[Gas gangrene with ulcerative colitis under immunosuppressive therapy: report of a case]

We report on a 30-year-old male with ulcerative colitis who developed a spontaneous gas gangrene in the right limb, the gluteal muscles and the retroperitoneal region under immunosuppressive therapy. In spite of immediate aggressive surgical and antibiotic therapy the massive infection led to septicemia and ultimately death. Clostridium septicum was identified with multiple local manifestations in the skeletal muscles. Gas gangrene is extremely rare in patients with ulcerative colitis or Crohn's disease and immunosuppression. The therapeutic options are discussed and the relevant present literature is reviewed.

Superselective embolization of deep femoral artery branch pseudoaneurysm with a coaxial microcatheter system

This report describes the use of transluminal coil embolization to treat pseudoaneurysm of deep femoral artery branch in two patients. The pseudoaneurysms had developed after coronary angiography in one patient and after hip replacement in the other. Immediate control angiography after embolization procedures demonstrated complete closure of the pseudoaneurysms. During follow-up of 19 and 3 months, respectively, there was no recurrent bleeding. The aim of this case report is to show the advances in endovascular microcatheter technology, and embolic materials, that made percutaneous transluminal embolization of arterial pseudoaneurysms safe and efficient. In addition, it keeps the medical personnel aware of vascular injuries at the access site related to endovascular procedures as well as vascular complications of total hip arthroplasty. It calls their attention to the possibility of endovascular treatment as an alternative to surgery.

[How should patients with completely resected gastrointestinal stromal tumours (GIST) be followed up?]

Gastrointestinal stromal tumours are topical because of their uncertain biological behaviour and the potential of treatment with imatinib. In the following study we have examined which pattern of follow-up is both appropriate for detecting recurrences and cost-effective.

PATIENTS AND METHODS

Between July 1997 and February 2004 we treated 43 patients diagnosed with a GIST. Patients with high risk (HR), intermediate risk (IR), or overtly malignant (OM) tumours were followed-up regularly. In 2004 we screened all patients independent of their risk of malignant disease with an ultrasound scan and endoscopy followed by endosonography. Further diagnostic procedures were carried out if necessary.

RESULTS

Overall, we diagnosed recurrences in five out of 33 patients at risk (two in patients with OM, one in a patient with HR, and 2 in patients with IR according to the NIH criteria). The time period between resection of the primary tumour and recurrence ranged from 4.5 to 33 months. One of the patients with a recurrence was seen before the imatinib era, the other four were treated with imatinib mesylate.

CONCLUSION

In our experience, regular follow-up should be restricted to patients with OM, HR, and IR GIST. We suggest that patients are initially seen in six months intervals for two years and annually for another three years thereafter.

Peripherally administered CRF stimulates colonic motility via central CRF receptors and vagal pathways in conscious rats

Corticotropin releasing factor (CRF) is one of the most important factors in the mechanism of stress-induced stimulation of colonic motility. However, it is controversial whether stress-induced stimulation of colonic motility is mediated via central or peripheral CRF receptors. We investigated the hypothesis that peripherally injected CRF accelerates colonic motility through the central CRF receptor, but not the peripheral CRF receptor. A strain gauge transducer was sutured on the serosal surface of the proximal colon. Colonic motility was monitored before and after the peripheral injection of CRF. An in vitro muscle strip study was also performed to investigate the peripheral effects of CRF. Subcutaneous injection of CRF (30-100 microg/kg) stimulated colonic motility in a dose-dependent manner. The stimulatory effect of peripherally administered CRF on colonic motility was abolished by truncal vagotomy, hexamethonium, atropine, and intracisternal injection of astressin (a CRF receptor antagonist). No responses to CRF (10(-9) -10(-7) M) of the muscle strips of the proximal colon were observed. These results suggest that the stimulatory effect of colonic motility in response to peripheral administration of CRF is mediated by the vagus nerve, nicotinic receptors, muscarinic receptors, and CRF receptors of the brain stem. It is concluded that peripherally administered CRF reaches the area postrema and activates the dorsal nucleus of vagi via central CRF receptors, resulting in stimulation of the vagal efferent and cholinergic transmission of the proximal colon.

