A sign on CT that predicts a hazardous ureteral anomaly.

INTRODUCTION: An aberrant course of the distal ureter can pose a risk of ureteral injury during surgery for inguinal hernia repair and other groin operations. In a recent case series of inguinoscrotal hernation of the ureter, we found that each affected ureter was markedly anterior to the psoas muscle at its mid-point on abdominal CT. We hypothesized that this abnormality in the abdominal course of the ureter would predict the potentially hazardous aberrant course of the distal ureter. PRESENTATION OF CASES: We reviewed all evaluable CT urograms performed at St. Louis University Hospital from June 2012 to July 2013 and measured the ureteral course at several anatomically fixed points. DISCUSSION: 93% (50/54) of ureters deviated by less than 1cm from the psoas muscle in their mid-course (at the level of the L4 vertebra). Reasons for anterior deviation of the ureter in this study included morbid obesity with prominent retroperitoneal fat, congenital renal abnormality, and post-traumatic renal/retroperitoneal hematoma. We determined that the optimal level on abdominal CT to detect the displaced ureter was the mid-body of the L4 vertebra. CONCLUSION: Anterior deviation of the ureter in its mid-course appears to predict inguinoscrotal herniation of the ureter. This finding is a sensitive predictor and should raise concern for this anomaly in the appropriate clinical setting. It is not entirely specific as morbid obesity and congenital anomalies may result in a similar imaging appearance. We believe that this association has not been reported previously. Awareness of this anomaly can have significant operative implications.

Laparoscopic adrenalectomy for Conn's syndrome complicated by ipsilateral congenital pelvic kidney.

A patient presented with hypertension, hypokalemia, and a 1.2-cm left adrenal tumor. Conn's syndrome was diagnosed, for which laparoscopic adrenalectomy is now the therapy of choice. This case was complicated by an ipsilateral ectopic pelvic kidney. A laparoscopic left adrenalectomy was performed via a lateral transabdominal approach. Without the usual anatomic landmark of the ipsilateral kidney, the left adrenal gland was difficult to identify, so intraoperative ultrasound was used to locate the lesion. Postoperatively, the patient's blood pressure and potassium normalized. This is the first documented report of a laparoscopic adrenalectomy performed for adrenal adenoma with the anatomic disruption of an ipsilateral pelvic kidney.

Identification of the high affinity binding site in transforming growth factor-beta involved in complex formation with alpha 2-macroglobulin. Implications regarding the molecular mechanisms of complex formation between alpha 2-macroglobulin and growth factors, cytokines, and hormones.

The biological activities of transforming growth factor-beta isoforms (TGF-beta(1,2)) are known to be modulated by alpha(2)-macroglobulin (alpha(2)M). alpha(2)M forms complexes with numerous growth factors, cytokines, and hormones, including TGF-beta. Identification of the binding sites in TGF-beta isoforms responsible for high affinity interaction with alpha(2)M many unravel the molecular basis of the complex formation. Here we demonstrate that among nine synthetic pentacosapeptides with overlapping amino acid sequences spanning the entire TGF-beta(1) molecule, the peptide (residues 41-65) containing Trp-52 exhibited the most potent activity in inhibiting the formation of complexes between (125)I-TGF-beta(1) and activated alpha(2)M (alpha(2)M*) as determined by nondenaturing polyacrylamide gel electrophoresis and by plasma clearance in mice. TGF-beta(2) peptide containing the homologous sequence and Trp-52 was as active as the TGF-beta(1) peptide, whereas the corresponding TGF-beta(3) peptide lacking Trp-52, was inactive. The replacement of the Trp-52 with alanine abolished the inhibitory activities of these peptides. (125)I-TGF-beta(3), which lacks Trp-52, bound to alpha(2)M* with an affinity lower than that of (125)I-TGF-beta(1). Furthermore, unlabeled TGF-beta(3) and the mutant TGF-beta(1)W52A, in which Trp-52 was replaced with alanine, were less potent than unlabeled TGF-beta(1) in blocking I(125)-TGF-beta(1) binding to alpha(2)M*. TGF-beta(1) and TGF-beta(2) peptides containing Trp-52 were also effective in inhibiting I(125)-nerve growth factor binding to alpha(2)M*. Tauhese results suggest that Trp-52 is involved in high affinity binding of TGF-beta to alpha(2)M*. They also imply that TGF-beta and other growth factors/cytokines/hormones may form complexes with alpha(2)M* via a common mechanism involving the interactions between topologically exposed Trp and/or other hydrophobic residues and a hydrophobic region in alpha(2)M*.

