Optimal timing of elective laparoscopic cholecystectomy after acute cholangitis and subsequent clearance of choledocholithiasis.

BACKGROUND: Elective laparoscopic cholecystectomy is recommended after endoscopic clearance of choledocholithiasis for patients with acute cholangitis, according to Tokyo guidelines. However, the optimal timing remains uncertain. METHODS: Perioperative outcomes were retrospectively reviewed and compared between patients with early (< 6 weeks) and late (> 6 weeks) surgeries, while risk factors for postoperative complications were assessed using multivariate analysis. RESULTS: One hundred twelve patients (mean age, 64 years; range, 30-85 years) were analyzed. Rate of conversion and intraoperative and postoperative complications (classified per Dindo et al) were 21.4% (24 of 112), 23.2% (26 of 112), and 34.8% (39 of 112), respectively. The late surgery group had significantly more intraoperative (28.8% vs 9.4%, P = .029) and postoperative (42.5% vs 15.6%, P = .007) complications compared with the early surgery group. Multivariate analysis showed both late surgery (95% confidence interval, 1.47-12.5; P = .008) and a history of endoscopic sphincterotomy (95% confidence interval, 1.06-8.26; P = .038) to be independent risk factors for postoperative complications. CONCLUSIONS: Patients with endoscopic clearance of choledocholithiasis, especially after endoscopic sphincterotomy, should receive elective laparoscopic cholecystectomy within 6 weeks after a cholangitic attack.

Factors associated with failure of the artificial bowel sphincter: a study of over 50 cases from Cleveland Clinic Florida.

PURPOSE: This study investigated the risk factors related to artificial bowel sphincter infection, complications, and failure. METHOD: Complications may occur at any time after artificial bowel sphincter implantation. Early-stage complication is defined as any complications that occurred before artificial bowel sphincter activation, whereas late-stage complications are defined as any complications that occurred after device activation. Assessment of the outcomes of all artificial bowel sphincter operations included evaluation of factors related to patient demographics, operative procedures, and postoperative events. RESULT: From January 1998 to May 2007, 51 artificial bowel sphincter implantations were performed in 47 patients (43; 84.3% female) with a mean age of 48.8 +/- 12.5 (range, 19-79) years and a mean incontinence score of 18 +/- 1.4 (range, 0-20). In 24 patients (54.5%), the etiology of incontinence was secondary to imperforate anus; 15 (24.2%) patients had obstetric injury or anorectal trauma. Twenty-three (41.2%) artificial bowel sphincter implantations became infected, 18 (35.3%) of which developed early-stage infection, whereas 5 (5.9%) had late-stage infection. One patient in the latter group had associated erosion, and two patient had fistula formation. Late-stage complications continued to increase with time. Multivariate analysis revealed that the time between artificial bowel sphincter implantation and first bowel movement and a history of perineal sepsis were independent risk factors for early-stage artificial bowel sphincter infection. CONCLUSION: The time from implantation to first bowel movement and history of perineal infection were risk factors for early-stage artificial bowel sphincter infection and failure. Late-stage failures were more often the result of device malfunction and indicated the need for mechanical refinement.

Symptomatic gallstones after sleeve gastrectomy.

BACKGROUND: Cholelithiasis is a common complication after bariatric surgery. Pure restrictive procedures such as sleeve gastrectomy and gastric banding theoretically should result in less gallstone formation because the food continues to follow the normal gastrointestinal transit, maintaining the enteric-endocrine reflex intact. To the authors' knowledge, the literature has no studies that analyze the incidence of gallstone formation after sleeve gastrectomy. This study aimed to compare the rates of symptomatic gallstones between laparoscopic Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG). METHODS: A retrospective chart review of patients who underwent laparoscopic RYGBP and SG between 2004 and 2006 was performed. The patients with previous cholecystectomy, known gallstones with or without concomitant cholecystectomy, and previous weight-reduction operations were excluded from the analysis. The outcome measures were the numbers of patients who had experienced symptomatic and complicated gallstones. Using Cox regression analysis, comparisons was made between the patients with laparoscopic RYGBP (group A) and those with laparoscopic SG (group B). RESULTS: Groups A excluded 174 (26%) of 670 patients, and group B excluded 27 (34.2%) of 79 patients. The patients in group A had a significantly higher preoperative body mass index (BMI) than those in group B. Additionally, more group A than group B patients had a BMI exceeding 45 and more than a 25% loss of original weight. No significant difference in the development of symptomatic (8.7% vs. 3.8%; p = 0.296) or complicated (1.8% vs. 1.9%; p = 0.956) gallstones was noted between the two groups CONCLUSIONS: There was no significant difference in symptomatic or complicated gallstone disease between the patients treated with laparoscopic SG and those treated with laparoscopic RYGBP. Routine prophylactic cholecystectomy should not be recommended for weight reduction during laparoscopic SG.

Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure?

BACKGROUND: Anastomotic complications such as leakage and bleeding remain among the most serious complications of laparoscopic colorectal surgery. No perfect method exists for accurate and reliable avoidance of these catastrophes. This study aimed to study the usefulness of routine intraoperative endoscopy (RIOE) by comparing the surgical outcomes for RIOE patients with those for selective intraoperative endoscopy (SIOE) patients. METHODS: A retrospective chart review was performed for consecutive patients who underwent elective laparoscopic colorectal resections with distal anastomosis between January 2004 and May 2007. One surgeon performed RIOE, whereas the other three surgeons performed SIOE as necessary. All the abnormalities of IOE patients were managed with a subsequent salvage procedure, and the postoperative outcomes were compared between the RIOE and SIOE groups. RESULTS: The study included 107 patients in the RIOE group and 137 patients in the SIOE group. Abnormalities were detected in 11 RIOE patients (10.3%) (six with staple line bleeding, three with positive air leak test results, and two with additional pathology identified). All but one abnormality was laparoscopically managed without conversion to laparotomy. Whereas one patient experienced postoperative staple line bleeding that required a second operation, the remaining 10 patients recovered uneventfully. The mean hospital stay was 6 days (range, 4-9) days. The RIOE group had overall rates of 0% for anastomotic leakage and 0.9% for staple line bleeding. Intraoperative endoscopies were performed for 30 (21.9%) of the 137 patients in the SIOE group. The postoperative outcomes comparison between the RIOE and SIOE groups showed a tendency toward more overall anastomotic complications (0.9% vs. 5.1%) in the SIOE group, which due to the small sample size did not translate into significant differences in terms of staple line bleeding and anastomotic leakage. There also were no significant differences in other outcomes such as ileus, abdominal or pelvic sepsis, reoperation, positive distal margin, distance from distal margins, length of hospital stay, or mortality. CONCLUSIONS: Routine IOE for patients undergoing elective laparoscopic colorectal surgery with distal anastomosis can detect abnormalities at or around the anastomosis. Although the RIOE group had fewer postoperative anastomotic complications, due to the small sample size, the 5.7-fold increase in anastomotic failure did not translate into significantly better postoperative outcomes than the SIOE group experienced. A larger-scale single or multicenter prospective randomized study or a metaanalysis including similar studies is necessary for further investigation of this issue.

A simple colostomy implantation model for evaluating colon cancer.

PURPOSE: Realistic models of colorectal cancer are necessary to study cancer biology and evaluate therapeutic interventions. Real-time observation and repeated sampling of implanted tumor is difficult to achieve in the current orthotopic animal colorectal cancer model. The aim of this study was to establish a simple colostomy implantation mouse model for evaluating colon cancer. EXPERIMENTAL DESIGN: The human colon cancer cell line LoVo was injected subcutaneously into the necks of five mice to generate a solid tumor. Colostomies were created from the ceca of 14 nude mice. Fragments from the solid tumors were then harvested and implanted into the submucosa of the stoma. Half of the tumor-bearing mice were treated with 5-fluorouracil (5-FU) and all were monitored for tumor growth and survival. Tumor tissue was taken at different time points to evaluate pathological changes, expression of hMSH2 and P53, and microsatellite instability (MSI). RESULTS: The stoma healed 2 weeks after the surgery. Twelve mice had developed detectable colon tumor 2 to 3 weeks after implantation of human colon cancer LoVo cells into the colostomy with mesenteric lymph node metastases. The median survival was 13 weeks. Histopathological and immunohistochemical examinations of tumor tissues collected at different time points of tumor progression showed similar histopathological changes and hMSH2 and P53 expression patterns to the original cell line. MSI analysis showed that five tumors were MSI-L from the second week after tumor implantation and all 12 colostomy tumors were MSI-H from 4 weeks after implantation. The tumors were highly sensitive to 5-FU treatment, which lead to a longer median survival of 15 weeks (P = 0.0374) and significant tumor growth inhibition. CONCLUSION: This study demonstrates that a colostomy implantation mouse model is an ideal model for evaluating colon cancer. Its advantages include high tumor take rate, easy real-time visualization, easy repeated sampling of the implanted tumor in live animals, and significant sensitivity to a commonly used chemotherapeutic agent.

Predictors of gallstone formation after bariatric surgery: a multivariate analysis of risk factors comparing gastric bypass, gastric banding, and sleeve gastrectomy.

