Intrapulmonary bronchogenic cysts: computed tomography, clinical and histopathologic correlations

BACKGROUND/PURPOSE

Bronchogenic cysts (BCs) are usually located in the mediastinum and they occur less commonly in the lung parenchyma. This study investigated the findings from computed tomography (CT) images, clinical presentation and histopathologic findings of intrapulmonary BCs.

METHODS

From the last 7 years, the CT images of 20 patients (12 females, 8 males; mean age, 38.8 +/- 21.7 years; median age, 34 years) with intrapulmonary BC were available. Contrast-enhanced CT findings were characterized and correlated with clinical presentation and histopathologic findings (using Fisher's exact tests).

RESULTS

The majority of intrapulmonary BCs were subpleural in location (55%), in the lower lobes (60%), symptomatic (80%), and in adults (90%). Three CT patterns were identified: cyst with content of fluid attenuation (9 patients), cyst with air and fluid content (9 patients), cyst with content of soft tissue attenuation (2 patients). Preoperative diagnosis of intrapulmonary BC was correct in only 20% using the CT criteria of cysts with fluid attenuation and without anomalous blood supply. Cysts with air component were significantly larger than those without air component (p = 0.0452), but cyst size and air component were not correlated with clinical presentation. Surrounding infiltration or thick wall on CT were significantly correlated with the presence of any clinical symptom (p = 0.014) or fever (p = 0.042). CT findings of surrounding consolidation, ground glass opacity or thick wall were significantly correlated with chronic inflammation or pneumonic change on histopathology (p = 0.0008).

CONCLUSION

There is a wide spectrum of intrapulmonary BCs that have CT findings that are correlated with clinical presentations and histopathologic findings.

Late recurrence of a prostatic adenocarcinoma as a solitary splenic metastasis

Splenic metastases of solid tumors are exceptional. We report the first case of an isolated splenic metastasis from prostate carcinoma, 5 years after radical prostatectomy. The splenic tumor was revealed by a pain and progressive increase in the serum prostate-specific antigen (PSA) level. Histology of the spleen showed an adenocarcinoma immunostained with cytokeratin and PSA markers. The patient remained asymptomatic and his serum PSA level was within normal limits 17 months after the splenectomy. This case suggests that splenic metastasis might be the result of the growth of an early blood-borne micrometastasis within the spleen after a period of clinical latency.

Avaliação da analgesia pós-operatória em pacientes submetidos à cirurgia orificial com anestesia local associada ou não à morfina

Ainda não esta comprovada a eficácia dos derivados morfínicos ao nível de receptores opióides periféricos. Estudos procuram demonstrar o poder da droga em interferir na intensidade da dor quando infiltrada em nervos periféricos. Avaliamos, então, a infiltração local de morfina associada à anestesia local em cirurgias orificiais proctológicas. Nesse estudo foram analisados 61 pacientes, independentemente do gênero, sendo divididos aleatoriamente em dois grupos: a um grupo foi associada morfina ao anestésico local enquanto ao outro houve a administração do anestésico local sem a droga morfínica. Os pacientes de ambos os grupos foram submetidos à sedação e analgesia pós-operatória padronizadas. Foram avaliados: a intensidade da dor, a analgesia pós-operatória e a morbidade. A intensidade da dor, no momento de seu surgimento, foi semelhante nos dois grupos; o tempo de analgesia pós-operatória foi maior no grupo em que a morfina foi administrada, entretanto, não se mostrou estatisticamente significativo; as complicações pós-operatórias foram irrelevantes nos dois grupos. Dessa forma, a infiltração local de morfina na região anorretal tem benefícios em relação à analgesia pós-operatória que não mostraram significância estatística e não aumenta a incidência dos efeitos colaterais tão temidos relacionados às drogas morfínicas como retenção urinária e prurido.

Role of image-guided fine-needle aspiration biopsy in the management of patients with splenic metastasis

BACKGROUND

Splenic metastases are very rare and are mostly diagnosed at the terminal phase of the disease or at the time of autopsy. The cytohistological diagnosis, when done, is made prevalently by splenectomy. Reports on splenic percutaneous biopsies in the diagnosis of splenic metastasis are fragmentary and very poor. The aims of this study are to analyse retrospectively the accuracy, safety and the clinical impact of ultrasound (US)-guided fine-needle aspiration biopsy (UG-FNAB) in patients with suspected splenic metastasis.

METHODS

A retrospective analysis of 1800 percutaneous abdominal biopsies performed at our institute during the period from 1993 to 2003 was done and 160 patients that underwent splenic biopsy were found. Among these 160 patients, 12 cases with the final diagnosis of solitary splenic metastases were encountered and they form the basis of this report. The biopsies were performed under US guidance using a 22-gauge Chiba needle. All the patients underwent laboratory tests, CT examination of the abdomen and chest, US examination of abdomen and pelvis.

RESULTS

There were 5 women and 7 men, median age 65 years (range 48-80). Eight patients had a known primary cancer at the time of the diagnosis of splenic metastasis: 3 had breast adenocarcinoma, 2 colon adenocarcinoma, 2 melanoma and 1 lung adenocarcinoma. Four patients were undiagnosed at the time of the appearance of splenic metastasis and subsequent investigations showed adenocarcinoma of the lung in 2 patients and colon adenocarcinoma in the remaining 2. There was a complete correspondence between the US and Computed Tomography (CT) in detecting focal lesions of the spleen. The splenic biopsies allowed a cytological diagnosis of splenic metastasis in all the 12 patients and changed clinical management in all cases. Reviewing the 160 patients that underwent UG-FNAB of the spleen we found no complications related to the biopsies.

CONCLUSION

These results indicate that UG-FNAB is a successful technique for diagnosis of splenic metastasis allowing an adequate treatment of the affected patients.

Long-term results after stapled hemorrhoidopexy: high patient satisfaction despite frequent postoperative symptoms

PURPOSE

Stapled hemorrhoidopexy has been demonstrated to be advantageous in the short term compared with the traditional techniques. We aimed to evaluate long-term results after stapled hemorrhoidopexy and to assess patient satisfaction in association with postoperative hemorrhoidal symptoms.

METHODS

This prospective study included 216 patients with Grade 2 or 3 hemorrhoids, who had stapled hemorrhoidopexy using the circular stapled technique. The results were evaluated by a standardized questionnaire at least 12 months after the operation. The primary end point was patient satisfaction; secondary end points included specific hemorrhoidal symptoms.

RESULTS

Followup data were obtained for 193 of 216 patients (89 percent) with a median follow-up of 28 (range, 12-53) months, most of whom (89 percent) were satisfied or very satisfied with the surgery. The main preoperative symptom was no longer present postoperatively in 66 percent of patients, was relieved in 28 percent, and had worsened in 2 percent. Postoperative complaints included symptoms of hemorrhoidal prolapse (24 percent of patients), anal bleeding (20 percent), anal pain (25 percent) fecal soiling/leakage (31 percent), fecal urgency (40 percent), and local discomfort (38 percent). Bivariate analysis showed significant associations between each of these symptoms and patient satisfaction. Nine patients (5 percent) were reoperated on during the follow-up period.

