Midgut volvulus presenting with acute chylous peritonitis

Key Clinical message

Midgut volvulus can rarely present with acute chylous peritonitis. Common etiologies for chylous ascites need to be excluded before this diagnosis is made. Correction of the volvulus and peritoneal lavage suffice as treatment.

Should doctors strike?

Last year in June, British doctors went on strike for the first time since 1975. Amidst a global economic downturn and with many health systems struggling with reduced finances, around the world the issue of public health workers going on strike is a very real one. Almost all doctors will agree that we should always follow the law, but often the law is unclear or does not cover a particular case. Here we must appeal to ethical discussion. The General Medical Council, in its key guidance document for practising doctors, Good Medical Practice, claims that 'Good doctors make the care of their patients their first concern'. Is this true? And if so, how is this relevant to the issue of striking? One year on since the events, we carefully reflect and argue whether it was right for doctors to pursue strike action, and call for greater discussion of ethical issues such as the recent strikes, particularly among younger members of the profession.

Comparison of RECIST 1.0 and RECIST 1.1 on computed tomography in patients with metastatic colorectal cancer

OBJECTIVE

We conducted this study to compare tumor measurement by computed tomography (CT) and tumor response assessment between Response Evaluation Criteria In Solid Tumors (RECIST) 1.0 and RECIST 1.1 in patients with metastatic colorectal cancer (CRC).

METHODS

We reviewed the medical records of patients with metastatic CRC who received first-line chemotherapy between January 2004 and December 2012 and compared CT tumor measurement using two RECIST versions.

RESULTS

A total of 58 patients who had target lesions according to RECIST 1.0 were included in the study. The number of target lesions recorded by RECIST 1.1 was significantly lower than that by RECIST 1.0, with a decrease experienced in 48 patients (82.7%). Six patients had no target lesions because of the new criteria of RECIST 1.1 for lymph node size. Out of 95 lymph nodes from 58 patients, only 40% were defined as target lesions according to RECIST 1.1. The overall response rate of first-line chemotherapy according to RECIST 1.0 and 1.1 was 41.5 and 40.4%, respectively. The best tumor responses showed almost perfect agreement between RECIST 1.1 and RECIST 1.0 (ĸ = 0.913). Three patients showed disagreement of the best responses between the two RECIST versions.

CONCLUSION

RECIST 1.1 showed a highly concordant response assessment with RECIST 1.0 in metastatic CRC and its clinical impact on therapeutic decisions was minimal.

A curious case of unilateral spider nevi, cirrhosis and stroke: unilateral nevoid telangiectasia syndrome

A 55-year-old Caucasian man presented with unilateral right facial spider nevi. Relevant medical history included a right-sided cerebrovascular accident (CVA) in 1997 and decompensated alcoholic liver disease, diagnosed in 2007. The literature describes approximately 100 cases of unilateral spider nevi associated with different aetiologies, grouped under 'unilateral nevoid telangiectasia syndrome' (UNTS). This is a rare presentation of a commonly observed sign in clinical practice. This case offers an opportunity to explore the origins of spider nevi and highlights the benefit of sharing knowledge in order to help elucidate the potential mechanisms underlying common signs.

Is hybrid robotic laparoscopic assistance the ideal approach for restorative rectal cancer dissection?

AIM

While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors' preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intra-operative and short-term outcomes.

METHOD

Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid robotic technique were included in our study. Demographics, margin positivity, intra-operative and short-term outcomes were evaluated.

RESULTS

The preferred approach was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and nine had a coloanal pull-through procedure (mean age 60.1 years; mean body mass index 28.0 kg/m(2) ; mean operative time 327 min; conversion rate 3.9%). Three patients (3.9%) had positive resection margins (one circumferential, two distal). Five patients had an anastomotic leak (6.4%). No robot-specific complications were observed.

CONCLUSION

The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This approach can be considered an viable option for surgeons new to robotic rectal dissection.

