Management of Malignant Large-Bowel Obstruction.

CASE SUMMARY: An otherwise healthy 59-year-old man presented to the emergency department with 2 weeks of narrowed stools, 5 days of obstipation, and 1 day of abdominal pain, nausea, and vomiting. Computed tomography revealed an obstructing sigmoid mass without evidence of metastatic disease, and the CEA was 1.2 ng/mL. Flexible sigmoidoscopy confirmed a circumferentially obstructing distal sigmoid neoplasm. Endoscopic stent placement was immediately followed by a firm distended abdomen. An upright radiograph obtained following the procedure demonstrated free intraperitoneal air. An emergent Hartmann procedure was performed for iatrogenic colon perforation in a patient with malignant obstruction and chronic dilation of the proximal colon.

Incorporating a Detailed Case Log System to Standardize Robotic Colon and Rectal Surgery Resident Training and Performance Evaluation.

OBJECTIVE: This study was designed to evaluate a novel case log used as part of a standardized robotic colon and rectal surgery resident training program. DESIGN: This observational study describes a detailed procedure log developed to standardize training of residents in robotic colorectal surgery. The procedure log tracks resident total case numbers and execution of specific steps of eleven colorectal procedures. Case log data were accumulated and analyzed to assess resident progress. SETTING/PARTICIPANTS: The study includes colon and rectal surgery residents during the 2016-2017 academic year. The national Colon and Rectal Surgery Robotic Training Program was developed and implemented during the 2010-2011 academic year in response to increasing adoption of robotic-assisted colorectal surgery. This program evolved to include online modules, dry lab exercises, simulation and cadaveric courses. RESULTS: Forty of 93 residents in 54 colon and rectal surgery programs participated in the case log system and the comprehensive training program. Residents participated as console surgeon in an average of 28 cases (range 1-115). Sixty-five percent of participating residents performed ≥20 complex colorectal cases as console surgeon. Of the 1080 operations entered, the three most frequently performed procedures were low anterior resections (n = 360, 33.3%), sigmoid resections (n = 172, 15.9%), and right colectomies with intracorporeal anastomosis (n = 138, 12.8%). Residents with 10 or more robotic cases had a 27% increase in cases as console surgeon and a 28% decrease in cases completed as bedside assistant. Experience and progression to the console varied by resident and by program. CONCLUSION: This detailed standardized case log system provides comprehensive assessment of resident experience that allows preparation for a robotic colon and rectal surgery practice after fellowship. As adoption of the robotic approach for colon and rectal cases continues to increase, novel methods that evaluate teaching methods and resident progress warrant further study.

Integrin and dystroglycan compensate each other to mediate laminin-dependent basement membrane assembly and epiblast polarization.

During early embryogenesis, endodermal γ1-laminin expression is required for basement membrane (BM) assembly, promoting conversion of non-polar pluripotent cells into polarized epiblast. The influence of laminin-111 (Lm111) and its integrin and dystroglycan (DG) receptors on epiblast in embryoid bodies (EBs), a model for differentiation of the embryonic plate, was further investigated. Lm111 added to the medium of EBs initiated conversion of inner nonpolar cell to the polarized epiblast epithelium with an exterior-to-central basal-to-apical orientation. Microinjection of Lm111 into EB interiors resulted in an interior BM with complete inversion of cell polarity. Lm111 assembled a BM on integrin-ß1 null EBs with induction of polarization at reduced efficiency. ß-Integrin compensation was not detected in these nulls with integrin adaptor proteins failing to assemble. A dimer of laminin LG domains 4-5 (LZE3) engineered to strongly bind to α-dystroglycan almost completely inhibited laminin accumulation on integrin ß1-null EBs, reducing BM and ablating cell polarization. When Lm111 was incubated with integrin-ß1/dystroglycan double-knockout EBs, laminin failed to accumulate on the EBs, the EBs did not differentiate, and the EBs underwent apoptosis. Collectively the findings support the hypotheses that the locus of laminin cell surface assembly can determine the axis of epithelial polarity. This requires integrin- and/or dystroglycan-dependent binding to laminin LG domains with the highest efficiency achieved when both receptors are present. Finally, EBs that cannot assemble a matrix undergo apoptosis.

CREG1 Interacts with Sec8 to Promote Cardiomyogenic Differentiation and Cell-Cell Adhesion.

Understanding the regulation of cell-cell interactions during the formation of compact myocardial structures is important for achieving true cardiac regeneration through enhancing the integration of stem cell-derived cardiomyocytes into the recipient myocardium. In this study, we found that cellular repressor of E1A-stimulated genes 1 (CREG1) is highly expressed in both embryonic and adult hearts. Gain- and loss-of-function analyses demonstrated that CREG1 is required for differentiation of mouse embryonic stem (ES) cell into cardiomyocytes and the formation of cohesive myocardium-like structures in a cell-autonomous fashion. Furthermore, CREG1 directly interacts with Sec8 of the exocyst complex, which tethers vesicles to the plasma membrane. Site-directed mutagenesis and rescue of CREG1 knockout ES cells showed that CREG1 binding to Sec8 is required for cardiomyocyte differentiation and cohesion. Mechanistically, CREG1, Sec8, and N-cadherin colocalize at intercalated discs in vivo and are enriched at cell-cell junctions in cultured cardiomyocytes. CREG1 overexpression enhances the assembly of adherens and gap junctions. By contrast, its knockout inhibits the Sec8-N-cadherin interaction and induces their degradation. These results suggest that the CREG1 binding to Sec8 enhances the assembly of intercellular junctions and promotes cardiomyogenesis. Stem Cells 2016;34:2648-2660.

New hemostatic dressing (FAST Dressing) reduces blood loss and improves survival in a grade V liver injury model in noncoagulopathic swine.

BACKGROUND: We performed this study to evaluate the hemostatic efficacy of the FAST Dressing in treating a grade V liver injury in noncoagulopathic swine. METHODS: Sixteen female splenectomized, noncoagulopathic swine underwent reproducible grade V liver injuries. The animals were blindly randomized to two treatment groups: (1) FAST Dressing (n = 8) or (2) IgG placebo dressing (n = 8). After 30 seconds of uncontrolled hemorrhage, dressings and manual compression were applied at 4-minute intervals. The number of dressings used, time to hemostasis, total blood loss, mean arterial pressure, blood chemistry, and total resuscitation fluid volume were monitored for 2 hours after injury. RESULTS: The mean total blood loss was 412.5 mL (SD 201.3) for the FAST Dressing group compared with 2296.6 mL (SD 1076.0) in the placebo group (p < 0.001). All animals in the FAST Dressing group achieved hemostasis and survived for the duration of the experiment (2 hours) after injury, whereas none of the animals in the placebo group attained hemostasis or survived to 2 hours after injury (p < 0.001). The mean time to hemostasis was 6.6 minutes (SD 2.5). A median of five dressings (mean absolute deviation 1.0, p = 0.007) was sufficient to control hemorrhage in the FAST Dressing group. CONCLUSION: The FAST Dressing reduced blood loss and improved survival compared with placebo in a noncoagulopathic, grade V liver injury swine model.