Outcomes and efficacy of magnetic resonance imaging-compatible sacral nerve stimulator for management of fecal incontinence: A multi-institutional study.

BACKGROUND: Fecal incontinence (FI) is an involuntary passage of fecal matter which can have a significant impact on a patient's quality of life. Many modalities of treatment exist for FI. Sacral nerve stimulation is a well-established treatment for FI. Given the increased need of magnetic resonance imaging (MRI) for diagnostics, the InterStim which was previously used in sacral nerve stimulation was limited by MRI incompatibility. Medtronic MRI-compatible InterStim was approved by the United States Food and Drug Administration in August 2020 and has been widely used. AIM: To evaluate the efficacy, outcomes and complications of the MRI-compatible InterStim. METHODS: Data of patients who underwent MRI-compatible Medtronic InterStim placement at UPMC Williamsport, University of Minnesota, Advocate Lutheran General Hospital, and University of Wisconsin-Madison was pooled and analyzed. Patient demographics, clinical features, surgical techniques, complications, and outcomes were analyzed. Strengthening the Reporting of Observational studies in Epidemiology(STROBE) cross-sectional reporting guidelines were used. RESULTS: Seventy-three patients had the InterStim implanted. The mean age was 63.29 ± 12.2 years. Fifty-seven (78.1%) patients were females and forty-two (57.5%) patients had diabetes. In addition to incontinence, overlapping symptoms included diarrhea (23.3%), fecal urgency (58.9%), and urinary incontinence (28.8%). Fifteen (20.5%) patients underwent Peripheral Nerve Evaluation before proceeding to definite implant placement. Thirty-two (43.8%) patients underwent rechargeable InterStim placement. Three (4.1%) patients needed removal of the implant. Migration of the external lead connection was observed in 7 (9.6%) patients after the stage I procedure. The explanation for one patient was due to infection. Seven (9.6%) patients had other complications like nerve pain, hematoma, infection, lead fracture, and bleeding. The mean follow-up was 6.62 ± 3.5 mo. Sixty-eight (93.2%) patients reported significant improvement of symptoms on follow-up evaluation. CONCLUSION: This study shows promising results with significant symptom improvement, good efficacy and good patient outcomes with low complication rates while using MRI compatible InterStim for FI. Further long-term follow-up and future studies with a larger patient population is recommended.

Thirty-day readmissions after inpatient laparoscopic cholecystectomy: factors and outcomes.

BACKGROUND: 30-day readmissions are a considerable financial burden on medical institutions due to penalties faced from the Centers for Medicaid and Medicare. METHODS: A retrospective review of 30-day readmissions was performed. The data were subdivided into medical severity-diagnostic related groups 417, 418, and 419, as categorized by the Centers for Medicaid and Medicare. Perioperative variables, diagnostic workup, operative interventions, and postoperative morbidity and outcomes were analyzed. RESULTS: Forty-four (5.9%) readmissions were recorded, of 747 inpatient discharges. The data were further divided into DRGs 417, 418, and 419 with readmission rates of 13.6, 3.6%, and 5.4%, respectively. The highest rate of readmission was within the first 7 days. Etiology was divided into surgical (54.5%) and nonsurgical (45.4%). CONCLUSIONS: Patients with major comorbidities had a higher rate of readmission (P < .05). In 45.4% of the readmissions, the cause was found to be nonsurgical. The surgical team was not consulted in 31.8% of the readmissions.

Minimally Invasive Management of Complicated Diverticular Disease: Current Status and Review of Literature.

BACKGROUND: Diverticulitis is a common condition which carries significant morbidity and socioeconomic burden (McGillicuddy et al in Arch Surg 144:1157-1162, 2009). The surgical management of diverticulitis has undergone significant changes in recent years. This article reviews the role of minimally invasive approach in management of complicated diverticulitis, with a focus on recent concepts and advances. MATERIALS AND METHODS: A literature review of past 10 years (January 2004 to September 2014) was performed using the electronic database MEDLINE from PubMed which included articles only in English. RESULTS: We identified total of 139 articles, out of which 50 were excluded resulting in 89 full-text articles for review 16 retrospective studies, 7 prospective cohorts, 1 case-control series and 1 systematic review were included. These suggest that urgent surgery is performed for those with sepsis and diffuse peritonitis or those who fail to improve despite medical therapy and/or percutaneous drainage. In addition, 3 randomized control trials: DILALA, LapLAND and the Scandinavian Diverticulitis trial are working towards evaluating whether laparoscopic lavage is safe in management of complicated diverticular diseases. Growing trend toward conservative or minimally invasive treatment modality even in severe acute diverticulitis was noticed. CONCLUSIONS: Laparoscopic peritoneal lavage has evolved as a good alternative to invasive surgery, yet clear indications for its role in the management of complicated diverticulitis need to be established. Recent evidence suggests that existing guidelines for optimal management of complicated diverticulitis should be updated. Non-resectional radiographic techniques are likely to play a prominent role in the initial treatment of complicated diverticulitis in the near future.

