Interactions of occult tumor spread and surgical technique on overall and disease-free survival in patients operated for stage I and II right-sided colon cancer

Purpose

To determine if “medial to lateral” (ML) dissection with devascularization first is superior to “lateral to medial” (LM) dissection regarding numbers of lymph node micro metastases (MM) and isolated tumor cells (ITC) as well as 5-year disease-free (5YDFS) and 5-year overall survival (5YOS) in stage I/II right-sided colon cancer.

Methods

Two datasets are used. ML group consists of consecutive stage I/II patients from a prospective trial. LM group is the original dataset from a previous publication. All harvested lymph nodes are examined with monoclonal antibody CAM 5.2 (immunohistochemically). Lymph node harvest and 5YOS/5YDFS were compared between ML/LM groups, stage I/II tumors and MM/ITC presence/absence.

Results

117 patients included ML:51, LM:66. MM/ITC positive in ML 37.3% (19/51), LM 31.8% (21/66) p = 0.54. The 5YDFS for patients in ML 70.6% and LM 69.7%, p = 0.99, 5YOS: 74.5% ML and 71.2% LM (p = 0.73). No difference in 5YDFS/5YOS between groups for Stage I/II tumors; however, LM group had an excess of early tumors (16) when compared to ML group, while lymph node harvest was significantly higher in ML group (p < 0.01) 15.1 vs 26.7. 5YDFS and 5YOS stratified by MM/ITC presence/absence was 67.5%/71.4%, p = 0.63, and 75.0%/71.4%, p = 0.72, respectively. Death due to recurrence in MM/ITC positive was significantly higher than MM/ITC negative (p = 0.012).

Conclusion

Surgical technique does not influence numbers of MM/ITC or 5YDFS/5YOS. Presence of MM/ITC does not affect 5YOS/5YDFS but can be a potential prognostic factor for death due to recurrence.

Clinical trial

Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-Detector Computed Tomography (MDCT) Angiography” registered at http://clinicaltrials.gov/ct2/show/NCT01351714 .

Comparison of Outcome of Borderline and Normal Amniotic Fluid Index in Term Pregnancy

Background Determination of Amniotic Fluid Index (AFI) is an important component of antepartum assessment of all normal pregnancies. Objective To compare the obstetric interventions and neonatal outcomes in term pregnancies with borderline Amniotic Fluid Index versus normal Amniotic Fluid Index. Method This hospital based prospective study was conducted at Tribhuwan University Teaching Hospital over 1 year between 2017 and 2018 in 128 women having uncomplicated term pregnancy admitted in labor ward. Of the 128 women, 64 women had borderline Amniotic Fluid Index (5.1-8 cm) and 64 normal AFI (8.1 - 24 cm). Parameters studied were induction of labor, cesarean section, instrumental delivery, intrapartum abnormal fetal heart rate, meconium staining of liquor, APGAR score at 5 and 7 minutes, birth weight, neonatal intensive care unit (NICU) admission and neonatal death. Data was analyzed using software OpenEpi. Result Statistically significant difference in result was obtained in the two groups in terms of rate of induction of labor (73.4% vs 35.9%, p = 0.0001, OR = 4.9), rate of cesarean section (42.1% vs 28 .1%, p = 0.04, OR = 1.8), tachypnea (50% vs 11.1%, p = 0.01) and low birth weight (9.1% vs 4.5%, p = 0.04). No statistical significance was found in meconium staining of liquor (33% vs 38.3%, p = 0.3) and APGAR score of <7 at 5 minutes (3.1% vs 1.5%, p = 0.06). There were no neonatal intensive care unit admissions and neonatal mortality in any of the babies. Conclusion Detection of amniotic fluid volume at term is important for timely maternal interventions to improve the overall fetal outcome.

Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer

Background

The treatment of flat rectal adenomas is challenging. The technical difficulty and the potential of malignancy in suspected benign lesions are the factors in question. Surgical and interventional endoscopic techniques are implemented in Europe without a clear strategy. To minimize recurrent adenoma and unclear histopathological work up en bloc excision is desirable.

