The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour.

AIM: The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib. METHOD: The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment. RESULTS: Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant. CONCLUSION: Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

[Fournier's gangrene as a delayed complication of closed hemorrhoidectomy].

BACKGROUND: Fournier's gangrene is recognized as a synergistic necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and the vulva in women. The major sources of Fournier's Gangrene are dermatologic, anorectal and genitourinary infections. Although anorectum is remarkably rich in bacterial flora, transanal procedures are generally free of infectious or septic complications. Nevertheless, five cases of Fournier's gangrene post hemorrhoidectomy have been published. OBJECTIVE: To report a case of Fournier's gangrene as a delayed complication of closed hemorrhoidectomy and to demonstrate the management of such complication. PATIENT: A sixty-six years old male who had undergone an uncomplicated closed hemorrhoidectomy was readmitted to the hospital on postoperative day 7 for fever, perirectal erythema and tenderness accompanied by a dirty brown discharge from the wound. The patient was treated with fluid resuscitation and broad-spectrum antibiotics. Radical debridement of the perianal and scrotal region was performed accompanied by diverting colostomy. Four months later a reconstruction of the perianal area was performed by meshed split thickness skin graft and the colostomy was closed. CONCLUSIONS: Fournier's gangrene is a rare immediate or delayed complication of hemorrhoidectomy. A review of the limited available literature suggests that neither the surgical technique nor the medical history of the patient have an influence on the development of such a rare and fatal complication.

Reversal of abnormal glucose metabolism in chronic pancreatitis by administration of pancreatic polypeptide.

Chronic pancreatitis, induced in dogs by pancreatic duct ligation, is associated with glucose intolerance due to insulin deficiency, reduced hepatic sensitivity to insulin, and a marked deficiency of pancreatic polypeptide. Treatment with a 14 day continuous subcutaneous infusion of pancreatic polypeptide resulted in improved oral glucose tolerance and improved hepatic glucose responses to insulin in dogs with chronic pancreatitis. No effect of continuous subcutaneous infusion of pancreatic polypeptide was seen in the control dogs. The time course of the effect of continuous subcutaneous infusion on the hepatic response to insulin was relatively immediate, whereas the effects on improvement in oral glucose tolerance were prolonged. We conclude that pancreatic polypeptide may function physiologically to enhance the hepatic glucose response to insulin and that alterations in glucose metabolism seen in chronic pancreatitis may be due, in part, to a deficiency in pancreatic polypeptide. Since treatment with continuous subcutaneous infusion of pancreatic polypeptide restored the hepatic response to insulin and oral glucose tolerance to more normal levels in our animal model, administration of pancreatic polypeptide may play a therapeutic role in the treatment of certain forms of pancreatogenic diabetes.

Relationship between biological changes and symptoms and health behaviour during the climacteric.

The object of this investigation was to assess the impact of biological (hormonal) changes during the climacteric on self-reported health status and health behaviour in a group of middle-aged women. The central research question was whether or not the menopausal phase (pre, peri, post) affects the number and frequency of the symptoms a women reports, the frequency of her visits to the primary-care clinic and her perception of her general state of health. The subjects comprised a random sample of 47 women aged 48-53 yr who were judged by their family doctors to be healthy or to be suffering from a chronic disease which was inactive at the time the study was carried out. The women were chosen from among a population of married couples under investigation in a larger study. The sample was homogeneous both ethnically (all subjects born in North Africa) and in terms of social class (lower to lower-middle class). No relationships were found between menopausal phase and any of the health criteria considered. The number and frequency of symptoms was low for all the women. Only a small number of women (2-10%) reported a frequent occurrence even of symptoms that are considered to be direct consequences of hormonal changes. These findings conflict with those deriving from studies of women attending gynaecological clinics, but confirm those of other community (non-clinic) studies. The results of this study bear out the general theoretical conclusion that climacteric symptoms are 'psychological and cultural artifacts' rather than consequences of biological changes.

Sexual satisfaction among middle-aged couples: correlation with frequency of intercourse and health status.

The central hypothesis of this investigation is that the greater the sexual satisfaction that a couple reports from their sexual relationship, the better will be their adjustment to the changes that occur during middle age, as reflected in their reported health status and health behaviour. Forty-seven married couples, of North African Jewish origin, were investigated, the women being in the age range 48-53 yr. The findings regarding reported frequency of sexual intercourse and sexual satisfaction of women and men separately showed that a great majority of both men (87%) and women (74%) reported a decrease in sexual activity over the 5 yr preceding the study. Most of the men (56%) said the change was due to the aging process, whereas the women's responses were more varied and included aging, worries and decrease in sexual interest or desire. Eighty percent of the men reported satisfaction in their sexual relationship with their wives, but only 43% of the women stated that they were satisfied. A significant correlation was found, for women only, between the degree of satisfaction and the change in frequency of intercourse. Among the women there was also a positive correlation between general life satisfaction and sexual satisfaction. The hypothesis in regard to mutual (couple) sexual satisfaction was not confirmed in the men. It was validated in the women in regard to only two of the four criteria used - their perception of their health status and of their well-being. The women perceived the sexual satisfaction of their husbands much more accurately than the husbands perceived that of their wives.

