Laparoscopic abdominosacral composite resection for locally advanced primary rectal cancer

BACKGROUND

En bloc resection of a primary rectal cancer that involves the sacrum is the only curative option for such locally advanced tumours. There is significant morbidity associated with this surgical procedure. A laparoscopic component would potentially provide the patient with the short-term benefits of a minimally invasive approach to the abdominal phase of this challenging operation. The aim of this study was to assess our initial experience with a combined laparoscopic and transsacral approach.

METHODS

A prospective review of patients carefully selected for a laparoscopic abdominosacral composite resection by a single colorectal multidisciplinary team.

RESULTS

Three male patients underwent the procedure. Median duration of surgery was 190 minutes and no blood transfusion was required. Two patients had full intestinal function on the second postoperative day and went home on day 12 and 13. The third patient had a laparotomy for postoperative small-bowel obstruction. All three patients had a R0 (complete) resection with a median lymph node harvest of 15 nodes.

CONCLUSIONS

A laparoscopic proctectomy provides an oncologically sound and minimally invasive option to the abdominal phase of this composite operation. We will continue to gain experience with this combined approach in order to lessen the inevitable morbidity inflicted on the patient in the quest for cure of their locally advanced disease.

Adenosine deaminase estimation and multiplex polymerase chain reaction in diagnosis of extra-pulmonary tuberculosis

SETTING

Extra-pulmonary tuberculosis (EPTB), including mycobacteriosis, contributes 15-20% of all tuberculosis (TB) cases. The diagnosis of EPTB remains elusive because of the inadequate sensitivity of routine and conventional bacteriological methods for the detection of Mycobacterium tuberculosis and related organisms in clinical specimens such as cerebrospinal fluid (CSF), pleural fluid and peritoneal fluid.

OBJECTIVE

To develop a better diagnostic marker for EPTB.

DESIGN

In our study, 179 cases of EPTB were analysed for acid-fast bacilli (AFB) smear, adenosine deaminase activity (ADA) and multiplex polymerase chain reaction (PCR). Although estimation of ADA is helpful, its sensitivity and specificity varies widely. On the other hand, a multiplex PCR using amplicons such as IS6110, dnaJ gene and hsp65 genes has high sensitivity (60-88%) and specificity (81-100%).

RESULTS

On comparing AFB and ADA results with PCR, the PCR is clearly more effective than AFB (P < 0.001) and ADA estimation (P < 0.02) in CSF. The same result was observed with peritoneal fluid (P < 0.001 vs. P < 0.05) and pleural fluid (P < 0.001 and P < 0.05).

CONCLUSION

The study shows that multiplex PCR remains the best tool and is a much better marker for diagnosing EPTB.

Measurement of the two-halo neutron transfer reaction (1)H((11)Li, (9)Li)(3)H at 3A MeV

The p((11)Li, (9)Li)t reaction has been studied for the first time at an incident energy of 3A MeV at the new ISAC-2 facility at TRIUMF. An active target detector MAYA, built at GANIL, was used for the measurement. The differential cross sections have been determined for transitions to the (9)Li ground and first excited states in a wide range of scattering angles. Multistep transfer calculations using different (11)Li model wave functions show that wave functions with strong correlations between the halo neutrons are the most successful in reproducing the observation.

Internal gamma decay and the superallowed branching ratio for the beta(+) emitter (38)K(m)

The branching ratio for the superallowed beta(+) decay of (38)K(m) was measured at TRIUMF's ISAC radioactive ion beam facility. The M3 internal transition between the isomer and the ground state of (38)K(m) was observed with a branching ratio of 330(43) ppm. A search for the nonanalogue beta-decay branch to the first excited 0(+) state in (38)Ar was also performed and yielded an upper limit of < or =12 ppm at 90% C.L. These measurements lead to a revised superallowed branching ratio for (38)K(m) of 99.967(4)%, and increase the (38)K(m) ft value by its entire quoted uncertainty to ft=3052.1(10) s. Implications for tests of the nuclear-structure dependent corrections in superallowed beta decays and the extraction of the Cabibbo-Kobayashi-Maskawa matrix element V(ud) are discussed.

