Small bowel stricture as a late sequela of superior mesenteric vein thrombosis

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64-year-old man admitted with abdominal pain and rectal bleeding found to have thrombosis of portal and superior mesenteric veins on abdominal CT.

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Managed conservatively but returned seven months later with obstruction requiring segmental small bowel resection.

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Case demonstrates that mesenteric vein thrombosis can be reversed by effective anticoagulation.

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Patients escaping early bowel resection due to bowel infarction may still require resection later due to stricture.

Introduction

The increasing frequency of use of CT in patients with acute abdomen is likely to improve the diagnosis of rarely occurring conditions/causes such as superior mesenteric vein thrombosis (MVT). Despite its severe consequences, MVT often presents with nonspecific clinical features.

Presentation of case

AD, a 64-year-old man was an emergency admission with vague abdominal discomfort of two weeks duration, acute upper abdominal pain, loose stools, fresh rectal bleeding and vomiting. A contrast enhanced abdominal CT showed thrombosis of the proximal portal vein and the entire length of the superior mesenteric vein (SMV) with small bowel ischaemia extending from the terminal ileum to the mid jejunal loops. Tests for paroxysmal nocturnal haemoglobinuria and Janus kinase 2 mutation yielded negative results. AD was readmitted seven months later with small bowel obstruction requiring segmental small bowel resection with end-to-end anastomosis. Abdominal CT had shown complete resolution of MVT but a small bowel stricture.

Discussion

Thrombosis limited to mesenteric veins results in earlier and more frequent development of infarction compared to portal combined with mesenteric venous thrombosis. Most patients may be successfully treated with anti-coagulation therapy alone. However, surgery may be required to deal with intestinal infarction or late sequela of MVT.

Conclusion

This case demonstrates that MVT can be reversed by effective anticoagulation. However, the price paid for a mild to moderate effect on the bowel may be significant stricture later on. Patients escaping early bowel resection due to massive MVT leading to bowel infarction may still require resection later due to stricture.

Neoadjuvant chemotherapy and primary-first approach for rectal cancer with synchronous liver metastases

AIM

Up to a quarter of patients with rectal cancer have synchronous liver metastases at the time of diagnosis. This is a predictor of poor outcome. There are no standardized guidelines for treatment. We reviewed the outcomes of our patients with synchronous rectal liver metastases treated with a curative intent by neoadjuvant chemotherapy with or without chemoradiotherapy followed by resection of the primary tumour and then liver metastases.

METHOD

Between 2004 and 2012, patients who presented with rectal cancer and synchronous liver metastasis were treated with curative intent with peri-operative systemic chemotherapy as the first line of treatment. Responders to chemotherapy underwent resection of the primary tumour with or without preoperative chemoradiotherapy followed by hepatic resection.

RESULTS

Fifty-three rectal cancer patients with 152 synchronous liver lesions were identified. After a median follow-up of 29.6 months, the median survival was 41.4 months. Overall survival was 59.0% at 3 years and 39.0% at 5 years.

CONCLUSION

Rectal resection before hepatic resection combined with neoadjuvant chemotherapy is associated with promising clinical outcome. It allows downstaging of liver lesions and removal of the primary tumour before the progression of further micrometastases. Furthermore, patients who do not respond to chemotherapy can be identified and may avoid major surgical intervention.

How can we treat a patient with liver cirrhosis (hepatitis C virus), hepatocellular carcinoma, and synchronous colon cancer?

INTRODUCTION

The coexistence of liver cirrhosis with hepatocellular carcinoma (HCC) and colon cancer (Ca), which is a rare clinical condition, was treated in a liver transplant recipient.

PATIENTS AND METHODS

A 46-year-old man, diagnosed incidentally during an ultrasound (US) examination with a 3.5-cm HCC in segment VII related to chronic hepatitis C virus (HCV), was referred for liver resection. He underwent a laparoscopic protocol evaluation for liver cirrhosis. Liver appearance and biopsy of the left lobe showed Child B/C liver cirrhosis. Because he fulfilled the Milan criteria, we suggested an orthotopic liver transplantation (OLT). During protocol colonoscopy, we discovered an ulcerative sigmoid colon Ca. Three weeks after completing the pre-OLT assessment he underwent an OLT and was discharged home on day 9 on an immunosuppressive regimen of Everolimus, Myfortic, and Prezolone. Two months after transplantation, the patient underwent a sigmoidectomy and for nearly 1 month thereafter received chemotherapy for colon Ca (6 cycles of FOLFOX:Folinic Acid+Fluorouracil+Oxaliplatin). One and a half years after OLT, patient was in good condition but presented with an increased alpha fetoprotein (a-FP) without other findings. A couple of months later we discovered a colon Ca recurrence and 3 small liver metastases. Patient underwent a bowel resection with Hartmann's procedure. Almost immediately after the last operation, he was found to suffer multiple myeloma. He underwent chemotherapy for both malignancies with good responses, but a few months later died of severe sepsis.