CONCLUSIONS

Long-term patient satisfaction was high in most of patients after stapled hemorrhoidopexy for second-degree and third-degree hemorrhoids. However, an unsatisfactory outcome was significantly related to postoperative hemorrhoidal symptoms such as prolapse, fecal soiling/leakage, and new onset of fecal urgency.

Intramural esophageal bronchogenic cysts: a review of the literature

Bronchogenic cysts are rare congenital cystic lesions mostly located in the middle and superior mediastinum. Esophageal bronchogenic cysts are extremely rare. We review here 23 cases reported in English in the literature to date of intramural esophageal bronchogenic cyst and their features, including our patient. Although they are extremely rare, intramural esophageal bronchogenic cysts should be kept in mind in the differential diagnosis of benign esophageal lesions. With accurate diagnosis and treatment the prognosis is excellent and serious complications may be prevented.

Impact of hybrid fluorodeoxyglucose positron-emission tomography/computed tomography on radiotherapy planning in esophageal and non–small-cell lung cancer

PURPOSE

The aim of this study was to investigate the impact of a hybrid fluorodeoxyglucose positron-emission tomography/computed tomography (FDG-PET/CT) scanner in radiotherapy planning for esophageal and non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

A total of 30 patients (16 with esophageal cancer, 14 with NSCLC) underwent an FDG-PET/CT for radiotherapy planning purposes. Noncontrast total-body spiral CT scans were obtained first, followed immediately by FDG-PET imaging which was automatically co-registered to the CT scan. A physician not involved in the patients' original treatment planning designed a gross tumor volume (GTV) based first on the CT dataset alone, while blinded to the FDG-PET dataset. Afterward, the physician designed a GTV based on the fused PET/CT dataset. To standardize PET GTV margin definition, background liver PET activity was standardized in all images. The CT-based and PET/CT-based GTVs were then quantitatively compared by way of an index of conformality, which is the ratio of the intersection of the two GTVs to their union.

RESULTS

The mean index of conformality was 0.44 (range, 0.00-0.70) for patients with NSCLC and 0.46 (range, 0.13-0.80) for patients with esophageal cancer. In 10 of the 16 (62.5%) esophageal cancer patients, and in 12 of the 14 (85.7%) NSCLC patients, the addition of the FDG-PET data led to the definition of a smaller GTV.

CONCLUSION

The incorporation of a hybrid FDG-PET/CT scanner had an impact on the radiotherapy planning of esophageal cancer and NSCLC. In future studies, we recommend adoption of a conformality index for a more comprehensive comparison of newer treatment planning imaging modalities to conventional options.

Preoperative loco-regional imaging in rectal cancer

Preoperative staging of rectal cancer can influence the choice of surgery and the use of neoadjuvant therapy. This review evaluates the use of endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) in the local staging of rectal cancer. Staging for distant metastases is beyond the scope of this review. A MEDLINE search for published work in English between 1984-2004 was carried out by entering the key words of ERUS, MRI and preoperative imaging and rectal cancer. Initially, 867 articles were retrieved. Abstracts were reviewed and papers selected according to the inclusion criteria of a minimum of 50 patients and papers published in English. Papers focusing on preoperative chemoradiotherapy and distal metastases were excluded. Thirty-one papers were included in the systematic review. The examination techniques and images obtained are discussed and the respective accuracy is reviewed. ERUS and MRI have complementary roles in the assessment of tumour depth. Ultrasound has an overall accuracy of 82% (T1, 2, 40-100%; T3, 4, 25-100%) and is particularly useful for early localized rectal cancers. MRI has an accuracy of 76% (T1, 2, 29-80%; T3, 4, 0-100%) and is useful in more advanced disease by providing clearer definition of the mesorectum and mesorectal fascia. Both methods have similar accuracy in the assessment of nodal metastases. Ultrasound is more operator dependent and accuracies improve with experience, but it is more portable and accessible than MRI. Improvements in technology and increased operator experience have led to more accurate preoperative staging. ERUS and MRI are complementary and are most accurate for early localized cancers and more advanced cancers, respectively.

Hemorrhoidopexy staple line height predicts return to work

PURPOSE

Previous studies identified reduction in pain and complications with stapled hemorrhoidopexy relative to conventional hemorrhoidectomy. Previously, the presence of resected squamous epithelium and a staple line height <20 mm above the dentate line were predictive of postoperative pain. The purpose of this study was to further investigate and refine the role of staple height in the prediction of postoperative outcomes.

METHODS

From July 2002 to October 2004, 75 patients with symptomatic Grade 3 and 4 mixed hemorrhoids underwent stapled hemorrhoidopexy in two teaching institutions with prospective data collection. All procedures were performed under the direct supervision of two colorectal teaching staff. The majority were performed under monitored anesthesia care as outpatient procedures. Preoperative, intraoperative, and postoperative patient characteristics were evaluated. This included demographics, staple line height, specimen histology, complications, days to return to work, duration of narcotic pain medicine, and preoperative/postoperative tone and seepage. The results were subjected to statistical analysis using t-test and ANOVA.

RESULTS

Seventy-five patients with a median age of 49 (range, 25-87) years were identified. Histology identified 62 specimens with columnar and/or transitional cells, 10 with squamous epithelium, and 3 with muscle present. Overall complication rate was 14 percent. Complications included three readmissions for pain control, three acute postoperative anal fissures, two postoperative bleeds (with one requiring examination under anesthesia without intervention), one patient with subcutaneous emphysema, and one admission for fecal impaction. Staple line height was not a statistically significant predictor of postoperative complication. Median return to work was 14 (range, 1-31) days. Median duration of narcotic use was six (range, 0-40) days. Patients with a staple line height>22 mm required a significantly shorter duration of narcotic pain management (P=0.024). Median follow-up was 24 (range, 9-253) days. Staple line heights below 20 mm had a mean return to work of 15 days. A staple line height>20 mm had a mean return to work of nine days. Staple line height was inversely related to return to work (P=0.01).

CONCLUSIONS

A hemorrhoidopexy staple line>or=22 mm above the dentate line correlates with a significantly shorter need for postoperative narcotics (P=0.024) and an earlier return to work (P=0.017). Staple line distance above the dentate line meaningfully impacts comfort-based outcomes.

Preoperative Staging of Rectal Cancer: Comparison of 3-T High-Field MRI and Endorectal Sonography

OBJECTIVE

The aim of this study was to compare phased-array 3-T MRI and endorectal sonography in the preoperative staging of rectal cancer.

MATERIALS AND METHODS

During an 8-month period, 24 patients with rectal cancer underwent both 3-T MRI performed with phased-array coils and 7.5- to 10-MHz endorectal sonography in the 3 weeks before surgical resection. Three radiologists independently reviewed the MR and endorectal sonographic images. The histopathologic findings in resected specimens were used to evaluate the sensitivities and specificities of these techniques for invasion of the muscularis propria and perirectal tissue and for lymph node involvement. Receiver operating characteristic (ROC) analysis was used to compare the diagnostic accuracies of the techniques.