How surgeon age affects post-treatment surveillance strategies for melanoma patients.

The intensity of post-treatment melanoma patient follow-up varies widely among physicians. We investigated whether physician age accounts for the observed variation in surveillance intensity among plastic surgeons. A custom-designed questionnaire was mailed to USA and non-USA surgeons, all of whom were members of the American Society of Plastic and Reconstructive Surgeons. Subjects were asked how they use 14 specific follow-up modalities during years 1-5 and 10 following primary treatment for patients with cutaneous melanoma. Repeated-measures analysis of variance was used to compare practice patterns by TNM stage, year post-surgery, and age. Of the 3,032 questionnaires mailed, 1,142 (38%) were returned. Of those returned, 395 (35%) were evaluable. Non-evaluability was usually due to lack of melanoma patient follow-up in surgeons' practices. Follow-up strategies for most of the 14 modalities were highly correlated across TNM stages and years post-surgery, as expected. The pattern of testing varied significantly by surgeon age for 3 modalities (complete blood count, liver function tests, and chest X-ray), but the variation was quite small. We concluded that the post-treatment surveillance practice patterns of ASPRS members caring for patients with cutaneous melanoma vary only marginally with physician age. Continuing medical education could account for this observation.

Effect of initial tumor stage on patient follow-up after potentially curative surgery for cutaneous melanoma.

The optimal follow-up strategy after completion of therapy for melanoma is not known. We evaluated the effect of TNM stage on the self-reported surveillance strategies employed by practicing plastic surgeons caring for otherwise healthy patients subjected to potentially curative treatment for cutaneous melanoma. Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to a random sample (N=3,032) of the 4,320 members of the American Society of Plastic and Reconstructive Surgeons. The effect of TNM stage on the surveillance strategies chosen was analyzed by repeated-measures ANOVA. There were 1,142 responses to the 3,032 surveys; 395 were evaluable. Plastic surgeons often do not provide postoperative follow-up themselves; this was the most frequent reason for non-evaluability. Surveillance of patients after resection of melanoma relies most heavily on office visits, chest X-ray, CBC, and liver function tests. All other surveillance modalities are used infrequently. Most respondents modify their surveillance practices slightly according to the patient's initial TNM stage. Most commonly used modalities are employed significantly more frequently with increasing TNM stage. This effect persists through ten years of follow-up, but the differences across stages are tiny. We conclude that most plastic surgeons performing surveillance after potentially curative surgery in otherwise healthy patients with melanoma use similar follow-up strategies for patients of all TNM stages. These data permit the rational design of a controlled clinical trial of high-intensity vs. low-intensity follow-up.

Renal cell carcinoma in patients with prior spinal cord injury.

INTRODUCTION: In patients with spinal cord injury (SCI), abdominal diseases such as renal carcinoma are often diagnosed and treated late in their course. METHODS: A population-based retrospective review of SCI patients receiving care for renal cell carcinoma (RCC) in all Department of Veterans Affairs (DVA) medical centers was conducted for fiscal years 1988 to 1998. RESULTS: Of 96 patients identified, 57 were evaluable and 27 met study criteria. The mean patient age was 59 (range, 41-79 years). The mean time between SCI and treatment for RCC was 25 years (range, 1-51 years). All patients were men; 22/27 (81%) had 1 or more comorbid conditions. RCC was an incidental finding on surveillance imaging studies in 81% (22/27) of the patients. All 27 patients were treated surgically, 74% (20/27) by radical nephrectomy and 26% (7/27) by partial nephrectomy. All tumors were renal cell adenocarcinomas. Pathological staging by the tumor, nodes, and metastasis system was possible in 25; 92% (23/25) of tumors were stage I and 8% (2/25) were stage II. Postoperative morbidity occurred in 56% (15/27), and death occurred in 7% (2/27). CONCLUSION: In SCI patients in the DVA system, diagnosis of RCC is usually the result of an incidental finding on surveillance imaging. Tumors are diagnosed at early stages and partial nephrectomy is often feasible. Many of the postoperative complications are related to the SCI, and may be preventable.