Endoclip closure of a large colonic perforation following colonoscopic leiomyoma excision

BACKGROUND AND OBJECTIVE

Endoscopic removal of large colonic submucosal lesions can lead to a higher risk of perforation. Although not as common following diagnostic and therapeutic colonoscopy, it does occur more often following therapeutic colonoscopy. We present a case of a large submucosal mass excised endoscopically, resulting in a large perforation that was closed using endoclips. While endoclips are typically used for smaller perforations, we have found that they can be used safely on a larger defect.

METHODS

A 68-y-old woman presented with a 2.9-cm benign submucosal mass found in the hepatic flexure. It was removed via endoscopic polypectomy, leaving a perforation of 3cm x 3cm. The perforation was closed with endoscopic clips.

RESULTS

Histology of the specimen showed clear margins. At 4-wk follow-up, the patient had no complications. A colonoscopy at 6-mo follow-up showed only a scar at the procedure site with no complaints.

CONCLUSIONS

Large iatrogenic colonic perforations can be managed successfully using endoclips, particularly in a prepped colon.

Estimation of the nares-to-epiglottis distance and the nares-to-vocal cords distance in young children

BACKGROUND

Estimation of the nares-to-epiglottis and nares-to-vocal cords distances would facilitate the selection of properly sized nasopharyngeal airways and appropriate positioning of a fibreoptic bronchoscope in young children. The purposes of this study were to measure the nares-to-epiglottis and nares-to-vocal cords distances and to create an algorithm to predict these distances based on anatomical landmarks and paediatric characteristic data.

METHODS

Two hundred and eleven children, aged 1-10 yr, undergoing elective surgery were investigated. After induction of general anaesthesia, the distances from the nares to the epiglottis/vocal cords were measured using a nasogastric tube. After intubation, the distances from the lateral border of the nose to the ipsilateral mandible angle (nares-to-mandible distance) and the tragus of the ear (nares-to-tragus distance) were measured using a tape measure.

RESULTS

The nares-to-epiglottis and nares-to-vocal cords distances were significantly correlated with the age, weight, height, and external measurements (P<0.001). By stepwise multiple linear regression analysis, formulas were obtained for the nares-to-epiglottis distance (cm)=2.606+0.058×height (cm)+0.231×the nares-to-mandible distance (cm)-0.304 (gender) (r(2)=0.754) and for the nares-to-vocal cords distance (cm)=4.947+0.06×height (cm)+0.228×nares-to-mandible distance (cm)-0.283 (gender) (r(2)=0.803).

CONCLUSIONS

The nares-to-epiglottis and nares-to-vocal cords distances can be predicted using the height and the nares-to-mandible distance in young children.

CLINICAL TRIAL REGISTRATION NUMBER

Clinical Research Information Service KCT0000150.

Mucosal protective effect of PGI2 on canine small bowel auto-transplantation

PURPOSE

We designed this experimental study to assess the mucosal protective effects of continuous prostaglandin I2 (PGI2) infusion after canine small bowel autotransplantation.

MATERIALS AND METHODS

Six Mongrel dogs were randomly divided two groups: PGI2 (n = 3) and control (n = 3). The small bowel from jejunum to ileum was obtained, including the mesenteric vascular pedicle. After cold flushing ex vivo, the harvested segment was preserved in an icebox for 3 hours. Thereafter we reimplanted the harvested intestinal segment. While completing the anastomosis, PGI2 (50 μg) was slowly infused through the mesenteric artery in the PGI2 group versus the same volume of saline in the control group. At 1, 3 and 6 days after autotransplantation, we obtained blood samples, and at 6 days, small bowel segments. Endotoxin and interleukin 6 (IL-6) levels were measured and all histologic specimens stained with hematoxylin-eosin H-E were reviewed by a pathologist to grade mucosal damage as: mild (1 point), moderate (2 points), or severe (3 points) change.

