Extensive Disease and Exposure to Multiple Biologics Precolectomy Is Associated with Endoscopic Cuffitis Post-Ileal Pouch-Anal Anastomosis in Patients With Ulcerative Colitis

INTRODUCTION

To better inform the risk of cuffitis in patients with ulcerative colitis (UC), we aimed to identify its occurrence and associated precolectomy factors in a large multicenter cohort of patients who underwent restorative proctocolectomy (RPC) with stapled ileal pouch-anal anastomosis (IPAA).

METHODS

This study was a retrospective cohort analysis of individuals diagnosed with UC or indeterminate colitis who underwent RPC with IPAA for refractory disease or dysplasia at Mount Sinai Hospital or the University of Chicago followed by at least 1 pouchoscopy with report of the pouch-anal anastomosis. The primary outcome was cuffitis defined as ulceration of the cuff as reported in each pouchoscopy report.

RESULTS

The pouch-anal anastomosis was mentioned in the pouchoscopy reports of 674 patients, of whom 525 (77.9%) had a stapled anastomosis. Among these, cuffitis occurred in 313 (59.6%) patients a median of 1.51 (interquartile range 0.59-4.17) years after final surgical stage. On multivariable analysis, older age (hazard ratio [HR], 1.01; 95% confidence interval [CI], 1.01-1.02), extensive disease (HR, 1.34; 95% CI, 1.01-1.78), exposure to biologics before colectomy (HR, 2.51; 95% CI, 1.93-3.27), and exposure to at least 2 or more biologics before colectomy (HR, 2.18; 95% CI, 1.40-3.39) were significantly associated with subsequent cuffitis.

CONCLUSIONS

In this multicenter study of patients who underwent RPC with stapled IPAA and at least 1 follow-up pouchoscopy, cuffitis occurred in approximately 60% and was significantly associated with extensive disease and exposure to multiple biologics precolectomy.

Evaluation of Postoperative Infection Rates in 3084 Rhinoplasty Cases Using Antibiotic Soaks and/or Irrigations

Background: Postoperative infections after rhinoplasties are rare, yet devastating on patient outcomes. The literature reports an overall incidence of <2% with higher numbers seen in those requiring revision procedures. Materials and Methods: A retrospective chart review of rhinoplasty patients from 2002 to 2019 of the primary author (D.M.T.) was performed. The objective of this study is to demonstrate the use of postoperative antibiotic soaks and irrigations in rhinoplasty, as well as evaluate the postoperative infection rates. Results: Of the 3084 rhinoplasty procedures evaluated, there were 19 postoperative infections (infection rate [IR] = 0.62%). Patients without antibiotic soaks or irrigations had 17 infections (IR = 1.01%). The IR of antibiotic soaks was 0.08% with a significant reduction compared with no soaks/irrigations (p = 0.0053). With antibiotic soaks and irrigations, there was 1 infection (IR = 0.49%) with no significant difference between no soaks/irrigations or soaks alone. Conclusions: The use of antibiotic soaks and irrigations resulted in an IR of 0.62%. Antibiotic soaks reduced the rate of postoperative infection, particularly in secondary rhinoplasty. Antibiotic soaks and irrigations are safe, effective, and well-tolerated by patients. As a result, these techniques may be considered in patients undergoing rhinoplasty, particularly those with an extensive revision history, trauma, filler, prior infection, or underlying disease processes.

Modeling the effect of ascites-induced compression on ovarian cancer multicellular aggregates

Epithelial ovarian cancer (EOC) is the most lethal gynecological malignancy. EOC dissemination is predominantly via direct extension of cells and multicellular aggregates (MCAs) into the peritoneal cavity, which adhere to and induce retraction of peritoneal mesothelium and proliferate in the submesothelial matrix to generate metastatic lesions. Metastasis is facilitated by the accumulation of malignant ascites (500 ml to >2 l), resulting in physical discomfort and abdominal distension, and leading to poor prognosis. Although intraperitoneal fluid pressure is normally subatmospheric, an average intraperitoneal pressure of 30 cmH2O (22.1 mmHg) has been reported in women with EOC. In this study, to enable experimental evaluation of the impact of high intraperitoneal pressure on EOC progression, two new in vitro model systems were developed. Initial experiments evaluated EOC MCAs in pressure vessels connected to an Instron to apply short-term compressive force. A Flexcell Compression Plus system was then used to enable longer-term compression of MCAs in custom-designed hydrogel carriers. Results show changes in the expression of genes related to epithelial-mesenchymal transition as well as altered dispersal of compressed MCAs on collagen gels. These new model systems have utility for future analyses of compression-induced mechanotransduction and the resulting impact on cellular responses related to intraperitoneal metastatic dissemination.This article has an associated First Person interview with the first authors of the paper.

