Extralevator abdominoperineal excision for low rectal cancer: oncological outcome after five-year follow-up.

BACKGROUND: Extralevator abdominoperineal excision (ELAPE) is a surgical technique that is indicated for low rectal cancer where sphincter preservation is not possible. Compared to conventional abdominoperineal excision major advantages of ELAPE are the risk reduction of intraoperative bowel perforation and positive circumferential margin which lead to a better oncological outcome. The aim of this study was to present our results in ELAPE surgery. METHODS: From February 2011 to February 2015, 40 patients underwent surgery for low rectal cancer at the Oncology Institute of Vojvodina. The collected data included sex, age, preoperative staging, neoadjuvant treatment, operative time, rate of intraoperative bowel perforation, rate of positive circumferential resection margins, histopathological analysis, postoperative mortality, tumour, node and metastasis (TNM) classification, local recurrence (LR) rate and presence of distant metastases. RESULTS: Positive circumferential margin was found in three (7.5%) patients while eight (20%) patients had intraoperative bowel perforation. LR during follow-up was seen in seven (17.5%) patients, three of them had intraoperative bowel perforation and two patients had positive circumferential margin. The estimated five-year cumulative incidence of LR is 7%. Distant metastases occurred in 18 (45%) patients. The estimated five-year survival rate is 62%.. CONCLUSION: The study shows satisfactory five-year survival rates of 62% in a highly complex patient group treated by ELAPE procedure.

Single versus double stapling anastomotic technique in rectal cancer surgery.

PURPOSE: The present study was designed to investigate whether there is a difference in the anastomotic leakage rate (AL) between the single stapling (CSA) and double stapling (DSA) anastomosis techniques. METHODS: One hundred consecutive rectal cancer patients who underwent rectal resection with primary anastomosis were enrolled in this study. RESULTS: The overall rate of clinical anastomotic leakage in both groups was 7 % (7/100); 6 % (3/50) in the CSA group and 8 % (4/50) in the DSA group. The anastomotic technique did not have any significant influence on the rate of AL. All AL were seen in low anastomoses (7 cm and below). The rate of AL in patients with a diverting stoma (13 %, 3/23) was not significantly different from that of the patients without (5.2 %, 4/77) (p = 0.195). The mean length of the operation was significantly shorter in the DSA group compared to the CSA group, at 127 and 141 min, respectively (p = 0.005). There were significantly higher rates of AL in patients receiving preoperative long course radiotherapy (15.4 %, 6/39) compared with those who did not receive radiotherapy (1.63 %, 1/61) (p = 0.014). CONCLUSIONS: The CSA and DSA techniques are equally safe for the creation of a rectal anastomosis, without any significant difference in the AL rate. However, we recommend using the DSA technique because it has other definite advantages. In cases of neoadjuvant treatment and a low anastomosis, proximal diversion is recommended.

The effect of melatonin on body mass and behaviour of rats during an exposure to microwave radiation from mobile phone.

BACKGROUND: Microwave radiation (MW) produced by wireless telecommunications and a number of electrical devices used in household or in healthcare institutions may cause various disorders in human organism. On the other hand, melatonin is a potent antioxidant, immunostimulator and neuromodulator. The aim of this research was to determine body mass and behaviour changes in rats after a chronic microwave exposure, as well as to determine the effects of melatonin on body mass and behaviour in irradiated rats. METHODS: Wistar rats were divided into the four experimental groups: I group (control) - rats treated with 0,9 % saline, II group (Mel) - rats treated with melatonin (2 mg/kg), III group (MW) - rats exposed to MW radiation (4 h/day), IV group (MW+Mel) - rats, which were both exposed to MW radiation and received melatonin premedication (2 mg/kg). RESULTS: A significant body mass reduction was noted in animals exposed to MW radiation when compared to controls after 20, 40 and 60 days (p<0.001). Furthermore, body weight was significantly increased (p<0.05) in irradiated rats, which received melatonin pretreatment (MW+Mel) in comparison to irradiated group (MW) after 20 days. Microwave radiation exposed animals showed an anxiety related behaviour (agitation, irritability) after 10 days of exposure. After the radiation source removal, changes in behaviour were less noticeable. Melatonin administration to irradiated rats caused a decrease in the stress induced behaviour. CONCLUSION: Microwave radiation causes body mass decrease and anxiety related behaviour in rats, however melatonin causes a reverse of those effects on both body weight and behaviour of irradiated animals (Fig. 2, Ref. 32).

