Anterior Resection of Rectal Cancer Without Bowel Preparation and Diverting Stoma

PURPOSE

Since the introduction of total mesorectal excision (TME) as the standard operation technique for rectal cancer, anastomotic leakage percentages of up to 18% have been reported. To prevent such leakage, the use of mechanical bowel preparation and also the construction of a diverting ileostoma or colostomy have been standard procedures for years. In our institute, however, all patients undergoing colorectal surgery are operated upon without these measures. The present study was undertaken to investigate the results of this strategy in terms of the occurrence of postoperative anastomotic leakage.

METHODS

All patients who underwent an elective (low) anterior resection between January 1996 and December 2001 (n = 144) entered the study. The clinical and pathological records of these patients were reviewed retrospectively. The exclusion criteria were patients with fixed rectal carcinoma who received preoperative radiotherapy and/or a stoma only at operation, emergency operations, abdominoperoneal resections, and Hartmann's procedures.

RESULTS

Anastomotic leakage occurred in 7 out of 144 patients (4.9%). There was a trend toward a higher leakage frequency in men, in patients with a distal anastomosis, in patients with a stapled anastomosis, and in patients with a T3-T4 tumor or with positive lymph nodes. None of these factors, however, had a significant prognostic value based on a univariate or multivariate analysis. Those who died after leakage tended to be older than those who did not (P < 0.05).

CONCLUSION

A (low) anterior resection can be performed safely without mechanical bowel preparation or a diverting stoma, and results in an anastomotic leakage percentage of less than 5%. Appropriate selection of patients may be important, but none of the investigated patient- or tumor-related factors could be identified as decisive.

[A malignant tumour in the breast is not always primary breast cancer]

In a 75-year-old woman with a swelling in her left breast, a 39-year-old woman with an anal fissure due to diarrhoea and a 65-year-old woman with chest pain, a mammary tumour was diagnosed that did not originate in mammary tissue. These were a recurrent melanoma, a carcinoma of the thyroid and a B-cell lymphoma, respectively. All patients were treated. The first patient developed new metastases one year later, the second died, partly as a result of the tumour, and the third showed no recurrence of the tumour after two years. Breast cancer is one of the most frequently occurring neoplasms in women. Primary tumours in the breast from other origins and metastatic lesions to the breast from extramammary tumours are rare. Most of these cases concern haematological malignancies and metastases from melanoma and lung cancer. Despite the fact that metastases to the breast are rare, one should always consider the possibility.

Incarcerated transdiaphragmatic intercostal hernia preceded by Chilaiditi's syndrome

Transdiaphragmatic hernia most often develops after blunt or penetrating thoracoabdominal trauma. We report on the case of a 73-year-old man who underwent emergency ileocoecal resection for an incarcerated transdiaphragmatic intercostal hernia. The patient's history included both a lumbotomy for right nephrectomy and Chilaiditi's syndrome. The literature regarding both transdiaphragmatic intercostal herniation and Chilaiditi's syndrome is reviewed in relation to the presented case.

[Diagnostic image (181). A child with a palpable mass in the left upper abdomen. Epidermoid cyst of the spleen]

A 10-year-old boy had a palpable mass in the left upper abdomen, which at laparotomy was diagnosed as an epidermoid cyst of the spleen.

The continued utility of needle localised biopsy for non-palpable breast lesions

AIM

To analyse the results of needle localised biopsy (NLB) for non-palpable breast lesions in our hospital and to compare them with data on stereotactic large-core biopsy (SCB), which has been recently introduced as a new less invasive method for evaluating mammographic abnormalities.

METHODS

We evaluated the results of all consecutive NLB procedures in our hospital in the period 1998-2000 and compared them with data from literature. Clinical, mammographic and pathological data were reviewed.