RESULTS

For muscularis propria invasion, the mean sensitivities of both MRI and endorectal sonography were 100%, and the mean specificities were 66.7% and 61.1%, respectively. The differences in the mean sensitivities and specificities were not statistically significant (p > 0.05 in each case). For perirectal tissue invasion, MRI and endorectal sonography had comparable sensitivities and specificities (91.1% vs 100%, 92.6% vs 81.5%; p > 0.05 in each case). They also had similar sensitivities and specificities for lymph node involvement (63.6% vs 57.6%, 92.3% vs 82.1%; p > 0.05 in each case). ROC curves for muscularis propria invasion and lymph node involvement showed no differences in diagnostic accuracy. The mean area under the ROC curve for endorectal sonography (A(Z) = 0.996) for perirectal tissue invasion, however, showed higher accuracy than that of MRI (A(Z) = 0.938, p = 0.028).

CONCLUSION

The sensitivity, specificity, and accuracy of 3-T MRI were similar to those of endorectal sonography for muscularis propria invasion and lymph node involvement, but for perirectal tissue invasion, 3-T MRI was less accurate than endorectal sonography.

Perianal local block for stapled anopexy

PURPOSE

This study was designed to demonstrate the usefulness of a method of regional anesthesia for circular stapler anopexy for prolapsing hemorrhoids.

METHODS

Thirty-three patients consented to stapled anopexy under perianal local anesthesia. Eighteen patients with stapled anopexy under general anesthesia were controls. The perianal block was applied with 40 ml of ropivacaine, 4.75 mg/ml, injected immediately peripheral to the external sphincter. A submucosal block with 15 ml of ropivacaine, 2 mg/ml, was added after applying the pursestring suture. Postoperative pain was rated by the patient for 14 days by using a ten-point visual analogue scale. Patients also submitted a preoperative and postoperative (3-6 months) symptom questionnaire to rate anal symptoms.

RESULTS

No operation was converted to general anesthesia. Operation time was similar in both groups. All patients in the local anesthesia group were pain free at discharge. The sums of pain scores during 14 days for daily average pain and peak pain were similar in both groups (average pain 23 (local anesthesia) vs. 35 (general anesthesia); peak pain 39 (local anesthesia) vs. 50 (general anesthesia); P>0.05). The preoperative symptom scores were 7.8 (local anesthesia) vs. 8.9 (general anesthesia) points, and the follow-up scores were 2.2 (local anesthesia) and 2.7 (general anesthesia), a significant improvement (P=0.001) in both groups but not different between groups.

CONCLUSIONS

A perianal local block is easy to apply and has a high degree of acceptance among patients. The operation time, postoperative pain, and success rates of the operation equaled those of stapled anopexy performed under general anesthesia. The advantages are quicker turnover between cases and simpler management of pain-free postoperative patients in day surgery.

Rectal stenosis after procedures for prolapse and hemorrhoids (PPH)--a report from China

OBJECTIVES

After it was introduced in China in 2000, the surgical procedure for prolapse and hemorrhoids (PPH) has become a widely accepted for third- and fourth-degree hemorrhoids. Stenosis of the lower rectum is one of the delayed complications. In order to evaluate this specific problem following PPH, we reviewed our data with special reference to potential predictive factors or stenotic events.

METHODS

A retrospective analysis of 554 consecutive patients that underwent PPH from July 2000 to December 2004 was performed. Only patients with follow-up check were evaluated; therefore 65 patients (11.7%) Hwere lost to follow-up, and the analysis therefore includes 489 patients with a mean follow-up of 324 days (+/-18 days). For statistical analysis, the groups with and without stenosis were evaluated using the chi-square test; using the Kaplan-Meier statistic, the actuarial incidence for rectal stenosis was plotted.

RESULTS

Rectal stenosis was observed in 12 patients (2.5%) in whom the median time to stenosis was 125 (89 approximately 134) days. All patients complained of obstructive defecation and underwent strictureplasty with electrocautery or balloon dilation through colonoscopy. A statistical analysis revealed that two factors were significantly more prevalent among patients with stenosis: prior sclerosis therapy for hemorrhoids (P=0.02) and severe postoperative pain (P=0.003). Other factors, such as gender (P=0.32), prior surgery for hemorrhoids (P=0.11), histological evidence of squamous skin (P=0.77) or revision (P=0.53) showed no significance.

CONCLUSIONS

Rectal stenosis is an uncommon event after PPH. Early stenosis will occur within the first 4 months after surgery. In most cases, the stenosis can be cured through colonoscopy surgery. Predictive factors for stenosis are previous sclerosis therapy for hemorrhoids and severe postoperative pain.

Analysis of surgical treatments for circumferentially protruding haemorrhoids: complete excision with repair using flaps versus primary excision with secondary suture-ligation

BACKGROUND

Circumferentially protruding haemorrhoids (CPH) are troublesome lesions for both patients and surgeons, and in most cases demand surgical intervention. However, such surgery carries the risks of complications and recurrence. This study compared two surgical procedures in order to identify the optimal approach for CPH.

METHODS

All patients underwent an open haemorrhoidectomy for primary haemorrhoids, after which patients underwent either of the two procedures for secondary haemorrhoids. Group 1 (n = 104) comprised patients who underwent submucosal excision with repair using remnant anodermal flaps; this procedure was performed between 1991 and 1996. Group 2 (n = 113) comprised patients who underwent suture-ligation; this procedure was performed between 1997 and 2002. Surgical outcomes including surgical variables, wound healing, complications and patient satisfaction were compared between the two groups.

RESULTS

For group 2, surgical time and duration of analgesic use (mean +/- SEM, 22 +/- 0 minutes and 3 +/- 0 days, respectively) were significantly shorter than for group 1 (28 +/- 1 minutes and 4 +/- 0 days, respectively; p < 0.001 for both comparisons). In terms of complication rates, there was no significant difference between group 2 (15 patients, 14%) and group 1 (25 patients, 22%), and most complications were satisfactorily treated using conservative management. Skin tags and perianal abscesses were more frequent in group 1 than in group 2. The final follow-up was undertaken at 6 months postoperatively, at which time there were no recurrences in patients of either group. For both groups, over 90% of patients reported that they were satisfied with the outcome of surgery.

CONCLUSION

Although both surgical approaches were successful for treating CPH, open haemorrhoidectomy for primary haemorrhoids combined with suture-ligation for secondary haemorrhoids appears to be the optimal approach considering its rapidity, simplicity and lower associated costs.

Treatment of rectal mucosal prolapse with radiofrequency coagulation and plication--a new surgical technique

BACKGROUND

This study was designed to assess the outcome of using a new technique of mucosal ablation using a radiofrequency device followed by its plication for rectal mucosal prolapse and to compare the results with those under the conventional ligature and excision procedure.

MATERIALS AND METHODS

The procedure of radiofrequency ablation and mucosal plication (RAMP) is described. A Ellman radiofrequency generator was used for the procedure. Out of the 46 patients with rectal mucosal prolapse, 24 patients were randomized to undergo ligature and excision procedure (LEP) and 22 were operated with RAMP. The operating time, amount of pain (VAS scale)[Primary end points], postoperative analgesic requirement, time to return to work, wound healing period and postoperative complications were documented.