Animal models of human colorectal cancer: Current status, uses and limitations.

AIM: To make orthotopic colon cancer murine models a more clearly understood subject. The orthotopic tumor models have been found to be more relevant in replicating the human disease process as compared to heterotopic models, many techniques for making orthotopic colorectal murine models have been reported. METHODS: We evaluated the current literature for various reported orthotopic colon cancer models to understand their techniques, advantages and limitations. An extensive literature review was performed by searching the National Library of Medicine Database (PubMed) using MeSH terms animal model; colon cancer; orthotopic model; murine model. Twenty studies related to colon cancer orthotopic xenograft model were evaluated in detail and discussed here. RESULTS: The detailed analysis of all relevant reports on orthotopic model showed tumor take rate between 42%-100%. While models using the enema technique and minimally invasive technique have reported development of tumor from mucosa with tumor take rate between 87%-100% with metastasis in 76%-90%. CONCLUSION: Over the years, the increased understanding of the murine models of human colon cancer has resulted in the development of various models. Each reported model has some limitations. These latest models have opened up new doors for continuing cancer research for not only understanding the colon cancer pathogenesis but also aid in the development of newer chemotherapeutic drugs as they mimic the human disease closely.

The disappearing abdominal mass: mesenteric pseudocyst.

INTRODUCTION: Mesenteric pseudocyst is a term used to describe an abdominal cystic mass with an unknown abdominal origin. They are rare intra-abdominal masses, with a reported incidence of approximately 1 per 100,000 to 250,000 hospital admissions. Most cysts are benign and they may present differently, such as a disappearing mass or a mass that changes locations, thus posing a diagnostic challenge to the clinician. CASE REPORT: We describe a case of a 29-year-old woman who presented with a 2-year history of feeling a large mass within her abdomen, which would then disappear for several days and would frequently change position and be felt in different quadrants of her abdomen. Computed tomography scan of the abdomen revealed a large cystic structure, and a computed tomography- guided biopsy was inconclusive. Diagnostic laparoscopic surgery revealed a firm mass arising from the jejunal mesentery; the patient underwent an en bloc resection. Histopathologic examination of the resected mass revealed a rare diagnosis of mesenteric pseudocyst. Mesenteric pseudocyst should be should be kept high on the list of differential diagnoses when a patient presents with a disappearing mass and/or an abdominal mass that changes location.

A New Type of Renal Cancer--Tubulocystic Carcinoma of the Kidney: A Review of the Literature.

In 2004, A new peculiar subtype of renal cell carcinoma, which later received the name of tubulocystic carcinoma (TCC-RC), was recognized. Though the tumor has distinct macroscopic, microscopic and immunohistochemical features, the tumor was previously considered to have some similarities to various other renal cancers. We did an extensive review of literature using PubMed and CrossRef, which yielded more than 80 cases reported from various parts of the world. We evaluated the epidemiology, tumor presentations, pathological characteristics, treatment, and outcome of TCC-RC.

Tubulocystic Renal Cell Carcinoma: A Rare Renal Tumor.

Tubulocystic renal cell carcinoma of the kidney is a rare entity with less than one hundred cases reported so far. It was previously considered to have some similarities to various other renal cancers although this tumor has distinct macroscopic, microscopic and immuno-histochemical features. It is now a well-established entity in renal neoplastic pathology and has been recognized as a distinct entity in the 2012 Vancouver classification of renal tumors. This review aims to give an overview of tubulocystic renal cell carcinoma after extensive literature search using PubMed and CrossRef.

Delayed presentation of a bowel Bovie injury after laparoscopic ventral hernia repair.

