The post-adjustable gastric band abdominoplasty

Serious complications associated with post-laparoscopic adjustable gastric band (LAGB) abdominoplasty have been reported in the medical literature. Furthermore, others have noted aesthetic problems with closure of the umbilicus due to apparatus port proximity. Currently, no clinical protocol or formal industry guidance for LAGB apparatus management during abdominoplasty is available in the medical literature. In this article, the authors describe their procedure for safe LAGB apparatus management during abdominoplasty and illustrate key surgical principles by presenting unique cases from their series of 20 patients treated with this technique.

Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature

OBJECTIVE

To evaluate the risk of gallbladder cancer (GBC) in patients with a porcelain gallbladder (PGB).

DESIGN

Retrospective analysis of our institutional experience and a systematic review of the literature.

SETTING

Academic teaching facility, Parkland Memorial Hospital, and the Dallas Veterans Affairs Medical Center (all in Dallas, Texas).

PATIENTS

Medical records of 1200 cholecystectomies performed between 2008 and 2009 at Parkland Memorial Hospital, The University of Texas Southwestern Medical Center, and the Dallas Veterans Affairs Medical Center were reviewed. Patients with radiologic or histologic evidence of PGB or GBC were included.

MAIN OUTCOME MEASURES

The risk of GBC in patients with a PGB was assessed by contingency table analysis.

RESULTS

We identified 13 patients with a PGB among 1200 cholecystectomies (1.1%). Most of these patients had concomitant gallstones (n = 9). None of the patients with a PGB had evidence of carcinoma. We also reviewed the histologic analysis results of 35 cases of GBC operated on between 1997 and 2009; none of these had gallbladder wall calcifications. Most patients underwent a laparoscopic cholecystectomy without any postoperative complications. We reviewed 7 published series that included 60,665 cholecystectomies. The overall incidence of PGB was 0.2%, and GBC occurred in 15% of the PGB cases. Most cases of GBC occurring in PGB were found in the older literature; in the contemporary series, there were few reports of GBC associated with a PGB.

CONCLUSIONS

Porcelain gallbladder is only weakly associated with GBC. Prophylactic cholecystectomy is not indicated for PGB alone and should be performed only in patients with conventional indications for cholecystectomy. A laparoscopic approach is appropriate for most patients with a PGB.

A strategy for reducing surgical backlogs: lessons from a veterans administration hospital

A process was developed to use a nontraditional operative day (Saturday) to increase the number of inguinal herniorrhaphies (IHs) performed. The purpose of this analysis was to compare operating times and outcomes between patients undergoing IH on Saturday versus the weekday. A retrospective review was conducted that included patients who underwent IH from October 2008 to January 2010. This cohort was divided based on the day on which surgery occurred. The outcome measures were operative times, room turnover time, and complication rates. Operative time was shorter for Saturday IHs (50.7 vs. 67.8 min, P ≤ 0.001). The greatest difference between the two groups occurred in turnover times. We considered Saturday turnover time to be zero, which was possible because of multiple support teams and additional room availability. Turnover times during the week averaged 40.5 ± 2 minutes. There was no difference in complication rates for the two groups (Saturday IHs 17.6% vs. 20.9% for weekday IHs, P = 0.75). Elective cases can be accomplished more rapidly during nontraditional operating times if there are multiple support teams and rooms available.

Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial

OBJECTIVE

To determine if an evidence-based practice bundle would result in a significantly lower rate of surgical site infections (SSIs) when compared with standard practice.

DESIGN

Single-institution, randomized controlled trial with blinded assessment of main outcome. The trial opened in April 2007 and was closed in January 2010.

SETTING

Veterans Administration teaching hospital.

PATIENTS

Patients who required elective transabdominal colorectal surgery were eligible. A total of 241 subjects were approached, 211 subjects were randomly allocated to 1 of 2 interventions, and 197 were included in an intention-to-treat analysis.

INTERVENTIONS

Subjects received either a combination of 5 evidenced-based practices (extended arm) or were treated according to our current practice (standard arm). The interventions in the extended arm included (1) omission of mechanical bowel preparation; (2) preoperative and intraoperative warming; (3) supplemental oxygen during and immediately after surgery; (4) intraoperative intravenous fluid restriction; and (5) use of a surgical wound protector.

MAIN OUTCOME MEASURE

Overall SSI rate at 30 days assessed by blinded infection control coordinators using standardized definitions.

RESULTS

The overall rate of SSI was 45% in the extended arm of the study and 24% in the standard arm (P = .003). Most of the increased number of infections in the extended arm were superficial incisional SSIs (36% extended arm vs 19% standard arm; P = .004). Multivariate analysis suggested that allocation to the extended arm of the trial conferred a 2.49-fold risk (95% confidence interval, 1.36-4.56; P = .003) independent of other factors traditionally associated with SSI.

CONCLUSIONS

An evidence-based intervention bundle did not reduce SSIs. The bundling of interventions, even when the constituent interventions have been individually tested, does not have a predictable effect on outcome. Formal testing of bundled approaches should occur prior to implementation.