Sigmoid colon carcinoma metastatic to the myometrium.

Metastases to the uterus from extragenital cancers are significantly rarer than metastases to the ovaries. Of the approximately 200 cases of metastases to the uterus from extragenital cancers that have been reported in the literature, more than half are cases of metastases from breast carcinoma and only 16 are cases of metastases from colorectal carcinoma. A case of isolated metastases restricted to the myometrium of the right uterine comu from sigmoid colon carcinoma, without involvement of the ovaries, is described. The patient who six months previously had surgery for sigmoid colon carcinoma presented with right lower abdominal pain and a palpable mass in the region of the right uterine cornu. The diagnosis of isolated metastases restricted to the myometrium of the right uterine cornu was confirmed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. This case illustrates that a growing uterine mass in a patient with a history of primary extragenital cancer, regardless of whether abnormal uterine bleeding is present or absent, should alert the physician to consider the possibility of uterine metastases.

Perianal and gluteal burns as a complication of hot water bottle treatment for anal fissure.

Contact with hot objects and surfaces often causes burns. We present a case of burns to the buttock and perineum caused by use of a hot water bottle to relieve the pain caused by an anal fissure.

[Uncommon presentation of perforated colonic diverticuli].

Diverticulosis of the colon is common in the sigmoid, but much less so in the cecum, ascending or transverse colon. We report 2 patients who presented with clinical findings of perforated diverticulitis of the transverse and left colon. A 42- and a 46-year-old man underwent extended right and left hemicolectomies, respectively. The first patient ran an excellent postoperative course. In the second, in whom a double-barrelled colostomy was formed, the proximal colostomy had to be redone because of stomal retraction, but both stomata eventually were closed. On follow-up both patients are symptom-free. The diagnosis of diverticulitis with complications should be considered in patients who present with intra-abdominal masses. Preoperatively, the condition often cannot be differentiated from carcinoma.

[Nd:YAG laser for anorectal surgery: initial experience in Israel].

The use of laser in gastrointestinal diseases started in the mid-70's. The 3 types of laser in use today are CO2, argon and Nd:YAG. We present the first clinical results in Israel of the use of the Nd:YAG laser in anorectal surgery. Between Oct. '91-Dec. '92, 275 patients with anorectal diseases (mostly hemorrhoids, anal fissures and fistulas) and 67 with various perineal lesions were operated on. Within an hour of the end of the operation, most patients were discharged to home with detailed follow-up instructions. 8 needed an extra day of observation in hospital. Postoperative complications included: bleeding (8 patients), wound infection (4) and urinary retention after hemorrhoidectomy (8). 1 patient complained of anal laxity after sphincterotomy, and 4 of recurrence of anal fissure. It is our impression that after laser hemorrhoidectomy patients return quickly to their normal lives; that the rate of complications is not greater than after other accepted techniques; and that the laser method for anal fistulectomy is most efficacious.

[Adjuvant therapy of colon cancer stage C MAC. Adverse effects and efficacy in the Department of Oncology, Soroka Medical Center in the years 1991-1994].

The National Institutes of Health (NIH) held a consensus conference which recommended 5-FU and levamisole as adjuvant chemotherapy for colon cancer MAC (Modified Astler Coller) stage C. From 1991-1994, 37 such patients diagnosed here were treated with 5-FU (intravenous dose of 450/mg/m2/d for 5 days and from day 29, once a week for 48 weeks) and oral levamisole (50 mg 3 times/d. for 3 days, every 2 weeks for a year), as suggested by NIH guidelines. 16 patients were males and 21 were females, mean age was 62 years and median 64. Cancer locations were: right colon (in 16, 43%), left colon (19, 51%), multiple colon primaries (2, 1%). 25 (68%) had 1-3 positive lymph nodes and 12 (32%) had 4 or more positive lymph nodes. Only 20 (54%) finished treatment as prescribed. In the others, 1 or both drugs caused side-effects for which the drugs had to be stopped. 6 patients relapsed while on treatment. The most common side-effects were diarrhea, stomatitis and bone marrow suppression. 3 were hospitalized due to neutropenic fever. 5-year actuarial survival of all patients was 61%; 5-year relapse-free survival was 61%; 5-year relapse-free survival of right versus left colon was 41% and 82%, respectively (p < 0.01). There was no significant difference in 5-year survival of those with 1-3 positive lymph nodes as compared to those with 4 or more (62% and 56%, respectively). 5-year survival in those who finished or did not finish treatment (excluding those who stopped treatment because of progressive disease) was 83% and 70%, respectively (NS). The 5-year survival of our series was similar to that of patients treated similarly elsewhere. The 5-FU and levamisole treatment was not tolerated well by our study population. It has recently been replaced in our service by a 5-FU and leucovorin regimen given for 6 months.

[Circumcision of new immigrants].