RESULTS

Mean basal serum endotoxin levels were similar in both groups the PGI2 groups versus control group were 0.216 ± 0.018 versus 0.223 ± 0.040 EU/mL, respectively. However, on day 3 after the operation, the PGI2 group showed much decreased levels of serum endotoxin compared to control levels: 0.349 ± 0.196 versus 0.842 ± 0.446 EU/mL. The mean concentration of serum IL-6 on day 1 after operation among the PGI2 versus control group were 32.13 ± 7.13 pg/mL versus 36.96 ± 3.65 pg/mL. The histologic scores at 6 days after the operation were PGI2 group versus control group: 1.33 versus 1.66 (P = NS).

CONCLUSION

Continuous infusions of PGI2 through the mesenteric artery after the canine small bowel autotransplantation may protect the small bowel mucosal barrier.

Robotic cylindrical abdominoperineal resection with transabdominal levator transection

PURPOSE

The extralevator approach to abdominoperineal resection is an emerging surgical option for patients with low rectal cancer. This technique involves a wide excision of the levator muscles that could reduce the high incidence of circumferential margin positivity associated with conventional abdominoperineal resections. We present our technique of robotic cylindrical abdominoperineal resection where the daVinci robot is used to perform a controlled transection of the levator muscles transabdominally under direct visualization.

METHODS

Five patients with rectal adenocarcinoma within 5 cm of the anal verge underwent robot-assisted cylindrical abdominoperineal resection. Safety, feasibility, immediate postoperative outcomes, and pathological adequacy of the specimen were assessed.

RESULTS

The procedure was successfully completed in all 5 patients without any intraoperative complications, robot-associated morbidity, or conversion to the open approach. The mean operative time and length of hospital stay were 343 minutes and 5.8 days. An intact mesorectal envelope and negative circumferential margin was achieved in all cases. All specimens had a cylindrical shape.

CONCLUSIONS

Robotic assistance enables the transabdominal transection of the levator muscles in cylindrical abdominoperineal resection, with acceptable perioperative and pathological outcomes. Further studies are essential to objectively define the safety, efficacy, and long-term results of this new technique.

Post Colonoscopy Colonic Intussusception Reduced via a Laparoscopic Approach

The authors discuss a case of colon intussusception following colonoscopy successfully treated by laparoscopic reduction.

Intussusception occurs when a mass in the bowel is pulled forward by normal peristalsis, with resultant invagination of the involved bowel wall. In the absence of a mass, intussusception may be caused by functional disturbances without gross mural abnormality. Colo-colonic intussusception in adult is relatively rare and usually secondary to a definable lesion, the majority of which are malignant in nature. Idiopathic intussusception in adults is rare and its pathogenesis is poorly understood.

We present a case report of an adult colo-colonic intussusception occurring after colonoscopy, which was treated successfully with laparoscopic reduction. We speculate that the intussusception was induced by post-polypectomy mucosal edema acting as a lead point and therefore can be treated without resection.

A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma

PURPOSE

This retrospective study was designed to compare open with robot-assisted total mesorectal excision for rectal adenocarcinoma.

METHODS

With use of predefined exclusion criteria, all consecutive laparoscopic-assisted (51 patients) and robot-assisted (36 patients) rectal resections for adenocarcinoma from August 2005 to November 2009 at a single institution were considered. Hand-assisted laparoscopy was used for splenic flexure mobilization in all cases. Patients were assigned into robotic and open groups on the basis of the technique used for total mesorectal excision. All 36 robot-assisted resections had the total mesorectal excision performed with robotic assistance and were included in the robotic group. Forty-six of the 51 patients who received a laparoscopic-assisted procedure had the total mesorectal excision performed through the hand port using open surgical technique and were included in the open group. Both groups were compared with respect to patient demographics, perioperative outcomes, and pathology.

RESULTS

The robotic and open groups were comparable in age, sex, body mass index, history of prior abdominal surgery, ASA class, number of patients receiving neoadjuvant chemoradiation, and tumor stage. There were more abdominoperineal resections (P = .019) and more low and mid rectal tumors (P = .007) in the robotic group. Total procedure time was longer in the robotic group (P = .003), but blood loss was less (P = .036). Lymph node yield, intraoperative and postoperative complications, and length of stay were all comparable. There were 3 positive circumferential margins in the open group vs none in the robotic group, but this did not reach statistical significance.