Tissue microarray constructs to predict a response to chemoradiation in rectal cancer

PURPOSE

To identify, using tissue microarray (TMA), an immunohistochemical panel predictive of response to ionizing radiation (IR) in rectal cancer.

METHODS

TMA constructs were prepared from archived stage II/III rectal tumors and matching adjacent mucosa (n=38) from patients treated with pre-operative chemoradiation. Immunohistochemistry (IHC) was performed for MIB, Cyclin E, p21, p27, p53, survivin, Bcl-2, and BAX. Immunoreactivity along with clinical variables was subjected to univariate and forward stepwise logistic regression analyses.

RESULTS

Pathological complete response (pCR) was 23.9%. The number of positive lymph nodes obtained in the resected specimen was associated with pCR. Immunoreactivity for MIB (Sn 15%, Sp 65%, OR 0.33), p53 (Sn 3%, Sp 84%, OR 0.16), Bcl-2 (Sn 11%, Sp 74%, OR 0.35), and BAX (Sn 92%, Sp 80%, OR 46) was associated with pathological response (all p's<0.001). Forward stepwise logistic regression analysis demonstrated that MIB was an independent predictor of a response to chemoradiation (p=0.001).

CONCLUSIONS

A combined panel of mediators of apoptosis alone or combined with clinical factors is a feasible approach that can be applied to rectal tumor biopsies to predict a response to chemoradiation. The most sensitive factor was BAX; while MIB independently predicted a response to chemoradiation.

Indications and recommended approach for surgical intervention of metastatic disease to the gallbladder

Metastatic disease to the gallbladder is unusual. The most common malignancy metastatic to the gallbladder is melanoma, followed by renal cell carcinoma (RCC) and breast cancer. Due to the unusual nature of the disease, there are no trials available for review. Thus, the management for these patients has been based on institutional experience and review of case series. The indications for surgical intervention for melanoma are metastatic disease discrete to the gallbladder and biliary symptoms, which are uncommon for melanoma, but might occur due to cystic duct obstruction culminating in cholecystitis. Laparoscopic cholecystectomy without a lymphadenectomy is emerging as the preferred approach for this metastatic deposit. The vast majority of patients with metastases to the gallbladder from RCC carry a good prognosis and a laparoscopic cholecystectomy should be considered. Patients with metastases to the gallbladder from the breast classically present with biliary symptoms and commonly undergo a laparoscopic cholecystectomy, which invariably demonstrates a deposit in the gallbladder from lobular breast cancer. In the present report, we review the indications for surgical intervention from various malignancies metastatic to the gallbladder and the current consensus for the laparoscopic approach from the diverse metastatic deposits to the gallbladder.

In vitro and in vivo radiosensitization of colorectal cancer HT-29 cells by the smac mimetic JP-1201

BACKGROUND

The response to neoadjuvant chemoradiation in rectal cancer is variable and unpredictable. Resistance to chemoradiation has been directly correlated with the levels of the inhibitors of apoptosis (IAPs) in several malignancies. Because smac-DIABLO is a pro-apoptotic gene product that directly inhibits the activity of the IAPs, molecules with similar activity might radiosensitize rectal tumors with phenotypes that express high levels of IAPs. This study was undertaken to assess the radiosensitizing properties of the smac mimetic JP-1201 in radioresistant HT-29 colorectal cancer cells in vitro and established xenografts in SCID mice.

METHODS

Survival was determined by clonogenic assays. PARP-1, caspase-8 cleavage, and IAP levels were assessed by Western blot analysis. SCID mice bearing HT-29 xenografts were treated with ionizing radiation: 2.0 Gy x 5; (n = 6), JP-1201 (5.0 mg/Kg i.p., n = 5) or combination treatment (n = 7) and compared to control (n = 8). DNA repair mechanisms were interrogated by gammaH2AX positive foci.

RESULTS

Pretreatment of HT-29 cells with JP-1201 (5.0 microM) prior to ionizing radiation (IR) significantly decreased the survival of these cells. SCID mice bearing HT-29 xenografts demonstrated no difference in tumor load in the group receiving exclusively JP-1201 versus control. At the end of the treatment (day 40), a 46% reduction of tumor load was observed in the IR+JP-1201-treated group compared to the IR-only treated group. Radiosensitization was achieved with a substantial elevation of cleaved PARP-1 in JP-1201- treated HT-29 cells versus control cells with a concomitant decrease of XIAP, but not of survivin or cIAP1/2. JP-1201-treated HT-29 cells had a reduced ability to repair double-stranded DNA breaks (DSBs).

CONCLUSION

The smac mimetic JP-1201 decreased the survival of HT-29 cells and tumor growth by an additive effect in apoptosis and a reduction in the level of XIAP and an impairment of DNA repair mechanisms. The pathways leading to this response need to be further investigated.

A report of laryngeal adenocystic carcinoma metastatic to the spleen and the role of splenectomy in the management of metastatic disease: a case report

Introduction

Adenoid cystic carcinoma (ACC) of the larynx is a rare malignancy characterized by an indolent course and late pulmonary metastases. Metastases from the larynx to the spleen are an unusual event. In the present report, we discuss a patient with adenoid cystic carcinoma of the larynx metastatic to the spleen. A review of the literature did not yield any other such incidents. We review the clinical presentation and course of adenoid cystic carcinoma, as well as the role of splenectomy for metastases.

