Mechanical small bowel obstruction precipitated by colonoscopy.

Mechanical small bowel obstruction (SBO) is rare complication of colonoscopy. We present a patient who developed SBO 24 h after surveillance colonoscopy. Four years prior to this procedure, he had undergone augmentation cecocystoplasty with continent ileal conduit. He subsequently underwent laparotomy and lysis of a band adhesion that caused extrinsic compression of the ileum proximal to ileotransverse colostomy. We further review the literature, describe the salient features of colononoscopy-induced bowel obstruction, and identify the risk factors for this unusual complication.

Blood supply of hemipelvectomy flaps: the anterior flap hemipelvectomy.

In posterior flap hemipelvectomy, preservation of the gluteus maximus with the flap guarantees its viability regardless of the level of ligation of the iliac vessels. In anterior flap hemipelvectomy with the quadriceps femoris attached to the flap, the dominant blood supply is through the lateral femoral circumflex branches of the profunda vessels, which is sufficient to maintain the flap.

Management of resectable rectal cancer: an update.

Successful management of rectal cancer entails adequate assessment of patient related risk factors (co-morbid conditions, body habitus, anal sphincter function) and tumor characteristics (level, stage, and histo-morphologic features), and adequate knowledge of available diagnostic and therapeutic modalities. This report provides an update on sonographic assessment, operative management, neo-adjuvant therapy, and follow up of resectable potentially curable rectal cancer.

Desmoid tumour: a pleomorphic lesion.

BACKGROUND: Desmoid tumour (DT) is an uncommon locally invasive non-metastasizing neoplastic lesion. The aetiology of this tumour is unknown and its treatment is controversial. Twelve cases of DT are presented and the literature is reviewed. METHODS: Twelve cases of DT treated at our institution during a 3.5-year period are analysed and the literature reviewed. Ten patients were referred with a primary tumour, one with local recurrence and one patient with a second primary desmoid tumour. One patient had multiple mesenteric DT (familial adenomatous polyposis coli-FAP), and in the remaining 11 patients the tumour was located in the abdominal wall in four, at an extremity in three, in the upper back in two patients, in the pelvis in one and retroperitoneally in one. RESULTS: The largest mesenteric DT was marginally excised en bloc with total jejunectomy. In the remaining 11 DT, complete excision to microscopically tumour-free margins was possible in nine cases and to microscopically involved margins in two cases. At a mean follow-up of 22 months (range 7-38 months), one patient was alive with stable disease (Gardner's syndrome), 10 patients were alive and free of recurrence and one patient (9%) developed local recurrence which was re-excised-she is disease-free 10 months later. CONCLUSIONS: Complete excision is the main modality of treatment for primary and recurrent DT. This is feasible in most cases except for tumours involving the base of the bowel mesentery. Surgical resection alone achieved local control of the tumour in most of the patients in this series (92%).

Thromboembolic disease susceptibility related to red cell membrane fluidity in patients with polycythemia vera and effect of phlebotomies.

Thromboembolic disorders are frequent complications in polycythemia vera. In addition to thrombocytosis with hyperaggregability, leukocytosis, and high hematocrit, hyperviscosity syndrome, a new component, is described in the pathophysiology of this phenomenon. There is decreased red cell membrane fluidity with decreased deformability which increases the susceptibility to microvascular occlusion and also increases the chance of disseminated intravascular coagulation (DIC). Periodic phlebotomies improved the hematologic picture in these patients and results in the removal of the "stiff" red cells with an increased production of young red cells, greater membrane fluidity, deformability and less chance of microvascular occlusion.

Results of immunoscintigraphy using a cocktail of radiolabeled monoclonal antibodies in the detection of colorectal cancer.

