Non-steroidal anti-inflammatory drug induced intestinal stricturing: diaphragm disease.

Diaphragm disease (DD) is a rare small bowel enteropathy associated with non-steroidal anti-inflammatory drug use. Since the first description there have only been approximately 100 cases of DD reported in the literature. Stricturing webs or 'diaphragms' form in the bowel, causing non-specific abdominal symptoms that can ultimately lead to bleeding and obstruction. Diagnosis is notoriously challenging as there is no single gold standard investigation. We present two cases of DD both of which were ultimately diagnosed by surgical resection. We also propose a novel flow algorithm that can be utilized for working up patients with suspected DD.

Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis.

BACKGROUND: The goal of the present study was to critically review and identify the strength of available evidence in the literature on the use of laparoscopic appendectomy (LA) in complicated appendicitis (CA). METHODS: The Cochrane Library and Controlled Trials Registry, MEDLINE (Ovid), PubMed, Web of knowledge, and SCOPUS databases were electronically searched, using the keywords "appendectomy," "laparoscopy," "appendicitis." "complicated appendicitis." "gangrenous appendicitis," "perforated appendicitis," with English language as a limit. Backward chaining was also employed. The NHS Public Health Resource Unit Critical Appraisal Skills Programme Tools were used for critical appraisal. RESULTS: Twelve retrospective case-control studies were included in the review. Overall methodological quality was moderate to poor, with heterogeneity, absence of randomization and blinding, and presence of important methodological flaws. Meta-analysis showed that LA in CA has reduced surgical site infection (SSI) rates compared to open appendectomy (OA), odds ratio (OR) 0.23, 95% confidence intervals (CI): 0.14-0.37 (level 3a evidence), and no difference with regard to intra-abdominal abscess (IAA) complication rates OR: 1.02, 95% CI 0.56-1.86 (level 3a evidence). CONCLUSIONS: When compared to OA, laparoscopic appendectomy is advantageous in CA with regard to SSIs, with no significant additional risk of IAA (level 3a evidence).

Stapled transanal rectal resection for obstructed defecation: a cautionary tale.

PURPOSE: This prospective study was designed to assess the efficacy and safety of a novel technique in treating outlet obstruction syndrome using a transanal double-stapling procedure. METHODS: Two hundred thirty patients (187 female) with obstructed defecation underwent stapled transanal rectal resection over a six-year period with follow-up at 2, 6, and 12 months, then yearly; median follow-up was 24 (range, 12-68) months. All failed conservative measures. Patients with slow transit constipation and puborectalis dyssynergia were excluded. RESULTS: Operating time was short (median, 35 (range, 20-95) minutes), with 159 (69%) performed as day cases (outpatient). Major complications were seen in 16 (7%); there were no deaths. Twelve (5%) patients reported severe postoperative pain. Immediate postoperative fecal urgency was reported by 107 (46%) patients, but persisted at six months in only 26 (11%). Three (1%) developed recurrent rectal prolapse. Nearly all incontinent patients (98%) reported an improvement, with a median Wexner score reduction of 5 points (P < 0.0001). Constipation improved in 77% of patients. Seventy-seven percent of patients were "very glad" they had the operation, and 86% "recommended" stapled transanal rectal resection to a friend. CONCLUSION: Stapled transanal rectal resection can be performed on a day-case basis with high levels of patient satisfaction. Incontinence and constipation are improved. However, significant morbidity occurs in 7% of patients, and urgency of defecation persists beyond six months in 11%.

Eotaxin-2 and colorectal cancer: a potential target for immune therapy.

PURPOSE: To study the production of chemokines by colorectal hepatic metastases. EXPERIMENTAL DESIGN: Biopsies of resected colorectal hepatic metastases and nonneoplastic adjacent liver tissue were screened for chemokines using protein arrays and results were confirmed by ELISA and immunohistochemistry. RESULTS: Two chemokines, eotaxin-2 and MCP-1, were found at elevated levels within the tumor biopsy compared with adjacent liver. The relative increase in expression from tumor was much higher for eotaxin-2 than MCP-1, with 10 of 25 donors having a >100-fold increase in expression compared with 0 of 24 donors for MCP-1. In a parallel analysis, eotaxin-2 was also found at elevated levels in the tumor region of primary colorectal cancer biopsies. Immunohistochemical staining indicated that carcinoembryonic antigen-positive tumor cells stained strongly for eotaxin-2, implicating these cells as the predominant source of the chemokine. In vitro studies confirmed that several colorectal tumor lines produce eotaxin-2 and that secretion of this chemokine could be depressed by IFN-gamma and enhanced by the Th2-type cytokines interleukin-4 and interleukin-13. Jurkat T cells were engineered to express the receptor for eotaxin-2 (CCR3). These cells effectively migrated in response to eotaxin-2 protein, suggesting that immune cells gene modified to express a chemokine receptor may have improved abilities to home to tumor. CONCLUSIONS: Taken together, these observations confirm eotaxin-2 as a chemokine strongly associated with primary and metastatic tumors of colorectal origin. Furthermore, the importance of this result may be a useful tool in the development of targeted therapeutic approaches to colorectal tumors.

Calcium carbonate gallstones in children.

BACKGROUND: In the United States, cholesterol stones account for 70% to 95% of adult gallstones and black pigment stones for most of the remainder. Calcium carbonate stones are exceptionally rare. A previous analysis of a small number of pediatric gallstones from the north of England showed a remarkably high prevalence of calcium carbonate stones. The aims of this study were to analyze a much larger series of pediatric gallstones from our region and to compare their chemical composition with a series of adult gallstones from the same geographic area. METHODS: A consecutive series of gallbladder stones from 63 children and 50 adults from the north of England were analyzed in detail using Fourier transform infrared microspectroscopy. Demographic and clinical data were collected on all patients. The relative proportions of each major stone component were assessed: cholesterol, protein and calcium salts of bilirubin, fatty acids, calcium carbonate, and hydroxyapatite. RESULTS: Thirty-nine (78%) adults had typical cholesterol stones, 7 (14%) had black pigment bilirubinate stones, and only 2 (4%) had calcium carbonate stones. In contrast, 30 (48%) children had black pigment stones, 13 (21%) had cholesterol stones, 15 (24%) had calcium carbonate stones, 3 (5%) had protein dominant stones, and 2 (3%) had brown pigment stones. In children, cholesterol stones were more likely in overweight adolescent girls with a family history of gallstones, whereas black pigment stones were equally common in boys and girls and associated with hemolysis, parenteral nutrition, and neonatal abdominal surgery. Calcium carbonate stones were more common in boys, and almost half had undergone neonatal abdominal surgery and/or required neonatal intensive care. CONCLUSION: The composition of pediatric gallstones differs significantly from that found in adults. In particular, one quarter of the children in this series had calcium carbonate stones, previously considered rare. Geographic differences are not the major reason for the high prevalence of calcium carbonate gallstones in children.