CONCLUSIONS

Robotic total mesorectal excision is feasible and safe, and is comparable to open total mesorectal excision in terms of perioperative and pathological outcomes. The longer operative time associated with robotic total mesorectal excision could decrease as experience with this relatively new technique increases. Large randomized trials are necessary to validate the potential benefits of less blood loss and lower margin positivity rates observed in this study.

Total mesorectal excision for rectal cancer: the potential advantage of robotic assistance

PURPOSE

The purpose of this study was to analyze the safety, feasibility, and efficacy of the da Vinci S HD robotic system in mesorectal excision for rectal adenocarcinoma, with the aim to identify areas of potential advantage for the robot in this procedure.

METHODS

This study was conducted as a retrospective review of a prospectively maintained database of 44 consecutive cases of robot-assisted mesorectal excision for rectal adenocarcinoma performed between August 2005 and February 2010. Patient demographics, perioperative outcomes, and complications were evaluated and compared with similar published reports and relevant literature.

RESULTS

There were 28 (63.6%) men and 16 (36.4%) women, with a mean age of 63 years. The majority of patients were either overweight or obese and 88.7% of lesions were in the mid or low rectum. We performed 36 low anterior resections (6 intersphincteric) and 8 abdominoperineal resections with a median blood loss of 150 mL (range, 50-1000), a median operative time of 347 minutes (range, 155-510), and a median length of stay of 5 days (range, 3-36). The median lymph node yield was 14 (range, 5-45) and the circumferential resection margin was negative in all patients. We had 1 distal margin positivity (2.7%), 2 anastomotic leaks (5.6%), 1 death (2.7%), and 2 conversions (4.5%) to the open approach. No robot-associated morbidity occurred in this series.

CONCLUSIONS

This series compares favorably with similar published reports with regard to the safety and feasibility of robotic assistance in total mesorectal excision for rectal cancer. The lower conversion rates reported for robotic rectal resection compared with laparoscopy require validation in large randomized trials.

Frequency of late drug-eluting stent thrombosis with non-cardiac surgery

Drug-eluting stents (DES) are highly effective in reducing restenosis but have a small but significant risk for late stent thrombosis (LAST). Cessation of antiplatelet drugs for noncardiac surgery has been implicated in precipitating LAST, prompting surgery to be done on antiplatelet therapy, with all the attendant bleeding risks, or deferred until 12 months after DES implantation, despite limited data defining the risk for LAST. Using billing data from 2 large health funds, members who had DES insertion (n = 9,321) with subsequent noncardiac surgery (n = 4,126) were mailed a questionnaire regarding their noncardiac procedures, antiplatelet use, and subsequent coronary events. From 1,086 returned, 710 were suitable for inclusion, identifying 11 patients (1.5%) with perioperative myocardial infarctions confirmed by medical records. Angiography showed that only 2 had stent thromboses, while 7 had new culprit lesion (2 patients did not undergo angiography). Before their noncoronary procedures, 66% were receiving dual-antiplatelet therapy, and 30% were taking single agents. Surgery was performed on dual therapy in 18%, on single agents in 23%, and with no antiplatelet therapy in 59%. The mean time to surgery from stent implantation was 348 days, with 56% <12 months. In conclusion, noncardiac surgery after DES implantation is frequent and appears to have low cardiac morbidity despite variable antiplatelet cessation. Perioperative myocardial infarctions occur because of narrowings in nonstented coronary arteries rather than from LASTs.

Robotic assistance in right hemicolectomy: is there a role?

PURPOSE

The purpose of this study was to evaluate the results, postoperative outcomes, and cost of robotic assistance in right hemicolectomy and determine its safety, feasibility, and efficacy as compared with the conventional laparoscopic approach.