The herbal medicine, Dai-Kenchu-to, accelerates delayed gastrointestinal transit after the operation in rats

BACKGROUND

Post-operative ileus (POI) is a transient bowel dysmotility after operation. We have previously shown that laparotomy alone significantly delayed gastrointestinal (GI) transit, compared to anesthesia alone. The GI transit was further delayed after laparotomy plus intestinal manipulation. Dai-Kenchu-to (DKT), an herbal medicine, has been used for treating adhesive bowel obstruction in Japan. We studied whether DKT improves delayed GI transit after the operation, with or without morphine administration in rats.

MATERIALS AND METHODS

Under isoflurane anesthesia, POI was induced by laparotomy with intestinal manipulation. Immediately after the operation, the rats received 51Cr by gavage. Three hours after the operation, the rats were sacrificed and GI transit was estimated by calculating the geometric center (GC). DKT (120, 360, and 1,200 mg/kg) were administered by gavage after the operation, with or without morphine administration (1 mg/kg s.c.). A muscarinic receptor antagonist (atropine; 50 mug/kg), a 5HT3 receptor antagonist (ondansetron; 1 mg/kg) and a 5HT4 receptor antagonist (GR113,808; 3 mg/kg) were administered before the operation. Truncal vagotomy was performed preceding the operation.

RESULTS

Laparotomy with intestinal manipulation produced a significant delay in GI transit (GC = 2.93 +/- 0.16), compared to that of anesthesia alone (9.51 +/- 0.45). DKT at the dose of 360 mg/kg (GC = 3.77 +/- 0.10, P < 0.01) and 1,200 mg/kg (GC = 3.77 +/- 0.20, P < 0.01) significantly accelerated delayed GI transit induced by operation. Ondansetron, GR113,808, atropine, and truncal vagotomy abolished the stimulatory effect of DKT (360 mg/kg). When morphine was administered, GI transit was further reduced (GC = 1.97 +/- 0.10). DKT at the dose of 360 mg/kg (GC = 2.81 +/- 0.22, P < 0.05) and 1,200 mg/kg (GC = 2.87 +/- 0.23, P < 0.05) significantly improved delayed GI transit in morphine treated rats.

CONCLUSIONS

DKT accelerates delayed GI transit induced by intestinal manipulation with and without concomitant morphine administration. DKT treatment may be useful for the patients with POI.

Minimally invasive and local treatment for mucosal early gastric cancer

BACKGROUND

Early gastric cancer (EGC) can present an indication for local resection procedures under pertain circumstances. Especially endoscopic mucosal resections (EMRs) and laparoscopic resections or those combined with endoscopy have been made possible in recent years.

METHODS

From 1996 to 2004, of a total of 425 patients with gastric cancer, 58 patients with EGC (13.6%) were prospectively analyzed and observed. Of these, 35 patients had preoperatively diagnosed submucosal infiltration and subsequently underwent gastrectomy and standard lymphnodectomy. Of the 23 patients with intramucosal EGC, 22 underwent local resection. One patient displayed lymph node and liver metastasis at the time of diagnosis and received chemotherapy following staging laparoscopy.

RESULTS

Among the 23 patients with intramucosal EGC, 13 were female and 10 male. The average age of the patients was 77.4 years (range: 69-86). The rate of lymph node metastasis was 12.5% (n = 35) for submucosal EGC and 4.3% (n = 23) for intramucosal EGC. Twenty-two patients with intramucosal EGC underwent local resection (four EMR, six laparoscopic intragastric resection, 12 laparoscopic wedge resection). The average tumor size was 1.2 cm (range 0.3-2.3). The definitive histological findings yielded in all patients tumor-free resection margins without venous or lymphangic infiltration. In 10 of 18 patients undergoing laparoscopic resection a simultaneous sentinel lymph node sampling (4 +/- 3 LN) was performed. There were no metastases detected. Method-specific complications did not occur. The morbidity of this patient group was 13.6% (three of 22). Mortality was zero. The average postoperative hospital stay was 6.5 days (range 2-12). In the median follow-up of 30.3 months (range 1-86) no recurrences have yet been diagnosed. Four patients died within the observation period of non-cancer-related causes.