Case presentation

We present a case of laryngeal adenoid cystic carcinoma in a 26-year-old Caucasian man treated with total laryngectomy and ionizing radiation. He initially developed asynchronous pulmonary metastases, which were resected. Our patient subsequently presented with a symptomatic splenic lesion consistent with metastatic disease, for which he underwent laparoscopic splenectomy.

Conclusions

Splenectomy might be indicated for isolated metastases. A splenectomy effectively addresses symptoms and serves as a cytoreduction modality.

Current evidence-based opinions in the management of adenocarcionoma of the rectum

The management of rectal cancer has drastically evolved over the past two decades as a result of implementation of circular stapling devices and the introduction of neoadjuvant chemoradiation. In spite of current aggressive multimodality treatments, the recurrence rate remains unacceptably high and the expected 5-year survival in patients who develop recurrent disease is dismal. The management of rectal cancer must involve a multidisciplinary approach. An understanding of the biology of rectal tumours may allow for selection of patients who may have an aggressive phenotype allowing for alterations in the operative and neoadjuvant planning. Efforts to improve local control and survival in rectal cancer are the focus of multiple current clinical and preclinical research efforts. Preoperative chemoradiation for and surgical management of rectal cancer, including the laparoscopic approach are areas of dynamic progression. In the present report, we review the current evidence in the new strategies pertaining to the multimodality approach in the management of rectal cancer.

Rectal cancer and importance of chemoradiation in the treatment

Neoadjuvant chemoradiation is used as a preoperative standard treatment for the majority of patients with Stage II/III rectal cancers and, in attempt to facilitate surgical intervention, reduce the rate of local recurrence and improve overall outcomes in patients suffering from this malignancy. However, this modality results in a wide range of clinical responses. In many cases, a pathological complete response is achieved, while in others, receiving the same form of treatment, the tumor continues to grow. The specific phenotype of the tumor plays a major role in rendering tumor cells a survival advantage to the cytotoxic effects of chemoradiation. Several factors participating in proliferation, cell cycle, apoptosis and hypoxiahave been investigated under a variety of conditions in pre-irradiated tissues and post-irradiated tumors. Mutations in the genes of these pathways have shown to lead to resistance to chemoradiation. This chapter describes colon cancer with emphasis on the molecular mechanisms that may lead to chemoradio-resistance of cells with cytotoxically induced DNA injury in rectal cancer.

Feasibility of a supervised inpatient low-calorie diet program for massive weight loss prior to RYGB in superobese patients

BACKGROUND

This study was undertaken to determine the feasibility of an inpatient low-calorie program for a substantial decrease of preoperative weight (>10 points in BMI) in superobese patients.

METHODS

Five patients were hospitalized for an average of 11 weeks and were placed on a low-calorie liquid diet (<900 kcal/day) and an exercise program. Following a drop of ten points in BMI, they underwent a Roux-en-Y gastric bypass (RYGB). Hemoglobin A1c and lipid profiles were obtained at the beginning of the diet, prior to surgery and at the last follow-up appointment. Our results were compared to the National Surgical Quality Improvement Program (NSQIP) database, which included 1,046 bariatric operations performed at VA centers between October 1999 and August 2007.

RESULTS

All five patients were massively obese men (body mass index (BMI) = 64.3 +/- 2.1 kg/m(2); 54.7 +/- 2.6 years old; four of five were white) with multiple comorbid conditions, which placed them in a substantially higher risk for bariatric surgery. Of the four diabetic patients, two were insulin dependent. There was an average decrease in BMI by 12.7 points (85.8 +/- 6.0 lb) during the preoperative diet period (11 weeks). All patients underwent RYGB without complications. This cohort of patients further decreased their BMI by 10.6 points (88.4 +/- 29.4 lb) following surgical intervention. The total combined preoperative and postoperative excess body weight loss was 89% (10.6-month average follow-up). Sleep apnea resolved following gastric bypass but did not improve during the preoperative weight loss period. Hypertension, osteoarthritis, and dyslipidemia all improved following surgical intervention. Hemoglobin A1c decreased by 1.9% during diet-induced weight loss with no further improvement being noted after surgery. The two insulin-dependent diabetic patients discontinued insulin therapy following surgery. The NSQIP database contained 77 patients with similar characteristics to our cohort of patients. The 30-day mortality for this cohort of patients was 3.9% with a complication rate of 33.8%.

CONCLUSIONS

Massive preoperative weight loss is possible to achieve with a liquid protein diet in superobese patients greatly facilitating gastric bypass surgery in an otherwise high-risk patient population.