BACKGROUND: External immunoscintigraphy using a single monoclonal antibody has been employed successfully to localize primary, recurrent, and occult colorectal carcinoma. This prospective study investigated the accuracy and sensitivity of external immunoscintigraphy when the combination or "cocktail" of radiolabeled monoclonal antibodies, CYT-103 (an IgG1a) and CYT-372 (an IgG2b) directed against TAG-72 and CEA, respectively, is given to patients with known or suspected colorectal cancer. METHODS: Eleven patients enrolled in this open label phase I/II study underwent preoperative external immunoscintigraphy after intravenous cocktail administration of two indium 111-labeled monoclonal antibodies (MoAb), CYT103 and CYT372. Antibody dose ranged from 0.2 mg (five patients) to 1.0 mg (six patients), each antibody radiolabeled with 2.5 mCi of indium 111, delivering a total dose of 5 mCi per patient. Planar and SPECT images were performed 2 to 5 days postinjection. Suspected lesions were surgically resected within 2 weeks of injection. RESULTS: A total of 23 lesions (sites) were identified in the eleven patients, 19 of which were confirmed by pathology (hematoxylin and eosin [H&E]). Cocktail immunoscintigrams identified 16 of the 19 confirmed lesions. Computed tomography (CT) scan detected 9 of the 19 lesions. The sensitivities of cocktail immunoscintigraphy and CT scan for the detection of colorectal cancer were 84% and 64%, respectively. The positive predictive value for immunoscintigraphy was 94%. The antibody scans detected six occult, previously unsuspected lesions. Cocktail immunoscintigraphy changed the surgical management in four of the 11 (36%) patients. CONCLUSIONS: The combination of In 111 CYT-103 and CYT-372 improved the sensitivity of external immunoscintigraphy for the detection of colorectal cancer compared to that obtained with a single MoAb imaging. Cocktail antibody imaging may enhance the staging and management of patients with cancers of colon and rectum.

Anal duct/gland cyst: report of a case and review of the literature.

PURPOSE: The purpose of this communication is to report a case of anal duct/gland cyst and review cases of perianal and presacrococcygeal mucus-secreting cysts reported in the literature with emphasis on their histopathologic features. METHOD: Our patient presented with coccydynia. An extraluminal retrorectal tumor was felt on rectal examination. A computerized tomographic scan demonstrated a presacrococcygeal mass closely related to the anorectal junction. The tumor and the coccyx were excised using a posterior approach. Cases of perianal and presacrococcygeal mucus-secreting cysts reported in the literature were reviewed. RESULTS: In our case, the tumor proved to be an anal duct/gland cyst. Some of the reported cases of presacrococcygeal glandular cysts had histopathologic features suggestive of anal duct/gland origin. CONCLUSION: Diagnosis of anal duct/gland cyst is based on routine histologic features, histochemical characteristics of mucus, and/or the presence of a communication with an anal duct or crypt. Based on these criteria, some of the reported cases of mucus-secreting cysts occurring around the anorectum may prove to be anal duct/gland in origin.

Leiomyosarcoma of the inferior vena cava: a clinicopathologic review and report of three cases.

BACKGROUND AND OBJECTIVES: We operated on three patients with leiomyosarcoma of the inferior vena cava. METHODS: Complete excision was possible in all three patients. RESULTS: One patient developed widespread metastasis at 23 months, one patient is alive with no evidence of disease at 70 months, and one patient is alive at 15 months. The third patient had subcutaneous and pulmonary metastases at the time of presentation, which are radiologically nondetectable at present following postoperative chemotherapy. CONCLUSIONS: The clinicopathologic features, prognostic factors, and treatment of 130 cases found in a comprehensive literature search and our three cases are reported.

Basal cell carcinoma arising in a fistula-in-ano.

Fistula-in-ano can be complicated by malignant degeneration. A case of basal cell carcinoma identified in the curettage specimen of a fistulotomy is reported. The clinicopathologic features of cases reported in the literature are reviewed.

Multimodality treatment of squamous cell carcinoma complicating pilonidal disease.

Malignant degeneration is an unusual complication of chronic primary or recurrent pilonidal disease. To date, only 43 cases have been reported, the great majority being squamous cell type. Historically, these cases were treated with primary excision. Recurrence following such treatment was high and prognosis poor compared with nonmelanoma skin cancer. We describe a patient with squamous cell carcinoma arising in chronic pilonidal disease, who is disease-free 3 years after adjuvant radiation therapy following radical excision. This communication describes the clinicopathologic features of 38 cases of squamous cell carcinoma arising in pilonidal disease and suggests treatment modalities.

