Laparoscopic Swenson procedure--an optimal approach for both primary and secondary pull-through for Hirschsprung's disease

BACKGROUND/PURPOSE

Several pull-through procedures are available for the surgical management of Hirschsprung's disease (HD) in children. The authors have adopted a laparoscopic approach since 1995, including laparoscopic Swenson procedure (LSw), both for one-stage primary and 2-stage secondary procedures. The aim of this study was to examine the role of LSw in children with HD in both primary and secondary procedures.

METHODS

From January 1995 to December 2001, 42 children with biopsy-proven HD underwent laparoscopic pull-through procedure for HD. This group included 29 children who underwent LSw, a detailed analysis of which forms the basis of this report.

RESULTS

Sixteen children underwent a single-stage neonatal LSw; the median weight of this group at the time of surgery was 3.2 kg and the median age was 5 days. Secondary LSw was performed in the remaining 13 children, which included 3 children with total colonic HD who underwent laparoscopic total colectomy and LSw. The median operating time was 105 minutes (range, 66 to 175 minutes). The median time to commence full diet was 48 hours (range, 24 to 86 hours), and median time to return to normal play and activity was 72 hours (range, 48 hours to 5 days). There was no difference in operating time between primary and secondary pull-through procedures. There were no intraoperative complications, and no patient required open conversion. Postoperative ileus was noted in 3 children and enterocolitis in 2. The median hospital stay was 4 days (range, 2 to 6 days). Follow-up was between 6 months to 7 years with a median follow-up of 2.2 years. At follow-up, 2 children required laparoscopic antegrade continence enema procedure. A satisfactory continence was noted in 15 of the 19 children who were older than 3 years at the time of last follow-up.

CONCLUSIONS

LSw seems to be a suitable procedure for laparoscopic management of HD in children. LSw is safe and effective, both for primary and secondary type of pull-through procedures, with good short-term results.

Stone composition, metabolic profile and the presence of the gut-inhabiting bacterium Oxalobacter formigenes as risk factors for renal stone formation

OBJECTIVE

To examine stone composition, metabolic evaluation and colonization of Oxalobacter formigenes as risk factors for renal stone formation.

SUBJECTS AND METHODS

Eighty patients with renal stones and 70 healthy controls were enrolled in the study. Of the 80 patients, 48 were first-time stone formers (FSF) and 32 were 'recurrent' stone formers (RSF), recurrent indicating 2 or more episodes of stone formation. Stone analysis by X-ray crystallography, 24-hour urine metabolic profile and detection of O. formigenes-specific DNA by PCR were performed for each patient. Detection of O. formigenes was also performed on 45 and urinary metabolic profile on an additional 25 controls.

RESULTS

Calcium oxalate monohydrate was the major component of stones, hyperoxaluria and hypocitraturia were the most common urinary abnormalities in the 80 patients, 46% of RSF patients had hypercalciuria. Urinary abnormalities were far less frequent in the controls, with the exception of hypocitraturia (40%). Of the urinary metabolites, only calcium levels were significantly different (p < 0.05) between FSF (6.50 +/- 4.08 mmol/24 h) and RSF (8.21 +/- 5.26 mmol/24 h) patients. Colonization of O. formigenes was higher in controls (62.2%) than in FSF (33.3%) or RSF (28%) patients, it was least in patients with more than 4 episodes (7%) of stone formation.

CONCLUSION

The findings indicate that lack of colonization of O. formigenes may be an important risk factor for recurrence of stone formation (calcium oxalate monohydrate).