RESULTS

Radiofrequency ablation and mucosal plication procedure on an average resulted in shorter operation time (9 vs. 32 minutes, p < 0.0001), shorter hospitalization (16 vs. 42 hours, p < 0.0001) significantly lesser postoperative pain, fewer cumulative requests for analgesia by the patients (21 vs. 54 tablets, p < 0.0001), earlier return to work (7 vs. 18 days, p < 0.0001) and faster wound healing time (14 vs. 35 days, p < 0.0001). The complication rate was 9 % with RAMP group and 29 % with LEP group.

CONCLUSION

The procedure of radiofrequency ablation and plication of mucosa shows promising results in patients with rectal mucosal prolapse. Being safe, effective, and a swift technique, it can be proposed as an improved alternative to conventional surgical procedure.

New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant

There have been several recent advances in the treatment of common perianal diseases. Stapled hemorrhoidopexy is a procedure of hemorrhoidal fixation, combining the benefits of rubber band ligation into an operative technique. The treatment of anal fissure has typically relied upon internal sphincterotomy; however, it carries a risk of incontinence. The injection of botulinum toxin represents a new form of sphincter relaxation, without division of any sphincter muscle; morbidity is minimal and results are promising. For the treatment of fistula in a fistulotomy remains the gold standard, however, it carries significant risk of incontinence. Use of fibrin sealant to treat fistulae has been met with variable success. It offers sealing of the tract, and then provides scaffolding for native tissue ingrowth.

Stapled versus conventional surgery for hemorrhoids

BACKGROUND

Hemorrhoids are one of the most common anorectal disorders. The Milligan‐Morgan open hemorrhoidectomy is the most widely practiced surgical technique used for the management of hemorrhoids and is considered the current "gold standard". Circular stapled hemorrhoidopexy was first described by Longo in 1998 as alternative to conventional excisional hemorrhoidectomy. Early, small randomized‐controlled trials comparing stapled hemorrhoidopexy with traditional excisional surgery have shown it to be less painful and that it is associated with quicker recovery. The reports also suggest a better patient acceptance and a higher compliance with day‐case procedures potentially making it more economical. A previous Cochrane Review of stapled hemorrhoidopexy and conventional excisional surgery has shown that the stapled technique is associated with a higher risk of recurrent hemorrhoids and some symptoms in long term follow‐up. Since this initial review, several more randomized controlled trials have been published that may shed more light on the differences between the novel stapled approach and conventional excisional techniques.

OBJECTIVES

This review compares the use of circular stapling devices and conventional excisional techniques in the surgical treatment of hemorrhoids. Its goal is to ascertain whether there is any difference in the outcomes of the two techniques in patients with symptomatic hemorrhoids.

SEARCH STRATEGY

We searched all the major electronic databases (MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1998 to December 2009.

SELECTION CRITERIA

All randomized controlled trials comparing stapled hemorrhoidopexy to conventional excisional hemorrhoidal surgeries with a minimum follow‐up period of 6 months were included.

DATA COLLECTION AND ANALYSIS

Data were collected on a data sheet. When appropriate, an Odds Ratio was generated using a random effects model.

MAIN RESULTS

Patients with SH were significantly more likely to have recurrent hemorrhoids in long term follow up at all time points than those with CH (12 trials, 955 patients, OR 3.22, CI 1.59‐6.51, p=0.001). There were 37 recurrences out of 479 patients in the stapled group versus only 9 out of 476 patients in the conventional group. Similarly, in trials where there was follow up of one year or more, SH was associated with a greater proportion of patients with hemorrhoid recurrence (5 trials, 417 patients, OR 3.60, CI 1.24‐10.49, p=0.02). Furthermore, a significantly higher proportion of patients with SH complained of the symptom of prolapse at all time points (13 studies, 1191 patients, OR 2.65, CI 1.45‐4.85, p=0.002). In studies with follow up of greater than one year, the same significant outcome was found (7 studies, 668 patients, OR 3.14, CI 1.20‐8.22, p=0.02). Patients undergoing SH were more likely to require an additional operative procedure compared to those who underwent CH (8 papers, 553 patients, OR 2.75, CI 1.31‐5.77, p=0.008). When all symptoms were considered, patients undergoing CH surgery were more likely to be asymptomatic (12 trials, 1097 patients, OR 0.59, CI 0.40‐0.88). Non significant trends in favor of SH were seen in pain, pruritis ani, and fecal urgency. All other clinical parameters showed trends favoring CH.

The impact of endoscopic ultrasound and computed tomography on the TNM staging of early cancer in Barrett's esophagus

INTRODUCTION

Computed tomography (CT) and endoscopic ultrasound (EUS) are part of the regular staging protocol in esophageal cancer. The value of the two methods was assessed in patients with early cancer in Barrett's esophagus.

METHODS

One hundred consecutive patients (median age 64 yr, interquartile range [IQR] 58-72) with suspected early cancer in Barrett's esophagus who were referred to our hospital for endoscopic therapy were prospectively included in a standardized staging program with upper gastrointestinal endoscopy, EUS (7.5 MHz in all cases plus 12.5 or 20 MHz for elevated and/or depressed lesions), CT of the chest and upper abdomen, and abdominal ultrasonography. The results were summarized in accordance with the TNM classification. On the basis of the lymph node findings on CT and/or EUS, the patients were assigned to three categories: C1, no suspicious lymph nodes; C2, paraesophageal lymph nodes < or =1 cm in size at the tumor level, lymph nodes > or =1 cm in size not at the tumor level in the mediastinum or celiac trunk; and C3, paraesophageal lymph nodes > 1 cm in size at the tumor level. The EUS and CT findings were checked every 6 months in patients who underwent endoscopic treatment. Surgical resection was scheduled in operable patients if staging showed a T category higher than T1 and/or the lymph node staging was assessed as C3. Patients with suspected submucosal infiltration underwent diagnostic endoscopic resection, and if submucosal involvement was confirmed were referred for surgery.

RESULTS

The median follow-up period was 25 months (IQR 19.5-30.0). The T category diagnosed with CT was < or = T1 in all patients. On EUS, the T category was classified as T1 in 92% of cases (N = 92) and as > T1 in 8% (N = 8, p < 0.05). Enlarged lymph nodes (C2 and C3) were detected in 45% of the patients. Significantly more C2 lymph nodes were diagnosed with EUS than CT (28 vs 19, p < 0.05). Lymph nodes at the level with the highest suspicion, C3, were detected using CT in only three of nine cases. Sensitivity of CT for N staging was not acceptable compared with EUS (38%vs 75%). No extranodal metastases were found on CT.

CONCLUSIONS

In suspected early cancer in Barrett's esophagus, EUS is superior to CT for T staging and N staging. As CT had no influence on the TNM classification in any of these patients, it may be possible to dispense with this method as a staging procedure in patients with cancer in Barrett's esophagus. By contrast, EUS is required in order to differentiate between patients with cancer in Barrett's esophagus in whom endoscopic therapy is suitable and those in whom surgical treatment is required.

EUS staging of upper GI malignancies: results of a prospective randomized trial

BACKGROUND

Electronic 270 degrees transverse-array EUS (TA-EUS) provides high-quality cross-sectional images but cannot guide FNA. Linear EUS (L-EUS) provides longitudinal images of malignancies and the ability to guide FNA.