Mechanisms of resistance to ionizing radiation in rectal cancer

While patients with breast cancers are not subjected to the adverse side effects of tamoxifen or trastuzumab if their tumors are negative for estrogen, progesterone or Her-2/Neu, neoadjuvant ionizing radiation with concurrent chemotherapeutic agents is administered almost universally to patients with stage II/III rectal cancers. There is, however, a tremendously wide range of response to this preoperative modality from complete pathological response to continuous tumor growth in patients receiving the same form of treatment. The specific phenotype of the tumor plays a major role in rendering tumor cells survival advantage to the cytotoxic effects of chemoradiation. Pathways such as proliferation, cell cycle, apoptosis and hypoxia have been investigated under a variety of conditions in preirradiated tissues and postirradiated tumors. This article reviews the current evidence available to identify a molecular profile predictive of the best response to ionizing radiation.

Radiosensitization of HT-29 cells and xenografts by the nitric oxide donor DETANONOate

BACKGROUND

Mechanisms of radioresistance in rectal cancer remain unclear.

OBJECTIVES

To determine mechanisms of radioresistance in rectal cancer cells and to assess the role of the nitric oxide donor DETANONOate as a radiosensitizing agent.

METHODS

Survival was determined by clonogenic assays, apoptosis by PARP-1 cleavage, and phenotypic differences by Western blot analysis. SCID mice bearing HT-29 xenografts were treated with ionizing radiation (IR) [2.0 Gy x 5], DETANONOate [0.4 mg/kg i.p.], or combination treatment.

RESULTS

Colorectal cancer HT-29-p53-null cells were resistant and HCT-116-p53 wild-type cells sensitive to IR, which correlated with cleaved PARP-1. Increased levels of p21 occurred in HCT-116 cells, while Bcl-2 and survivin were elevated in HT-29 cells. Radiosensitization was achieved with a substantial elevation of cleaved PARP-1 in DETANONOate-HT-29-treated versus control cells, which was accompanied by elevation of p21, p27, and BAX, and a concomitant decrease in Bcl-2. SCID mice bearing HT-29 xenografts demonstrated a 37.6%, 51.1%, and 70.1% inhibition in tumor growth in mice receiving IR, DETANONOate, and combination treatment versus control, respectively.

CONCLUSIONS

Radioresistant HT-29 cells are p53-null and have substantially decreased levels of p21. DETANONOate radiosensitized HT-29 cells in vitro and in vivo by an additive effect in apoptosis.

Metastatic rectal cancer to the breast

Rectal cancer metastatic to the breast is an exceedingly rare event with around 15 cases reported in the literature. A metastatic breast deposit from the rectum signifies diffuse disseminated disease or a highly aggressive tumor such that surgical intervention other than palliation has a limited role. In the present report, we discuss a patient who presented with rectal cancer and developed a breast metastatic deposit. She soon developed progressive metastatic involvement of the lungs and the soft tissues and succumbed to the malignant course of this disease 12 months after the diagnosis of the primary rectal tumor.

Nitric oxide donors: novel cancer therapeutics (review)

The development of cancer cell resistance to various cytotoxic stimuli continues to be a major challenge in oncology and novel therapeutic approaches are urgently needed. Nitric oxide (NO) is emerging as a potential anti-oncogenic agent to overcome tumor cell resistance to conventional therapeutic agents. NO is a ubiquitous, water-soluble, free radical gas that exerts a wide range of biological effects. The actions of nitric oxide are highly variable in oncology with reports in the literature on both sides of the spectrum as an anti-neoplastic vs. a pro-neoplastic agent. The final activity of NO in oncology is dependent on its working microenvironment, including the type of cell exposed to the compound, the redox state of the reaction, as well as the final intracellular concentration and the duration of intracellular exposure to nitric oxide. There is, however, no unifying mechanistic explanation for the biphasic role of nitric oxide in oncology. Nitric oxide donors mimic continuous production of NO in a wide range of time intervals (seconds to days). Thus, multiple biological and (pro- vs. anti-) neoplastic responses are elicited from NO donors depending on the half-life and the type of cell exposed to the compound. The large variety of nitric oxide donors may serve as a tool to explore the wide range of oncologic properties of NO in cancer. In the present report, we discuss classic nitric oxide donors and their potential therapeutic roles as cytotoxic agents or chemo-radio or -immune-sensitizing compounds in the treatment of drug-resistant cancers.

Preoperative weight loss decreases the operative time of gastric bypass at a Veterans Administration hospital

BACKGROUND

This study assessed whether preoperative weight loss resulted in favorable outcomes after open Roux-en Y gastric bypass (RYGB).

METHODS

A retrospective review of all patients who underwent RYGB at the DVAMC was undertaken. Patients were divided into: patients who did not lose weight within 3 months preoperatively (n=25) and group II, those who did (n=15).

RESULTS

Both groups had similar demographics, body mass index, comorbid conditions, and American Society of Anesthesiology class. Group II lost 28.2+/-6.5 lbs (8.3% of body weight) within 3 months before RYGB. Operative time was longer in group I compared to group II (180.0+/-0.0 vs 161.0+/-0.0 min; p=0.05). Both groups had the same rate of postoperative complications and the same long-term weight loss at a 2-year follow-up (n=6 both groups).

CONCLUSIONS

An 8% reduction of body weight is associated with a decrease in operative time. These preliminary data suggest that preoperative weight loss results in a technically less challenging operation in the super-obese patient.