BACKGROUND: Risk factors for gallstone formation in the general population have been well studied while those after weight reduction surgery are unknown. The aim of this study was to identify the risk factors for the development of symptomatic gallstones after bariatric surgery. METHOD: Retrospective review was performed for patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), adjustable gastric banding (LAGB) or sleeve gastrectomy (LSG) between 2004 and 2006. Statistical evaluation was performed using a univariate and multivariate analysis. Risk factors, including age, gender, preoperative body mass index (BMI), BMI > 45 kg/m(2), diabetes mellitus, hyperlipidemia, types of operation, and weight loss >25% of original weight, were analyzed for their association with postoperative symptomatic gallstones formation. RESULTS: 670 laparoscopic RYGBP, 47 LAGB, and 79 LSG were performed in our institute. Preoperative gallbladder disease, as indicated by presence of gallstones or sludge on preoperative transabdominal ultrasound, or previous cholecystectomy, were found in 25.3, 14.9, and 30.4% of patients who subsequently had RYGBP, LAGB, and LSG, respectively. A total of 586 patients were included for analysis. Mean follow-up was 25.9 (range 12-42) months. Overall rate of symptomatic gallstone formation was 7.8% and mean time for its development was 10.2 (range 2-37) months. Incidence of symptomatic gallstones with complications as initial presentation was found in 1.9% of the patients. Logistic regression analysis showed that only postoperative weight loss of more than 25% of original weight was associated with symptomatic gallstones formation [B = 1.482, SE = 0.533, odds ratio 4.44, 95% confidence interval (CI) 1.549-12.498, p = 0.005]. CONCLUSIONS: Traditional risk factors for gallstone formation in the general population are not predictive of symptomatic gallstone formation after bariatric surgery. Weight loss of more than 25% of original weight was the only postoperative factor that can help selecting patients for postoperative ultrasound surveillance and subsequent cholecystectomy once gallstones were identified.

Primary hepatic carcinoid tumour: a detailed account of imaging findings.

Primary hepatic carcinoid tumours are very rare and less than 60 cases have been reported in the literature. This study reports a 35-year-old female with 2 synchronous primary hepatic carcinoid tumours in her right hepatic lobe. She was examined with various imaging investigations including ultrasound scan, computed abdominal tomography, magnetic resonance imaging, mesenteric angiography and positron emission tomography. She underwent right hepatectomy and the lesions were proven to be carcinoid tumours. She has been free of disease for more than 5 years of follow-up and the diagnosis of primary hepatic carcinoid tumour is suggested.

Detection of mismatch repair gene germline mutation carrier among Chinese population with colorectal cancer.

BACKGROUND: Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant syndrome. The National Cancer Institute (NCI) has recommended the Revised Bethesda guidelines for screening HNPCC. There has been a great deal of research on the value of these tests in other countries. However, literature about the Chinese population is scarce. Our objective is to detect and study microsatellite instability (MSI) and mismatch repair (MMR) gene germline mutation carriers among a Chinese population with colorectal cancer. METHODS: In 146 prospectively recruited consecutive patients with clinically proven colorectal cancer, MSI carriers were identified by analysis of tumor tissue using multiplex fluorescence polymerase chain reaction (PCR) using the NCI recommended panel and classified into microsatellite instability-low (MSI-L), microsatellite instability-high (MSI-H) and microsatellite stable (MSS) groups. Immunohistochemical staining for MSH2, MSH6 and MLH1 on tissue microarrays (TMAs) was performed, and methylation of the MLH1 promoter was analyzed by quantitative methylation specific PCR (MSP). Germline mutation analysis of blood samples was performed for MSH2, MSH6 and MLH1 genes. RESULTS: Thirty-four out of the 146 colorectal cancers (CRCs, 23.2%) were MSI, including 19 MSI-H CRCs and 15 MSI-L CRCS. Negative staining for MSH2 was found in 8 CRCs, negative staining for MSH6 was found in 6 CRCs. One MSI-H CRC was negative for both MSH6 and MSH2. Seventeen CRCs stained negatively for MLH1. MLH1 promoter methylation was determined in 34 MSI CRCs. Hypermethylation of the MLH1 promoter occurred in 14 (73.7%) out of 19 MSI-H CRCs and 5 (33.3%) out of 15 MSI-L CRCs. Among the 34 MSI carriers and one MSS CRC with MLH1 negative staining, 8 had a MMR gene germline mutation, which accounted for 23.5% of all MSI colorectal cancers and 5.5% of all the colorectal cancers. Five patients harbored MSH2 germline mutations, and three patients harbored MSH6 germline mutations. None of the patients had an MLH1 mutation. Mutations were commonly located in exon 7 and 12 of MSH2 and exon 5 of MSH6. Right colonic lesions and mucinous carcinoma were not common in MSI carriers. CONCLUSION: Our data may imply that the characteristics of HNPCC in the Chinese population are probably different from those of Western countries. Application of NCI recommended criteria may not be effective enough to identify Chinese HNPCC families. Further studies are necessary to echo or refute our results so as to make the NCI recommendation more universally applicable.