Current practice of patient follow-up after potentially curative resection of cutaneous melanoma.

Follow-up care for patients who have undergone potentially curative resection of cutaneous melanoma varies widely among physicians, and the underlying rationale has not been assessed. To quantify current practice patterns and to discern motivation, a custom-designed questionnaire was mailed to U.S. and non-U.S. surgeons, all of whom were members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Surveys were mailed to 3,032 ASPRS members, chosen randomly from a total of 4,320 members. Of the 1,142 questionnaires that were returned, 395 were evaluable. Nonevaluability was usually due to lack of melanoma patients receiving follow-up in the surgeons' practices. Surveillance of patients after resection of melanoma relies most heavily on office visit, chest x-ray, complete blood count, and liver function tests. There was surprisingly little influence of elective node dissection on follow-up practices. Imaging tests such as computed tomography, magnetic resonance imaging, and position emission tomography scan were rarely employed. Surveillance is motivated by many factors, particularly early detection of recurrence of the index melanoma and second primary melanomas. This survey provides information regarding current follow-up strategies recommended by ASPRS surgeons after potentially curative resection of cutaneous melanoma. There is considerable variation in surveillance intensity and in motivation among practitioners, thus representing a lack of consensus.

Racial distribution of Dupuytren's disease in Department of Veterans Affairs patients.

Dupuytren's disease is a polyclonal fibroproliferative disorder of the palmar fascia of unclear pathogenesis. It has been described as a disease of northern European men and is reportedly rare in other races. A 10-year retrospective study using the Department of Veterans Affairs computer system was conducted to determine the racial distribution of this disorder among patients treated at all Department of Veterans Affairs medical centers. The study also determined demographic and clinical characteristics of black veterans treated for the condition at department medical centers. There were 9938 patients identified between the fiscal years of 1986 and 1995, of whom 412 were black (estimated prevalence of 130 per 100,000 population), 9071 were white (734 per 100,000), 234 were Hispanic white (237 per 100,000), 11 were Native American (144 per 100,000), 8 were Asian (67 per 100,000), and 202 were of unknown race. The characteristics of the disease in blacks are similar to those in whites. In both groups, the disease has a late onset, affects predominantly the ulnar digits, and is associated with other medical conditions, such as alcoholism, smoking, and diabetes. Unlike Dupuytren's disease in whites, however, the disease is rarely bilateral in blacks. The differential prevalence among racial groups suggests a genetic component to the pathogenesis of the disease.

Adrenalectomy for isolated adrenal metastases from non-adrenal cancer.

Adrenalectomy for metastatic cancer is rarely performed. The survival benefit for patients undergoing resection of isolated adrenal metastases is not clear. The goal of this study was to compile a series of such cases from national and international sources and examine patient survival. The patient series was derived from published series and case reports, plus eight new cases from an international registry of patients. We found 77 patients. We examined the effect of primary tumor site, metastasis size, and disease-free interval on postoperative survival duration, including only cases where complete resection with negative margins was achieved. We compared these patients with a large series from Memorial Sloan-Kettering Cancer Center (N=37). The median survival time after adrenalectomy was 23 months, with an operative mortality rate of 3.9%. There was a significant difference in survival duration depending on primary tumor site. A longer disease-free interval from time of primary cancer therapy to adrenal metastasis was associated with a longer postoperative survival after adrenalectomy. Metastasis size did not affect survival. Survival times for USA and non-USA patients were similar. Survival duration of the 77 analytical patients was similar to that of the 37 non-analytical patients from Memorial Sloan-Kettering Cancer Center. Selected patients, particularly those with long disease-free intervals and favorable tumor biology, should be offered resection for isolated adrenal metastases.

Geographic variation in patient surveillance after radical prostatectomy.