The clinical role of micrometastatic disease in sentinel lymph nodes in breast cancer.

PURPOSE: Complete axillary lymph node dissection (cALND) is the standard procedure in treating the patients with tumor-positive sentinel nodes (SLNs). However, approximately half of these patients have not additional metastases in their axilla and therefore do not benefit from cALND. Our aim was to examine the outcome of patients with tumor-positive SLNs without cALND. METHODS: All patients (n=591) were women with clinically T1-2N0-1M0 breast cancer. SLN marking was performed with blue dye (Patentblau V) and radiotracer (antimony sulfide marked with Tc99m). Both contrast media were applied peritumorally or periareolarly. After SLN biopsy all patients underwent breast-conserving surgery or mastectomy with or without lymph node dissection of level I and II (depending on SLN status). RESULTS: In 37 (17.84%) out of 185 patients cases SLNs contained micrometastases. In 19 of 37 cases (57.58%) cALND was performed, and in 14 (42.42%) was not. The mean and median duration of follow-up were 50.59 and 55 months, respectively (range 4-108). Two cases without cALND developed ipsilateral enlarged lymph nodes at 26 and 59 months. Biopsy showed that the enlarged nodes were tumor-free. In all other cases with micrometastases in SLNs neither axillary lymphadenopathy nor distant metastases were seen. After performing surgical treatment, all patients received adjuvant chemotherapy or hormonotherapy and radiotherapy. CONCLUSION: Patients with SLN micrometastases who had not undergone cALND showed no regional recurrence and distant metastases. ALND is not necessary for regional control in patients with micrometastatic or isolated tumor cells in SLNs. By avoiding cALND the number of complications was reduced and the quality of life was improved.

Quantitative evaluation of stromal myofibroblasts and their significance for the metastatic capacity of colorectal carcinoma.

PURPOSE: To quantify the myofibroblasts in the tumor stroma of colorectal carcinomas using immunostaining with anti smooth muscle actin (SMA) as a marker for myofibroblasts. METHODS: The study was carried out on 46 surgically resected primary colorectal adenocarcinomas from the archive of the Centre for Pathology and Forensic Medicine of the Military Medical Academy in Belgrade, from 2008-2010. All samples were analysed by the scientific software "Image J". Myofibroblasts were visualized using anti-SMA antibody and quantified in order to predict tumor capacity for invasion and metastasis. Receiver Operator Characteristic (ROC) analysis was carried out, and a score of 5.72 was suggested as the score of SMA that is significant for the clinical outcome with lymph node involvement. RESULTS: Overall, the average SMA was 7.29 (range 0.39-16.84). Further analysis showed correlation of SMA with clinical and pathological tumor characteristics, i.e. SMA was significantly higher in tumors with more advanced stage, higher histological grade, greater amount of desmoplasia, smaller amount of inflammatory infiltrate, lymph node involvement, vascular and perineural invasion and infiltrative tumor growth. CONCLUSION: Our study suggests that it is possible to define the tumor capacity for invasion and metastasis by quantifying the myofibroblasts in the tumor stroma of colorectal carcinomas. Therefore, further investigations are needed to determine targeted therapies to signaling pathways in myofibroblasts.

Awareness during general anaesthesia--implications of explicit intraoperative recall.

Anaesthesia awareness (AA) is postoperative recall of events experienced under general anaesthesia. Most frequently patients remember an auditory perception, the feeling of motor function lost, pain, helplessness, anxiety, panic, impending death. The prevalence of awareness in nonobstetric and noncardiac surgical cases is 0.1%-0.2%. The prevalence is higher in cardiac surgery, obstetric and major trauma cases. According to the results of many studies light anaesthesia is the most common cause of the AA. Posttraumatic stress disorder appears in 33%-56% of patients who experienced awareness during general anaesthesia. Extreme awareness experiences are very uncommon, but traumatic and can have lasting effects on patients. Several brain-function monitors based on the processed electroencephalogram or evoked potentials have been developed to assess anaesthetic depth. Measures to prevent awareness include avoidance of light anesthesia, gaining more knowledge about patient anaesthetic requirements and development of methods to detect consciousness during anesthesia.

