCLUSION: Patients with colorectal cancer who have preoperative serum vascular endothelial growth factor-A levels >575 pg/ml are more likely to develop recurrence. Trials are warranted to investigate the efficacy of adjuvant therapy for this high-risk group.

Changes in superior mesenteric artery blood flow after oral, enteral, and parenteral feeding in humans.

OBJECTIVE: Alterations in splanchnic blood flow cause gut ischemia and may predispose to gut-derived sepsis. Increases in superior mesenteric artery (SMA) blood flow occur follow the oral ingestion of food, but the effects of enteral nutrition (EN) on splanchnic perfusion are poorly defined and those of parenteral nutrition (PN) are unknown in humans. The aim of this study was to investigate changes in SMA flow in healthy controls and patients receiving adjuvant nutrition. DESIGN: Qualitative before-after study. SETTING: Intensive care and general wards at Scarborough Hospital, Scarborough, United Kingdom. PATIENTS: Fourteen healthy volunteers and 20 consecutive hemodynamically stable patients receiving adjuvant nutrition. INTERVENTIONS: Oral, EN, or PN after an overnight fast. MEASUREMENTS AND MAIN RESULTS: Duplex ultrasonography was used to assess SMA flow after an overnight fast. Subjects were then rescanned 3 hrs later after commencement of the appropriate test feed so that postprandial flows could be determined. Of the 20 patients recruited, 10 were receiving EN (120 kcal) and 10 PN (175 kcal). Of the 14 volunteers, three received no feed before their second scan (controls), six received an oral meal (530 kcal), and five received EN (120 kcal). Changes in SMA flow within groups were assessed. The control (fasting) volunteers showed no change between the two scans (p = 1.000). All subjects fed intraluminally demonstrated significant increases in postprandial SMA blood flow. Conversely, all patients fed parenterally showed decreased postprandial SMA flows with a median (interquartile range) fasting SMA flow of 14.5 (4.8-24.8) mL/sec, which decreased to 6.1 (2.4-9.2) mL/sec postprandially (p = 0.013). CONCLUSIONS: Splanchnic flow is modulated by the route of feeding. The clinical significance of these findings requires further investigation as they may be important in the management of the critically ill patient, particularly in those with cardiovascular instability or any patient predisposed to gut ischemia.

Preoperative serum levels of serum VEGF-C is associated with distant metastasis in colorectal cancer patients.

PURPOSE: Vascular endothelial growth factor-C (VEGF-C) is one of the most potent lymphangiogenic members of the VEGF family that has been associated with lymph node metastasis and poor prognosis in patients with colorectal cancer (CRC). In this study, we evaluated the relationship of preoperative serum VEGF-C (sVEGF-C) and survival in CRC patients. MATERIALS AND METHODS: sVEGF-C levels were determined, prior to resection, in a cohort of 120 newly presenting patients with CRC by quantitative ELISA. RESULTS: Patients who had positive lymph node involvement and higher Dukes' staging (C&D) were associated with shorter time to metastases as expected (p = 0.002 and 0.001, respectively). Patients with distant metastasis had significantly lower levels of sVEGF-C than those without histopathologically proven disease (p = 0.004). However, there was no significant difference in the median sVEGF-C level in patients with or without lymph node metastatic involvement (91 pg/ml vs. 124 pg/ml; p = 0.81). Patients with a sVEGF-C concentration less than the median value (103 pg/ml) showed a poorer overall survival than patients with sVEGF-C levels greater than the median; but this was not statistically significant. CONCLUSIONS: In this study, low sVEGF-C levels are associated with distant metastasis; hence, preoperative levels may aid in the selection of CRC patients who require further investigation.

Squamous cell carcinoma of the nasopharynx metastasising to rectum: first case report and literature review.

Squamous cell carcinoma (SCC) of the nasopharynx is amongst the most common head and neck cancers. However, distant metastases are clinically underdiagnosed, as demonstrated by significantly higher metastatic rates in autopsy studies, compared to clinical studies. The incidence of metastases continues to rise with improvements in diagnostic imaging, locoregional control and survival. Metastases to the colorectum are extremely rare. This is the first case of nasopharyngeal SCC, metastasising to the rectum. A brief review of the literature is performed, with discussion on the screening, diagnosis and treatment of non-primary / metastatic tumours of the colorectum, from SCC and other primary tumours.