CONCLUSIONS

Minimally invasive local resection of intramucosal EGC represents a favorable option when strict determination of indication has taken place.

[Prospective multicenter trial of gastric cancer surgery--a contribution to clinical research on quality control]

By the mean of a prospective multicenter observational study (East German Gastric Cancer Study - EGGCS), 1 139 consecutive patients with gastric cancer were enrolled in 80 East German surgical departments from January 1 to December 31, 2002. Out of them, 1,031 (90.5%) underwent surgical intervention. The resection rate was 86.4% (n = 891); the R0 resection rate (n = 726) was 81.5%. Gastrectomy was performed in 79.8 % (n = 649) of subjects with radical resections (n = 813). In approximately 70 % of the interventions with curative intention, lymph node resection of the D2 compartment was carried out. The postoperative hospital mortality was 8.3%. The results were compared with the data obtained in the German Gastric Cancer Study (GGCS 1992); relevant differences and aspects were discussed.

Intensified concurrent chemoradiotherapy with 5-fluorouracil and irinotecan as neoadjuvant treatment in patients with locally advanced rectal cancer

This study aimed to evaluate the feasibility and efficacy of neoadjuvant chemoradiotherapy intensified with irinotecan in patients with locally advanced rectal cancer. Eligible patients had nonmetastatic disease at a locally advanced stage that made R0 resection and sphincter preservation uncertain. They received preoperative radiation over 6 weeks to 45 Gy and boost of 5.4 Gy and concurrent continuous infusion 5-fluorouracil 250 mg m⁻² day⁻¹ and weekly irinotecan 40 mg m⁻². In all, 37 patients entered the study. T stage at baseline as determined by ultrasound was T2/T3/T4 in 2/19/16 patients; 31 patients had lymph node involvement. The predominant toxicity was diarrhoea (grade 3/4 in 10/2 patients). Haematologic toxicity and surgical complications were moderate. Among 36 patients undergoing surgery, 32 (89%) had R0 resection and 23 (64%) sphincter preservation. Pathologic complete response (pCR) was achieved in eight (22%) of 36 patients, and 10 patients (28%) had only microscopic residual disease. At 4 years, overall survival was 66%, disease-free survival 73%, local relapse rate 7%, and distant failure rate 24%. Extent of resection and postoperative nodal status were significant predictors of overall and disease-free survival. Intensified neoadjuvant chemoradiotherapy with irinotecan can be safely administered and results in a high pCR rate.

Acoustic radiation force impulse (ARFI) imaging of the gastrointestinal tract

The evaluation of lesions in the gastrointestinal (GI) tract using ultrasound can suffer from poor contrast between healthy and diseased tissue. Acoustic Radiation Force Impulse (ARFI) imaging provides information about the mechanical properties of tissue using brief, high-intensity, focused ultrasound to generate radiation force and ultrasonic correlation-based methods to track the resulting tissue displacement. Using conventional linear arrays, ARFI imaging has shown improved contrast over B-mode images when applied to solid masses in the breast and liver. The purpose of this work is to (1) investigate the potential for ARFI imaging to provide improvements over conventional B-mode imaging of GI lesions and (2) demonstrate that ARFI imaging can be performed with an endocavity probe. ARFI images of an adenocarcinoma of the gastroesophageal (GE) junction, status-post chemotherapy and radiation treatment, demonstrate better contrast between healthy and fibrotic/malignant tissue than standard B-mode images. ARFI images of healthy gastric, esophageal, and colonic tissue specimens differentiate normal anatomic tissue layers (i.e., mucosal, muscularis and adventitial layers), as confirmed by histologic evaluation. ARFI imaging of ex vivo colon and small bowel tumors portray interesting contrast and structure that are not as well defined in B-mode images. An endocavity probe created ARFI images to a depth of over 2 cm in tissue-mimicking phantoms, with maximum displacements of 4 microm. These findings support the clinical feasibility of endocavity ARFI imaging to guide diagnosis and staging of disease processes in the GI tract.