Early complications after nipple-sparing mastectomy and immediate breast reconstruction with silicone prosthesis: results of 214 procedures.

BACKGROUND AND AIMS: breast reconstruction with silicone prosthesis following nipple-sparing mastectomy has become widely accepted as a reconstruction option in women requiring mastectomy for cancer. The purpose of this study was to evaluate the incidence and some factors influencing early local complications in patients undergoing NSM with immediate implant reconstruction. MATERIAL AND METHODS: prospective study was performed on a consecutive series of 214 breast reconstructions in 205 patients. All complications during the six weeks after surgery were recorded. 42 prostheses were implanted after neoadjuvant chemotherapy, 27 patients previously had radiotherapy due to breast conserving surgery and in all other cases surgery was the pri-mary treatment for cancer. RESULTS: the overall six-week complication rate was 16% (35) and included: major skin flap necrosis (4%, 9 procedures), minor skin necrosis (3%, 7), major infection (2%, 5), minor infection (3%, 7), prolonged seroma formation (3%, 6), haematoma (1%, 2) and epidermolysis (1%, 2). In 6% (12) reconstruction procedures explantation of prosthesis was done. Neoadjuvant chemo-therapy and radiotherapy were not associated with higher rate of complications. CONCLUSION: nipple-sparing mastectomy with immediate implant reconstruction has acceptable morbidity rate in the hand of experienced oncoplastic surgeon and therefore should be considered as treatment option to women requiring mastectomy.

Radiographic enlargement of mandibular canal as first feature of non-Hodgkin's lymphoma.

Non-Hodgkin's lymphoma has the propensity to affect non-lymphoid tissue including oral tissue. Primary non-Hodgkin's lymphoma of the mandible mistreated as chronic periodontitis with diffuse enlargement of the mandibular canal and ice-cold numbness is very rarely described in English medical literature. A 57-year-old patient presented with a painful swelling on the left side of the mandible with a clinically chronic periodontitis associated with ice-cold numbness. A panoramic radiograph showed a diffuse uniform enlargement of the mandibular canal. Histological examination showed that the lesion was a primary intraosseous non-Hodgkin's lymphoma of the mandible. Immunohistochemical examination showed a positive reaction for CD20+, Ki-67+. Seven months after chemotherapy the patient was observed for possible life-threatening propagation of the disease. In conclusion, primary (extra-nodal) non-Hodgkin's lymphoma of the mandible usually clinically presents with bone swelling, teeth mobility and neurological disturbance. Radiographic features presenting as diffuse enlargement of the mandibular canal could be considered as non-Hodgkin's lymphoma.

Severe dyspnea as atypical presenting symptom of Madelung's disease.

Madelung's disease (benign symmetrical lipomatosis) is a rare disease of unknown etiology manifesting as symmetric abnormal deposits of adipose tissue in the head, neck and upper trunk. We report a case of a 58-year-old man with a long lasting Madelungs disease in whom progressive fatty tissue accumulation caused a severe inspiratory dyspnea as atypical presenting symptom. The etiopathogenetic, clinico-diagnostic and therapeutic aspects of this rare disease are discussed. Due to its progressive but not so easily predictable enlarging behavior Madelung's disease has not only aesthetic but also functional and sometimes life threatening consequences which need to be treated.

Hyperprolactinemia: different clinical expression in childhood.

BACKGROUND: Hyperprolactinemia is the most common disturbance in pituitary gland secretion. Functional diversity of prolactin action is responsible for different initial clinical expressions of hyperprolactinemia. PATIENTS AND METHODS: We investigated causes of hyperprolactinemia in 11 children and adolescents (6 females and 5 males), aged from 1.5 to 17.5 years. Children with primary hypothyroidism, iatrogenic hyperprolactinemia and adolescents with polycystic ovaries were excluded. RESULTS: Four patients had short stature or growth deceleration, the same number were clinically obese, 2 adolescent girls had secondary amenorrhea, 1 girl had premature thelarche and gynecomastia, and hypogonadism was the indication for the endocrinologic examination of two adolescent boys. Delayed pubertal development was present in both sexes. Hyperprolactinemia was also found in the youngest girl with multiple ovarian cysts. A very high prolactin (PRL) level was documented in the PRL profile of all patients (mean 2,553.00 +/- 1,020.97 mU/l). MRI of the pituitary was indicated and revealed 4 microprolactinomas, one congenital hypophyseal cyst and one tumor of the hypothalamus. Dopamine agonist treatment was efficacious in almost all the patients. CONCLUSION: Hyperprolactinemic children expressed a wide variety of initial clinical presentations. The most common were growth and puberty disorders and obesity. PRL determination should be included in investigation protocols of obese and short stature children.