Recent advances in the molecular diagnosis and prognosis of colorectal cancer

Colon cancer remains a leading cause of mortality worldwide despite the well-characterized molecular events in the adenoma-to-carcinoma sequence. There has been a strong emphasis on early detection of colon cancer, and fecal DNA-based methods have been developed to assist with early screening. Tissue-based assays have been utilized for many years to assess tumor aggressiveness and to determine prognosis and response to chemotherapeutic interventions. The most widely used serum marker for colon cancer (carcinoembryonic antigen) remains a useful modality to assess for occult disease following curative resection. Identification of tumor mutations in circulating tumor cells and microarray analysis holds a great deal of promise in the diagnosis and prognosis of patients with colorectal cancer. The inhibitors of apoptosis may be important markers to determine resistance to radiation cytotoxicity in rectal cancer. This report presents a summary of the current status of the molecular markers of colorectal cancer to establish a diagnosis, determine prognosis and chemoradiotherapeutic interventions, and assess relapse following curative surgery.

Surgical site infections after colorectal surgery: do risk factors vary depending on the type of infection considered?

BACKGROUND

The purpose of this study was to compare risk factors for the development of incisional versus organ/space infections in patients undergoing colorectal surgery.

METHODS

An institutional review board-approved retrospective review was performed examining a 4-year period (January 2002 to December 2005). Patients were included if they had undergone abdominal operations (open or laparoscopic) in which the colon/rectum was surgically manipulated. Patients were excluded if the surgical wound was not closed primarily. A standardized definition of incisional and organ/space infection was employed.

RESULTS

A total of 428 operations were performed. Overall, 105 infections were identified (25%); 73 involved the incision and 32 were classified as organ/space. Multivariate analysis suggested that incisional infection was independently associated with body mass index (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.02-1.11) and creation/revision/reversal of an ostomy (OR, 2.2; 95% CI, 1.3-3.9). Organ/space infection was independently associated with perioperative transfusion (OR, 2.3; 95% CI, 1.1-5.5) and with previous abdominal surgery (OR, 2.5; 95% CI, 1.2-5.3).

CONCLUSIONS

Factors associated with infection differed based on the type of surgical site infection being considered. The lack of overlap between factors associated with incisional infection and organ/space infection suggests that separate risk models and treatment strategies should be developed.

Colonic stent versus surgery for the management of acute malignant colonic obstruction: a decision analysis

BACKGROUND

Acute colonic obstruction because of advanced colonic malignancy is a surgical emergency.

AIM

To compare the clinical outcomes and cost-effectiveness of endoscopic self-expanding metal stent (SEMS) vs. surgery for emergent management of acute malignant colonic obstruction in patients with metastatic colorectal cancer over a 6-month period.

METHODS

Decision analysis was used to calculate the cost-effectiveness and success of two competing strategies in a hypothetical patient with metastatic colon cancer presenting with acute, malignant colonic obstruction: (i) emergent colonic stent (SEMS cohort); (ii) emergent surgical resection followed by diversion (surgery cohort).

RESULTS

Self-expanding metal stent resulted in a success and a lower mortality rate when compared to surgery over a 6-month period. Colonic SEMS was also associated with a lower mean cost per patient (USD 27,225 vs. USD 57,398). Mortality in the surgery group was 25 times that of the SEMS cohort. One- and two-way sensitivity analyses identified SEMS as the dominant strategy.

CONCLUSION

Colonic stent insertion is more effective and less costly than surgery for the management of colonic obstruction in patients with metastatic colon cancer.

Modification of Gene Products Involved in Resistance to Apoptosis in Metastatic Colon Cancer Cells: Roles of Fas, Apaf-1, NFκB, IAPs, Smac/DIABLO, and AIF

BACKGROUND

Colon cancer becomes resistant to apoptosis as it acquires metastatic potential. SW480 and SW620 colon cancer cells were established from the same patient at different stages of tumor progression. The stage III colorectal cancer cell line (SW620) is more resistant to apoptosis. In the present report, we investigated the apoptotic gene products that might account for colon cancer evasion of immune attack and chemoradioresistance-induced apoptosis.

METHODS

SW480 and SW620 cells were used for this experiment. Type 1 apoptosis was induced by CH-11. Type 2 apoptosis was induced by cisplatin and ionizing radiation. Apoptosis was determined by caspase-3 activity and terminal deoxynucleotidyl transferase mediated dUTP nick end labeling. Gene products Fas, TRAIL, c-FLIP, Bid, BAX, Bcl-2, Bcl-xL, Apaf-1, nuclear factor-kappa B, Smac/DIABLO, apoptosis inducing factor, and the inhibitors of apoptosis were investigated by immunocytochemistry and Western blot analyses.