METHODS

From August 2005 to February 2009, 40 robot-assisted right hemicolectomies were performed by the authors at a single institution. These were compared with 135 laparoscopic right hemicolectomies performed by the authors, at the same hospital and during the same time period. Cost data from July 2006 until the end of the study period were compared between the 2 groups.

RESULTS

Both groups were comparable with respect to age, sex, body mass index, American Society of Anesthesiologists' class, history of prior abdominal surgery, and diagnosis. There was no significant difference in the lymph node harvest, estimated blood loss, conversion rate, length of stay, or incidence of complications and wound infection between the 2 groups. A robotic procedure was associated with a longer operative time (P < .001) and a higher cost (P = .003).

CONCLUSION

Robotic assistance in right hemicolectomy is safe and feasible but is associated with a longer operative time and, at present, with a higher cost compared with laparoscopy. However, right hemicolectomy serves as an ideal procedure to begin the learning curve in robotic colorectal surgery, which can subsequently progress to robotic rectal resections where the robot has the greatest potential for benefit.

Robotic pursestring technique in low anterior resection

PURPOSE

Rectal division and anastomosis are difficult steps in a laparoscopic low anterior resection. This difficulty is due to the limitations of laparoscopic instrumentation within the anatomical confines of the pelvis. Robotic technology overcomes most of these limitations to simplify the procedure. We describe our technique of controlled rectal transection and robotic purse-string placement by use of the da Vinci Robotic system.

METHODS

Three patients with rectal cancer who were scheduled to undergo a robot-assisted low anterior resection were selected to undergo this procedure. Safety, feasibility, and immediate postoperative outcomes were assessed.

RESULTS

The procedure was successfully completed in all 3 patients with no intraoperative complications. One patient had a postoperative bilateral femoral neuropathy that resolved spontaneously. The mean operating time was 339.6 minutes, and all 3 patients were sent home by the fifth postoperative day.

CONCLUSIONS

The advanced surgical dexterity of the da Vinci Robot enables a controlled rectal transection and purse-string suture placement on the rectal stump. This achieves a right-angled rectal division and a secure, single-stapled anastomosis in a low anterior resection. The feasibility of this technique has been demonstrated in 3 patients, in whom this technique has been safely performed with acceptable results. A larger series of patients and a long-term follow-up is required to demonstrate an objective benefit.

Neuroimaging and cerebral palsy in children

Cerebral palsy (CP) is a description of a spectrum of central nervous system (CNS) impairments that affect mobility, communication, intellectual ability, and neurobehavior as a result of developmental brain dysfunction. CP is the most common contributor to motor disability in children with prevalence of about 2-3/1000 live births globally. Presently, no curative therapies or successful methods of prevention on a population level are available for children with one of the cerebral palsy syndromes. Despite these challenges, orthopedic, rehabilitation, neuropharmacological, and other management interventions can help maintain mobility, prevent deformity, and promote quality of life for children with CP. Typically, the diagnosis of CP is based on clinical observations and parent concerns regarding delays in attaining motor milestones (e.g., rolling, sitting, crawling, walking), not on laboratory testing or neuroimaging. However, since 2004 the American Academy of Neurology (AAN) has recommended that neuroimaging of the CNS be part of diagnostic process for cerebral palsy. Although the guideline was initially met with controversy and criticism, neuroimaging has allowed a broader appreciation of timing of lesions, extent of white matter involvement, and the complexity of the motor spectrum of disability. In this article we shall describe the major types of neuroimaging techniques and review their roles in identification and evaluation of children with one of the cerebral palsy syndromes. The authors will focus on the emerging knowledge of how brain structure can inform us about children's functioning, especially among children with prematurity, recognizing that we are only beginning to understand brain plasticity and developmental resiliency.

Combination treatment with leflunomide and methotrexate for patients with active rheumatoid arthritis

OBJECTIVE

To determine the efficacy and safety of the combination of leflunomide and methotrexate for the treatment of patients with active rheumatoid arthritis (RA) in an open, non-comparative, multicentre trial.