Methods and results

We demonstrate in this article the transanal endoscopic microsurgical submucosa dissection (TEM-ESD) procedure as a feasible method for en bloc excision of rectal adenomas and early rectal cancer. The surgical technique is demonstrated in detail with the help of a video of the operation that is available online. The results of a consecutive series of 78 patients are presented.

Conclusion

TEM-ESD is a safe procedure for resection of rectal adenomas and low risk carcinomas. It offers the possibility of organ preservation and minimizes functional disturbances. In case of a necessary salvage operation, the preserved integrity of the rectal muscle tube grants maximal oncological safety.

Electronic supplementary material

The online version of this article (10.1007/s00053-018-0291-3) includes a video on the surgical technique: TEM ESD. The article and supplemental material are available at http://www.springermedizin.de/der-chirurg. The supplemental material can be found at the end of the article under “Supplementary material”.

Oncological outcome after MRI-based selection for neoadjuvant chemoradiotherapy in the OCUM Rectal Cancer Trial

BACKGROUND

It is not clear whether all patients with rectal cancer need chemoradiotherapy. A restrictive use of neoadjuvant chemoradiotherapy (nCRT) based on MRI findings for rectal cancer was investigated in this study.

METHODS

This prospective multicentre observational study included patients with stage cT2-4 rectal cancer, with any cN and cM0 status. Carcinomas in the middle and lower third that were 1 mm or less from the mesorectal fascia, all cT4 tumours, and all cT3 tumours of the lower third were classified as high risk, and these patients received nCRT followed by total mesorectal excision (TME). All other carcinomas with a minimum distance of more than 1 mm from the mesorectal fascia and those in the upper third were classified as low risk; these patients underwent TME alone (no nCRT). Patients were followed for at least 3 years. Outcomes were the rates of local recurrence, distant metastasis and survival.

RESULTS

Among 545 patients included, 428 were treated according to the study protocol: 254 (59·3 per cent) had TME alone and 174 (40·7 per cent) received nCRT and TME. Median follow-up was 60 months. The 3- and 5-year local recurrence rates were 1·3 and 2·7 per cent respectively, with no differences between the two treatment protocols. Patients with disease requiring nCRT had higher 3- and 5-year rates of distant metastasis (17·3 and 24·9 per cent respectively versus 8·9 and 14·4 per cent in patients who had TME alone; P = 0·005) and worse disease-free survival compared with that in patients who did not need nCRT (3- and 5-year rates 76·7 and 66·7 per cent, versus 84·9 and 76·0 per cent in the TME-alone group; P = 0·016).

CONCLUSION

Restriction of nCRT to high-risk patients achieved good results.

Air Transfer of Obstetric Emergencies to a Tertiary Care Center in Nepal

Aims: This study was performed to review the places, indications, maternal-perinatal outcomes requiring emergency air transfer to a tertiary level referral center.Methods: A hospital based descriptive study of one year duration, conducted in Tribhuvan University Teaching Hospital (TUTH), over a period of twelve months. All the women who were air transferred for pregnancy complications were enrolled.Results: There were total 19 airlifted obstetric emergencies to TUTH over one year period:  majority (68%) from hilly areas and others (32%) from mountain region. Out of them, referred cases were 11 [district hospital (5), healthpost (4); Primary Health Center (PHC) (2)]; and rest were from home (8). Two cases were abortion related; septic abortion (1) and incomplete abortion (1). There were three antepartum cases: pregnancy with meningoencephalitis (1), eclampsia (1) and bleeding placenta previa (1); maximum, eleven intrapartum cases, obstructed labor (6),labor dystocia (3), breech in labor (1) and undelivered second twin (1). Rest three were postpartum cases, one each of eclampsia, puerperal sepsis and retained placenta. Maternal morbidities were one each case of uterine rupture, acute kidney injury, retained placenta with PPH and vesicovaginal fistula that developed in the case of shoulder dystocia. Maternal mortality occurred in 2 cases, first women with antepartum eclampsia who had intracerebral bleed and second was a case of pregnancy with meningoencephalitis who later developed brain death. Regarding perinatal outcome 12/14 (86%) had live birth and 2/14 (14%) had IUFD upon arrival.Conclusion: Air lift on personal expenditure, despite economic constraints has proven beneficial in our country’s context with difficult geographical terrain and inadequate health services, whereas anticipation of any critical condition right in the beginning and timely transfer however could have been more advantageous.

