Klippel-Trénaunay syndrome associated with great saphenous vein aplasia

Klippel-Trénaunay syndrome (KTS) is a rare, sporadic, congenital vascular disease of unknown aetiology. KTS could be associated with infliction of other regions. An association with great saphenous vein aplasia has never been described.

[Hybrid procedures in the treatment of type IV and V thoracoabdominal aneurysms]

OBJECTIVE

To evaluate our experience with hybrid endovascular and open surgical treatment of thoracoabdominal aneurysms.

MATERIAL AND METHODS

Between 1996 and 2008 8 patients with thoracoabdominal aneurysm (6 Crawford type IV and 2 type V) from the total of 257 aortic aneurysms with elective endovascular repair were treated using hybrid procedure. A retrograde revascularisation of visceral and renal arteries through the open access and endovascular exclusion of aneurysms using a stent-graft were done.

RESULTS

A primar technical success of the hybrid procedure was in all cases. There was no severe ischaemia of visceral organs, kidneys (no need of haemodialysis) or spinal cord (paraplegia). One patient died on an acute pancreatitis 14 postperative day. Further follow up (in range 16-52 months) showed henceforth a successful exclusion of all the aneurysms without evidence of endoleak and patency of all bypasses with a good function of revascularised organs.

CONCLUSION

Owing to minimal haemodynamic load and technical simplicity with a short time of organ ischaemia hybrid procedure represents an acceptable possibility of type IV and V thoracoabdominal aneurysms repair.

Peroneal nerve injury during varicose veins surgery

AIM

The aim of the presented work was to assess the causes of injury to great nerves during varicose vein surgery and comment on the consequences.

METHODS

This was a retrospective study of 2344 patients operated on for primary varicose veins between the years 1980 and 2005.

RESULTS

In three patients out of 2344 the peroneal nerve was injured. The three patients underwent neurosurgery. In the first patient transplantation of the sacral nerve was performed. In the second patient the nerve was released from ligatures, and in the third patient the nerve was first released from the cicatrice and the transposition of the tendon of the posterior tibial muscle followed. All three patients went through intensive rehabilitation. The first patient still wears peroneal splint, the limb is atrophic. In the second patient the function has been well restored and he is not disabled anymore. However, the restitution of the lower limb function is not sufficient for him to work as a teacher of physical education. The third patient still suffers from serious paresis of the peroneal nerve.

CONCLUSIONS

Even a frequent and relatively simple intervention such as varicose vein surgery may be accompanied by serious complications affecting patients for the rest of their lives. Serious motor nerve injuries are encountered only in operations in the popliteal fossa and the fibula head. Complications are more frequent when operations are performed by young general surgeons than when they are performed by an experienced surgeon or an expert in vascular surgery. The affected patients should be referred for neurosurgery; however, results are unpredictable. In spite of an intensive rehabilitation and possible plastic surgery the patients are permanently affected.

Support for the small saphenous vein surgery

AIM

The aim of the present work was to assess the new device for the small saphenous vein surgery.

METHODS

The authors described the device which has been used since 2003 without any complications.

RESULTS

The primary objective of varicose veins surgery is to eliminate reflux in saphenofemoral junction and saphenopoplietal junction. In concurrent surgery of both long and small saphenous veins the patient must be rotated on the operation table. The authors describe their own mechanism supporting the elevated leg during the surgery so that it is not necessary to rotate the patient while the area of small saphenous vein is well accessible.

CONCLUSIONS

The support for small saphenous vein (surgery appears to be a simple and effective device making the preparation in the area of fossa poplitea much easier and comfortable. The patient's position is not changed and, therefore, it is not necessary to disinfect and dressing anew the operation table. This allows to save time and money at the same time.

[Infrarenal aortic graft infection]

INTRODUCTION

The incidence of vascular replacement infection is reported between 0.5-6.0%. The infection of aortal valve replacement is usually managed by its removal and axilofemoral reconstruction. Replacement removal and reconstruction in situ is another alternative. The aim of our work is to give the comparison of the results obtained with the extra-anatomic reconstruction and alternative techniques.