OBJECTIVE

We conducted a prospective randomized comparison of TA-EUS and L-EUS for the staging of upper-GI (UGI) malignancies.

DESIGN

Forty-three patients underwent L-EUS immediately followed by TA-EUS (N = 27, 63%) or TA-EUS immediately followed by L-EUS (N = 16, 37%).

PATIENTS

Forty-three subjects (mean age, 64 years; 37 men) with an UGI malignancy (4 stomach and 38 esophageal) were evaluated with both TA-EUS and L-EUS.

INTERVENTIONS

Abnormal lymph nodes were sampled by FNA for cytology.

RESULTS

There was agreement on the T stage by linear and radial techniques in 38 of 43 subjects (88%). Twenty-seven of 43 patients (63%) had abnormal lymph nodes by linear or transverse-array imaging. L-EUS demonstrated 66 abnormal lymph nodes in 27 subjects (average of 2.4 nodes/subject). TA-EUS demonstrated 90 abnormal lymph nodes in 27 subjects (average of 3.3 nodes/subject, P = .009, compared with L-EUS). In 16 of the 27 subjects, an FNA was performed, which was positive in 13 cases (81%) and negative in 3 cases (10%) for malignancy.

CONCLUSIONS

TA-EUS and L-EUS provide similar results of T staging of UGI malignancies. However, the number of abnormal lymph nodes detected by TA-EUS was more than by L-EUS. These findings suggest that radial or transverse-array EUS imaging should be the primary method for staging of UGI malignancies.

Cancer in Crohn's disease

There has been a multitude of case reports, case series, hospital-based, and population-based studies that link CD to various types of cancers. When each of these studies is scrutinized, however, there is only enough evidence to support a link between colorectal adenocarcinoma, SBA, and squamous and adenocarcinomas that are associated with perianal fistulizing disease. All of the studies of large bowel adenocarcinoma or SBA follow patients in an era during which there were far fewer effective medicines to treat CD and surgery was more commonplace. The only surveillance study of patients who had extensive, long-duration Crohn's colitis showed a 22% risk for developing neoplasia (low-grade, high-grade, or cancer) after four surveillance examinations. Overall results from this study and the multitude of the other studies show that the risk for cancer in Crohn's colitis is equal to that in UC given equal extent and duration of disease. Patients who have Crohn's colitis that affects at least one third of the colon and with at least 8 years of disease should undergo screening and surveillance, just as in UC. Although the absolute risk for SBA in CD is low (2.2% at 25 years in one study), we should not rule out screening and surveying for this complication that is associated with significant morbidity and mortality in patients who have long-standing, extensive, small bowel disease. The risk for lymphoma and leukemia in CD is low, but immunomodulators and biologics may increase this risk. The evidence that links carcinoid tumors to CD is weak, and population-based studies need to be done. The study of cancers that are associated with CD is an evolving field that surely will change given that immunomodulators and biologics are being used with greater frequency.

Randomized controlled study: radiofrequency coagulation and plication versus ligation and excision technique for rectal mucosal prolapse

BACKGROUND

A novel technique of radiofrequency ablation and plication of the rectal mucosa (RAMP) as a treatment for rectal mucosal prolapse is reported. The results of this technique are compared with the conventional ligature and excision procedure (LEP).

METHODS

Radiofrequency ablation was performed using an Ellman radiofrequency generator. Patients with rectal mucosal prolapse were randomized to undergo either LEP or RAMP. The intra- and postoperative outcomes and complications were recorded.

RESULTS

RAMP on average resulted in reduced operation time, shorter hospitalization, and significantly less postoperative pain. Return to work was earlier and wound healing times were shorter than that of patients in the control group. The complication rates also were significantly shorter (9% in the RAMP group and 29% in the conventional LEP group).

CONCLUSION

The procedure of radiofrequency ablation and plication of rectal mucosa is safe, effective, and swift. It can be proposed as an effective alternative to conventional surgical procedures.

Video-assisted thoracic surgery lobectomy: experience with 1,100 cases

BACKGROUND

Although many video-assisted thoracic surgery (VATS) lobectomies have been performed over the 12 years since the first VATS lobectomy, controversies about the procedure remain regarding the safety and associated morbidity and mortality of that procedure. This series is reviewed to assess these issues.

METHODS

Between 1992 and 2004, we performed 1,100 VATS lobectomies in 595 women (54.1%) and 505 men (45.9%), with a mean age of 71.2 years. Diagnoses were as follows: benign disease (53), pulmonary metastases (27), lymphoma (5), and lung cancer (1,015). Of the primary lung cancers, 641 (63.1%) were adenocarcinoma. With visualization on a monitor, anatomic hilar dissection and lymph node sampling or dissection were performed, primarily through a 5-cm incision without spreading the ribs.

RESULTS

There were 9 deaths (0.8%), and none was intraoperative or due to bleeding; 932 patients had no postoperative complications (84.7%). Blood transfusion was required in 45 of 1,100 patients (4.1%). Length of stay was median 3 days (mean, 4.78). One hundred eighty patients (20%) were discharged on postoperative day 1 or 2. Conversion to a thoracotomy occurred in 28 patients (2.5%). Recurrence developed in the incisions in 5 patients (0.57%). In 2003, 89% of 224 lobectomies were performed with VATS.

CONCLUSIONS

VATS lobectomy with anatomic dissection can be performed with low morbidity and mortality rates. The risk of intraoperative bleeding or recurrence in an incision seems minimal.

Two Cases of Thoracoscopic Resection of Esophageal Duplication in Children

We report two cases of thoracoscopic resection of esophageal duplication cysts. Both patients underwent successful thoracoscopic excision. They were discharged on postoperative day 2 and 4, respectively. They made uneventful recoveries and were completely asymptomatic at 1-month followup. One child was lost to long-term follow-up. In the other child, barium swallow study 10 months after surgery demonstrated a pseudodiverticulum at the site of cyst excision. Thoracoscopic resection of esophageal duplications is safe. Complete excision is possible even if the cyst shares a common muscular wall with the esophagus. Pseudodiverticulum may develop at the site of excision: follow- up is necessary and consideration should be given to closure of the muscular defect at the time of excision. To help avoid esophageal injury and, should it occur, recognize esophageal perforation, we recommend performing the dissection under intraesophageal endoscopic supervision.

Isolated metachronous splenic metastasis from synchronous colon cancer

Background

Isolated splenic metastases from colorectal cancer are very rare and there are only 13 cases reported in the English literature so far. Most cases are asymptomatic and the diagnosis is usually made by imaging studies during the evaluation of rising CEA level postoperatively.

Case presentation

A 76-year-old man underwent an extended left hemicolectomy for synchronous colon cancers located at the left flexure and the sigmoid colon. The tumors were staged as IIIC (T3N2M0) clinically and the patient received adjuvant chemotherapy. During the first year follow-up period, the patient remained asymptomatic with normal levels of laboratory tests including CEA measurement. However, a gradually rising CEA level after the 14^th postoperative month necessitated further imaging studies including computed tomography of the abdomen which revealed a mass in the spleen that was subsequently confirmed by ¹⁸FDG- PET scanning to be an isolated metastasis. The patient underwent splenectomy 17 months after his previous cancer surgery. Histological diagnosis confirmed a metastatic adenocarcinoma with no capsule invasion. After an uneventful postoperative period, the patient has been symptom-free during the one-year of follow-up with normal blood CEA levels, although he did not accept to receive any further adjuvant therapy. To the best of our knowledge, this 14^th case of isolated splenic metastasis from colorectal carcinoma is also the first reported case of splenic metastasis demonstrated preoperatively by ¹⁸FDG PET-CT fusion scanning which revealed its solitary nature as well.