Factors affecting results of treatment of Hypopharyngeal Carcinoma.

OBJECTIVE: A retrospective review of patients with malignant neoplasms of the hypopharynx treated with combined surgery and radiotherapy is presented to highlight the results of treatment and the factors of treatment success for this malignant disease. PATIENTS AND METHODS: Between 1995 and 2004 at the University ORL Clinic Nis 89 patients with malignant neoplasms of hypopharynx (85 males, 4 females, and age ranging from 44 to 77 years) were treated. In the 89 patients (stage I, n=4; stage II, n=3; stage III, n=34; stage IV, n=48), the sites of origin were pyriform sinus (n=75), postcrycoid (n=8), posterior pharyngeal wall (n=3) and superior hypopharynx (n=3). RESULTS: Laryngeal preservation surgery was achieved in 11.2% of patients, while 88.8% had laryngectomy with partial or total pharyngectomy. Pyriform sinus was the most common site of origin of hypopharyngeal carcinoma in 84.3%. Totally 93% of patients had neck metastases, and tumors extended beyond the hypopharynx in 41.6% of patients. TNM stage was highly significant parameter of outcome. Five year survival was 100% for stage I, 66.6% for stage II, 53.9% for stage III, and 33.3% for stage IV. Residual disease (5.6%) and recurrent disease (2.2%) were low. Postoperative fistula developed in 16.8% of patients, and in 60% it was closed successfully using local flaps, while in 40% pectoralis flap was needed. Localization of disease was also an important factor of survival. Retrocrycoid carcinoma resulted in very poor survival rate (12.5%), high residual disease, lymph node metastasis, and pharyngocutaneous fistula formation. CONCLUSION: Localization and TNM stage are highly significant factors for clinical course, treatment, and outcome of hypopharyngeal carcinoma.

Mandible schwannoma (neurilemmoma) presenting as periapical lesion.

Schwannoma is a benign nerve tumour that originates from Schwann cells, which cover peripheral nerves. Intraosseous schwannoma of the jaw is rare. Primary schwannoma of the mandible presenting as a periapical radiolucency on a non-vital endodontically treated tooth has rarely been referred to in the English medical literature. A rare case of intraosseous schwannoma is reported in a 23-year-old woman. The patient presented clinically with a painful swelling on the right side of the mandible and with a radiologically ill-defined unilocular periapical lesion around the mesial root of the endodontically treated first molar. Surgical treatment involved complete excision of the lesion with a mesial and distal root resection. Histological and immunohistochemical examination showed that the lesion was a primary intraosseous schwannoma of the mandible. Immunohistochemical examination showed a positive and strong reaction for S-100 protein, characteristic of neural tumours. 1 year following surgery, there were no regional recurrences. Radiographically, mandibular intraosseous schwannoma is difficult to differentiate from bone tumours such as ameloblastoma, myxoma, fibrous dysplasia, neurofibroma, central giant cell lesion or periapical lesion, so it should be included in the list of possible periapical pathoses.

[Precision TACE in therapy of primary malignant tumors of liver/hepatocellular carcinoma (HCC)].