MATERIALS AND METHODS

Between January 1987 and August 2008 1324 abdominal aortal replacements were performed in our department. In 14 patients (1.05%) the infection of the replacement occurred; one of the patients was operated on in another hospital. In eight patients axilobifemoral/axilopoplietal by-pass was applied (Group A). In two patients the whole replacement was removed together with in situ reconstruction (ISR) using a new bifurcation replacement. In two patients a partial resection of the replacement and the resected part substitution or femoro-femoral cross-over by-pass was performed. Three patients were treated with a total or partial replacement removal without the following reconstruction.

RESULTS

In Group A no haemorrhage from the aortal stub occurred. The mean value of surgical management due to the replacement infection was 3.5 (1-6). For Group B the number was 5 (1-16). In Group B there were three reinfections, in Group A none. In both Group A and B one patient died; one thigh amputation was necessary in Group A, two in Group B.

CONCLUSIONS

The partial or total removal of the replacement followed with in situ reconstruction is considered a safe and good method solving the infection of the aortal replacement in some patients. The results are comparable to those obtained with extra-anatomic reconstruction that remains the method of choice in patients with virulent infections.

Interim analysis of a phase II trial of 5-azacitidine (5AC) and entinostat (SNDX-275) in relapsed advanced lung cancer (NSCLC)

8055

Background: Epigenetic gene silencing mediated through aberrant DNA methylation and histone deacetylation is a key contributor to lung carcinogenesis. Pre-clinical studies suggest that combining inhibitors of DNA methyltransferase (DNMT) with inhibitors of histone deacetylase (HDAC) synergistically induce re-expression of epigenetically-silenced tumor suppressor genes. Clinical studies at our institution combining the DNMT inhibitor, 5AC, with the HDAC inhibitor, entinostat, in hematologic malignancies have shown remarkable clinical activity. We hypothesized a similar effect would be seen in lung cancer. This study aims to assess the response rate and time to progression of 5AC and entinostat in NSCLC. Methods: Patients (pts) include adults with histologically confirmed recurrent NSCLC and progressive disease after ≥1 prior chemotherapy regimen. 40 mg/m2 of 5AC is administered SQ days 1–6 and 8–10 with 7 mg of entinostat PO days 3 and 10 of a 28 day cycle. A standard Simon two stage design is being used. The sample size is calculated with a power of 90% and a two-sided type 1 error allowance of 5%. Stage 1 included 18 pts, with subsequent expansion to a total of 32. Results: 25 pts have enrolled to date. Demographic characteristics include: mean age (range) - 63 (46- 80); M:F - 1:2; 80% former smokers; 80% adenocarcinomas; mean # of previous therapies - 3. One pt. has had a complete response. She remained on therapy for 14 m and came off therapy due to a new nodule which was resected. Molecular analysis suggests a second primary stage I NSCLC. She remains disease free at 20 m. Another man has stabilization of disease (SD) for ≥16 m with marked symptomatic improvement. Another pt had SD for 4 months. The remaining pts have progressed after 2 cycles of therapy. Main toxicities included injection site reactions, nausea/vomiting, constipation, fatigue, and hematologic toxicities. Conclusions: The combination of 5AC and entinostat is safe and well tolerated in advanced NSCLC pts. 2 pts have had durable benefit from treatment, including a complete response. Pharmacodynamic and pharmacokinetic analyses are being conducted to identify characteristics of the subset of pts responding to this novel therapy.

[Table: see text]

Breaking symmetry: the marine environment, prey size, and the evolution of asymmetry in cetacean skulls