Recent immigration from eastern Europe to Israel (1990-1992) has brought to the Negev many uncircumcised newcomers. The rationale for circumcising healthy children has been a matter of controversy, not yet settled. Healthy adults are not usually circumcised except for ritual reasons. In the past 3 years we circumcised 2857 males 1-64 years old, mostly of Russian origin. All were operated on as outpatients on a 1-day, ambulatory service. 75% of the newcomers were operated on during the first 6 months after immigration. 86% of the circumcisions were done under general anesthesia and the rest under local. After stretching the prepuce backwards, the foreskin was excised. Hemostasis was achieved with the aid of electrocautery and the skin was approximated with in absorbable sutures. All patients were re examined 1 week later. There were complications in 50 (1.75%), consisting mostly of postoperative bleeding and wound infections. We conclude that ritual circumcision is a safe procedure in normal adults.

[Laparoscopic-assisted colectomy].

After gaining experience in laparoscopic cholecystectomy, laparoscopic appendectomy and other laparoscopic procedures, we decided to perform laparoscopic-assisted colectomy. During July 1992 to February 1993 we performed 14 such procedures. Ages ranged from 46-83 years (mean, 68). In all cases the indication for surgery was neoplasm of the colon. 8 of the tumors were located in the right colon and 6 in the sigmoid. Procedures performed were laparoscopic-assisted right hemicolectomy with a biofragmentable anastomotic ring or laparoscopic-assisted sigmoidectomy with end-to-end anastomosis. In 1 operation we combined laparoscopic cholecystectomy with laparoscopic right hemicolectomy. Operation time varied from 90-130 min (mean, 100 min). In our opinion the procedure is as radical as standard laparotomy with the number of lymph nodes per specimen ranging from 4-10 (mean, 7); the surgical margins were free of tumor in all cases. There was less pain in the postoperative period than with the standard procedure and the average time from operation to discharge was 7 days (range, 5-9). Complications included 1 fatality due to postoperative myocardial infarction, and 1 case of duodenal perforation which was sutured during the operation. We conclude that laparoscopic-assisted right hemicolectomy and laparoscopic sigmoidectomy are feasible for carcinoma, and that recovery is quicker and with less pain. However, we need a larger series and long-term follow-up to conclude whether the laparoscopic assisted technic is an adequate operation in cases of cancer.

Rectal bleeding and previous anticoagulant treatment in patients with colorectal cancer do not predict outcome.

BACKGROUND: The aim of this study was to determine whether the outcome of patients with colorectal cancer who presented with bleeding and a history of anticoagulant treatment was different from those who did not have bleeding or previous anticoagulant treatment. METHODS: This was a single institution, retrospective study of patients with colorectal cancer with and without a history of rectal bleeding and treatment with anticoagulants, assessed for age, gender, tumor site, stage, recurrence rate, and survival. RESULTS: A total of 621 consecutive patients (309 men) with a mean age of 70 years (range, 36-94 years) diagnosed with colorectal cancer between 1998 and 2004 were studied. Of these, 149 patients (24%) were referred for symptoms of rectal bleeding and 161 patients (26%) had been previously treated with anticoagulants. A total of 592 patients (95%) underwent curative or palliative surgery; endoscopic polypectomy was performed in 3 cases only and in 26 patients (4%) surgery was not performed due to advanced disease or critical illness. Patients with bleeding and a history of anticoagulant treatment presented commonly with stage I cancer. In addition, tumor stage III was less common in patients with previous anticoagulant treatment irrespective of presenting signs. Disease-free and overall survival rates were similar in all groups, irrespective of bleeding at presentation or anticoagulant treatment. CONCLUSIONS: Rectal bleeding and anticoagulant treatment do not affect the outcome of newly diagnosed patients with colorectal cancer.

Brachial plexus injury as a complication after colorectal surgery.

Peripheral neuropathy associated with anesthesia is a significant source of morbidity and the second most frequent cause of professional liability in anesthetic practice. Nerve injuries are a well-recognised complication of anesthesia. Brachial plexus neuropathy is a rare syndrome with an incidence of 1.6 cases per 100,000. Unfortunately, we have a limited understanding of the relations between conventional perioperative care and the genesis of peripheral neuropathy. We describe 3 cases of postoperative brachial plexus neuropathy that occurred after abdominoperineal anterior resection for rectal cancer. The symptoms resolved postoperatively in two patients by 8 weeks and in one patient by 10 weeks with conservative treatment. The differential diagnosis between brachial plexus neuropathy and other peripheral neuropathies is important, as the prognosis of brachial plexus neuropathy is generally better. The anesthetist and the surgeon should know the risks of positioning to prevent nerve injuries, and should be aware of the possibility of brachial neuropathy in order to properly make an early diagnosis.

Combined treatment of basaloid anal carcinoma using cisplatin, 5-fluorouracil and resection of hepatic metastasis.

The combination of chemotherapy and radiotherapy with subsequent repeated local biopsy has become the standard treatment of epidermoid carcinoma. The optimal treatment of metastatic anal carcinomas is controversial. We present the case of 54-year-old woman with a diagnosis of metastatic basaloid anal carcinoma. The patient underwent resection of liver metastasis in combination with cisplatin + 5FU and local radiotherapy, without evident disease 3 years after diagnosis.