AIM: Hepatocellular carcinoma is one of the most frequent malignant tumors in general and most common liver malignancy. Aim of this study was to determine the therapeutic effect of chemoembolization with microspheres charged with doxorubicin in HHC patients. MATERIAL AND METHODS: During for period of four-year (November 2005- November 2009) at Institute of radiology CC Ni transarterial chemoembolization procedures (precision TACE) was performed on 27 patients. There were 17 male and 10 female patients with average age of 62 years. Total number of 64 TACE interventions were done in total, minimally one, maximally 6 per patient. HCC was pathophysiologically verified in all patients included in this study. After selective catheterization of tumor feeding artery, followed by application of microspheres a follow-up study with evaluation of therapeutic effects was conducted. RESULTS: Patients were enrolled in the study and followed four years in total. The therapy effects were estimated according to RECIST criteria. CONCLUSION: Precision TACE represents effective and controlled method for application of chemotherapeutic agencies with reduced systemic toxicity. Our preliminary results show increased therapeutic efficacy, diminished mortality and subsequently prolonged survival rate and improved quality of life in patients with HCC.

Surgery for patients with gastric cancer in the terminal stage of the illness - TNM stage IV.

PURPOSE: To assess any survival advantage in patients with incurable gastric cancer who had undergone resection, bypass or exploratory surgery. In nonresectable patients with pain, the effect of celiac plexus neurolysis was assessed. METHODS: We retrospectively analysed data of 330 patients, operated between 1992 and 2006. The patients were followed until death or last examination. Incurable gastric cancer was defined as TNM stage IV disease: locally advanced (LA), with solitary distant metastasis (SM) or with multiple metastases and/or peritoneal carcinomatosis (MMC). The patients were divided into these 3 groups. Their postoperative survival was calculated and compared in relation to the surgical technique used. Factors which influenced mortality and survival were identified. RESULTS: 131 patients (39.7%) had locally LA cancer, 98 (29.7%) SM, and 101 (30.6%) belonged to the MMC group. The surgical procedures included 138 (41.8%) exploratory laparotomies, 84 (25.5%) bypass procedures and 108 (32.7%) resections. Thirty-three (10%) unresectable patients with pain underwent celiac plexus neurolysis. The mean survival was 21.8 months after resections, 7 months after by-passes and 4.8 after exploratory laparotomies (p = 0.0001). It was 14.57 months (p=0.001) in the LA group, 12.53 (p = 0.005) in the SM group, and 5.2 in the MMC group. Survival was shorter in patients with preoperative weight loss of more than 20 kg (3.2 months, p <0.0001). Postoperative 30-day mortality was 23.2% after exploratory laparotomies, 23.8% after bypasses and 20.4% after resections. Increased mortality was observed in the MMC group (27.7%) and in multivisceral resections (41%, p > 0.05), while significantly increased mortality occurred in patients with weight loss of over 20 kg (32%, p=0.03). Celiac plexus neurolysis was immediately effective in 30 out of 33 (91%) patients (p=0.0001), while 3 months later it was still effective in 15 (45.5%) patients (p=0.08). CONCLUSION: Resections are suggested in the LA and SM groups, and neurolysis in all nonresected patients with pain.

Blue dye versus combined blue dye-radioactive tracer technique in detection of sentinel lymph node in breast cancer.

BACKGROUND: Sentinel lymph node biopsy in breast cancer can be used to select patients in which axillary lymph node dissection could be avoided. In this study we compared the value of two methods for identification of sentinel node (SN) using either only blue dye or combination of blue dye and radioactive tracer. MATERIAL AND METHODS: All patients were women with clinically T(1-2)N(0)M(0) breast cancer. They were randomized into two groups. In Group A (50 patients) SN marking was performed only with blue dye and in Group B (100 patients) combined SN marking with blue dye and radiotracer was done. We used 2 ml of blue dye Patentblau V (Byk Gulden). Radiotracer was Antimony sulfide marked with Tc 99m and of 0.3 mCy (11.1 MBq) activity. Application method of both contrasts was peritumoral. After SN biopsy all patients underwent mastectomy or conservative surgery with axillary lymph node dissection of levels I and II. RESULTS: In Group A mean of 1.7 SNs were identified (median 1, range 1-4). False-negative rate in this group was 3/17 (17.6%) with negative-predictive value 20/23 (86.9%), sensitivity 14/17 (82%), specificity 20/33 (60%) and accuracy 34/50 (68%). In Group B mean number of SNs excised per case was 1.6 (median 1, range 1-5). False-negative rate was 2/44 (4.5%), negative-predictive value 41/43 (95.3%), sensitivity 42/44 (95%), specificity 41/56 (73%) and accuracy 83/100 (83%). The combination technique was significantly superior to blue-dye alone technique for negative-predictive value (p=0.033) and overall accuracy (p=0.048). CONCLUSIONS: The prediction of axillary lymph node status in breast cancer patients using combined technique has significantly higher accuracy than marking of SN with blue dye alone and therefore should be preferred.