RESULTS

In the present study 314 patients with 319 non-palpable mammographic abnormalities were included. Seventy percent of patients were referred to us from the national screening program. In all but one patient the NLB procedure was successful. The mean duration of hospital stay was 3 (1-10) days. Histological diagnosis was invasive carcinoma in 31%, invasive carcinoma with DCIS in 32%, DCIS alone in 13% and benign in 24%. The invasive carcinoma group scored tumour-free margins after the first operation in 77% of patients, for both the DCIS with invasive carcinoma group and DCIS alone group the tumour-free margin rate was 47%. Patients with invasive carcinoma and/or DCIS were re-operated in 88%. Of all procedures, 91% was performed without complications.

CONCLUSION

NLB is a safe, relatively simple procedure with a high diagnostic accuracy combined with a lower failure and false-negative rate compared to SCB.

Lymphatic drainage routes of the gastric cardia visualized by lymphoscintigraphy

This study was undertaken to assess the feasibility of lymphoscintigraphy of the gastric cardia and to identify the incidence of paraesophageal lymphatic drainage, precluding total gastrectomy with esophagojejunostomy as a potentially curative therapy for gastric cardia cancer.

METHODS

Ten patients scheduled for esophagectomy with high-grade dysplasia or with esophageal cancer at least 3 cm above the esophagogastric junction were enrolled in this study. Preoperatively, 111 MBq of(99m)Tc-labeled nanocolloid (n = 5) or sulfur colloid (n = 5) were injected into the submucosa of the tumor-free cardia. Subsequently, lymphoscintigraphy in combination with CT was obtained. Locoregional lymph node stations were measured for radioactivity by a gamma-probe intraoperatively and ex vivo in the resection specimen.

RESULTS

In each patient, at least 1 radioactive lymph node station was detected. In total, 42 radioactive lymph node stations were detected by gamma-probe. Of those 42 areas, 38 (90%) were visible at preoperative lymphoscintigraphy. In the group of 5 patients in whom nanocolloid was used, a median of 2 (range, 1-4) node stations per patient was identified, whereas when sulfur colloid was administered a median of 6 (range, 4-8) active lymph node stations per patient could be detected (P < 0.002). Paraesophageal drainage was identified in 1 patient.

CONCLUSION

Lymphoscintigraphy of the gastric cardia is feasible and can accurately determine the location of radioactive lymph nodes. Early paraesophageal lymphatic drainage is rare.

[Diagnostic image (160). A woman with a tapeworm in a stoma. Taenia saginata]

A 39-year-old woman had a proctocolectomy, an ileo-pouch-anal anastomosis and a temporary intestinal stoma. The stoma discharged a tapeworm, Taenia saginata.

Long-term results of a double perfusion schedule using high dose hyperthermia and melphalan sequentially in extensive melanoma of the lower limb

The aim of this study was to assess the results of an isolated limb perfusion (ILP) schedule with high dose hyperthermia (42-43 degrees C) and melphalan, applied sequentially in patients with advanced melanoma of the limbs. Seventeen patients with extensive recurrent or bulky melanoma of a limb were treated with hyperthermic femoral ILP (42-43 degrees C) without drugs followed by normothermic (37-38 degrees C) ILP with melphalan. Eleven patients (65%) had a complete response. Three patients (27%) had limb recurrences after 5, 6 and 18 months, respectively. The 5 year limb recurrence-free interval for patients with a complete response was 63%. Limb toxicity was mild; pressure-related blistering and transient sensory disturbances occurred after the hyperthermic ILP, and 88% of the patients had a grade II reaction (mild erythema and oedema) after the second ILP. This sequential ILP schedule resulted in a high complete response rate and a low limb-recurrence rate in patients with extensive, recurrent melanoma of the limbs at the cost of only mild toxicity. This regimen could be an alternative to ILP with tumour necrosis factor-alpha and melphalan.