DISCUSSION

The relevant literature regarding treatment of liver cirrhosis complicated with HCC and synchronous colon Ca reveals poor and controversial outcomes. Our patient underwent chemotherapy immediately after colon resection in the presence of with a good functioning liver. Although his condition was satisfactory after OLT, the optimal treatment of such complicated patients is as yet uncertain.

Synchronous primary epithelial tumors of the pancreas

INTRODUCTION

Pancreatic incidentalomas are diagnosed at increased rates due to advanced pancreatic imaging. Coexistence of such lesions with another pancreatic pathology, however, is uncommon and their management might be perplexed by the anatomical location and the histological features of the lesion.

PRESENTATION OF CASE

A patient with obstructive jaundice was diagnosed with adenocarcinoma of the pancreatic head and underwent routine pancreatic imaging (CT) which revealed the coexistence of a small cystic lesion at the pancreatic body. Further investigation with MRCP and ERCP was unable to confirm a benign lesion and total pancreatoduodenectomy was performed. Histological examination showed a rare type of mixed serous-mucinous cystadenoma of borderline malignancy at the pancreatic body coexistent with an adenocarcinoma of the pancreatic head.

DISCUSSION

Coexistence of a peripheral pancreatic cystic tumor with a ductal adenocarcinoma of the pancreatic head is a very rare incidence in medical literature. The management of the peripheral lesion is not straightforward and there can be uncertainty as to the extent of the pancreatic resection that may be required.

CONCLUSION

Appropriate preoperative imaging has a significant impact on the definitive management of synchronous pancreatic tumors. Implications of a common pathogenetic pathway are also raised for this rare occurrence of two primary epithelial pancreatic tumors.

Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis

BACKGROUND

Single-incision laparoscopic surgery (SILS) has gained increasing attention due to the potential to maximize the benefits of laparoscopic surgery. The aim of this systematic review and pooled analysis was to compare clinical outcome following SILS and standard multiport laparoscopic cholecystectomy for the treatment of gallstone-related disease.

METHODS

An electronic search of Embase and Medline databases for articles from 1966 to 2011 was performed. Publications were included if they were randomised controlled studies in which patients underwent either single-incision or multiport cholecystectomy. The primary outcome measures for the meta-analysis were postoperative complications and postoperative pain score [visual analogue scale (VAS) on the day of surgery]. Secondary outcome measures were operating time and length of hospital stay. Weighted mean difference was calculated for the effect size of SILS on continuous variables, and pooled odds ratios were calculated for discrete variables.

RESULTS

In total, 375 cholecystectomy operations from 7 randomised controlled trials were included, 195 by single-incision (SILS) and 180 by conventional multiport. Operating time was significantly longer in the SILS group compared to the standard multiport laparoscopic cholecystectomy group (weighted mean difference = 2.13; P = 0.0001). There was no significant difference in the incidence of postoperative complications, postoperative pain score (VAS), or the length of hospital stay between the two groups.

CONCLUSION

The results of this meta-analysis demonstrate that single-incision laparoscopic cholecystectomy is a safe procedure for the treatment of uncomplicated gallstone disease, with postoperative outcome similar to that of standard multiport laparoscopic cholecystectomy. Future high-powered randomized studies should be focused on elucidating subtle differences in postoperative complications, reported postoperative pain, and cosmesis following SILS cholecystectomy in more severe biliary disease.

Medullary thyroid carcinoma: The third most common thyroid cancer reviewed

Medullary thyroid cancer is a type of thyroid cancer of neuroendocrine origin. It occurs in hereditary and sporadic forms, and its aggressive behavior is associated with the clinical presentation and type of RET mutation. Total thyroidectomy remains the ideal choice of treatment. Early diagnosis and treatment are the fundamental for a 100% cure rate. In this study, we present our experience of 3 cases, along with a complete review of the literature derived from a Pubmed Database search.

Giant liposarcoma of the back with 4 types of histopathology: a case report

The incidence of soft tissue tumours, both malignant and benign, is very common. However, the coexistence of 4 types of histopathology is rare and the aim of this article is to present one treated in our Department. An 87-year-old Greek man was treated in our Department for a huge tumour on his back, under local anaesthesia. The pathology report of the specimen referred 4 types of neoplasia. This case represents this incidence in a giant liposarcoma of the back.