Skulls of odontocetes (toothed whales, including dolphins and porpoises) are typified by directional asymmetry, particularly in elements associated with the airway. Generally, it is assumed this asymmetry is related to biosonar production. However, skull asymmetry may actually be a by-product of selection pressure for an asymmetrically positioned larynx. The odontocete larynx traverses the pharynx and is held permanently in place by a ring of muscle. This allows prey swallowing while remaining underwater without risking water entering the lungs and causing injury or death. However, protrusion of the larynx through the pharynx causes a restriction around which prey must pass to reach the stomach. The larynx and associated hyoid apparatus has, therefore, been shifted to the left to provide a larger right piriform sinus (lateral pharyngeal food channel) for swallowing larger prey items. This asymmetry is reflected in the skull, particularly the dorsal openings of the nares. It is hypothesized that there is a relationship between prey size and skull asymmetry. This relationship was examined in 13 species of odontocete cetaceans from the northeast Atlantic, including four narrow-gaped genera (Mesoplodon, Ziphius, Hyperoodon, and Kogia) and eight wide-gaped genera (Phocoena, Delphinus, Stenella, Lagenorhynchus, Tursiops, Grampus, Globicephala, and Orcinus). Skulls were examined from 183 specimens to assess asymmetry of the anterior choanae. Stomach contents were examined from 294 specimens to assess prey size. Results show there is a significant positive relationship between maximum relative prey size consumed and average asymmetry relative to skull size in odontocete species (wide-gape species: R2 = 0.642, P = 0.006; narrow-gape species: R2 = 0.909, P = 0.031). This finding provides support for the hypothesis that the directional asymmetry found in odontocete skulls is related to an aquatic adaptation enabling swallowing large, whole prey while maintaining respiratory tract protection.

Normal esophageal mucosae adjacent to esophageal adenocarcinomas in both Japanese and U.S. patients have a field defect of methylation changes

4636

Background: Esophageal mucosae that reside next to gross cancer are often without histological premalignant changes. We hypothesized that DNA hypermethylation could be detected in “normal” tissues adjacent to esophageal adenocarcinomas (EAC). Methods: A cohort of patients from Japan (J, n=14) and the United States (US, n=41) with locally advanced EAC were evaluated for methylation status. Esophagectomy specimens provided a source of paired normal and tumor tissues. After DNA extraction, methylation specific PCR was used to evaluate the promoters of APC, p16 and MGMT in all samples. Methylation frequency was calculated for each patient and expressed as a percentage of total. Results: Age, gender, pathologic stage and epigenetic analyses of primary tumors were similar in each cohort. Methylation frequency of tumors was: APC (66% US; 70% J). p16 (39% US; 20% J). MGMT (63% US; 75% J). In adjacent histologically “normal” esophageal mucosae, the percentage of patients with methylation at 0, 1, 2 or 3 genes was 79%, 14%, 0%, 7% for the J group and 56%, 44%, 10% and 2% for the U.S. group. In both cohorts, the majority of the normal samples had no methylation changes. In over half of the total cohort, however, there was at least one gene in the adjacent histologically “normal” tissue positive for DNA hypermethylation. Very few samples in either group, however, had more than one gene methylated in histologically “normal” esophageal mucosae. In general, the same methylation pattern present in the “normal” tissue persisted in the primary malignancy. Conclusions: Histologically negative esophageal mucosae adjacent to cancer frequently show at least one hypermethylated gene in a multiple gene panel. These data suggest that for patients with EAC, regardless of nationality, there is a field defect of promoter hypermethylation changes in adjacent esophageal mucosae. These events reflect those of the primary malignancy, and are probably early and cumulative during carcinogenesis.

No significant financial relationships to disclose.

A safety and efficacy trial of lethally irradiated allogeneic pancreatic tumor cells transfected with the GM-CSF gene in combination with adjuvant chemoradiotherapy for the treatment of adenocarcinoma of the pancreas