Endovascular treatment of traumatic thoracic aortic rupture combined with diaphragmatic rupture--a case report

The purposes of this report are to describe the immediate repair of a diaphragmatic rupture and subsequent endovascular treatment of a thoracic aortic rupture secondary to blunt chest and abdominal trauma and to discuss the outcome in the light of the trauma scores. A 29-year-old man was injured in a car collision. There were signs of a left diaphragmatic rupture and spleen injury. After urgent laparotomy, the diaphragm was repaired. The spleen appeared uninjured; however, there was a dissection with a transmural tear of the thoracic aorta, which was subsequently treated intraluminally by using a Talent endovascular graft and two AneuRx aortic extension cuffs. The patient fully recovered, and the thoracic endograft showed no evidence of endoleak both 1 month and 1 year after treatment. Fourteen months after the operation, the patient is doing well. Endoluminal techniques can be used successfully in the immediate repair of thoracic aortic injuries, even in the presence of a diaphragmatic rupture. With the introduction of advanced repair modalities, such as endovascular techniques, mortality rates will decrease and may eventually alter injury-scoring systems such as the Injury Severity Score.

Surgery for unusual histopathologic variants of esophageal neoplasms: a report of 23 cases with emphasis on histopathologic characteristics

BACKGROUND

Adenocarcinoma and squamous cell carcinoma are the most frequent pathologic diagnoses with esophageal malignancy. Unusual pathologic variants are encountered in only 1% to 7% of patients, and therefore data evaluating the treatment and survival in this group of esophageal neoplasms are sparse.

METHODS

To get more insight into the unusual pathologic variants, patients were selected from our computer-assisted database containing data from 426 consecutive patients treated with esophageal resection or enucleation at our institute during 1993 to 2000.

RESULTS

Uncommon variants of esophageal neoplasms were encountered in 23 patients (5.3%). The following unusual histopathologic variants were seen: basaloid squamous cell carcinoma (n = 3), small-cell carcinoma (n = 1), leiomyoma (n = 5), gastrointestinal stromal tumor (n = 2), leiomyosarcoma (n = 1), adenosquamous carcinoma (n = 5), carcinosarcoma (n = 4), collision tumor (n = 1), and melanoma (n = 1). Presentation, histopathologic characteristics, treatment, and prognosis are described in reference to the existing literature.

CONCLUSIONS

Survival data of the unusual pathologic variants seem to be comparable to those of the most frequently encountered neoplasms. Only in case of small-cell carcinoma does there seem to be a definite role for chemotherapy, especially in a multimodality treatment protocol.

Lesion progression with time and the effect of vascular occlusion following radiofrequency ablation of the liver

BACKGROUND

The effectiveness of radiofrequency ablation (RFA) under selective vascular occlusion and its effects on architecture and viability of normal liver parenchyma was studied in a porcine model.

METHODS

RFA was applied in the liver under general anaesthesia in 18 pigs. Six animals were killed immediately after the procedure and 12 at 24 h. RFA was performed sequentially under four conditions: (1) without vascular occlusion, (2) during occlusion of the hepatic artery, (3) during occlusion of the portal vein and (4) during occlusion of the hepatic artery and portal vein. Liver biopsies from the treated area were stained for conventional histological examination, reduced nicotinamide adenine dinucleotide diaphorase and 5'-nucleotidase activity.

RESULTS

Vascular occlusion significantly increased the size of the coagulation centre after RFA. Combined portal venous and arterial occlusion had no additional effect on lesion size compared with venous or arterial occlusion alone. After 24 h, deterioration of viability was observed in the parenchyma up to 3 cm from the coagulated area.

CONCLUSION

The efficacy of RFA in liver increases with occlusion of the portal vein or hepatic artery. The extent of secondary heat-induced necrosis in liver parenchyma should be considered for determination of the final size of the ablated area.

Local Recurrence of Rectal Cancer After Total Mesorectal Excision Without Preoperative Radiotherapy

BACKGROUND

At this moment, it is still debatable whether all patients with mobile rectal cancer who undergo surgical removal of the tumor should be treated with preoperative radiotherapy, since it is likely that only certain patients will benefit from this strategy. In this study, patients with mobile rectal cancer were immediately operated upon and only those with positive nodes or with incomplete resection received adjuvant radiotherapy.