Conclusion

Isolated splenic metastasis is a rare finding in the follow-up of colorectal cancer patients and long-term survival can be achieved with splenectomy.

Nerve stimulator guided pudendal nerve blockversus general anesthesia for hemorrhoidectomy

PURPOSE

A randomized clinical trial was undertaken to test the hypothesis that patients receiving a nerve stimulator guided pudendal nerve block for hemorrhoidectomy would experience more effective and prolonged postoperative analgesia and shorter hospital stay compared to patients receiving general anesthesia.

METHODS

This was a prospective randomized observer-blinded study. Following Ethics Committee approval and informed consent, 80 patients scheduled for hemorrhoidectomy were randomized to two groups of 40 patients each: general anesthesia alone, or nerve stimulator guided pudendal nerve block. Postoperative pain, the primary outcome variable of the study, was assessed by visual analogue scale scores at predetermined intervals during the postoperative period. Analgesic consumption, time to return to normal activities, patients' and surgeons' satisfaction, and duration of hospital stay were recorded.

RESULTS

The guided pudendal nerve block group failed in three patients, requiring their conversion to general anesthesia. Otherwise, patients in the pudendal nerve block group experienced better postoperative pain relief at rest (P < 0.0001), on walking, sitting, and defecation (P < 0.001), reduced need for opioids (11/35 vs 32/37; P < 0.0001), a more rapid return to normal activities (7.2 vs 13.8 days; P < 0.0001) and also a shorter hospital stay (25/35 vs 3/37 outpatient cases; P < 0.0001) compared to the general anesthesia group. Pudendal nerve block was also associated with overall higher patient satisfaction compared to general anesthesia (30/35 vs 9/37; P < 0.0001).

CONCLUSION

Nerve stimulator guided pudendal nerve block is associated with reduced postoperative pain, shortened hospital stay, and earlier return to normal activity compared to general anesthesia for hemorrhoidectomy.

Randomized Controlled Trial to Determine the Effectiveness of the Nivatvongs Technique Versus Conventional Local Anaesthetic Infiltration for Outpatient Haemorrhoidectomy

BACKGROUND

Conventional local anaesthesia in outpatient haemorrhoidectomy, using a diamond-shaped perianal block, is reliable, safe and inexpensive. It allows for early ambulation and short hospital stay. However, without sedation, local infiltration is perceived to be both uncomfortable and painful. Nivatvongs described a technique in which the anaesthetic is injected intra-anally into the insensitive area above the dentate line, allegedly causing less pain.

METHODS

This randomized, controlled, parallel-group, single-blind clinical trial compared the effectiveness of the conventional and Nivatvongs techniques in reducing the pain of anaesthetic infiltration in adult patients undergoing outpatient haemorrhoidectomy. A total of 112 patients were randomized into either treatment (n=57) or control groups (n=55). Assigned surgeon-anaesthetists performed the local anaesthetic infiltration. The Milligan-Morgan technique was used for haemorrhoidectomy. Pain was assessed using a standardized visual analogue scale. Patient and surgeon satisfaction were measured with a pre-validated questionnaire.

RESULTS

Median scores for pain assessment during local anaesthetic infiltration were 2 and 3 in the control and treatment groups, respectively. Patient satisfaction with the method of anaesthetic infiltration and the procedure itself were 3 and 2, respectively, for both groups. The surgeon's overall satisfaction with the technique of anaesthetic infiltration was similar in the two groups. There was no significant difference in any of the outcomes measured.

CONCLUSION

Both local anaesthetic techniques for outpatient haemorrhoidectomy were generally effective and well tolerated. The Nivatvongs technique did not confer any significant additional benefit.

Thoracoscopic resection of esophageal duplication cysts

Esophageal duplication is a rare congenital esophageal disorder. Surgical excision is the standard treatment for symptomatic esophageal duplication cysts. Traditionally, the resection is accomplished via thoracotomy; however, a minimally invasive approach is possible, avoiding the long hospital stay, the discomfort and the long recovery time due to a thoracotomy. The authors describe two cases of esophageal duplication resected via a left thoracoscopic approach.

Management of recurrent rectal prolapse: surgical approach influences outcome

INTRODUCTION

Recurrent rectal prolapse is an unresolved problem and the optimal treatment is debated. This study was designed to review patterns of care and outcomes in a large cohort of patients after surgery for recurrent prolapse.

METHODS

From 685 patients who underwent operative repair for full-thickness external rectal prolapse, we identified 78 patients (70 females; mean age, 66.9 years) who underwent surgery for recurrence. We reviewed the subsequent management and outcomes for these 78 patients.

RESULTS

Mean interval to their first recurrence was 33 (range, 1-168) months. There were significantly more re-recurrences after reoperation using a perineal procedure (19/51) compared with an abdominal procedure (4/27) for their recurrent rectal prolapse (P = 0.03) at a mean follow-up of nine (range, 1-82) months. Patients undergoing abdominal repair of recurrence were significantly younger than those who underwent perineal repair (mean age, 58.5 vs. 71.5 years; P < 0.01); however, there was nosignificant difference between the two groups with regard to the American Society of Anesthesiologists classification (P = 0.89). Eighteen patients had surgery for a second recurrence, with perineal repairs associated with higher failure rates (50 vs. 8 percent; P = 0.07). Finally, when combining all repairs, the abdominal approach continued to have significantly lower recurrence rates (39 vs. 13 percent; P < 0.01).

CONCLUSIONS

The re-recurrence rate after surgery for recurrent rectal prolapse is high, even at a relatively short follow-up interval. Our data suggest that abdominal repair of recurrent rectal prolapse should be undertaken if the patient's risk profile permits this approach.

[Postoperative pain and long-term results after hemorrhoidal treatment with anopexy]

AIMS

Anopexy allows treatment of hemorrhoidal symptoms with a less painful postoperative course. This information is important for the patient, but may lead to dissatisfaction if pain level is higher than expected. To evaluate perceived pain and physical limitation levels in relation to patient's expectation. Evaluate long-term functional results.

RESULTS

Sixty-eight consecutive patients (56 males) were prospectively included. Distribution of haemorrhoid grades were 4 grade 2 (6%), 52 grade 3 (76%) and 12 grade 4 (18%). Postoperative pain level was less or equal than expected for 85% of patients, with a better acceptance superior to 45 years. Physical limitation was equally or less important than expected for 89%. At the 32 weeks follow-up hemorrhoidal symptoms were present in 23%, uninfluenced by any patient's or operative characteristics. Incontinence with urgency was reported by 17%. Presence of an alliterated continence was linked to stapled line inferior to 6,5 mm from pectineate line, doughnut height inferior to 22 mm, external hemorrhoids and related to surgeon.