Chronic myeloid leukemia presenting with absence of basophils and marked dyspoiesis

A 61-year old woman presented to us with fever, weakness and ecchymotic patches for one year. She had leucocytosis, anemia and thrombocytopenia. Peripheral blood smear showed 62% neutrophils, 32% myelocytes and metamyelocytes, 2% promyelocytes, 1% blasts, 2% monocytes, 1% lymphocytes but no basophils and marked dyspoiesis. Bone marrow picture was essentially the same. A diagnosis of atypical chronic myeloid leukemia was suggested. The correct diagnosis of chronic myeloid leukemia-accelerated phase was, however, made on cytogenetic analysis which showed Philadelphia chromosome (Ph) and isochromosome 17q [i(17q)]. This case describes a rare and diagnostically difficult presentation of CML arising out of a combination of prominent dyspoiesis and near absence of peripheral blood basophils.

Gastroesophageal reflux in asthmatic children not responding to asthma medication: a scintigraphic study in 126 patients with correlation between scintigraphic and clinical findings of reflux

Gastroesophageal reflux (GER) is frequently found in association with asthma. Successful control of GER in these patients may improve in their asthma symptoms. The present retrospective analysis was undertaken to find out the incidence of GER in asthmatic children not responding to routine antiasthmatic medications and to find out if there is a clinical correlation between the symptoms of GER and scintigraphic evidence of GER in these patients. A total of 126 children with a mean age of 2.31 years and range 6 months to 6 years were evaluated. The children were divided into two groups. Group I (n = 100) consisted of children with asthma but no clinical symptoms of GER. Group II (n = 26) consisted of those children with asthma and clinical symptoms of GER. Radionuclide scintigraphy was performed with 100-200 microCi (3.7-7.4 MBq) of Tc99m-sulphur colloid. All 33 out of 126 (26%) children had GER on scintigraphy. In Group I, only 23 (23%) had reflux while in Group II, 10 (38.5%) had reflux. In conclusion, esophageal scintiscanning can be used to detect GER in asthmatic children refractory to routine antiasthmatic medication irrespective of the presence or absence of symptoms suggestive of GER.

Magnitude of pesticidal contamination in winter vegetables from Hisar, Haryana

Monitoring of 80 winter vegetable samples during 1997-1998 for pesticidal contamination was carried out on GC-ECD and GC-NPD systems with capillary columns following multiresidue analytical technique. The tested samples were found 100% contaminated with low but measurable amounts of pesticide residues. Among the four major chemical groups, residue levels of organophosphorous insecticides were highest followed by carbamates, synthetic pyrethroids and organochlorines. About 32% of the samples showed contamination with organophosphorous and carbamate insecticides above their respective MRL values. On the basis of observations made in these studies, it is suggested that more extensive monitoring studies covering all vegetable crops from different agro-climatic regions of the state be carried out to know exact level of pesticidal contamination, which may serve as basis for future policy on chemical use.

Filters in anaesthesia and intensive care

The use of various types of filters in anaesthesia and intensive care seems ubiquitous, yet authentication of the practice is scarce and controversies abound. This review examines evidence for the practice of using filters with blood and blood product transfusion (standard blood filter, microfilter, leucocyte depletion filter), infusion of fluids, breathing systems, epidural catheters, and at less common sites such as with Entonox inhalation in non-intubated patients, forced air convection warmers, and air-conditioning systems. For most filters, the literature failed to support routine usage, despite this seemingly being popular and innocuous. The controversies, as well as guidelines if available, for each type of filter, are discussed. The review aims to rationalize the place of various filters in the anaesthesia and intensive care environment.

Gigantism associated with slipped capital femoral epiphysis

The etiology of slipped capital femoral epiphysis (SCFE) is unknown, though hormonal as well as mechanical factors have been implicated. We report a case of gigantism who presented with SCFE. This case provides an insight into the genesis of SCFE, which in this case was related to growth hormone excess and sex-hormone deficiency.