AIMS OF THE STUDY

To investigate the local recurrence rate after the use of a selective policy of adjuvant radiotherapy and to determine risk factors for local recurrence.

METHODS

In a 5-yr-period, 178 patients with rectal cancer were referred to our institute. A total of 131 patients with mobile rectal cancer were treated with curative intent, which implied a microscopically radical resection and no signs of distant metastasis at operation. A retrospective analysis was undertaken to investigate the incidence of local recurrence in this curative group and to determine risk factors for local recurrence.

RESULTS

The postoperative mortality in the curative group was 5.3%. Local recurrences were observed in 6 patients (4.6%) after a median period of 25 mo (range 11-37); two of them also had distant metastases detected at the same time. The highest local recurrence rates were seen in men (5.3%), in distal rectal cancers (6.9%), and in the node-positive group (8.7%).

CONCLUSION

A low local recurrence rate can be achieved after total mesorectal excision (TME) without preoperative radiotherapy. Our results suggest using preoperative radiotherapy only for those patients who are at a higher risk for local recurrence. Staging techniques for selection of these patients are at this moments till inappropriate.

Partial matrix excision or segmental phenolization for ingrowing toenails

OBJECTIVE

To decide whether partial nail extraction with phenolisation or with partial excision of the matrix should be the standard treatment in patients with ingrowing toenails of the hallux.

DESIGN

Randomized clinical trial with 12-month follow-up evaluations performed by observers who did not know which procedure was applied.

SETTING

Outpatient department of a surgical teaching hospital.

PATIENTS

Fifty-eight consecutive patients with a total of 63 ingrowing toenails were randomized.

INTERVENTION

Thirty-four partial matrix excisions ("matrix" group) and 29 phenolizations ("phenol" group) were performed.

MAIN OUTCOME MEASURES

Recurrence rate, postoperative morbidity (pain, wound exudates, and scar discomfort), and time to complete recovery (wearing shoes, performing normal activities/work).

RESULTS

Recurrences were seen after 7 procedures in the matrix group and also after 7 procedures in the phenol group, of which patients were symptomatic and required a second operation in 4 and 3 instances, respectively. None of the observed differences in wound healing, postoperative pain, and recovery were statistically significant.

CONCLUSIONS

Partial matrix excision and phenolization are equally effective in treating ingrowing toenails. Because the use of the toxic agent phenol should be avoided, partial matrix excision is the preferable procedure. But in view of the high recurrence rate, there is a need for further improvement of the treatment of ingrowing toenails.

[Local and regional in-hospital trauma care following fireworks depot explosion in Enschede]

On Saturday 13 May, 2000 at about 15:30 h, the Dutch city of Enschede was struck by the explosion of a midtown firework depot. Twenty-two people were killed and almost 1,000 people were wounded. A complete district with 1,000 houses was destroyed. In total, 527 victims were treated in one of the regional hospitals, 76 (14%) of whom were admitted and 451 (84%) were treated as outpatients. Of the clinically treated victims, 11 patients were triaged as T1 and needed immediate intervention, 63 patients were triaged as T2 where treatment within six hours was indicated, and two T3 patients did not need urgent treatment. The outpatients mainly suffered secondary blast injuries to the head and extremities due to flying debris. Of the 11 T1 patients, 10 underwent acute surgery; intervention radiology was performed in one patient. The injuries of the severely wounded T1 patients consisted of penetrating thoracic, abdominal and skull injuries, as well as blunt abdominal trauma and compound fractures. Two patients from the disaster area underwent acute vascular surgery for acutely burst aortic aneurysms. The in-hospital trauma care was characterised by the spontaneous arrival of a large number of extra medical personnel. The regional distribution of the trauma patients was adequate. The regional capacity of the emergency rooms, IC-units and operating facilities proved to be sufficient. Routing of lightly-wounded patients was found to be important. The communication in all phases of the disaster management appeared to be poorly structured.