The role of immunoscintigraphy in the staging and management of colorectal cancer.

Colorectal cancer has continued to increase in incidence over the past 25 years. It now ranks as the second most common noncutaneous malignancy for men and women together. The projected 1995 statistics predict 153,000 new cases in the United States, with 109,000 of colonic origin and 44,000 cancers of the rectum. The shift to more proximal colonic involvement and a decrease in size of the presenting lesion is again noted. Unfortunately, the warning signals (rectal bleeding, change in bowel habits and, later, abdominal pain, distention, and weight loss), often become evident only after the tumor has progressed significantly in the patient. Despite improvements in endoscopic detection, anesthesia, pre- and postoperative care and more extensive en-bloc resections, the cure rate for all patients with colorectal cancer remains unchanged at 53 per cent at five years. Although radical resectional surgery is relied on for locoregional control of the disease, there has been an increased use of cross-sectional radiologic studies for staging of the cancer. This newer management of colorectal cancer is the result of a better understanding of the natural history and biologic behavior of the cancer. The main strategy presently is to diagnose the disease sooner, stage the cancer more accurately, select tumors that will respond to adjuvant therapy, and detect recurrences more efficiently. It is in the area of staging of the primary tumor and accurate localization of recurrences that this new modality, immunoscintigraphy, is felt to have an impact.

Barotrauma complicating duodenal perforation during ERCP.

Diagnostic endoscopic retrograde cholangiopancreatography (ERCP) is a remarkably safe procedure in experienced hands. A series of complications directly related to both the manipulation and cannulation of the ampulla of Vater, as well as consequent to medication and cardiorespiratory events, has been described. Herein we report a case of severe barotrauma complication of diagnostic endoscopic cholangiography.

Squamous cell carcinoma complicating idiopathic inflammatory bowel disease.

Squamous cell carcinoma of the colon and rectum, originating proximal to the transitional zone, is a rare complication of idiopathic inflammatory bowel disease (IIBD). To date there are only 15 single case reports of such an occurrence. This carcinoma develops more commonly in females and in patients with pancolonic disease of more than 8 years' duration. The rectum is affected in two thirds of the cases. Squamous cell changes, in the vicinity of the primary adenocarcinoma, are present in 27% of cases. The carcinoma is in a pathologically advanced stage in one third of the cases. Colectomy is the main therapeutic modality. Survival following surgical resection ranged from 7 months to 21 years. We present an additional case of rectal squamous cell carcinoma (SCC) complicating chronic ulcerative colitis in a 33-year-old woman who had the disease for 15 years. Multiple biopsies of a gross lesion located 5 cm above the dendate line were consistent with invasive basaloid cell carcinoma. The patient received 5-FU, mitomycin C, and radiotherapy prior to a proctocolectomy and ileostomy. The only histopathologic finding at pathologic review of the surgical specimen was severe squamous dysplasia.

Embolization of illicit needle fragments.

Complications encountered with retained or embolized foreign bodies (FB) are mainly reported in association with invasive intravascular monitoring or diagnostic devices. Retrieval of these large FB is recommended. On the other hand, the embolization of hypodermic needle fragments in the intravenous drug abuser is infrequently reported. The natural history and management of this complication is controversial. To date, only ten cases have been reported in the literature. We present a case of a hypodermic needle fragment that embolized to the lung from a forearm vein of an intravenous drug abuser. The embolization occurred during an attempt at removal of the needle fragment from the vein at the injection site. The needle fragment lodged in the lung parenchyma and was left in situ. No complications related to the needle occurred during a 10-month follow-up.

A complication of the Greenfield filter: fracture and distal migration of two struts--a case report.

This is a case report of a 41-year-old woman who required surgical removal of a Greenfield filter 7 months after placement. The filter developed several complications. Two struts were noted to be completely separated from the filter and lodged in the infrarenal vena cava. The filter had migrated to a resting position in the right renal, vein with two struts perforating the renal vein and inferior vena caval junction. The perforating struts were intraperitoneal and were found to impinge on the right ureter with seromuscular involvement of the second portion of the duodenum. No free perforation was noted at the time of exploration.