Positron emission tomography imaging in evaluation of cancer patients

Positron emission tomography (PET) is a diagnostic imaging technique that has progressed rapidly from being a research technique in laboratories to a routine clinical imaging modality. The most widely used radiotracer in PET is Fluorine18-fluorodeoxyglucose (F18-FDG), which is an analogue of glucose. The FDG uptake in cells is directly proportional to glucose metabolism of cells. Since glucose metabolism is increased many fold in malignant tumors PET has a high sensitivity and a high negative predictive value. PET with FDG is now the standard of care in initial staging, monitoring the response to the therapy, and management of lung cancer, colonic cancer, lymphoma, melanoma, esophageal cancer, head and neck cancer and breast cancer. Other indications of PET like bone tumor, ovarian cancer and cancer of unknown primary (CUP) has also been discussed in brief. The aim of this review article is to review the clinical applications of PET in various malignancies and only limited number of important studies will be discussed for this effort.

Estimation of thyroid mass in Graves' disease by a scintigraphic method

scintigraphic method for the estimation of the thyroid mass in patients with Graves' disease is described. The method was first standardized using thyroid phantoms with eight different volumes ranging from 5 to 110 cm(3). The planar and single photon emission computed tomography (SPECT) images of each phantom were acquired with four different activities [3.7 MBq (100 microCi), 11.1 MBq (300 microCi), 22.2 MBq (600 microCi) and 37 MBq (1.0 mCi) of 99mTc-pertechnetate] with a 20% window symmetrically placed over the photopeak of 99mTc. The thyroid lobes were enclosed with the help of regions of interest (ROI) tools and a threshold was selected to identify the thyroid boundaries. The same threshold was used in all slices of an image. In the phantom study, a 20% threshold for planar images and a 30% threshold for SPECT were found to be optimum for measuring the thyroid volume. The volume from planar images was calculated by the formula described by Allen and Goodwin (The scintillation counter as an instrument for in-vivo determination of thyroid weight. Radiology 1952; 58: 68-79), whereas, in SPECT images, the sum of the slice areas was multiplied by the slice thickness. The estimated volume of each phantom was compared and correlated with its actual volume. After standardization of the technique with phantom studies, planar scintigraphy (with 20% threshold) in 51 patients and SPECT (with 30% and 35% threshold) in 40 patients with Graves' disease were performed to estimate the thyroid size. The thyroid size was also estimated by ultrasonography, which showed good agreement with the scintigraphic method, particularly with SPECT.

Case report: managing fractures in non-compliant alcoholic patients--a challenging task

AIMS

To investigate whether there are extractable conclusions for limb fracture management in dependent alcoholics.

METHODS

We discuss four cases of dependent alcoholics who presented in our department over a 12-month period, and who developed significant complications owing to non-compliance with treatment.

RESULTS

Initial treatment, although appropriate, failed because of non-compliance. This led to further admissions, wound infections and surgery to enable cure.

CONCLUSIONS

Our case reports indicate that for upper limb fractures of the middle third of the humerus, non-operative treatment or internal fixation with out-patient detoxification is appropriate. Lower limb fractures, on the other hand, should be dealt with by external fixation and in-patient detoxification. It is imperative that the alcohol dependence is addressed if we are to decrease non-compliance.

Acute carpal tunnel syndrome: two rare cases

Acute carpal tunnel syndrome is an orthopaedic emergency that requires prompt surgical treatment. We describe two rare cases of this condition, one secondary to pyogenic infection and one secondary to prolonged pressure on the upper limb brought on by overdose.

Intraventricular sodium nitroprusside therapy: a future promise for refractory subarachnoid hemorrhage-induced vasospasm

A prospective study was carried out to evaluate the efficacy of intraventricular sodium nitroprousside (SNP) in the reversal of refractory vasospasm secondary to aneurysmal subarachnoid hemorrhage (SAH). Ten patients of aneurysmal SAH with symptomatic vasospasm, corroborated on Transcranial Doppler (TCD) and/or angiography, were included in the study. The mean age distribution of the patients was 50.8 years (range 33-65 years) with an equal number of males and females. Once vasospasm was refractory even after 12 hours of SAH therapy, intraventricular SNP was instilled in an escalating dose and the reversal of vasospasm was monitored on TCD and/or angiography. All patients showed improvement in TCD velocity on day 0 through day 3. Partial to complete reversal of vasospasm was demonstrated on angiography in all the patients, though not in all the vessels. Two patients who had weakness of limbs due to vasospasm improved following intraventricular SNP therapy. Vomiting was the commonest adverse effect (7/10). Three patients had mild fluctuation in blood pressure. The overall outcome was good in 6 out of 10 patients. The study suggests that intraventricular SNP therapy is effective in reversing the changes even in established cases of SAH-induced vasospasm.