CONCLUSION

Pragmatic information, although vague, about postoperative pain does not expose to patient's dissatisfaction. Functional results are not influenced by technical variation. Continence alterations are not severe, but frequent when stapled line is too close from pectineate line.

Experience of 3711 stapled haemorrhoidectomy operations

BACKGROUND

Stapled haemorrhoidectomy has been routinely performed in the Department of Colorectal Surgery, Singapore General Hospital since 1999.

METHODS

A retrospective review was undertaken of all patients who underwent stapled haemorrhoidectomy between October 1999 and May 2004. The outcomes studied were patient profiles, priority of operation, indications for surgery, length of operation, postoperative complications and recurrences.

RESULTS

A total of 3711 patients (51.1 per cent women) had the surgery. The median patient age was 50 (range 18-88) years. The main indications were bleeding (80.7 per cent), haemorrhoidal prolapse (59.6 per cent) and thrombosis (3.9 per cent). The median duration of operation was 15 (range 5-45) min. Minor complications occurred in 12.3 per cent of patients: acute retention of urine (4.9 per cent), bleeding (4.3 per cent), significant postoperative pain requiring admission (1.6 per cent), anorectal stricture (1.4 per cent), perianal haematoma (0.05 per cent) and significant residual skin tags (0.05 per cent). One patient developed a perianal abscess after stapled haemorrhoidectomy. Anastomotic dehiscence occurred in three patients (0.08 per cent). Twelve (0.3 per cent) patients had a recurrence at a median of 16 (range 5-45) months.

CONCLUSION

Considerable experience of stapled haemorrhoidectomy confirms it as a safe and effective procedure.

Stapled haemorrhoidopexy in fourth degree haemorrhoidal prolapse: is it worthwhile?

INTRODUCTION

Ten years after the introduction of stapled haemorrhoidopexy few studies have stratified patients by degree of haemorrhoidal disease when analysing results. Objective The aim of this study was prospectively to evaluate 116 patients who underwent stapled anopexy conducted by the same surgeon for III or IV degree haemorrhoidal prolapse.

MATERIALS AND METHODS

One hundred and sixteen consecutive patients affected by symptomatic haemorrhoids of III or IV degree underwent stapled anopexy using the technique described by Longo in the period January 2001 to October 2003. Mean follow-up was 28.1 months. Fischer's exact test was used for statistical analysis. Results, in terms of morbidity and recurrence rates, were stratified according to degree of haemorrhoidal disease.

RESULTS

There was no statistically significant difference between the results for third degree compared with fourth degree prolapse although there was a trend towards increased incidence of postoperative bleeding and recurrence.

CONCLUSION

Third degree haemorrhoidal prolapse remains the best indication for stapled haemorrhoidopexy. This procedure may also be indicated in fourth degree haemorrhoidal prolapse. Patients with fourth degree haemorrhoids may be subjected to this procedure following adequate discussion of the outcome.

Adult case of accessory cardiac bronchus presenting with bloody sputum

We report an adult case of accessory cardiac bronchus (ACB) which extended from the carina to the diaphragm. A 32-year-old woman, with a history of frequent respiratory infections since childhood, recently presented with bloody sputum, and was admitted to our hospital. The ACB was detected as a supernumerary bronchus diverging from tracheal bifurcation. Complete resection of the ACB was performed by video-assisted thoracic surgery via minithoracotomy, approaching from the 5th intercostal space. The bloody sputum was caused by chronic inflammation of the ACB. She has been asymptomatic since surgery.

Surgical Treatment of Rectal Cancer: Local Resection

Local treatment of rectal cancer aims to decrease the morbidity and the functional sequela associated with radical surgery without compromising local tumor control and long-term survival. Local excision is associated with a higher rate of local recurrence compared with radical surgery, and salvage radical surgery cannot guarantee equivalent long-term survival compared with radical surgery as the primary form of therapy. Therefore, strict criteria for patient selection are critical for local excision to be successful. Selecting the optimal therapy for an individual patient with rectal cancer is crucial and requires consideration of both tumor and patient characteristics. Endorectal ultrasonography is essential for the accurate assessment of rectal wall invasion and nodal metastasis. Only patients with well- or moderately differentiated T1 tumors without blood vessel or lymphatic vessel invasion are candidates for curative local excision as the only form of treatment. Tumors penetrating the muscularis propria should not be treated by local excision alone. These patients can be asked to participate in a trial of chemoradiation followed by local excision. Otherwise, they should undergo radical surgery. The tumor should be removed by full-thickness local excision with an adequate normal margin for pathologic evaluation. Final decisions regarding the treatment strategy should be based on the pathology of the surgical specimen. Intense, close follow-up is critical for early diagnosis of local recurrences as many of them may be surgically salvaged by radical resection. Local treatment can also be used for palliation of patients with histological unfavorable or advanced tumors, and those who are medically unfit for radical surgery.

Intra-abdominal esophageal duplication cyst in an adult

Esophageal duplication cysts are congenital anomalies of the foregut that are rarely found in the abdomen. An accurate preoperative diagnosis is not always possible, so the definitive diagnosis can be made by histologic examination of the surgical specimen. We experienced a case of Intra-abdominal esophageal duplication cyst in a 52-year-old female, who initially presented with an esophageal submucosal tumor on upper gastrointestinal endoscopy. She did not have any gastrointestinal symptoms. Barium esophagography, chest computed tomography scan and endoscopic ultrasonography demonstrated the cystic lesion in the intra-abdominal esophagus. Transhiatal enucleation of the lesion was performed successfully via the abdominal approach with no postoperative complications. Histologic study showed that the cyst wall contained a two-layered muscle coat and the surface of the lumen was lined by pseudo-ciliated columnar epithelium. The patient has been doing well without any complaints for 3 months of follow-up period.

Practice patterns and attitudes toward the role of endoscopic ultrasound in staging of gastrointestinal malignancies: a survey of physicians and surgeons

BACKGROUND AND AIMS

It is unknown how physician specialties other than gastroenterologists that manage gastrointestinal (GI) malignancies utilize endoscopic ultrasound (EUS) in their practices. The aim of this study was to (i) assess the proportion of gastroenterologists, oncologists, and surgeons that utilize EUS for staging of GI malignancies; (ii) assess the general availability of EUS; and (iii) determine which factors are associated with the use and availability of EUS.

METHODS

A self-administered questionnaire was mailed out to 1,200 randomly selected gastroenterologists, oncologists, and surgeons throughout the United States.

RESULTS

The data was analyzed from 521 (43%) responses. There were 60% respondents who had EUS available within their practices. There was greater availability of EUS within the practices of surgeons (81%; p < 0.001), within academic practices (87%; p= < 0.001), and in practices that serve a population >500,000 (p < 0.001). The majority of respondents (71%) utilized EUS in their practices. There was a similar utilization of EUS across specialties (p= NS). There was greater utilization of EUS in academic centers (82%; p < 0.001), in practices that served a community of >500,000 (p= 0.003), and among respondents who had been in practice for less than 5 yr (p= 0.005). Employing logistic regression models for utilization of EUS, lesser number of years in practice, and availability of EUS were found to be the only significant predictors of utilization.