INTRODUCTION: Bowel injury during laparoscopic surgery is a rare but serious complication. A Bovie injury to the bowel can cause delayed perforation of the viscus, thus increasing the possibility of a preventable morbidity. Patients presenting with perforation peritonitis within 24 hours and up to 2 to 3 weeks after laparoscopic Bovie injury to the bowel have been reported in the literature. CASE DESCRIPTION: A 74-year-old woman underwent a laparoscopic ventral hernia mesh repair. Intraoperatively, a small area of superficial Bovie injury to the small bowel was repaired with Lembert sutures and tissue glue. Postoperatively, the patient recovered well, but she presented with perforation peritonitis 3 months after surgery. An exploratory laparotomy showed a jejunal perforation in the same area that was injured with cautery and repaired during the previous surgery. The patient was only using inhaled steroids for asthma on and off but had a remote history of chemotherapy and radiation for colorectal cancer. CONCLUSION: Bovie injury to the bowel has a hidden depth, causing a slow transmural tissue necrosis, and it might also impair local healing and eventually lead to perforation. Thus, the patient may present later than the usual period for wound healing and remodeling as previously reported. Given the disastrous consequence, it is imperative to perform a good surgical repair of even a minor Bovie injury to the bowel. This is the first report of a delayed presentation (>1 month) of a Bovie injury of the bowel.

Intranodal palisaded myofibroblastoma: a review of the literature.

Intranodal palisaded myofibroblastoma is a rare benign primary mesenchymal neoplasm originating from differentiated smooth muscle cells and myofibroblasts. The precise etiology and pathogenesis has not been adequately explained as yet. Very few series and cases have been reported in the literature. Though inguinal region is the commonest site of this rare tumor, but the tumor at other diverse sites have been reported. Because of its rarity, it can be often misdiagnosed and confused with other disorders and more commonly with metastasis. We report an extensive review of literature about intranodal palisaded myofibroblastoma--its characteristics, presentations, features, and management.

A true orthotopic gastric cancer murine model using electrocoagulation.

BACKGROUND: Orthotopic mouse models of human gastric cancer represent an important in vivo tool for testing chemotherapeutic agents and for studying intraluminal factors. Currently, orthotopic mouse models of gastric cancer require an operative procedure involving either injection or implantation of tumor cells in stomach layers. The resultant tumor does not grow from the stomach's mucosal surface, so it does not mimic the human disease process. STUDY DESIGN: A low-dose gastric mucosal coagulation was done transorally in the body of stomach using a specially designed polyethylene catheter in 16 female severe combined immunodeficient mice. This was followed by the instillation of SNU-16 human gastric cancer tumor cells (1 × 10(6) cells). Five mice each were euthanized at 1 and 2 months, and 6 mice were euthanized at 3 months. Three control mice underwent electrocoagulation alone and 3 mice underwent cell line instillation alone. RESULTS: Tumors were detected in 11 of 16 experimental mice, but not in the control mice. Tumors were noted in mice at 1 month. Over time, there was an increase in tumor growth and metastasis to lymph nodes and surrounding organs. Histopathologic evaluation showed that the tumors grew from the gastric mucosa. CONCLUSIONS: Our model is easy to create and overcomes the limitations of the existing models, as the tumor arises from the stomach's mucosal layer and mimics the human disease in terms of morphology and biologic behavior. This is the first report of a true orthotopic gastric cancer murine model. This model opens new doors for additional studies that were not possible earlier.

Intratumoral acetic acid injection eradicates human prostate cancer tumors in a murine model.

INTRODUCTION: To treat localized prostate cancer without substantial morbidity, an ideal treatment would be an effective local therapy with minimal morbidity. Direct injections have been used to treat benign prostatic hyperplasia without major complications, but in limited cases. We evaluated the local oncotoxic effects of acetic acid in a prostate cancer xenograft murine model. MATERIALS AND METHODS: PC3 and LNCaP human prostate cancer cell lines were used to grow subcutaneous tumors in SCID mice. For each cell line, 14 mice underwent intratumor injection with 25% acetic acid (0.05 ml/100 cm3 of tumor) after the tumor was >300 mm3. Post-treatment one mouse/group was euthanized after 2 h, 24 h, 1 and 2 weeks; remaining mice (n = 10) were killed at 120 days. Control mice (8/group) were euthanized after they met the humane criteria for tumor burden and overall health. RESULTS: Tumor necrosis was noted immediately post-injection; by 24 h, ulceration and crusting of overlying skin were noted, which healed into scars by 23 ± 5 days. Histological examination showed tumor degeneration and necrosis with blood vessel obstruction. Ten treated mice in both groups survived for 120 days, which was much longer than the mean survival of PC3 (40 ± 9 days) and LNCaP (56 ± 10) control mice. CONCLUSIONS: Direct injection of acetic acid successfully eradicated both tumors. This treatment option could potentially be used in humans for treatment of early localized prostate cancer and nonoperative management of locally advanced cases. This is the first report of successful local chemical therapy for prostate cancer.