CONCLUSION

During the initial trauma care, the routing of vast numbers of ambulant, lightly-wounded patient, as well as extra doctors and nurses, needs careful planning.

[Injury to the right A. pulmonalis due to blunt thoracic trauma]

Immediately after a moped accident a 16-year old patient was haemodynamically unstable. Following adequate drainage of a haematopneumothorax in the hospital the patient collapsed into a shock. Thoractomy revealed a tear of the right A. pulmonalis. The hilus was clamped and a lobectomy was performed. After this the patient was haemodynamically stable; due to bone and nerve damage he was transferred to a rehabilitation centre. Laceration of the A. pulmonalis as a consequence of blunt thoracic trauma is rare and mostly fatal. In the case of a patient with a massive haematothorax rapid transport to the nearest hospital is preferable to thorax drainage at the site of the accident.

Regional toxicity after isolated limb perfusion with melphalan and tumour necrosis factor- alpha versus toxicity after melphalan alone

AIMS

To determine whether the addition of high-dose tumour necrosis factor-alpha (TNF alpha) to isolated limb perfusion (ILP) with melphalan increases acute regional tissue toxicity compared to ILP with melphalan alone.

METHODS

A retrospective, multivariate analysis of toxicity after normothermic (37--38 degrees C) and 'mild' hyperthermic (38--40 degrees C) ILPs for melanoma was undertaken. Normothermic ILP with melphalan was performed in 294 patients (70.8%), 'mild' hyperthermic ILP with melphalan in 71 patients (17.1%) and 'mild' hyperthermic ILP with melphalan combined with TNF alpha in 50 patients (12.0%). Toxicity was nil or mild (grades I--II according to Wieberdink et al.) in 339 patients (81.7%), and more severe acute regional toxicity (grades III--V) developed in 76 patients (18.3%). A stepwise logistic regression procedure was performed for the multivariate analysis of prognostic factors for more severe toxicity.

RESULTS

On univariate analysis, 'mild' hyperthermic ILP with melphalan plus TNF alpha significantly increased the incidence of more severe acute regional toxicity compared to normothermic and 'mild' hyperthermic ILP with melphalan alone (36% vs 16% and 17%; P=0.0038). However, after ILP using TNF alpha no grade IV (compartment compression syndrome) or grade V (toxicity necessitating amputation) reactions were seen. Significantly more severe toxicity was seen after ILPs performed between 1991 and 1994 compared with earlier ILPs (33%vs 14%P=0.0001). Also, women had a higher risk of more severe toxicity than men (22% vs 7%; P=0.0007). After multivariate analysis, prognostic factors which remained significant were: sex (P=0.0013) and either ILP schedule (P=0.013) or treatment period (P=0.0003).

CONCLUSIONS

Regional toxicity after 'mild' hyperthermic ILP with melphalan and TNF alpha was significantly increased compared to ILP with melphalan alone. This may be caused by increased thermal enhancement of melphalan due to the higher tissue temperatures (39--40 degrees C) at which the melphalan in the TNF alpha-ILPs was administered or by an interaction between high-dose TNF alpha and melphalan.

Monitoring of impending myocardial damage after pleuropneumonectomy and intraoperative photodynamic therapy for malignant pleural mesothelioma using biochemical markers

In five patients who were treated for malignant pleural mesothelioma (MPM) with pleuropneumonectomy and intraoperative photodynamic therapy (IPDT), impending myocardial damage was monitored using ECG, the classical biochemical markers (creatine kinase [CK], total activity; CKMB, mass; and myoglobin), and the new cardiac markers troponin I (cTnI) and troponin T (cTnT). In the peroperative and postoperative period all classical markers were elevated, in contrast to cTnI and cTnT, because of the concomitant skeletal muscle damage. Sequential electrocardiogram monitoring showed no signs of myocardial damage. From this study in patients with MPM treated with pleuropneumonectomy and IPDT it can be concluded that measurement of cTnI and cTnT for the detection of myocardial damage is more suitable than measurement of the classical markers.