BACKGROUND: Prostate cancer is often diagnosed early enough in its clinical course to permit radical prostatectomy to be done with curative intent, yet many patients experience tumor recurrence. Most patients receive postoperative surveillance, but the intensity of testing varies appreciably. We sought to evaluate the influence of geographic location on the variability of surveillance intensity. METHODS: Questionnaires pertaining to postoperative surveillance were mailed to 4467 members of the American Urological Association (AUA). Practice pattern variation was assessed among 24 large metropolitan statistical areas, among nine United States census regions, and by health maintenance organization penetration rate. RESULTS: Of 4467 urologists surveyed, 1416 (32%) responded and 1050 (24%) responses were evaluable. Correlation analysis showed that mean follow-up intensity across modalities surveyed was highly correlated across tumor, node, metastasis (TNM) stages and years postsurgery. We found no significant main effects attributable to metropolitan statistical area, United States (US) census region, or health maintenance organization (HMO) penetration rate for commonly used surveillance modalities: serum prostate-specific antigen (PSA), office visit, and urinalysis. For infrequently used modalities, there were minimal effects on testing intensity of US census region, metropolitan statistical area, and HMO penetration rate. Few two-way and three-way interactions were significant. CONCLUSIONS: The utilization of commonly used surveillance modalities by urologists caring for patients after radical prostatectomy is not affected by metropolitan statistical area, US census region, or HMO penetration rate.

Risk factors for morbidity and mortality after colectomy for colon cancer.

PURPOSE: Comorbid conditions affect the risk of adverse outcomes after surgery, but the magnitude of risk has not previously been quantified using multivariate statistical methods and prospectively collected data. Identifying factors that predict results of surgical procedures would be valuable in assessing the quality of surgical care. This study was performed to define risk factors that predict adverse events after colectomy for cancer in Department of Veterans Affairs Medical Centers. METHODS: The National Veterans Affairs Surgical Quality Improvement Program contains prospectively collected and extensively validated data on more than 415,000 surgical operations. All patients undergoing colectomy for colon cancer from 1991 to 1995 who were registered in the National Veterans Affairs Surgical Quality Improvement Program database were selected for study. Independent variables examined included 68 preoperative and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting the 30-day mortality rate and 30-day morbidity rates for each of the ten most frequent complications. RESULTS: A total of 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis. One or more complications were observed in 1,639 of 5,853 (28 percent) patients. Prolonged ileus (439/5,853; 7.5 percent), pneumonia (364/5,853; 6.2 percent), failure to wean from the ventilator (334/5,853; 5.7 percent), and urinary tract infection (292/5,853; 5 percent) were the most frequent complications. The 30-day mortality rate was 5.7 percent (335/5,853). For most complications, 30-day in-hospital mortality rates were significantly higher for patients with a complication than for those without. Thirty-day mortality rates exceeded 50 percent if postoperative coma, cardiac arrest, a pre-existing vascular graft prosthesis that failed after colectomy, renal failure, pulmonary embolism, or progressive renal insufficiency occurred. Preoperative factors that predicted a high risk of 30-day mortality included ascites, serum sodium >145 mg/dl, "do not resuscitate" status before surgery, American Society of Anesthesiologists classes III and IV OR V, and low serum albumin. CONCLUSIONS: Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.

How tumor stage affects american urologists' surveillance strategies after prostate cancer surgery.

The factors which influence decision-making among urologists are not well understood. We evaluated how tumor stage in patients subjected to potentially curative surgery for carcinoma of the prostate affects the self-reported follow-up strategies employed by practicing United States urologists. Standardized patient profiles and a detailed questionnaire based on these profiles were mailed to 4,467 randomly selected members of the American Urological Association (AUA), comprising 3,205 US and 1,262 non-US urologists. The effect of TNM stage on the surveillance strategies chosen by respondents was analyzed by repeated-measures ANOVA. There were 1, 050 respondents who provided evaluable data of whom 760 were from the US. The three most commonly used surveillance modalities by urologists were office visit, serum PSA level, and urinalysis. Nine of the 11 most commonly requested modalities were ordered significantly (p<0.001) more frequently with increasing TNM stage. This effect persisted through 10 years of follow-up, but the differences across stage were tiny. Fifty-five percent of US respondents do not modify their strategies at all according to the patient's TNM stage. Most American AUA members performing surveillance after potentially curative radical prostatectomy for otherwise healthy patients use the same follow-up strategies irrespective of TNM stage. These data permit the rational design of a randomized clinical trial of two alternate follow-up plans. The two trial arms would employ office visits, blood tests, and urinalyses at different frequencies based on current actual practice patterns; there would be no imaging tests in either arm.