Changing trends in caesarean deliveries at a tertiary care Centra: a ten year appraisal

Introduction: Over the last few decades, the rise in the rates of Caesarean Sections (CS) has become a global phenomenon. The objective of this study was to follow the CS rates over the last 10 years and to compute the various indications of CS in an attempt to analyze the possible reasons for this changing trend in the institute.Methods: All deliveries that took place between April 13, 2004 to April 14, 2014 (Baisakh 2061 BS and Chaitra 2070 BS) in TUTH were retrospectively collected. Annual total number of deliveries, rates of CS, instrumental deliveries and Vaginal Birth after Caesarian Section (VBAC) along with indications for CS were computed and analyzed.Result: A total of 38,770 deliveries were conducted over ten years with 26,791 (69.10%) vaginal deliveries and 11,979 (24.80%) CS. There was a steep rise in the rates of CS from 21.04% in 2004 to 39.23% in 2014. Rates of instrumental deliveries and VBAC remained low at 0.86% to 3.35% and 0.15% to 0.7 % respectively. Fetal distress was the commonest indication of emergency CS while previous CS was the commonest indication for elective CS.Conclusion: Over the last decade, the global trend of rising CS rates was also found to be mirrored at TUTH. The causes for rise in CS  rates were- increased diagnosis of fetal distress and oligohydramnios, delivery of most breech by Caesarean sections, low rates of VBAC and instrumental deliveries, complicated referrals from all over the country and last but not the least,  threat of malpractice litigations.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 7-11

[Spincter preservation after selective chemoradiotherapy of rectal cancer. Interim results of the OCUM study]

BACKGROUND

In a prospective multicenter observational study (OCUM) neoadjuvant chemoradiotherapy (nRCT) was selectively administered depending on the risk of local recurrence and based on the distance between tumor and mesorectal fascia in pretherapeutic high-resolution magnetic resonance imaging (MRI).

OBJECTIVE

Frequency and quality of abdominoperineal excision (APE) and sphincter preserving operations.

PATIENTS AND METHODS

Of 642 patients treated in 13 hospitals 389 received surgery alone and 253 nRCT followed by surgery. By univariate and multivariate analysis risk factors for APE were determined. Quality parameters were the quality grade of mesorectal excision, the pathohistological involvement of the circumferential resection margin and intraoperative local dissemination of tumor cells.

RESULTS AND DISCUSSION

In 12.8 % of the patients APE was performed. Independent risk factors for APE were tumor location in the lower third of the rectum and the individual hospitals, where APE varied between 0 and 32 %. This variation was chiefly caused by the different case mix. Hospitals with a high APE rate (> 30 %) treated significantly more patients with very low lying carcinomas (< 3 cm above the anal verge) and more advanced tumors. The median height of the tumor in cases of APE was nearly equal in all participating hospitals. Independent on the number of cases the quality of rectal surgery was high. Within the patient groups of primary surgery and nRCT the oncological quality parameter did not significantly differ between sphincter preservation and APE. As far as sphincter preservation is concerned the results justify a selective application of nRCT in patients with rectal carcinoma. The long-term results still have to be awaited.

Study of Contraceptive Use Among Comprehensive Abortion Care Clients in Family Planning Clinic of Tribhuban University Teaching Hospital

Aims: This study was done to assess the use of family planning method among comprehensive abortion care clients in Tribhuvan University Teaching Hospital (TUTH).   Methods: A hospital based observational study was conducted in family planning clinic at TUTH from 14th April 2009 to 14th June 2010 among one hundred clients who opted for comprehensive abortion care (CAC) at the hospital CAC centre and met the inclusion criteria of this study.   Results: Around 98% women had knowledge of different types of modern contraceptive methods. Majority of CAC clients (91%) had ever used contraceptive methods in the past. Injectables were the most common method of contraceptive used by the CAC clients (55%). Almost 22% clients had come for repeat induced abortion. About 43% clients opted CAC service for complete family and 33% for contraceptive failure. Withdrawal method failure was seen in 17% of clients. Almost 86% women intend to use contraceptive after CAC service in future.   Conclusions: This study concluded that despite knowledge of modern contraceptive methods and ever uses of different family planning methods, majority of clients had no consistency in use of various contraceptives. Effective family planning counseling along with information of emergency contraceptive is required for each CAC clients to prevent unwanted pregnancy and abortion.DOI: http://dx.doi.org/10.3126/njog.v9i2.11740