RESULTS

SW620 cell lines were more resistant to both Type 1 and Type 2 apoptosis induced by CH-11, cisplatin, and ionizing radiation, respectively. Examination of the extrinsic pathway demonstrated Fas receptor to be down-regulated in SW620. Apaf-1 was decreased in SW620 cells; while other members of the mitochondrial pathway including Bax, Bid, Bcl-xL, and Bcl-2 demonstrated minimal alterations of protein levels in both cell lines. Survivin and XIAP protein levels were increased in SW620 cells, which correlated with nuclear expression of nuclear factor-kappa B in SW620 cells but not SW480. Mitochondrial-released factors including Smac/DIABLO and apoptosis inducing factor were increased in SW480 cells.

CONCLUSIONS

SW620 cells have acquired genetic defects both in the intrinsic and extrinsic pathways of apoptosis, which may explain in part the ability of colon cancer cells to escape the immune system and to become chemoradioresistant. These genes may be potential targets for chemoradiosensitization in advanced colorectal cancer.

Predictors of early mortality in veteran patients with pancreatic cancer

BACKGROUND

Identification of predictors of outcome may assist in guiding treatment options for patients with pancreatic cancer. The aim of the current study was to determine clinical factors and laboratory values that predicted mortality of less than 6 months in a male population of the same age and body mass index at the time of diagnosis of pancreatic cancer who died as a result of their disease.

METHODS

Only patients with proven diagnosis of pancreatic cancer (n = 69) were included in the study. Patients were grouped into early (< or = 6 months; n = 31) and late (> 6 months; n = 38) survivors. Forty-four clinical factors were assessed by univariate analysis. Significant factors (P <.05) were included in a multivariate regression model to determine independent predictors of early mortality.

RESULTS

All patients in the cohort were men. Both the early and late death cohorts were of similar age and body mass index. Twenty-five patients (36%) underwent surgical intervention (palliative 17%, exploratory laparotomy without resection 6%, pancreaticoduodenectomy 13%). Thirty-six patients (52%) underwent placement of a biliary stent. Eight patients received exclusively palliative care. The mean overall length of survival was 7.8 +/- .6 months. Univariate analysis demonstrated that patients who died within 6 months had a significantly increased blood level of carbohydrate antigen 19-9, alkaline phosphatase, and white blood cell (WBC) count. Early mortalities also had a decreased blood albumin level. Multivariate analysis of these factors revealed that low serum albumin and an increased WBC count independently predicted survival of less than 6 months.

CONCLUSION

Serum albumin and WBC count may be used in conjunction with other diagnostic modalities and overall patient status in determining treatment options for patients with pancreatic cancer.

Smac/DIABLO and colon cancer

Apoptosis is a genetically programmed process of controlled and orderly cell suicide, which is critical for multicellular organisms during development and tissue homeostasis. In cancer, the ratio of apoptosis to cell division is altered, resulting in a net gain of malignant tissue. Tumor cells may acquire resistance to apoptosis by the expression of anti-apoptotic proteins, or by the down-regulation or mutation of pro-apoptotic mediators. In the classic pathway of apoptosis, this process is primarily coordinated by activation of caspases. Decreased expression of caspases inversely correlates with the aggressiveness of cancer. Increased activity of caspases renders cancer cells susceptible to chemoradiotherapeutic modalities. Thus, caspase activity is pivotal in carcinogenesis. The functions of activated caspases are inhibited by the binding of inhibitors of apoptosis (IAPs). The function of IAPs is regulated by pro-apoptotic protein Second Mitochondria-Derived Activator of Caspases (Smac) or Direct IAP Binding Protein with low isoelectric point, pI (DIABLO). Induction of apoptosis leads to increased mitochondrial permeability to Smac/DIABLO, which adheres to IAPs inhibiting their caspase-binding activity. The role of Smac/DIABLO, therefore, may have significant diagnostic and therapeutic features in carcinogenesis. The role of Smac/DIABLO in colorectal carcinogenesis is ill defined. Data continues to accumulate to suggest that decreased levels of Smac/DIABLO may be important in chemoradiation-resistance to apoptosis in advanced colon cancer. The aim of this review is to provide the available evidence of the role of Smac/DIABLO in colon carcinogenesis.

Assessment of comorbid conditions in veteran patients after Roux-en-Y gastric bypass

BACKGROUND

The present study assessed the degree to which comorbid conditions improved after bariatric surgery in veteran patients.

METHODS

A retrospective review of 55 patients (age 49.1 +/- 1.2, body mass index 49.3 +/- 1.2 kg/m2; 62% male) who underwent open Roux-en-Y gastric bypass surgery at the Dallas Veterans Administration Medical Center was performed. Univariate and multivariate analyses were used to determine factors associated with outcomes.

RESULTS

There were 17 minor (8 patients with anastomotic ulcer, 5 patients with hernia, 1 patients with cholecystitis, 1 patients with a wound infection, and 2 patients with seroma) and 4 major (3 patients with pulmonary embolism and 1 patients with gastrojejunostomy leak) complications. Univariate analysis demonstrated that body mass index was associated with increased length of hospital stay but not with morbidity. Age was not associated with length of hospital stay or morbidity. There was improvement in 91% of patients affected with diabetes mellitus, in 89% with hypertension, in 80% with dyslipidemia, and in 62% with obstructive sleep apnea.