Safety and diagnostic yield of laparoscopically assisted full-thickness bowel biospy

Advances in minimally invasive surgery have made laparoscopy and full-thickness bowel biopsy possible in the investigation of patients with suspected gastrointestinal neuromuscular disorders. The safety and diagnostic yield of this investigation have not been formally reported. A prospective study was undertaken of 124 patients with clinico-physiological diagnoses of chronic intestinal pseudo-obstruction, enteric dysmotility and severe irritable bowel syndrome undergoing LFTB in three European teaching centres with expertise in the management of gastrointestinal neuromuscular disorders. Perioperative data were collected including complications. Diagnostic yield was expressed as proportion with well-established specific neuromuscular abnormalities based on a protocol of routine and immunohistochemical techniques. The majority of patients underwent a laparoscopically assisted procedure with extracorporeal biopsy. Median operating time was 50 min, conversion rate 2% and length of stay 1 day. There was an 8% readmission rate for obstructive symptoms but minimal other morbidity and no mortality. Overall specific diagnostic yield was 81%, being high for jejunal biopsies (89%) but low for a small number of ileal and colonic biopsies. Laparoscopy and full-thickness biopsy of the bowel appears acceptable in terms of safety. It should be performed in a jejunal site to achieve a high diagnostic yield.

Surgical trauma, minimal residual disease and locoregional cancer recurrence

The persistence of residual tumour is associated with the histology and stage of the primary cancer, the completeness and quality of surgery, and postoperative events such as anastomotic leakage or entrapment of cells in exudating wound surfaces. At present, there is no clinical evidence that the use of laparoscopic techniques adversely influences the risk of residual disease. The inflammatory process associated with surgery shares a number of central mediators and pathways with tumour growth and invasiveness. Both cellular components (mainly macrophages and fibroblasts) and humoral factors associated with inflammation have been shown to enhance tumour growth in numerous preclinical studies. Tumour foci at a distance from the main cancer are kept in a dormant state by a range of anti-angiogenic mediators produced by the main cancer. Preclinical studies have shown that removal of the primary cancer reactivates proliferative and metastatic pathways in the residual tumour. Clinically, this phenomenon has been proposed as underlying the observed rapid systemic relapse after surgery in young node positive breast cancer patients. Strategies proposed to prevent residual disease encompass avoidance of tumour spill and minimization of surgical trauma and related inflammation. Efforts to remove or kill free intraperitoneal cells by local antiseptic or cytotoxic regimens have met only limited clinical success. Specific targeted therapy aimed at inhibiting the inflammatory response, tumour cell adhesion, or the metastatic phenotype of dormant cells appears promising in preclinical models and needs to be addressed in future clinical trials.

Oncologic implications of laparoscopic and open surgery

Although instrumental manipulation and mechanical tumor cell spillage seem to play the major role in port-site metastases from laparoscopic cancer surgery, minimally invasive procedures are used more and more in the resection of malignancies. However, port-site metastases also have been reported after resection of colon cancer in International Union Against Cancer (UICC) stage I [2, 14]. Therefore, changes in the peritoneal environment during laparoscopy also might influence intra- and extraperitoneal tumor growth during laparoscopy and pneumoperitoneum. Different results of experimental studies presented at the Third International Conference for Laparoscopic Surgery are analyzed and discussed.

Beta-adrenoceptor agonist stimulation of acid secretion by rat stomach in vitro is mediated by 'atypical' beta-adrenoceptors

1. A previous study showed beta-adrenoceptor agonists stimulated acid secretion by rat stomach in vitro. The receptors could not be classed as either the beta 1- or beta 2-subtype. This study examines the effect of 2 'atypical' beta-agonists on acid secretion. 2. Basal and isoprenaline-stimulated acid secretion were compared in tissues bathed either in HEPES/O2- or HCO3-/CO2-buffer. Basal secretion was underestimated in HCO3- by an amount equal to the rate of base section. Tissues responded well in HEPES buffer and there was no base secretion following acid inhibition with SCH 28080. HEPES was used for the study. 3. SR 58611A stimulated acid in a concentration-related way (0.1-5 microM). Maximum response at 1 microM was equal to the response to a maximal concentration of isoprenaline. BRL 37344 (1 microM) also stimulated to the same extent. 4. Responses to isoprenaline (5 microM) and SR 58611A (1 microM) were reduced by propranolol (10 microM) but not by alprenolol (10 microM) or by practolol (12.5 microM) plus ICI 118551 (1 microM). 5. Exposure to SR 58611A (1 microM) led to desensitization to isoprenaline but not to bethanechol (1 microM) or histamine (50 microM). 6. We conclude that a HEPES/O2-buffer is advantageous when measuring gastric acid secretion in vitro and the stimulatory effect of beta-adrenoceptor agonists is mediated by 'atypical' receptors.