3010

Background: Pancreatic cancer remains the fourth leading cause of cancer related deaths in the US in 2006. Surgical resection provides the only possibility of cure. A standard adjuvant treatment approach for patients with resected disease has not yet been determined. We have developed an irradiated GM-CSF transfected allogeneic whole cell line pancreas adenocarcinoma vaccine. We have previously reported a follow-up 60 patient study in this same population using the highest bioactive vaccine dose identified in the initial phase I study. Methods: Single institution phase II study of 60 patients with resected pancreatic adenocarcinoma administered a total of 5 vaccines using two pancreatic cancer cell lines each delivering 2.5 X 10 8 cells ID. Vaccine one was administered 8–10 weeks following surgical resection. Patients subsequently were treated with 5-FU CI based chemotherapy integrated with radiotherapy. Patients who were disease-free one month after completion of chemoradiotherapy received vaccines 2–4, each 1 month apart. A fifth and final booster vaccine was administered 6 months after vaccine 4. The objectives of the study were: 1. To estimate overall survival and disease-free survival in patients with minimal residual disease treated with adjuvant chemoradiotherapy in sequence with the irradiated allogeneic GM-CSF transfected pancreatic tumor cell lines. 2. To characterize toxicities associated with intradermal injections of the vaccine. Results/Conclusions: The study completed enrollment of new patients in January 2005. Median follow-up for these patients is approximately 36 months. 1) The administration of a GM-CSF allogeneic pancreas cancer vaccine is safe and well tolerated; 2) The median survival is approximately 26 months. These results compare favorably with published data for resected pancreas cancer; 3) A matched cohort analysis comparing patients enrolled on this adjuvant vaccine study to the Johns Hopkins Surgery database of patients receiving surgery followed by chemoradiotherapy alone will be presented at this meeting; 4) Immune correlates will be presented at this meeting.

No significant financial relationships to disclose.

Neoadjuvant chemoradiation for rectal cancer: A 5-year institutional experience at Sparrow Hospital

14601

Continued efforts to improve local control and to maximize sphincter preservation in patients with rectal carcinoma led to consideration of preoperative chemoradiation. The purpose of this retrospective study is to examine clinical outcomes and find out which prognostic factors are related to survival in patients treated with neoadjuvant chemoradiation in Sparrow Hospital from 1998–2003. Forty two patients with biopsy proven rectal carcinoma without evidence of extra pelvic spread were treated in this fashion. Radiation therapy was administered for a total dose of 5.00 cGy. Chemotherapy used was 5-FU in 37 patients, and in combination with leucovorin in additional 5 patients. Surgical treatments performed were abdominoperineal resection (23 pts), low anterior resection in 13 pts., transanal excisions (2 pts), 2 patients had only exploratory laparotomy and for 2 patients records were not available. Cox proportional hazards regression techniques were used to estimate survival rates. Univariate and multivariate Cox proportional hazards analyses were used to evaluate relationship between risk factors and the survival. The SAS system (V9.1.3, Cary NC) was used for all analyses. Out of 42 patients analyzed 25 were males and 17 females. Mean age was 65 years (range 31 - 85). Median follow-up time was 57 months with a range from 7 to 98 months. After the surgery 4 patients had complete response, 12 were stage I, 10 stage II, 12 patients stage III, one patient had metastatic disease and for 2 patients records were inadequate. Analysis of disease free survival showed actuarial 5-year disease free survival to be 59%. Actuarial 5-year overall survival was 67%. Median overall survival was still not reached, while median disease-free survival is 78 months . Univariate and multivariate analyses showed that only postoperative stage was associated significantly with overall survival. Specifically, there was an increase in the risk of mortality of just over 3-fold for each increment in post-operative stage. In conclusion, in the community settings preoperative chemoradiation seem to provide good overall and disease free survival for patients with rectal cancer. Postoperative stage appears to be the most important prognostic factor for the survival.

No significant financial relationships to disclose.

[Ultrasound mapping of lower-limb vascular system with regard to occurrence and anatomy of additional front great saphenous vein]

A primary survey study involving a set of 113 lower limbs of 66 patients was focused on the prevalence of additional front great saphenous vein (AFGSV) and the measurement of the distance between its start in the great saphenous vein (GSV) and the saphenofemoral junction (SFJ), the measurement of the distance between the passage of AFGSV through the saphenous fascia and its start in GSV, and compared the width of AFGSV anechogenous lumen with the calibre of GSV. The prevalence of AFGSV in the observed set was 42.5%. Reflux was proved in 6 AFGSVs (12.5%). The width of the AFGSV anechogenous lumen was on an average 0.29 cm (M 0.26 cm, SD +/- 0.15 cm), and the width of GSV anechogenous lumen measured on lower limbs with simultaneous occurrence of AFGSV was 0.38 cm (M 0.38 cm, SD +/- 0.11 cm) on an average. Comparison of the anechogenous lumen width of the two veins showed a statistically significant difference (p < 0,001). AFGSV in the observed set of lower limbs started in VS at an average distance of 0.8 cm from the saphenofemoral junction (M 0.8 cm, SD +/- 0.46 cm). The minimum start point distance was 0.1 cm, the maximum was 1.84 cm. In 3 cases (6.3%), AFGSV started directly in the common femoral vein (v. femoralis communis), which was the place where also the saphenous vein begins. The distance between the passage of AFGSV through saphenous fascia to upper subcutaneous layers and the start of the vein in GSV was on an average 13.2 cm (M 14.5 cm, SD +/- 6.5 cm). The maximum distance between the passage of AFGSV through saphenous fascia and the start of the vein in GSV was 4 cm, the maximum distance being 30 cm.