COMMENTS

Roux-en-Y gastric bypass results in a marked amelioration or elimination of obesity-related comorbid conditions in veteran patients. Morbidity and mortality are within acceptable rage for these patients with substantial comorbidities.

Apoptosis inducing factor is decreased in metastatic colon cancer in ex-vivo models of colon carcinogenesis by tissue microarray

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Background: In vitro studies suggest that apoptosis inducing factor (AIF) expression is decreased in metastatic cells relative to those derived from primary tumors. This study was undertaken to determine AIF expression patterns in patients with stage I/II vs. stage III/IV colorectal cancers. Methods: Colon cancer specimens were prospectively collected (11/05–6/06) from 12 patients from 3 different sites: tumor, adjacent to tumor, and tissue 2 cm from the tumor. Paraffin-embedded specimens were examined by tissue microarray with AIF-specific antibodies. Total AIF expression as well as cytoplasmic and nuclear expression was assessed by an investigator blinded to the tissue site and patient stage. Staining was assessed as: 1=absent, 2=mild, 3=moderate, 4=high and 5=very high. The clinical characteristics and tumor stage of all patients were analyzed. Results: All patients were male. Eight patients had non-metastatic disease at the time of laparotomy, four had metastasis to: lymph nodes (n=3) and liver (n=1). Stage I/II patients (n=8) were of similar age compared to stage III/IV patients (n=4) [61.3±4.2 vs. 54.4±6.0 y.o.; p=0.6] had similar tumor size (3.81±0.7 vs. 4.08±1.4 cm; p=0.4). There was no difference in the level of expression of AIF in normal tissue collected 2-cm away from the tumor site in stage I/II vs. stage III/IV colon cancers in the cytoplasm (3.81±0.17 vs. 3.30±0.38; p=0.4), nucleus (3.19±0.43 vs. 2.49±0.46; p=0.8) or overall (4.06±0.27 vs. 3.37±0.8). A significant decrease in AIF expression was observed in stage III/IV tumors compared to stage I/II tumors in tissue collected adjacent to the tumor in the cytoplasm (3.12±0.22 vs. 4.46±0.25; p=0.03), the nucleus (2.10±0.44 vs. 3.63±0.32; p=0.03) and overall (3.12±0.22 vs. 4.46±0.25; p=0.03). There was a trend towards a decrease in AIF expression between stage III/IV vs. I/II tumors in tissue collected directly from the tumor in the cytoplasm (2.55±0.24 vs. 3.56±0.26; p=0.12), the nucleus (1.39±0.25 vs. 2.73±0.63; p=0.14) and overall (2.79±0.38 vs. 3.90±0.37; p=0.22). Conclusion: AIF expression is decreased in metastatic colon cancer. The main differences occur in the normal mucosa adjacent to the tumor.

No significant financial relationships to disclose.

Predictors of distant metastasis and mortality in patients with stage II colorectal cancer

The aim of our study was to determine clinical factors that predicted distant metastasis and mortality in patients with stage II colorectal cancer (CRC). A retrospective review of all patients admitted to the Dallas Veteran's Affairs Medical Center from 1998 to 2002 with stage II CRC was performed. Factors associated with distant metastasis and mortality were assessed by univariate analysis. Independent predictors of mortality and distant metastasis were assessed by multivariate analysis. Fifty-five patients with stage II CRC were identified (96% men, age 65 +/- 1.2 years old). Univariate analysis demonstrated that patients with distant metastasis (n = 13) had a history of alcohol intake (54% vs 20%; P = 0.029), less history of angiotensin-converting enzyme inhibitor use for the management of hypertension (31% vs 67%; P = 0.029), greater incidence of a rectal location for cancer (54% vs 12%; P = 0.004), an abdominoperineal resection (APR) for surgical management of their cancers (23% vs 0%; P = 0.011), and less negative lymph nodes examined during surgical resection (9 +/- 2.2 vs 15 +/- 1.2, P = 0.022). Follow-up of at least 3 years revealed 14 mortalities. Survivors had a less preoperative serum carcinoembryonic antigen level (5.9 +/- 0.9 vs 19.1 +/- 8.6; P = 0.031), an average less tumor depth involvement (T stage: 3.0 +/- 0.03 vs 3.2 +/- 0.11; P = 0.065), more negative lymph nodes examined at the time of surgical resection (14.0 +/- 1.3 vs 10.0 +/- 1.7; P = 0.058), less incidence of rectal cancer (21% vs 43%; P = 0.060), and none had undergone an APR (0% vs. 21%; P = 0.010). Multivariate analysis revealed that alcohol intake (P = 0.014; odds ration [OR] = 5.3), patients undergoing an APR (P = 0.011; OR = 25), and less frequency of angiotensin-converting enzyme inhibitor use (P = 0.007; OR = 4.5) independently predicted distant metastasis, whereas preoperative carcinoembryonic antigen (P = 0.038; OR = 2.8) and patients undergoing an APR (P = 0.019; OR = 25) independently predicted mortality.