METHODS

Seventy-four patients with active RA were enrolled to receive concomitantly leflunomide (no loading dose, 10 mg/day) and methotrexate (starting at 7.5 mg/week and titrating up to 15 mg/week) for 20 weeks. The primary end-point was a 20% improvement in the American College of Rheumatology (ACR) criteria at 20 weeks. Safety measures included evaluation of adverse events at each visit and laboratory data, including haematology and liver function tests. Intention-to-treat analyses were conducted.

RESULTS

Sixty-five patients completed 20 weeks of treatment, and 71.6% were responders based on the ACR20 criteria. After 20 weeks, the mean changes were -16.3 for tender joint count, -12.0 for swollen joint count, -44.0 for physician global assessment, -34.3 for patient global assessment, -22.7 for erythrocyte sedimentation rate, and -0.65 for the Health Assessment Questionnaire score. Adverse events occurred in 40.5% of the patients, and were considered serious in four patients who discontinued therapy. Abnormal liver function was noted for 16 patients (21.6%). Two of these patients were withdrawn from the study; after discontinuing the medication, their liver function recovered fully.

CONCLUSION

THE combination of leflunomide and methotrexate was effective and well tolerated in the treatment of active RA patients. This combination may be a useful option as an initial treatment for active RA before starting biological agents.

Efficacy of Helicobacter pylori eradication therapy in chronic liver disease

BACKGROUND/AIMS

Peptic ulcers occur more commonly in patients with liver cirrhosis (LC). Helicobacter pylori is recognized as the most important etiology in the pathogenesis of peptic ulcers. We investigated the efficacy of proton pump inhibitor (PPI)-based triple therapy in patients with chronic liver disease and peptic ulcer.

PATIENTS AND METHODS

One hundred sixty-three patients with LC or chronic hepatitis (CH) with a peptic ulcer and proven H. pylori infection were included. The combination of PPI, amoxicillin (1.0 g), and clarithromycin (500 mg), each given twice daily, was administered for 1 or 2 weeks. The eradication of H. pylori was determined by the rapid urease test, histology, or the 13C-urea breath test at least 4 weeks after completing the treatment.

RESULTS

The eradication rate of H. pylori was similar between the LC and CH groups; 82.6% and 88.1%, respectively. In addition, there were no significant differences in eradication rates between the patients with Child-Pugh class A and Child-Pugh class B/C disease. The side effects in each group were generally mild. Only the serum ALT levels showed a significant correlation with the success of H. pylori eradication in both the LC and CH groups.

CONCLUSION

The PPI-based triple therapy achieves high eradication rates for H. pylori infection, in patients with chronic liver disease, without significant side effects.

Change of melanocortin receptor expression in rat kidney ischemia-reperfusion injury

OBJECTIVES

alpha-Melanocyte stimulating hormone (alpha-MSH) may ameliorate renal ischemia-reperfusion (I/R) injury. Recent data suggest that melanocortin receptors may be related to the anti-inflammatory and immunomodulating action for alpha-MSH. We designed this experiment to determine the renal distribution of alpha-MSH receptors; melanocortin-1 receptor (MC-1R) and melanocortin-3 receptor (MC-3R).

METHODS

Sprague-Dawley male rats (n = 24) were randomly divided into 2 groups: the sham (n = 2) and the operation groups with warm ischemia (n = 12). Animals in the operation group were subjected to 40 minutes of warm renal ischemia. Western blotting analyses and immunohistochemistry were employed to determine expression of MC-1R and MC-3R.

RESULTS

Expression of MC-1R and MC-3R was decreased on 1 day after reperfusion. Immunohistochemical study confirmed the findings of Western blot analysis.

CONCLUSIONS

The present study demonstrated novel renal expression of MC-1R and MC-3R, especially in the outer medulla, representative of the renal I/R injury. Our current study suggested that the mechanisms of action of alpha-MSH may significantly attenuate the renal I/R injury by specific kidney-targeted effects via MC-Receptors as well as by systemic cytokine effects.