Abstract A38: Modeling ascites-induced changes in peritoneal mechanobiology and ovarian cancer metastatic success

Ovarian cancer (OvCa) is frequently accompanied by accumulation of intraperitoneal ascites fluid early in disease progression. This fluid is rich in soluble and cellular components including tumor cells and multicellular aggregates (MCAs) of 150-300 um diameter shed from the primary tumor. In addition to chemical cues, ascites fluid buildup can also alter the force environment in the peritoneal cavity, thereby impacting the primary tumor, disseminating cells and MCAs, and host peritoneal tissues. Whereas the intraperitoneal pressure (IPP) of the normal peritoneal cavity is subatmospheric (-5 mmHg), the IPP measured in ovarian cancer patients with tense ascites is reported to be 24 mmHg. The potential effect of ascites-induced changes in peritoneal mechanobiology on tumor cells and host structures has not been investigated due to a lack of appropriate model systems. As a first approximation, we have begun preliminary investigations into the response of tumor and host structures to compressive and strain (stretching) forces. Our initial experiments used MCAs sealed in nonadherent cell culture bags placed into a temperature-controlled stainless-steel pressure vessel and subjected to a compressive force of 22-24 mmHg using an Instron system. While this approach is feasible for short-term experiments, longer-term compression experiments require a system with gas exchange to maintain cell viability. Thus, we fabricated a mold designed to fit within a Flexcell-400C Compression system Biopress+ Bioflex 6-well plate. This mold was used to produce porous hydrogels containing defined void areas so as to encapsulate MCAs within the hydrogel carrier and thereby ensure a more uniform encounter with the Flexcell compression plate. Our initial experiments investigated the effects of MCA compression on gene expression associated with epithelial-to-mesenchymal transition (EMT). Data indicate that short-term static compression (6h) downregulates CDH2 (N-cadherin, Ncad) with cell line-dependent inhibition of EMT regulators including SNAI1, SNAI2, and TWIST. In contrast, long-term compression (24h) upregulated expression of mesenchymal genes including CDH2, MMP14, Wnt5a, ROR1, and ROR2. To examine the impact of strain on receptivity of host peritoneal tissues to metastatic implantation, we used control or strained ex vivo explants of murine peritoneal tissue immobilized on silastic resin. Strained peritoneal tissue exhibited a 3-fold increase in stiffness as determined by atomic force microscopy. Concomitantly, adhesion of ovarian cancer cells to strained peritoneum increased by 4.5-fold. Together these data provide support for a more detailed investigation of the complex role of peritoneal mechanobiology as an important microenvironmental regulator of ovarian cancer metastatic success.

Citation Format: Yuliya Klymenko, Rebecca Wates, Yueying LIu, Rachel Lombard, Holly Weiss-Bilka, Leigh Campbell, Diane Wagner, Matthew J. Ravosa, M. Sharon Stack. Modeling ascites-induced changes in peritoneal mechanobiology and ovarian cancer metastatic success. [abstract]. In: Proceedings of the AACR Conference: Addressing Critical Questions in Ovarian Cancer Research and Treatment; Oct 1-4, 2017; Pittsburgh, PA. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(15_Suppl):Abstract nr A38.

Teaching approaches in South African dental schools: direct restorative procedures

INTRODUCTION

Worldwide the use of amalgam has declined and mercury-containing products are banned in several countries. National and international opinions on amalgam were recently discussed in journals. According to surveys, significant time is spent on the teaching of amalgam in American, Canadian, Irish and United Kingdom Dental Schools.

AIMS AND OBJECTIVES

To i) investigate the teaching approaches on direct restorative techniques and materials in South African Dental Schools; ii) compare the teaching approaches of the dental schools in South Africa with each other as well as with the American, Canadian, Irish and United Kingdom schools; iii) use the information of this study as baseline data for future studies on teaching approaches.

METHODS

A questionnaire regarding the teaching and training of direct restorations was e-mailed to the heads of Restorative Dentistry departments in four South African Dental Schools in 2007.

RESULTS

Significant time is spent on teaching and training of amalgam as a restorative material. Teaching and training on direct restorations are very similar in all South African Dental Schools.

CONCLUSION

Although there is a decline in the use of amalgam worldwide, significant time is spent on teaching of amalgam restorations in South African Dental Schools and this corresponds to the curriculums of American, Canadian, Ireland and United Kingdom Dental Schools.