Obstetric Hysterectomy and Maternal Survival

Aims: This study was done to analyze the cases of obstetric hysterectomy and maternal complications and survival after that. Methods: A retrospective study was carried out from the review of records   of the near miss, maternal mortality, cesarean audit and operation theater record of the Department of Obstetrics and Gynaecology, Tribhuvan University Teaching Hospital (TUTH), Kathmandu from 2057-2071 BS. Results: Fourteen maternal survival resulted following total of 19 obstetric hysterectomy, subtotal hysterectomy being the procedure of choice in 11 cases, emergency peripartum hysterectomy (EPH) being performed in abundance (18/19) in comparison to an elective peripartum hysterectomy, which was undertaken in a single case of placenta percreta, and inclusive of latter were four cases of morbid placental adhesion, a placenta increta and two placenta accreta. Eight out of 19 cases had vaginal delivery and rest had cesarean section. Among seven cases of cesarean hysterectomy 3 were done for placenta previa with accreta one case each done for abruptio placentae  and placenta accreta and two cases were done for extra placental causes. Among four cases of emergency peripartum hysterectomy (EPH), which were relaparotomy followed by hysterectomy, three cases were done for complication of cesarean section and one done for uterine atonicity. Four cases of spontaneous vaginal deliveries needed peripartum hysterectomy two of them were complicated by morbid placental adhesion placenta increta (1), placental percreta (1), two cases were vaginal birth after cesarean (VBAC). Seven cases of uterine rupture had undergone peripartum hysterectomy.   Conclusions: Obstetric hysterectomy is a lifesaving surgical procedure for maternal survival whenever necessary and mandates a quick decision making process, however in consideration of younger age and low parity or nulliparity, the best obstetric governance and services must foresee not to let mothers meet such situation necessitating organ removal and to enjoy potential reproductive life cycle.DOI: http://dx.doi.org/10.3126/njog.v9i2.11759    

Use of Misoprostol in the Management of Early Pregnancy Loss

Aims: To evaluate the effectiveness of Misoprostol administered vaginally to assist complete evacuation in early pregnancy losses (incomplete abortion, missed abortion and blighted ovum). Methods: It is a descriptive study conducted in the Department of Ob/Gyn and Emergency Department Tribhuvan University Teaching hospital. All women with clinical/USG diagnosis of incomplete abortion, missed abortion and blighted ovum ≤12 weeks POG either from last menstrual period (LMP) or USG were inserted tab. misoprostol 800 mcg in the posterior fornix. Same dose was repeated when the evacuation was incomplete on day 3 of follow-up. Manual vacuum aspiration (MVA) was offered on day 14 if evacuation was incomplete or any complications like excessive bleeding/severe pain occurred during this period. Results: A hundred and thirty three women with incomplete/missed/blighted ovum were reported, of which 112 (84.3%) were analyzed as 21(15.7%) lost to follow up. Among the 112, 51 (45.5%) were incomplete abortion, 34(30.3%) blighted and 27 (24.1%) missed abortion. Complete evacuation was achieved in 98/112 (87.5%) cases [73 (65%) cases with single dose & 25(22.3%) with double doses]. Evacuation was failed in 14(12.5%) cases [incomplete abortion 6 (42%), blighted 7 (50%) & missed abortion 1 (7.1%)]. Failure for complete evacuation (n=14) related to gestational age: 10-12 weeks 9/14(64%), 7-9 weeks 5 (35%) and none in the ≤6 weeks. Although the plan was to evacuate on day 14 of follow-up for incomplete evacuation which was applicable only in 11(78.5%) cases, 3(21.5%) cases were surgically (MVA) treated beforehand (2 for excessive bleeding, 1 for severe pain). No severe complications and side effects requiring treatment were observed. Conclusions: Vaginal Misoprostol is proved to be effective and safe in cases of incomplete abortion, missed abortion and blighted ovum. In the cases that failed to achieve complete evacuation by medical means using misoprostol were subjected to surgical manual vacuum aspiration (MVA) on day 14 of follow-up. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11133   Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 9-13