CONCLUSIONS

The majority of practitioners utilized EUS in management of GI malignancies. There was similar utilization of EUS across specialties. EUS is available to the majority of practitioners who manage GI malignancies.

S100A1 Gene Therapy Preserves in Vivo Cardiac Function after Myocardial Infarction

Myocardial infarction (MI) represents an enormous clinical challenge as loss of myocardium due to ischemic injury is associated with compromised left ventricular (LV) function often leading to acute cardiac decompensation or chronic heart failure. S100A1 was recently identified as a positive inotropic regulator of myocardial contractility in vitro and in vivo. Here, we explore the strategy of myocardial S100A1 gene therapy either at the time of, or 2 h after, MI to preserve global heart function. Rats underwent cryothermia-induced MI and in vivo intracoronary delivery of adenoviral transgenes (4 x 10(10) pfu). Animals received saline (MI), the S100A1 adenovirus (MI/AdS100A1), a control adenovirus (MI/AdGFP), or a sham operation. S100A1 gene delivery preserved global in vivo LV function 1 week after MI. Preservation of LV function was due mainly to S100A1-mediated gain of contractility of the remaining, viable myocardium since contractile parameters and Ca(2+) transients of isolated MI/AdS100A1 myocytes were significantly enhanced compared to myocytes isolated from both MI/AdGFP and sham groups. Moreover, S100A1 gene therapy preserved the cardiac beta-adrenergic inotropic reserve, which was associated with the attenuation of GRK2 up-regulation. Also, S100A1 overexpression reduced cardiac hypertrophy 1 week post-MI. Overall, our data indicate that S100A1 gene therapy provides a potential novel treatment strategy to maintain contractile performance of the post-MI heart.

Pneumonia recorrente com uma causa rara: carcinoma mucoepidermóide

A pneumonia recorrente caracteriza-se por episódios repetitivos de infecção e radiologicamente por infiltrados recorrentes em um único ou em múltiplos lobos pulmonares. São causas da doença localizada: obstrução intraluminal das vias aéreas, compressão extrínseca e alterações estruturais. O padrão, a freqüência e a gravidade das infecções, associados a uma revisão completa de todos os radiogramas de tórax, guiam a avaliação diagnóstica. Relata-se um caso de pneumonia recorrente devida à obstrução endobrônquica por carcinoma mucoepidermóide.

Endoscopic ultrasound for preoperative staging of esophageal carcinoma

BACKGROUND

Endoscopic ultrasound (EUS) is potentially the best method for pretreatment staging of esophageal carcinoma once distant metastases have been excluded by other methods. However, its apparent accuracy might be influenced by the use of neoadjuvant therapy. To determine the accuracy of EUS in patients undergoing esophageal resection, the authors reviewed their experience with EUS.

METHODS

A total of 73 patients with esophageal carcinoma who underwent an esophagectomy between April 2000 and February 2005 were examined using preoperative EUS and computed tomography (CT). Of these patients, 39 also underwent preoperative neoadjuvant chemoradiotherapy. Both EUS and CT scan were used to determine the depth of tumor penetration (T-stage) and the presence of lymph node metastases (N-stage). These results then were compared with staging determined after pathologic examination of the resected surgical specimen.

RESULTS

For patients not undergoing neoadjuvant therapy, T-stage was accurately determined by EUS in 79%, N-stage in 74%, and tumor node metastasis (TNM) classification in 65% of the cases. However, when patients who had undergone neoadjuvant chemoradiotherapy were included, the overall accuracy of EUS was 64% for T-stage, 63% for N-stage, and 53% for TNM classification. For the patients who underwent neoadjuvant therapy, EUS indicated a more advanced T-stage in 49%, N-stage in 38%, and TNM classification in 51% of the cases, as compared with pathology. The overall accuracy of EUS for T- and N-stage carcinomas was superior to that of CT scanning.

CONCLUSION

For patients who do not undergo preoperative neoadjuvant chemotherapy and radiotherapy, EUS is a more accurate method for determining T- and N-stage resected esophageal carcinomas. Neoadjuvant therapy, however, results in apparent overstaging, predominantly because of tumor downstaging, and this reduces the apparent accuracy of EUS (and CT scanning) in this patient group. Nevertheless, EUS staging before neoadjuvant therapy could be more accurate than pathologic staging after treatment, thereby providing better initial staging information, which can be used to facilitate treatment.

Tumors of the mediastinum

Tumors of the mediastinum represent a wide diversity of disease states. The location and composition of a mass is critical to narrowing the differential diagnosis. The most common causes of an anterior mediastinal mass include the following: thymoma; teratoma; thyroid disease; and lymphoma. Masses of the middle mediastinum are typically congenital cysts, including foregut and pericardial cysts, while those that arise in the posterior mediastinum are often neurogenic tumors. The clinical sequelae of mediastinal masses can range from being asymptomatic to producing symptoms of cough, chest pain, and dyspnea. This article will review the anatomy of the mediastinum as well as the different clinical, radiographic, and prognostic features, and therapeutic options of the most commonly encountered masses.

Stapled haemorrhoidectomy: bothersome staple line bleeding

BACKGROUND

The stapled haemorrhoidectomy procedure has been popularized as a painless and effective treatment for prolapsing haemorrhoidal disease. We have noted that staple line bleeding is a contributory factor to postoperative morbidity.

METHODS

This was a retrospective analysis of the clinical records of consecutive stapled haemorrhoidectomy procedures performed in patients over a 1-year period. The outpatient, operative and inpatient records were reviewed. We assessed the incidence of intraoperative staple line bleeding, its management and early postoperative outcomes in our patients undergoing stapled haemorrhoidectomy.

RESULTS

From March 2000 to March 2001, 39 stapled haemorrhoidectomy procedures were performed. Intraoperative staple line bleeding was recorded in 17 patients (44%) and suture reinforcement of this staple line was required in 12 (31%). Nine patients (23%) were admitted for postoperative per rectal bleeding, four of whom required surgical haemostasis of bleeding points along the staple line. Delayed secondary haemorrhage was seen in one patient. The incidence of postoperative bleeding in patients with noted staple line bleeding was 35%, compared with 14% in those without evidence of bleeding.

CONCLUSION

Staple line bleeding is a technical difficulty and complication associated with stapled haemorrhoidectomy. It should be managed with meticulous haemostatic suture placement in order to avoid postoperative bleeding and the morbidity of re-operation for haemostasis.

Bronchogenic cyst of the gastric fundus presenting as a gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GIST) of the stomach are being recognized with increasing frequency. The diagnosis is usually made on the basis of appearance on computed tomography (CT) and excision is recommended for GIST larger than 5 cm. We report a 39-year-old woman referred for resection of a presumed GIST of the gastric fundus diagnosed by CT scan and upper gastrointestinal (UGI) series. A laparoscopic resection was performed, but upon pathologic examination the mass proved to be a bronchogenic duplication cyst of the stomach. Bronchogenic and esophageal duplication cysts usually arise in the chest or mediastinum. On rare occasions bronchogenic cysts may lose their connection to the tracheobronchial tree and migrate to a subcutaneous position in the neck or descend into the retroperitoneum. The importance of this case is that it demonstrates a rare yet essential component to the differential diagnosis of lesions of the stomach.