Effect of woven glass fibre reinforcement on the flexural strength of composites

To measure and compare the flexural strength of composites reinforced with fibres, four groups of specimens (N = 10) were prepared from the combinations: Filtek Flow/Filtek Z250 and Esthet-X flow/Esthet-X dental composite. One group from each combination was reinforced with woven glass fibre (everStick net) and all the specimens subjected to three-point bend flexural testing. The mean and standard deviations for each test group were calculated and compared using one-way analysis of variance (ANOVA) followed by pairwise Bonferroni T-tests at a preset alpha of p < 0.05. It was found that fibre reinforcement significantly (p < 0.001) increased the flexural strength of both types of composites. As the inclusion of only one layer of glass fibre net produced an increase of approximately 30% in the flexural strength of the composite samples, it can be speculated that multiple layers would increase it even more. The use of fibre-reinforcement to strengthen directly placed composite crowns and bridges will enable the clinician to provide a more cost effective service as well as aesthetic dentistry to more patients.

Microleakage of different amalgams bonded with dual cure resin cements

INTRODUCTION

To reduce microleakage in high-copper amalgam restorations, bonding of amalgam was introduced.

AIM

This study compared the microleakage of admixed and spherical amalgams when bonded with different bonding intermediates under thermo- and non-thermocycling conditions.

METHOD AND MATERIALS

Class II butt-joint cavities were prepared in 200 extracted human molar teeth, and randomly divided into 5 groups. Calibra, Duo Cement Plus, RelyX ARC and Amalgambond Plus were applied to 4 of these groups. The fifth group was left untreated. The groups were further divided and restored with either Dispersalloy or Oralloy Magicap S. Ten specimens of each group were thermocycled between 5 degrees C and 55 degrees C, placed in basic fuchsin for 8 hours, sectioned and evaluated for dye penetration under 40X magnification. The mean microleakage scores were analysed using the chi-squared test at a confidence level of 95%.

RESULTS

Microleakage of the non-bonded amalgams was significantly higher (p < 0.0001) than for the bonded amalgams (thermocycled and non-thermocycled). The microleakage of the different intermediates bonded to Dispersalloy (thermocycled and non-thermocycled) was not significantly different (p > 0.05). The microleakage of the different intermediates was not significant different except for Duo Cement compared to Calibra (p < 0.0001), RelyX (p < 0.0001) and Amalgambond (p = 0.0433) and Amalgambond compared to Calibra (p = 0.0433) and RelyX (p = 0.0433). The microleakage of the bonded amalgams was not significantly increased by thermocycling (p > 0.05). The microleakage of the two amalgams when bonded with the same resin cements (thermocycled and non-thermocycled) was not significantly different except for Duo Cement (thermocycled) (p = 0.0051) and RelyX (non-thermocycled) (p = 0.0356).

CONCLUSIONS

Bonding amalgam restorations to tooth structure in butt-joint cavities will reduce microleakage of both admixed and spherical amalgam restorations. Thermal stress does not affect the bond adversely.

[Ambulatory treatment of hemorrhoids]

DGHAL (Doppler Guided Hemorrhoid Arterial Ligation) represents a new approach to the treatment of internal hemorrhoids; it entails exact and selective ligation of the arteries supplying the piles (hemorrhoids). The intervention can be performed on ambulatory patients under local anaesthesia. An anoscope is used which incorporates a Doppler head. The superior hemorrhoidal arteries are identified under guidance of the arterial Doppler sound and ligated through a window located just above the Doppler head. The intervention lasts some 30 minutes. Local discomfort can ensue for a few days following surgery. At one month, the time required for the internal haemorrhoids to fade away, the patient is seen again; an external hemorrhoid or residual skintag can then be considered for treatment under local anaesthesia if needed. As of November 2001 until today, more than 350 patients have been treated, and we report here on 150 of them. Long term data (6 months to 2 years) have been collected which includes 85 to 90% patient satisfaction.

[Long-term results in ileo-anal reservoirs in the treatment of ulcero-hemorrhagic rectocolitis]

The authors report long term results of 53 ileo-anal anastomosis for ulcerative colitis. They used a "J" pouch technique with anastomosis to the anal canal after mucosectomy of the lower rectum. An upstream ileostomy should be created and left in place for two to three months. Early morbidity primarily involves pelvic or parietal infectious problems, while late complications comprise pelvic fistulae, obstructive events, and episodes of pouch inflammation. Functional results improve over the first year and remain stable thereafter. The major long term problem remains that of pouch inflammation its treatment, and the understanding of its pathophysiology.

