The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour

AIM

The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib.

METHOD

The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment.

RESULTS

Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant.

CONCLUSION

Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

Rectal bleeding and previous anticoagulant treatment in patients with colorectal cancer do not predict outcome

BACKGROUND

The aim of this study was to determine whether the outcome of patients with colorectal cancer who presented with bleeding and a history of anticoagulant treatment was different from those who did not have bleeding or previous anticoagulant treatment.

METHODS

This was a single institution, retrospective study of patients with colorectal cancer with and without a history of rectal bleeding and treatment with anticoagulants, assessed for age, gender, tumor site, stage, recurrence rate, and survival.

RESULTS

A total of 621 consecutive patients (309 men) with a mean age of 70 years (range, 36-94 years) diagnosed with colorectal cancer between 1998 and 2004 were studied. Of these, 149 patients (24%) were referred for symptoms of rectal bleeding and 161 patients (26%) had been previously treated with anticoagulants. A total of 592 patients (95%) underwent curative or palliative surgery; endoscopic polypectomy was performed in 3 cases only and in 26 patients (4%) surgery was not performed due to advanced disease or critical illness. Patients with bleeding and a history of anticoagulant treatment presented commonly with stage I cancer. In addition, tumor stage III was less common in patients with previous anticoagulant treatment irrespective of presenting signs. Disease-free and overall survival rates were similar in all groups, irrespective of bleeding at presentation or anticoagulant treatment.

CONCLUSIONS

Rectal bleeding and anticoagulant treatment do not affect the outcome of newly diagnosed patients with colorectal cancer.

Combined treatment of basaloid anal carcinoma using cisplatin, 5–fluorouracil and resection of hepatic metastasis

The combination of chemotherapy and radiotherapy with subsequent repeated local biopsy has become the standard treatment of epidermoid carcinoma. The optimal treatment of metastatic anal carcinomas is controversial. We present the case of 54-year-old woman with a diagnosis of metastatic basaloid anal carcinoma. The patient underwent resection of liver metastasis in combination with cisplatin + 5FU and local radiotherapy, without evident disease 3 years after diagnosis.

Expression of D-type cyclins in colon cancer and in cell lines from colon carcinomas

Cyclins D1, D2 and D3 play important roles in cell proliferation and differentiation. Although their abnormal expression has been linked to cancer development and progression in a number of tissues, the expression of cyclin D2 and D3 proteins in colon cancer has not yet been characterised. In this study, we examined cyclin D1, D2 and D3 protein expression by Western blot analysis in tumour and adjacent normal colon tissues of 57 patients. In addition, we examined D-type cyclins protein expression in HT29 and LoVo39 cell lines from colon carcinomas, as a function of induced proliferation and differentiation. In both cell lines, the expression of the three D-type cyclins increased as a result of induced proliferation, whereas the expression of cyclin D3 increased as a result of induced differentiation. In colon tumours, cyclin D1 was overexpressed in 44%, cyclin D2 was overexpressed in 53% and cyclin D3 was overexpressed in 35% of the cases. We also found that in 16% of the cases, cyclin D3 protein expression was reduced in the tumour, as compared to the adjacent normal tissue. Examination of D-type cyclin protein overexpression in relation to the TNM stage of the tumours revealed that overexpression of cyclins D1 and/or D2, but not cyclin D3, is linked to colon carcinogenesis and that overexpression of cyclin D2 may be related to a higher TNM stage of the tumour.

Brachial plexus injury as a complication after colorectal surgery

Peripheral neuropathy associated with anesthesia is a significant source of morbidity and the second most frequent cause of professional liability in anesthetic practice. Nerve injuries are a well-recognised complication of anesthesia. Brachial plexus neuropathy is a rare syndrome with an incidence of 1.6 cases per 100,000. Unfortunately, we have a limited understanding of the relations between conventional perioperative care and the genesis of peripheral neuropathy. We describe 3 cases of postoperative brachial plexus neuropathy that occurred after abdominoperineal anterior resection for rectal cancer. The symptoms resolved postoperatively in two patients by 8 weeks and in one patient by 10 weeks with conservative treatment. The differential diagnosis between brachial plexus neuropathy and other peripheral neuropathies is important, as the prognosis of brachial plexus neuropathy is generally better. The anesthetist and the surgeon should know the risks of positioning to prevent nerve injuries, and should be aware of the possibility of brachial neuropathy in order to properly make an early diagnosis.