Sigmoid volvulus in Department of Veterans Affairs Medical Centers.

PURPOSE: Sigmoid volvulus is the third leading cause of large-bowel obstruction. The optimal management strategy remains controversial. This study was undertaken to evaluate the care of patients with sigmoid volvulus recently treated at Department of Veterans Affairs hospitals. METHODS: All patients with the International Classification of Diseases, Ninth Revision, Clinical Modification, Third Edition code for colonic volvulus during the period 1991 to 1995 were identified in the computerized national Department of Veterans Affairs database. Data on patient demographics, clinical course, and outcomes were analyzed. RESULTS: Two hundred twenty-eight patients had volvulus of the sigmoid colon and sufficient clinical data for evaluation. The mean age was 70; all were males. Endoscopic decompression was attempted in 189 of 228 (83 percent) patients and was successful in 154 of 189 (81 percent). Management included celiotomy in 178 of 228 (78 percent) patients. There were no intraoperative deaths. Twenty-five of 178 (14 percent) patients died within 30 days of surgery. The mortality rate was 24 percent for emergency operations (19/79), and 6 percent for elective procedures (6/99). Mortality was correlated with emergent surgery (P < 0.01) and necrotic colon (P < 0.05). Among those 50 patients managed by decompression alone, six (12 percent) died during the index admission. Ten of the remaining 44 (23 percent) patients eventually developed recurrent volvulus requiring further treatment, and 2 of 10 (20 percent) patients died. CONCLUSIONS: In this cohort sigmoid volvulus often presents as a surgical emergency. Initial endoscopic decompression resolves the acute obstruction in the majority of cases. Surgical intervention carries a substantial risk of mortality, particularly in the setting of emergent surgery or in the presence of necrotic colon.

Mechanical deformation induces proliferation of human colorectal carcinoma cells.

The cell biology of intravascular tumor cells is clinically important but the many important variables of this environment have proved difficult to model. We studied the effects of repetitive mechanical deformation, a phenomenon affecting all intravascular cells, on human colon cancer cell line HCT 116 in vitro. Cell proliferation, assessed by [3H]-thymidine incorporation and cell count, increased by about 30% at two days in cells subjected to deformation at 30 cycles/min as compared to controls; levels of the nuclear proliferation antigen detected by monoclonal antibody MIB-1 were also increased. Deformation increased transforming growth factor beta1 (TGF-beta1) and plasminogen activator inhibitor-1 gene expression sevenfold at two days, but mannose-6-phosphate did not affect cell proliferation, indicating that endogenous TGF-beta is not involved in the proliferative response. HCT 116 cells lack TGF-beta type II receptors, but stable transfection of TGF-beta type II receptor cDNA did not alter the cellular response to mechanical deformation, as assessed by cell proliferation, morphology, or gene expression. Mechanical deformation affects several important aspects of HCT 116 cell biology, suggesting that the intravascular environment may regulate tumor cell biology in general. Endogenous TGF-beta and TGF-beta receptor-mediated signaling are not responsible for the deformation-induced proliferative response in HCT 116.

Current follow-up strategies after potentially curative resection of extremity sarcomas: results of a survey of the members of the society of surgical oncology.