Predictors of Distant Metastasis and Mortality in Patients with Stage II Colorectal Cancer

The aim of our study was to determine clinical factors that predicted distant metastasis and mortality in patients with stage II colorectal cancer (CRC). A retrospective review of all patients admitted to the Dallas Veteran's Affairs Medical Center from 1998 to 2002 with stage II CRC was performed. Factors associated with distant metastasis and mortality were assessed by univariate analysis. Independent predictors of mortality and distant metastasis were assessed by multivariate analysis. Fifty-five patients with stage II CRC were identified (96% men, age 65 ± 1.2 years old). Univariate analysis demonstrated that patients with distant metastasis (n = 13) had a history of alcohol intake (54% vs 20%; P = 0.029), less history of angiotensin-converting enzyme inhibitor use for the management of hypertension (31% vs 67%; P = 0.029), greater incidence of a rectal location for cancer (54% vs 12%; P = 0.004), an abdominoperineal resection (APR) for surgical management of their cancers (23% vs 0%; P = 0.011), and less negative lymph nodes examined during surgical resection (9 ± 2.2 vs 15 ± 1.2, P = 0.022). Follow-up of at least 3 years revealed 14 mortalities. Survivors had a less preoperative serum carcinoembryonic antigen level (5.9 ± 0.9 vs 19.1 ± 8.6; P = 0.031), an average less tumor depth involvement (T stage: 3.0 ± 0.03 vs 3.2 ± 0.11; P = 0.065), more negative lymph nodes examined at the time of surgical resection (14.0 ± 1.3 vs 10.0 ± 1.7; P = 0.058), less incidence of rectal cancer (21% vs 43%; P = 0.060), and none had undergone an APR (0% vs. 21%; P = 0.010). Multivariate analysis revealed that alcohol intake ( P = 0.014; odds ration [OR] = 5.3), patients undergoing an APR ( P = 0.011; OR = 25), and less frequency of angiotensin-converting enzyme inhibitor use ( P = 0.007; OR = 4.5) independently predicted distant metastasis, whereas preoperative carcinoembryonic antigen ( P = 0.038; OR = 2.8) and patients undergoing an APR ( P = 0.019; OR = 25) independently predicted mortality.

Screening and detection of apoptosis

Since programmed cell death was first described by the electron microscopic cellular changes demonstrating an organized form of cell death over 30 years ago, it has undergone a great deal of scrutiny as a potential target for several diseases including cancer. The techniques for the study of apoptosis have evolved accordingly. Methodologies for the study of apoptosis were examined by a MEDLINE search of the English-language literature and are summarized in this review. This review discusses the various ways to study apoptosis with specific assays, reagents, and molecules. The particular advantages and disadvantages of each method are reviewed.

Surgical bypass versus endoscopic stenting for malignant gastroduodenal obstruction: a decision analysis

The treatment options for palliating malignant gastroduodenal obstruction include open gastrojejunostomy (OGJ), laparoscopic gastrojejunostomy (LGJ), and endoscopic stenting (ES). The aim of this study was to compare the clinical outcomes and costs among ES, OGJ, and LGJ in patients who present with gastroduodenal obstruction from advanced upper gastrointestinal tract cancer. We designed a model for patients with malignant gastroduodenal obstruction. We analyzed success rates, complication rates and costs of the three treatment modalities: ES, OGJ, and LGJ. Baseline outcomes and costs were based on published reports. Success was defined as no major procedure-related and long-term complications over a 1-month period. Failure of therapy was defined as recurrent symptoms or death due to a procedural complication. Sensitivity analyses and cost-effectiveness analyses for the various strategies were performed. ES resulted in the lowest mortality rate and the lowest cost of the three treatment options analyzed. Mortality in the OGJ group was 2.1 times that in the ES cohort and 1.8 times that in the LGJ cohort. Sensitivity analyses confirmed ES as the dominant strategy. In conclusion, ES is the preferred treatment for palliation of duodenal obstruction due to advanced upper gastrointestinal tract cancer.

Meckel's diverticulitis: a rare etiology of an acute abdomen during pregnancy

Perforated Meckel's diverticulum (MD) is a rare complication of pregnancy. Its diagnosis, however, must be considered in all cases of intra-abdominal disease, as its presentation is similar to appendicitis. Prompt diagnosis and appropriate treatment is imperative in these cases due to the high rate of perforation leading to fetal and maternal morbidity and mortality. The usual lesion affecting a patient with MD and a review of the literature on other unusual causes of an acute abdomen in pregnancy is presented in the following report.

Hepatobiliary cystadenoma: a case report and a review of the literature

BACKGROUND

Hepatic cystic lesions are rare; however, their management and treatment is dependent on early recognition and diagnosis.

METHODS

In this report, the authors discuss a 72-year-old woman who presented to their clinic for treatment of a hepatocystadenoma.

RESULTS

The history, physical examination, and diagnostic modalities lead to surgical intervention despite an unclear diagnosis.

CONCLUSIONS

This case illustrates an unusual hepatic lesion in which the diagnosis was not known until the time of laparotomy. However, diagnostic modalities were important in establishing the need for surgical intervention. The authors offer a pertinent review of the literature and discuss current treatment modalities.