Influence of endotoxin on the disposition kinetics and dosage regimens of oxytetracycline in calves

The influence of endotoxin on the disposition kinetics of oxytetracycline (OTC) (10 mg/kg) was investigated in five healthy ruminating male crossbred calves. The serum concentration-time data of OTC before and after endotoxin challenge were best described by a two-compartment open model. Repeated administration of Escherichia coli endotoxin (1 microg/kg, i.v.) at an interval of 12 h up to 48 h produced a clear rise in the body temperature and an increase in the pulse and respiration rates. Endotoxin caused a significant reduction in mean transit time in tissue compartment (MTTT) (P < or = 0.05), mean residence time in the peripheral tissue compartment (MRTT) (P < or = 0.05), mean residence time in the body (MRTB) (P < or = 0.05), elimination half-life (t1/2lambda2) (P < or = 0.05) and distribution space in tissues (VT) (P < or = 0.01) and at steady-state (Vd(ss)) (P < or = 0.01). Endotoxin had no effect on the distribution clearance (ClD), systemic clearance (Cl) and distribution half-life of OTC, while the values of first order rate constant of transfer of drug from tissue to central compartment (K21) and the zero time intercept at terminal phase (C2) were significantly high. The drug dosage regimens to maintain serum OTC concentrations of 0.5, 1, 2, 4, 6 and 8 microg/mL were also determined in febrile and clinically healthy animals.

Adaptive hypersensitivity to estrogen: mechanism for superiority of aromatase inhibitors over selective estrogen receptor modulators for breast cancer treatment and prevention

Clinical observations suggest that human breast tumors can adapt to endocrine therapy by developing hypersensitivity to estradiol (E(2)). To understand the mechanisms responsible, we examined estrogenic stimulation of cell proliferation in a model system and provided in vitro and in vivo evidence that long-term E(2) deprivation (LTED) causes "adaptive hypersensitivity". The enhanced responses to E(2) do not involve mechanisms acting at the level of transcription of estrogen-regulated genes. We found no evidence of hypersensitivity when examining the effects of E(2) on regulation of c-myc, pS2, progesterone receptor, several estrogen receptor (ER) reporter genes, or c-myb in hypersensitive cells. Estrogen deprivation of breast cells long-term does up-regulate both the MAP kinase and phosphatidyl-inositol 3-kinase pathways. As a potential explanation for up-regulation of these signaling pathways, we found that ERalpha is 4- to 10-fold up-regulated and co-opts a classic growth factor pathway using Shc, Grb-2 and Sos. This induces rapid non-genomic effects which are enhanced in LTED cells. E(2) binds to cell membrane-associated ERalpha, physically associates with the adapter protein SHC, and induces its phosphorylation. In turn, Shc binds Grb-2 and Sos, which results in the rapid activation of MAP kinase. These non-genomic effects of E(2) produce biological effects as evidenced by Elk activation and by morphological changes in cell membranes. Further proof of the non-genomic effects of E(2) involved use of cells which selectively expressed ERalpha in the nucleus, cytosol and cell membrane. We created these COS-1 "designer cells" by transfecting ERalpha lacking a nuclear localization signal and containing a membrane localizing signal. The concept of "adaptive hypersensitivity" and the mechanisms responsible for this phenomenon have important clinical implications. Adaptive hypersensitivity would explain the superiority of aromatase inhibitors over the selective ER modulators (SERMs) for treatment of breast cancer. The development of highly potent third-generation aromatase inhibitors allows reduction of breast tissue E2 to very low levels and circumvents the enhanced sensitivity of these cells to the proliferative effects of E(2). Clinical trials in the adjuvant, neoadjuvant and advanced disease settings demonstrate the greater clinical efficacy of the aromatase inhibitors over the SERMs. More recent observations indicate that the aromatase inhibitors are superior for the prevention of breast cancer as well. These observations may be explained by the hypothesis that estrogens induce breast cancer both by stimulating cell proliferation and by their metabolism to genotoxic products. The SERMs block ER-mediated proliferation only, whereas the aromatase inhibitors exert dual effects on proliferation and genotoxic metabolite formation.