BACKGROUND: The follow-up of patients after potentially curative resection of extremity sarcomas has significant clinical and fiscal implications. However, the ideal postoperative surveillance regimen for these uncommon neoplasms remains ill-defined. This study was designed to determine the current follow-up practices of a large, diverse group of physicians who care for sarcoma patients. METHODS: The 1592 members of the Society of Surgical Oncology (SSO) were surveyed regarding their follow-up practices with a detailed questionnaire mailed in 1997. Information regarding frequency of follow-up testing was requested for extremity sarcoma patients treated for cure based on 4 vignettes: low grade lesion 5 cm and high grade lesion 5 cm. Respondents were asked to indicate the number of office visits, laboratory tests and imaging studies performed annually during the first 5 years and the 10th year after surgery. RESULTS: Forty-five percent (716 of 1592) completed the survey. Of the 343 respondents who performed sarcoma surgery, 318 (93%) also provided long term postoperative follow-up for their patients. Ninety-four percent of respondents (295 of 318) were trained in general surgery and 5% (15 of 318) completed orthopedic residencies. Ninety-one percent (291 of 318) were also fellowship trained (80% in surgical oncology). Sixty-three percent (201 of 318) were in academic practice. Routine office visits and chest X-ray (CXR) were the most frequently performed items for each of the years. The frequency of office visits and CXR increased with tumor size and grade and decreased with postoperative year. Complete blood count and liver function tests were the most commonly ordered blood tests, but many respondents did not order any blood tests routinely. Imaging studies of the extremities were performed on the majority of patients with large (> 5 cm) low grade lesions and on both large and small high grade lesions during the first postoperative year. CONCLUSIONS: Postoperative sarcoma surveillance strategies utilized by members of the SSO rely most heavily on office visits and CXR. Tumor grade, tumor size, and postoperative year affect surveillance intensity.

Appendicitis in patients with previous spinal cord injury.

BACKGROUND: Acute abdominal emergencies are particularly dangerous in patients with impaired sensation. METHODS: Thirty patients with spinal cord injury who later developed appendicitis were identified in Department of Veterans Affairs computer files over a 5-year period; 26 were evaluable. RESULTS: The mean age was 55 years (range 27 to 79); all were males. Abdominal distention or discomfort was present in 16 of 26 (62%), while 2 of 26 (8%) presented in shock. A palpable right lower quadrant mass was present in 6 of 26 (23%). The mean initial white blood cell count was 18,000/mm3. Only 9 of 26 (35%) had the diagnosis of appendicitis made on admission. In 12 of 26, computed tomography was done; all correctly diagnosed appendicitis. The mean delay in diagnosis after hospitalization was 2 days (range 0 to 5). Perforated appendicitis was found at surgery in 24 of 26 (92%). Twenty-three of 26 (88%) underwent appendectomy; 3 of 26 (12%) underwent right colectomy. The 30-day mortality rate was 4%. Six of 26 (23%) developed a postoperative complication. The mean length of stay was 16 days. CONCLUSIONS: Acute appendicitis in spinal-cord-injured patients frequently presents late and complications are common. Computed tomography appears to be an excellent diagnostic modality. Some of the adverse outcomes which are related to preexisting spinal cord injury may be preventable with early intervention.

The age of the urologist affects the postoperative care of prostate carcinoma patients.

BACKGROUND: Strategies utilized by urologists in managing prostate carcinoma patients after radical prostatectomy vary appreciably. The reason for this is unclear. The authors investigated the effect of practitioner age on management strategies. METHODS: From among the total of 12,500 American Urological Association (AUA) members, 4467 were randomly selected to receive a custom-designed survey about their care of prostate carcinoma patients after radical prostatectomy. Respondents were asked to describe their follow-up practices for patients treated with curative intent, their motivations regarding postoperative surveillance, their methods of evaluating a postoperative increase in serum prostate specific antigen (PSA) level, and their choices of treatment for patients with recurrent prostate carcinoma. RESULTS: One thousand fifty responses were analyzed. There was a statistically significant influence of practitioner age on the management of at-risk patients, but it was quite small. The typical workup for an elevated postoperative serum PSA level also varied significantly according to practitioner age; older urologists ordered more serum prostatic acid phosphatase levels and computed tomography scans of the abdomen and pelvis, whereas younger urologists ordered more bone scans. The treatment of recurrent prostate carcinoma did not vary significantly according to urologist age. The opinions of older urologists regarding the survival benefits of postoperative surveillance were considerably different from the opinions of their younger colleagues. CONCLUSIONS: The results of this study suggest that urologist age accounts for some of the variation in the postoperative management of prostate carcinoma patients. Differences in beliefs regarding the benefits of surveillance may be partially responsible for this. Persuasive clinical research will probably be required to increase the uniformity of practice in this important area.