Over-the-counter use of oral contraceptives in Kuwait.

Oral contraceptive pills (OCPs) are available over-the-counter (OTC) in Kuwait, and constitute a leading method for spacing and limiting children. Data from a nationally representative survey of Kuwaiti women are used to examine OTC use of OCPs. One-fourth of the women initiated use without consulting a doctor, and 50% bought OCPs from the pharmacy. No socioeconomic or demographic differences were found between those who consulted a physician, implying that women of different background have similar accessibility to the physician. Using multivariate analysis, the odds of consulting a physician were found to be significantly lower for women who first bought OCPs directly from the commercial pharmacy. The duration of first time OCP use did not differ according to physician consultation. It is concluded that OTC availability of OCPs has many advantages and prevents unwanted pregnancy. However, there is a need for better packaging and instructions that would enable high-risk women to identify themselves and to use OCPs under physician supervision.

On substance abuse in Kuwait (1992-1997). Evidence from toxicological screening of patients.

PURPOSE: To assess preference for different psychoactive substances and time trends in Kuwait. METHODS: Analysis of urine and blood samples of specimens sent by attending physicians to the only public health reference laboratory for toxicological screening in the country. RESULTS: A total of 28,548 tests were performed on 3781 samples. Cannabinoids were positive in 40% of the tested samples, opiates in 24%, ethanol in 10%, and amphetamines in 5%. Elevated concentrations of methadone, cocaine, and phencyclidine did not exceed 0.1%. About 40% of samples was positive for benzodiazepines, but their therapeutic use obscures the informativeness of this finding. There was a significant increase in the proportion of positive results for ethanol, amphetamines, and benzodiazepines. IMPLICATIONS: It is high time to implement a modern and comprehensive preventive and control program. The tendency to blame the Iraqi invasion for drug addiction has hampered efforts to recognise and address the problem in its entirety.

Prevalence of smoking among currently married Kuwaiti males and females.

A structured questionnaire was administered to a random sample of 608 Kuwaiti couples through a household face-to-face interview. Both spouses were non-smokers in more than half (50.8%) of all the couples, and there was a single couple (0.2%) with both spouses currently smoking. Only 0.5% of the wives reported current smoking. The prevalence of smoking was 3.2% among divorced/widowed women from the same households. The difference between the two groups of women remained significant upon controlling for the confounding effect of age. Among the husbands, frequencies of current and ex-smokers were 37% and 11%, respectively. Younger respondents consumed more tobacco and were initiated to smoking at an earlier age. Logistic regression showed that people with one to 11 years of formal education were more likely to be current smokers as compared to the rest of the respondents (adjusted relative risk: 2.07, 95% confidence interval (CI): 1.46-2.93). Reasons for the observed findings have been discussed.

Prevalence and social correlates to consanguinity in Kuwait.

BACKGROUND: Kuwait has one of the highest consanguinity rates in the world. Our objectives in this study were to assess the frequency and trend in consanguineous marriages, and to identify factors associated with inbreeding. PATIENTS AND METHODS: A representative sample of 482 households from the most developed (the Capital), and the least developed (Jahra), of the five governorates in Kuwait was selected. The study involved only Kuwaiti nationals. A structured questionnaire was administered by previously trained team members through a household face-to-face interview. RESULTS: Data were obtained for 959 current or previous marriages. Frequency of total (first and second cousin) consanguinity was much higher in Jahra governorate (42.1%) than the Capital (22.6%). Over the last decade, the inbreeding has decreased in the Capital but not in Jahra. Bivariate analysis indicated that several socioeconomic and demographic variables were significantly associated with consanguinity. The control of confounding factors by logistic regression showed, however, that Bedouin origin and year of marriage were the only variables significantly related to consanguinity. CONCLUSION: There is a widening gap between Bedouins and non-Bedouins in the practice of consanguinity in Kuwait.