Surgical corrections of endovascular aneurysms: repair complications

The authors describe their experience with the use of 21 open surgical corrections after endovascular abdominal aneurysm repair, reporting the frequency, type and outcome of these procedures in their group of 165 patients treated during a 10-year period.

Clinical and molecular evaluation of patients with esophageal adenocarcinoma from the United States and Japan

4087

Background: Esophageal adenocarcinoma (EAC) is more common than squamous cancer (ESC) in the US versus Japan (J); however, EAC in J is now more frequently recognized. We assessed features of EAC in J and US patients to determine if the cohort of EAC in Japan is similar to the US. Methods: Patients with EAC who underwent primary curative surgery were identified by reviewing all surgical cases from 1998 to the present at Johns Hopkins Hospital (n = 57) and Juntendo University Hospital (n = 20). Clinical variables included: gender, age, pathologic stage, date of surgery and of death. Methylation of APC, E-cadherin, MGMT, ER, p16, DAP-kinase and TIMP3 was determined with methylation specific-PCR for each J patient and compared to historical control US EAC patients. Logistic regression and survival analysis were used to evaluate the relationship between clinical variables and methylation status to outcome in these two patient groups. Results: Age and gender were similar in each cohort. Gender (50M/6F in US; 16M4F p = 0.29). Median age (65.5 in US; 64 in J). Path stage was lower in US patients but not significant compared to J patients. Stage distribution US: stage I (n = 30), IIA (n = 2), stage IIB (n = 6), stage III (n = 9) and stage IV (n = 4). Stage distribution in J: stage I (n = 6), IIA (n = 5), stage IIB (n = 5), stage III (n = 3) and stage IV (n = 3). Path stage unavailable in 5 US patients. Overall median survival was 4.2 years. Median survival for US was 2.9 years but not reached for J (note 15/20 J patients outcome not known). For the combined cohort, age and path stage (adjusted for clinical co-variates) correlated with worse survival. Age HR 1.05; 95% CI 1.01–1.09. Pathologic Stage HR 1.4; 95% CI 1.19–1.65. These were also predictive within each subgroup. The fraction of patients with methylation is available for three genes: APC (66% US; 70% J). p16 (39% US; 20% J). MGMT (63% US; 75% J). Conclusions: Clinical data are similar for US and J patients with EAC. Early stage in US patients may by due to induction chemoRT in the US. Predictors of survival (age and pathologic stage) are also similar. This suggests that EAC is similar in US and J patients, perhaps reflecting similar environmental and molecular causes. Methylation data for all 7 genes and their correlation with outcome will be presented at the meeting.

No significant financial relationships to disclose.

[Prevalence and causes of reflux in deep venous system of the leg in patients with insufficiency of superficial veins]

The aim of the prospective study was to find out the following: 1. What is the prevalence of deep vein reflux of the leg in patients with superficial vein reflux detected by ultrasonography? 2. What are the possible causes of deep vein insufficiency of the leg retrospectively detectable on the basis of targeted medical history? 3. Is the incidence of identified deep vein insufficiency of the leg gender specific? The sample consisted of 100 legs with superficial vein reflux detected on ultrasonography (C1 - C4 / CEAP) of 79 randomized patients (59 women aged 45 +/- 12 years and 20 men aged 52 +/- 15 years). We collected the medical history of all patients and examined them for any vascular diseases of the leg. Superficial and deep venous system of the leg was examined by routine duplex ultrasonography with 7.5 a 10 MHz linear probe in B-mode, colour flow mapping and pulse Doppler using Valsalva manoeuvre and manual compression of thigh. During the examination, patients lay both prone and on their back.