Photoinduced dermal pigmentation in patients taking tricyclic antidepressants: histology, electron microscopy, and energy dispersive spectroscopy

Two patients had been taking long-term tricyclic antidepressant therapy. Each developed a blue to slate-gray hyperpigmentation in sun-exposed areas. On histologic examination there were refractile golden brown granules free in the dermis along collagen bundles. Similar pigment was present in macrophages and along the basement membrane zone. The granules stained for melanin, but not for iron, and were bleached by the permanganate method. Electron microscopy showed varying size and shaped electron-dense granules within lysosomes and free in the dermis, which, in unstained sections, showed a less dense peripheral halo. This peripheral halo was also evident on light microscopy. Energy dispersive spectroscopy showed these granules to be rich in copper and sulfur (elements present in tyrosinase and pheomelanin, respectively). We believe that this represents a drug-melanosome complex, which is most likely caused by chronic photoactivation.

[Treatment with stents in the upper gastrointestinal tract]

A wide range of therapeutic methods for treatment of malignant and benign stenoses of the upper gastrointestinal tract is at one's disposal with esophageal mechanical dilatation, laser therapy, insertion of plastic tubes and stent implantation. It has become routine to insert flexible metal stents in the treatment of esophageal carcinoma and tracheoesophageal fistula. Case reports exist describing the use of flexible metal stents in complicated benign esophageal stenoses of stomach and duodenum. Until January 1997 we implanted 18 stents (7 Z-stents[Wilson and Cook], 4 covered and 4 uncovered Ultraflex stents [Boston Scientific], 3 Endocoil stents [Instent]) in 15 patients. We treated patients with esophageal carcinoma, recurrent stenoses after gastrectomy and tracheoesophageal fistula. They were followed by questionnaires. Four days after stent implantation 50% of the patients were able to consume normal solid food, the other half semisolids. The main problem was the stent migration (28%). The decisive factors for stent migration were the quality of surface of the stent and its position in the gastroesophageal junction. The stents which were dislocated in the stomach could easily be extracted endoscopically. The endoscopic extraction of a dislocated Z-stent in the small bowel was impossible. The high rate of stent dislocation (20-30%) in distal stent position (gastroesophageal junction) is not to be tolerated with respect to the purchase price.

[Endoscopic palliation of malignant esophageal stenoses]

The choice of the appropriate endoscopic procedure for treating a malignant esophageal obstruction depends on the tumor localisation, the tumor configuration, on specific patient data and last but not least on the technical possibilities of the hospital involved. Successfully performed is the mechanical dilatation, the tube insertion and stent implantation, the laser therapy, the argon plasma coagulation and the local sclerotherapy. The procedures differ in rate of complication, long term palliation and the improvement of dysphagia. In a case discussion we demonstrate that in the wide range of disease and patient specific facts that have to be dealt with, only the combined use of different endoscopic procedures will lead to the best results.

Lymphomatoid papulosis with antigen deletion and clonal rearrangement in a 4-year-old boy

Lymphomatoid papulosis (LyP) is rarely seen in children. We report a case of LyP in a 4-year-old boy in whom immunopathologic studies demonstrated T cell antigen deletions. In contrast to all but two previous reports, a T suppressor (CD-8) phenotype was predominant. Southern blot analysis of DNA isolated from a typical skin lesion indicated a clonal rearrangement of the T cell receptor beta gene. Because of a 10% frequency of malignant lymphomas in patients with LyP, long-term observation is crucial, especially in children. We recommend routine clonal rearrangement studies for aid in diagnosis and follow-up, and as possible prognostic indicators in children with this condition.

Vulvitis circumscripta plasmacellularis

In this paper we present what is apparently the tenth published case of vulvitis circumscripta plasmacellularis (Zoon). The patient had eroded, red-brown, asymptomatic vulvar lesions that were recalcitrant to treatment. The characteristic histopathology--dense plasma cell infiltrate and deposition of hemosiderin--was present.