Relationship between surgeon caseload and sphincter preservation in patients with rectal cancer

PURPOSE

The aim of this study was to determine by means of a national database whether higher surgeon caseload correlates with greater utilization of sphincter-sparing procedures than of abdominoperineal resections in treatment of patients with rectal cancer.

METHODS

Patients with a primary International Classification of Diseases-9 diagnosis code of rectal cancer who underwent a sphincter-sparing procedure or abdominoperineal resection were selected from the 1997 Nationwide Inpatient Sample, a database that represents 20 percent of all U.S. community hospital discharges. Multivariable logistic regression models were used on a 20 percent sample of this database to estimate the risk-adjusted relationship between surgeon caseload volume and the odds of receiving a sphincter-sparing procedure. All models were adjusted for age, gender, race, hospital region, and patient comorbidity.

RESULTS

The study population (n = 477) was 70.4 percent white and 57.9 percent male with an average age of 67.6 years. The mean Deyo comorbidity score was 7.0. Patients treated by surgeons in the highest-volume category (> or =10 rectal cancer surgeries per year) compared with those treated by surgeons in the lowest-volume category (1-3 rectal cancer surgeries per year) were significantly more likely to undergo a sphincter-sparing procedure, after adjustment for other covariates (odds ratio = 5.05; 95 percent confidence interval, 2.5-10.22).

CONCLUSION

This analysis suggests that rectal cancer patients treated by high-volume surgeons are five times more likely to undergo sphincter-sparing procedures than those treated by low-volume surgeon. This has significant implications for those seeking a sphincter-preserving option for the treatment of their rectal cancer.

[Mycoserologic tests in surgical intensive care patients and patients with Candida oesophagitis]

We retrospectively analysed the results of Candida serological testing of 126 surgical intensive care patients. There were high numbers of patients which were mycoserologically positive (haemagglutination test HAT 86.4%, immunoglobulin subclasses 85.3%). Positive microbiological cultures of Candida spp. were found in 43.7% of the patients. Patients with positive cultural findings had an increased HAT titre in 83.9% and increased immunoglobulins in 74.2%. These patients were suspected to have a Candida infection. The correlation to higher titres was much closer in patients with an invasive Candida infection like candidaemia and oesophagitis.

Influence of voriconazole and fluconazole on reconstituted multilayered oesophageal epithelium infected by Candida albicans

Reconstituted multilayered oesophageal epithelium appears to be a good basis to test the efficacy of voriconazole (VOR) and fluconazole (FLU) in the tissue. The resulting model of a Candida oesophagitis was approaching the in vivo situation. We infected the tissue with 2 x 10(6) cfu of the Candida albicans strain SC5314. In the trials with FLU we also used clinical strains. Four hours after infection a good growth of C. albicans appeared mainly with hyphae on the surface of the tissue and a tendency to invasion. The destruction of the tissue began after 36 h. VOR (2 and 16 microg ml-1, respectively) prevented the penetration of hyphae into the tissue, when it was given 4-8 h after infection. It was less effective in reduction of Candida growth on the tissue surface. When VOR was given 16-24 h postinfection, the Candida infiltration stopped more slowly. Thirty-six hours after infection VOR application could not stop the destruction of the tissue despite reducing the fungi. The results with FLU (32 microg ml-1) were in principle the same, but not so distinct. FLU seems to be more effective against clinical strains of C. albicans than against the type strain.