Laparoscopic highly selective vagotomy

Between February 1991 and August 1992, 35 patients underwent laparoscopic highly selective vagotomy (HSV) for recurrent duodenal ulcer disease. An antireflux procedure was also performed in 25 of these patients. There was no 30-day mortality and morbidity. The mean operating time was 110 (range 85-205) min for HSV and 155 (range 100-300) min for vagotomy and antireflux repair. Follow-up is short but initial postoperative gastric acid secretion studies have demonstrated results similar to those obtained after conventional open HSV. The main advantage of laparoscopic HSV is the reduction of 70 per cent in hospital stay and 50 per cent in the overall recovery period compared with open surgery.

Colpocystodefecography

PURPOSE

To assess, in one single procedure, a complete study of the female pelvis, including the Douglas pouch.

METHODS

Colpocystodefecography (CCD) combines vaginal opacification, voiding cystography, and defecography. Three hundred examinations are reviewed.

RESULTS

Thanks to the simultaneous visualization of the pelvic structures, CCD proved to be more useful than clinical evaluation to diagnose prolapses and particularly Douglas pouch hernias (enteroceles), the clinical diagnosis of which was missed in 93 of 111 cases. Moreover, in addition to morphologic and functional information, CCD brings about a new insight in the study of pelvic organs reciprocal influences, should they be positive (supporting function) or negative (external compression). Finally, significative pelvic surgery and particularly hysterectomy enhances greatly the risk of enteroceles.

CONCLUSION

CCD is helpful in the preoperative staging, especially in the selection of the surgical procedure that will least likely predispose to possible late postoperative complications such as vaginal prolapses or enteroceles.

Laparoscopic Nissen fundoplication: detailed analysis of 132 patients

With the world-wide use of laparoscopy, new applications have been found, particularly in the field of esophageal and gastric surgery. From January 1991 through April 1992, 132 patients underwent laparoscopic Nissen fundoplication. The indication for laparoscopic intervention was symptomatic gastroesophageal reflux disease (GERD) not responding to medical treatment. The preoperative assessment included esophagogastroscopy, barium meal, esophageal manometry, and, in selected cases, 24 h pH studies. There was no operative-related mortality. The overall morbidity was 7.5%. Ninety-eight patients were seen 3 months after surgery and evaluated for control of reflux symptoms. One patient complained of mild recurrence of reflux symptoms; however, endoscopic examination revealed no evidence of recurrent esophagitis. Three complained of occasional dysphagia and two, of mild dysphagia. One individual required reoperation for persistent, severe dysphagia. The excellent results observed so far with this procedure have led us to believe that laparoscopic Nissen fundoplication is the procedure of choice for patients with intractable GERD.

Percutaneous catheter drainage of abdominal abscess after abdominal surgery. Results in 121 cases

One hundred and twenty-one peritoneal, retroperitoneal and pelvic abscesses were treated percutaneously using CT or US guidance. The lesions developed after abdominal surgery. Sixty-three abscesses (52%) were situated in the peritoneal cavity, 31 (26%) in the retroperitoneal cavity and 27 (22%) in the pelvis. A definitive treatment was obtained in 74% of peritoneal abscesses, 67% of retroperitoneal abscesses and 82% of pelvic abscesses. Failure most commonly occurred with multiloculated lesions or lesions associated with fistulous communication. There was a low rate of complication (1%). percutaneous drainage avoids the risks inherent in surgery and anesthesia, saves considerable time and meets greater patient acceptance. If a total cure is not systematic, a beneficial temporizing effect may however be obtained by percutaneous drainage. This procedure should be indicated for the initial treatment of postsurgical abscesses.

[Tolerance of adjuvant treatment combining postoperative intraportal chemotherapy and a systemic treatment based on 5-fluorouracil in colorectal carcinoma with a histologically poor prognosis]

From April 89 to October 90, 41 patients operated for a Dukes B or C colorectal cancer were randomized to receive 6 courses of adjuvant treatment with (A) 5-FU alone (440 mg/m2 IV bolus 5/21 days) or (B) folinic acid (200 mg/m2 IV bolus 5/21 days) preceding 5-FU (370 mg/m2 in short infusion 5/21 days). Ten patients received also one course of immediate post-operative continuous portal infusion (5-FU 500 mg/m2/day x 7 followed by a 2 hours infusion of mitomycin C 10 mg/m2). The portal treatment was well tolerated (1 case of GI tract disturbances, 1 catheter obstruction). The toxicity of adjuvant systemic treatment was evaluated on 232 courses (125 A, 107 B). Hematologic and skin toxicities, alopecia and nausea-vomiting were mild. The limiting toxicities (expressed as percentages of courses) were stomatitis (grades 2-3: 11.4% A; 22.6% B) and diarrhea (grades 3-4: 7.3% A; 14.2% B; one toxic death was to deplore in arm B from a grade 4 diarrhea). The pilot study has demonstrated the feasibility of the adjuvant treatment proposed; a multicentric randomized trial (expected accrual: 800 patients) has therefore been activated on 11.01.90; all patients will also receive levamisole while radio-therapy will be mandatory for rectal cancer.