Spontaneous idiopathic subcapsular biloma

Spontaneous biloma is an uncommon entity. We report a case of subcapsular biloma in an elderly patient with a nonobstructed biliary channel, without prior history of surgery, instrumentation, or trauma. Computed tomography (CT) and magnetic resonance imaging are described. We believe that this is the first reported case of spontaneous subcapsular biloma of idiopathic origin.

Scleredema of Buschke: a rare post-streptococcal complication

A 19-year male presented with acute onset, gradually progressive symmetric indurations involving the skin over the face, neck, shoulders and upper part of chest following an upper respiratory tract infection. Detailed history and examination did not reveal evidence of Raynauds' phenomenon, nail changes, digital ulcers, pigmentation or any systemic involvement. Autoantibodies for systemic sclerosis were absent. Histopathology of skin biopsy documented scleredema. Antistreptolysin O (ASO) titer was elevated. We diagnosed a case of Scleredema adultorum of Buschke following a streptococcal throat infection. We report this case to highlight the importance of clinically differentiating this relatively benign, self-limiting disorder from systemic sclerosis.

A rare variant of Ellis van Creveld syndrome

A nine-year-old boy presented with progressively-increasing exertional dyspnoea for the last three months. The only significant finding in the general survey was polydactyly. His vital signs were normal. He had a prominent apical diastolic thrill, a prominent S1 with a low-pitched grade 4/6 mid diastolic rumbling murmur over the apex. The S2 was widely split, fixed and the second component was louder than the first one. There was a grade 3/6 ejection systolic murmur over the left second intercostal space. Electrocardiography showed features of left axis deviation, bi-atrial enlargement and right ventricular hypertrophy. Transthoracic echocardiography identified a thin undulating intra-atrial membrane on the left side along with an ostium-primum defect. In this patient, the diagnosis of a variant of Ellis van Creveld syndrome was made.

Massive recurrent hemorrhage due to duodenal diverticulum--role of tattooing and suture plication

We report a 79-year-old lady with massive recurrent GI bleeding from a duodenal diverticulum arising at the mesenteric border. We used tattooing during endoscopy as a method for identifying the bleeding source at surgery. The diverticulum was treated with suture plication.

Doubtful descent, dilemma and diagnosis: a case of Kallmann syndrome

A 16-year-old boy with a diagnosis of bilateral cryptorchidism was referred for preoperative evaluation. He had diminished hearing and difficulty in vision since birth, with inattentiveness, poor school performance and delayed milestones. He was previously operated on for cleft lip. General survey revealed bilateral short fourth metacarpals and an operative scar mark over the left nostril and upper lip. He had a micropenis, small soft testes with anosmia, and sensory-motor deafness. The hormonal assay was consistent with hypogonadotrophic hypogonadism. Magnetic resonance imaging of the brain and computed tomography cisternography revealed almost hypoplastic olfactory bulb with an ill-defined olfactory tract and sulci, supporting the clinical diagnosis of Kallmann syndrome.

Observations of hepatic encephalopathy profile in a tertiary care centre

A study was conducted among 67 patients presenting with hepatic encephalopathy to establish the aetiological diagnosis and record the incidence of acute and chronic liver diseases. They all had undergone thorough clinical and laboratory evaluation. The factor precipitating encephalopathy was also identified. Among 67 patients 19 (28.4%) had acute liver disease and 48 (71.6%) had chronic liver disease. Majority of patients had grade 2 encephalopathy at presentation. Among the acute cases most common aetiology was acute viral hepatitis due to hepatitis B and E viruses whereas alcoholic liver disease was the most frequent cause of chronic liver disease. The most common precipitating factor was gastro-intestinal haemorrhage.