Radiotherapy for desmoplastic fibroma of bone: a case report

Desmoplastic fibroma is a rare benign tumour of bone. Diagnosis is not easy and is often made by excluding other tumours. Histopathological diagnosis of this tumour is also sometimes not easy. The treatment modalities for this tumour are non-uniform and often controversial. In the present case surgical options were left aside because the patient did not consent to surgery, so radiotherapy was used, with success at 3-year follow-up. This case is presented here along with a review of relevant literature.

Scintigraphic patterns of lymphocele in post-renal transplant

Lymphocele is a common cause of fluid collection in post-renal transplant patients. Most of these patients are routinely followed up with 99mTc diethylenetriaminepentaacetate renal dynamic scintigraphy. The present study retrospectively reviews the range of findings with renal dynamic scintigraphy in documented lymphoceles. A lymphocele was diagnosed when there was a pelvic collection on ultrasonography with a similar biochemical composition to plasma. Four types of scintigraphy patterns were noted in lymphocele in a total of 13 patients. In nine patients there was an initial photopenic area, which progressively filled up with tracer activity equal to that of the background level in delayed images. In two other patients, the activity in the initial photopenic area exceeded the background activity in delayed images. A persistently photopenic area was seen in early and delayed images in the two remaining patients. In addition, a rim of increased tracer activity was noted surrounding the photopenic area in four patients in the early images. In conclusion, an initial photopenic area (with or without a surrounding rim of increased tracer activity), which fills up with tracer in delayed images seems to be the most common pattern seen in lymphoceles in scintigraphic studies of renal transplants. The presence of a rim sign may add confidence to the reporting of a collection as a lymphocele.

Expression of HOX11 in childhood T-lineage acute lymphoblastic leukaemia can occur in the absence of cytogenetic aberration at 10q24: a study from the Children's Cancer Group (CCG)

Clonal genetic aberrations in tumour cells provide critical information for the development of new diagnostic and therapeutic strategies for patients. In paediatric T-cell acute lymphoblastic leukaemia (T-ALL) chromosomal translocations are present in 30-35% of cases. HOX11 and the closely related HOX11L2 genes play a key role in T-ALL. HOX11 is aberrantly activated by either of the two chromosomal translocations, t(7;10) and t(10;14). In this study, HOX11 expression levels were measured by real-time quantitative reverse-transcriptase polymerase chain reaction. We show that leukaemic blasts from 15/76 (19.7%) paediatric T-ALL patients expressed the HOX11 gene at high level and 22/76 (28.9%) at low level, yet the reported frequency for chromosomal rearrangement of 10q24 is 4-7%. Direct cytogenetic analysis revealed that only 2/16 specimens that showed HOX11 expression exhibited abnor-malities at 10q24. These results confirm and extend our previously published findings, and implicate mechanisms other than gross chromosomal translocations for the deregulation of HOX11. Analysis of clinical outcome for the whole study group showed a trend for better outcome for patients with leukaemic blasts expressing HOX11 at high level. A statistically significant difference in clinical outcome was found in a subgroup of 20 patients treated for high-risk disease on CCG-1901 from the Children's Cancer Group, where HOX11 expression in leukaemic blasts conferred a prognostic advantage (P=0.01).