RESULTS

Prevalence of deep vein reflux in patients with superficial vein reflux detected by ultrasonography was 43 %. Prevalence of deep vein reflux in patients only with primary venous insufficiency (i.e. personal medical history without phlebothrombosis of the leg, trauma, surgery or plaster fixation) was 35.4% in our sample. The possible causes of deep vein reflux in our patients are the following: overweight and obesity (58.6%), primary valvular insufficiency (35.4%), secondary valvular insufficiency--post-thrombotic, post-traumatic (34.9%) and various combinations of these factors. Deep vein insufficiency increased with the BMI. Deep vein reflux was significantly more frequent in men (80%) as compared with women (54.2%).

[Myocardial ischaemia resulting from compression of coronary artery caused by herniation of abdominal organs into thoracic cavity]

A case of 40-year-old patient with compression of coronary artery and myocardial ischaemia is presented. Compression resulted from the herniation of abdominal organs into the thoracic cavity, which developed many years after the car accident trauma.

[Distal protection during primary coronary angioplasty in patients with acute myocardial infarction]

BACKGROUND

The aim of the study was to assess the safety, feasibility and efficacy of mechanical distal protection during primary angioplasty using FilterWire EZ (FW).

METHOD AND RESULTS

Thirty-one patients with acute myocardial infarction (AMI) were treated by primary angioplasty with distal protection using FW. The results were compared with a matched control group consisting of 33 patients with AMI treated by primary angioplasty alone. Successful FW positioning was obtained in 30 patients (97%). In these patients a lower rate of distal embolisation (3 vs. 18%, p=0.04) was found and a more effective reperfusion was assessed by ST elevation's resolution >50% immediately after the procedure (83 vs. 61%, p=0.05). A higher number of patients with corrected TIMI frame count <27 in FW group supported more effective reperfusion to but this difference did not reached statistical significance (87 vs. 73%, p=0.09). There were no differences between groups regarding average peak CK and CK-MB. However, there is a trend to lower release in FW group (32.1+/-24.5 vs. 35.3+/-31.0, p=0.33; 4.2+/-3 vs. 4.4+3.7, p=0.44).

CONCLUSIONS

The presented study confirmed that distal embolisation during primary angioplasty is a frequent phenomenon. In this setting, adjunctive use of the FW is feasible and save, and it may improve myocardial reperfusion by reducing the embolic events.

[Surgery of the low extremity varices as a part of a same-day surgery programme]

INTRODUCTION

One-day surgical methods lower the procedures costs as well the need for urgent beds in surgical clinics. The varix operation seem to be the optimal diagnosis suitable for the one-day surgical procedure.

AIM

The aim of this work is to assess a feasibility of the one-day surgery for the low extremities varix operations.

METHODOLOGY

During the period starting in January until December 2003, 98 extremities were operated for varices. The surgical procedure was the same for the hospitalized as well as for the patients assigned to the one-day surgery programme. Each patient was examined with the duplex ultrasound prior to the surgery, after the surgery a compressive bandage was indicated.

RESULTS

We operated 98 extremities in 96 patients suffering from varices during the period from January 2003 to December 2003. The trial group consisted of 67 females and 29 males aged 21-79 years of age (the average of 45.3 years). According to the CEAP classification, 57 extremities (58.2%) were assigned to the C2 category, 30 extremities (30.6%) to the C3 category, 6 extremities (6%) to the C4 category, 4 extremities (4%) to the C5 category and one extremity (1%) to the C6 category. 14 extremities in the group were operated due to the disease relapse. 62 patients (i.e. 65%) were released for the home-care on the day of the operation, 27 patients (28%) were released the following day. One patient was hospitalized for two days, three patients for three days, one patient for four days and two patients for five days. 91 out of the total 98 extremities (i.e. 93%) underwent the one-day surgery.

CONCLUSION

Although some patients require hospitalization, the varix surgery is safe and suitable for the one-day surgery. A thorough preoperative examination as well each patient's cooperation are both very important.