Estimation of strength in different extra Watson–Crick hydrogen bonds in DNA double helices through quantum chemical studies

It was shown earlier, from database analysis, model building studies, and molecular dynamics simulations that formation of cross-strand bifurcated or Extra Watson-Crick hydrogen (EWC) bonds between successive base pairs may lead to extra rigidity to DNA double helices of certain sequences. The strengths of these hydrogen bonds are debatable, however, as they do not have standard linear geometry criterion. We have therefore carried out detailed ab initio quantum chemical studies using RHF/6-31G(2d,2p) and B3LYP/6-31G(2p,2d) basis sets to determine strengths of several bent hydrogen bonds with different donor and acceptors. Interaction energy calculations, corrected for the basis set superposition errors, suggest that N-H...O type bent EWC hydrogen bonds are possible along same strands or across the strands between successive base pairs, leading to significant stability (ca. 4-9 kcal/mol). The N-H...N and C-H...O type interactions, however, are not so stabilizing. Hence, consideration of EWC N-H...O H-bonds can lead to a better understanding of DNA sequence directed structural features.

Successful treatment of a patient with chronic lymphocytic leukaemia (CLL) presenting with bony metastases with aggressive antibody and chemotherapy

Osteolytic lesions are rare in chronic lymphocytic leukaemia (CLL) and thought to result from Richter's transformation or metastatic disease from nonlymphoid malignancies. We report a patient who presented with a large femoral metastatic lesion and hypercalcaemia caused by CLL itself. Complete remission of CLL with resolution of the osteolytic lesion was achieved with rituximab and cyclophosphamide, adriamycin, oncovin and prednisolone [CHOP (R-CHOP)] combination chemotherapy.

Small bowel obstruction due to inflammation secondary to ingested bone

We report the CT appearances of an ingested pork bone in the lumen of small bowel in a 66-year-old man with an intact and virgin gastrointestinal tract. CT scan demonstrated the site of obstruction at distal jejunum with associated irregular narrowing and proximal small bowel dilatation as well as the bone lodged in the non-dilated terminal ileum. Laparotomy and histology of the resected small bowel confirmed the CT appearances that the obstruction was caused by adhesions and extensive inflammation across the bowel wall in the distal jejunum from trauma as the bone traversed down the lumen. We believe that this is the first reported preoperative CT scan finding of a case of small bowel obstruction due to adhesions and inflammation secondary to ingested bone.

Direct Access Minor Surgery service--patient satisfaction and effectiveness

INTRODUCTION

Waiting lists for surgical out-patients and elective operations are a major concern of the National Health Service. A Direct Access Minor Surgery programme in an ambulatory minor theatre area has been introduced to expedite patient treatment. The response of patients to this service has been assessed.

PATIENTS AND METHODS

A postal questionnaire was offered to all patients attending for the Direct Access Minor Surgery over a period of 20 months (January 2002 to August 2003). Patients were asked about direct attendance for surgery without a prior out-patient appointment, about waiting time before operation on the day of surgery and the adequacy of pre-operative information. Overall satisfaction was assessed using a scoring system. The incidence of inappropriate referrals was analysed. The influence of the service on waiting lists and resources was assessed.

RESULTS

A total of 221 patients were operated on, 257 lesions being excised. Response rate to the postal questionnaire was 55%. Of respondents, 75% thought that it was appropriate to attend the hospital directly without an out-patient clinic appointment. To 83% the waiting time was acceptable. Of patients, 90% were happy with the pre-operative information. Overall, 91% of respondents were very satisfied with the service. Inappropriate referrals were 4%. The new service reduced waiting time for minor surgery from 53 to 10 weeks. It also released approximately 140 new out-patient slots per annum.

CONCLUSION

Direct Access Minor Surgery is a safe and favoured service with high patient satisfaction.

Pancreatic carcinoma: report of two cases presenting with unusual metastases

We report two patients with adenocarcinoma of the body and tail of the pancreas who presented with features localized to the metastatic sites. A 67-year-old gentleman presented with right groin mass due to spermatic cord metastasis and later developed duodenal obstruction; the other gentleman was 69 years old and presented with change of bowel habit as a result of pelvic/pararectal metastasis.

Role of Sulfur Compounds in the Detection of Amino Acids by Ninhydrin on TLC Plate

Three new sulfur reagents for specific identification of amino acids on thin-layer chromatography plates have been introduced. These three sulfur containing reagents are capable of developing various distinguishable colors with many of them. A probable mechanism for such color formation is proposed.