Single-incision laparoscopic cholecystectomy (SILC) using non-articulating instruments and conventional trocars-single surgeon experience.

PURPOSE: Single-incision laparoscopic cholecystectomy (SILC) was first described in 1999. Many techniques using newer instruments have emerged but none has been standardized. We describe our technique and experience, using non-articulating instruments with conventional trocars. METHOD: Patients who underwent SILC over 2 years (July 2009-July 2011) were included in the study group. All consecutive laparoscopic cholecystectomies done during the same period by the same surgeon were included in the control group. Demographic data, previous abdominal surgeries, bile spillage, conversion, and duration of surgery were analyzed. RESULTS: Seventy patients underwent SILC while 115 patients had laparoscopic cholecystectomy. Ninety-three percent of SILCs were done in women as compared to 68 % in the control group (p < 0.0001). More SILC patients were younger (65 % were 30-50 years old) as compared to control patients (40 % were 50-70 years old, p < 0.001). The mean duration of SILC was 68 ± 2.15 min as compared to 66 ± 6.27 min in controls (p < .0001). Of the initial 20 SILC, nine required insertion of additional instruments and one was converted to conventional laparoscopic cholecystectomy. The subsequent 50 cases of SILC had only one conversion (p = 0.001). In the first 20 SILC, one patient (out of three) with BMI above 35 kg/m(2) required conversion to laparoscopic cholecystectomy and one required insertion of an additional instrument. In the subsequent 50 cases, all the six patients with BMI above 35 (up to 40) were operated on successfully without any additional instrument insertion or conversion. CONCLUSIONS: SILC has a learning curve. Patients with symptomatic cholelithiasis, biliary dyskinesia, and cholecystitis, age less than 75 years, and BMI <40 can undergo SILC. With experience, SILC using conventional laparoscopy instruments has comparable outcomes to laparoscopic cholecystectomy in properly selected patients and is economical.

Receptor changes in metachronous breast tumors--our experience of 10 years.

INTRODUCTION: Patients with primary breast cancer (PBC) are at 2 to 6 times higher risk for developing synchronous and metachronous breast cancer (MBC). The pathology and behavior of MBC still remains unclear. METHODS: We reviewed the charts of 108 women with MBC at our hospital over the past 10 years. Profile patterns of the estrogen receptor (ER), the progesterone receptor (PR), and Her2/neu receptors were explored. RESULTS: Of 33 patients with ER(+)/PR(+) in the primary tumor, 23 (70%) retained the status in MBC. Forty-five (92%) of 49 patients with ER(-)/PR(-) in the primary tumor remained the same in MBC. Most Her2(-) tumors (22/31, 71%) remained negative, but 50% (8/16) of Her2(+) tumors became negative. CONCLUSIONS: Most MBC retained the ER/PR expression patterns irrespective of the treatment for the primary tumor, thus suggesting a common origin. Because MBCs tend to be triple negative and thus more aggressive, early detection and close surveillance techniques must be devised.

Transvesical NOTES: survival study in porcine model.

BACKGROUND AND OBJECTIVES: The optimal access route and method for natural orifice transluminal endoscopic surgery (NOTES) has not been established. A transvesical approach, with its low rate of peritoneal contamination, is an effective clean portal of entry, but a safe urinary bladder closure has been a challenge. We developed a new technique for a safe, pure transvesical NOTES approach. METHODS: Four female piglets were used in the study. With the pigs under anesthesia, a flexible cystoscope (15Fr) was used to make an endoscopic cystotomy; diagnostic peritoneoscopy of the abdominal quadrants was done with biopsies and hemostasis. At the end, a Vicryl loop was pushed to close the bladder incision while the incision edges were pulled inwards. The pigs were euthanized after 2 wk, and necropsies were performed. RESULTS: No bowel injury was noted in any of the 4 pigs. Satisfactory bladder closure was done in 2 pigs, while a partial closure was achieved in 1 case. In the postoperative period, the pigs showed no signs of pain or distress, voided normally, and had a good appetite. On necropsy, we noted healed cystotomy incisions, no intraabdominal adhesions, and no adhesions at the site. CONCLUSION: Our new technique for endoscopic cystotomy overcomes previously reported risks for bowel injuries. Using this route gives good spatial orientation and access to all quadrants, including the pelvis. Biopsies with good hemostasis can be easily achieved. Lack of intraperitoneal changes postoperatively indicate that this procedure may be safe for humans.