[Cholecystectomy using celioscopy: analysis of 368 operations]

The management of calculous disease of the biliary tract has undergone significant changes during the past decade. Yet, the only radical method of treatment remains cholecystectomy. The surgical option has been improved by the development of laparoscopic cholecystectomy. From February 1990 to February 1991, we performed 368 laparoscopic cholecystectomies, with no mortality and a morbidity rate of 3.8%. There were 283 women and 85 men, with a mean age of 56.2 years (range 18 to 92 years). Two patients were asymptomatic but presented with a growing gallbladder polyp. All the other patients were symptomatic: biliary colic (63.8%), dyspepsia (18.6%), or acute cholecystitis (17.6%); 36 patients had an history of stone migration to the main biliary tract. Mean operating time was 58.3 minutes (22 to 180 minutes) and mean postoperative stay was 3.4 days. There were four systemic complications and 10 local technically related complications: two have been controlled by a laparoscopic approach (one hemorrhage and one biliary leak), one by laparotomy (bile duct injury). The other 7 local complications resolved spontaneously (4 biliary fistulas) or by percutaneous punction (3 subphrenic abscesses). Twenty-six patients (7%) required conversion to open cholecystectomy because of technical difficulties with the dissection or main biliary tract stones. We conclude that laparoscopic cholecystectomy is a safe and effective procedure.

Laparoscopic Nissen fundoplication: preliminary report

Twelve patients presenting with symptomatic esophagitis associated with hiatal hernia and gastroesophageal reflux underwent operative management under laparoscopic guidance. The antireflux procedure employed was the Nissen fundoplication. The authors completed the operation laparoscopically in nine patients. Postoperatively, patients were evaluated with repeat fiberoptic endoscopy, esophageal manometry, and barium contrast studies. Postoperative results were considered excellent on the basis of these studies and complete control of symptoms. The mortality rate was 0%. The only major operative complication was a pneumonia that occurred in one patient. At 1 month follow-up, six patients were totally asymptomatic. The authors conclude that laparoscopic treatment of gastroesophageal reflux associated with a hiatal hernia is feasible by a procedure that has already proven its value during open surgery.

[Defecation disorders. Characteristics of manometric studies and rehabilitation]

The authors review the literature and their personal experience about the systematic exploration of defecation disorders by anorectal manometry and colpocystodefecography. They stress the importance of combining functional and morphological evaluation, in order to avoid inappropriate surgery. Concerning anorectal manometry, the determination of the smallest volume of rectal distention inducing a complete relaxation of the internal anal sphincter was found more useful than the maximal tolerable volume in the exploration of defecation disorders. Finally, the authors report the results of biofeedback conditioning prescribed in 30 patients (27 women, 3 men, mean age: 55 years) with defecation disorders (terminal constipation in 21, fecal incontinence in 9 patients). Several characteristics of anorectal manometry and of defecography were significantly improved after biofeedback conditioning.

[Preoperative chemotherapy of ovarian cancer in anesthesia and resuscitation]

Anti-mitotic chemotherapy has become more efficient but also more toxic. This toxicity complicates later operations. Sixty cases of ovarian cancer one analysed and the various complications related to chemotherapy described.

The management of abdominal wall stomata: skin protection, peristomal wound healing and support for the collecting bag. A multi-center study

The specific properties of Stomahesive tested in 116 stomal and 20 fistulous patients render it really useful in stomatherapy where it increases the comfort of the patients: 1. it offers an excellent peristomal skin protection whatever the nature of the stoma or origin of the fistula; 2. it promotes rapid healing of skin lesions, even in ileostomy, transverse colostomy, ureterostomy and fistula patients; 3. it ensures an effective degree of impermeability; 4. it provides a large base for adhesion of the collecting bag; 5. it can be kept on for about 6 days in most cases; 6. The local tolerance is excellent (Acta chir. belg., 1977, 76, 533-537).