[Fournier's gangrene as a delayed complication of closed hemorrhoidectomy]

BACKGROUND

Fournier's gangrene is recognized as a synergistic necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and the vulva in women. The major sources of Fournier's Gangrene are dermatologic, anorectal and genitourinary infections. Although anorectum is remarkably rich in bacterial flora, transanal procedures are generally free of infectious or septic complications. Nevertheless, five cases of Fournier's gangrene post hemorrhoidectomy have been published.

OBJECTIVE

To report a case of Fournier's gangrene as a delayed complication of closed hemorrhoidectomy and to demonstrate the management of such complication.

PATIENT

A sixty-six years old male who had undergone an uncomplicated closed hemorrhoidectomy was readmitted to the hospital on postoperative day 7 for fever, perirectal erythema and tenderness accompanied by a dirty brown discharge from the wound. The patient was treated with fluid resuscitation and broad-spectrum antibiotics. Radical debridement of the perianal and scrotal region was performed accompanied by diverting colostomy. Four months later a reconstruction of the perianal area was performed by meshed split thickness skin graft and the colostomy was closed.

CONCLUSIONS

Fournier's gangrene is a rare immediate or delayed complication of hemorrhoidectomy. A review of the limited available literature suggests that neither the surgical technique nor the medical history of the patient have an influence on the development of such a rare and fatal complication.

Rectovaginal septal repair: case presentations and introduction of a modified reconstruction technique

Rectovaginal fistula are a relatively rare kind of anorectal fistulas. Spontaneous healing is rare and the rectal advancement flap repair is the most popular procedure with success rates ranging between 60% and 80%. We present a new technique for repairing damage in the rectovaginal septum that consists of placing a folded polyglycolic acid mesh (Dexon) between the levator ani muscle closure area and the vaginal wall. This absorbable mesh separates the suture lines on the vaginal and rectal walls, and induces fibrosis and healing. The technique was performed in four women suffering from a rectovaginal fistula due to different causes. It was successful in all cases.

Chronic perineal fistula as a late failure manifestation of pseudomyxoma peritonei syndrome

Pseudomyxoma peritonei syndrome (PMP) is a rare but fascinating entity in surgical oncology. It consists of the accumulation of mucus in the peritoneal cavity, sometimes in huge amounts, in most of the cases after rupture of an appendiceal tumor. The diagnosis and management of PMP has changed significantly in the past 15 years, with the institution of an aggressive therapeutic combination: cytoreductive surgery and intraperitoneal perioperative chemotherapy. Few reports deal with the late manifestations and complications at endstage of the disease. The cases presented here are unique in that they illustrate a late 'failure' in the perianal area in three patients with long-term PMP.

Detection of abnormal proliferation in histologically 'normal' colonic biopsies using FTIR-microspectroscopy

BACKGROUND

Abnormal crypt proliferation and development in the colon has been associated with premalignant stages of colon cancer. Conventionally, molecular markers are used to detect abnormal crypt proliferation.

METHODS

In the present work, feasibility studies of FTIR-MSP to distinguish between normal and abnormal crypts from colon biopsies that show normal histopathological features have been undertaken.

RESULTS

The results indicate that abnormal crypts show deviations in the pattern of absorbance in the Mid IR region along the crypt height when compared with the normal crypts. The crypts could be empirically classified into three groups such as crypts having a normal absorbance pattern for all biochemical components, crypts with abnormal absorbance pattern for some biochemical components and crypts with completely abnormal absorbance pattern along the height for all or most biochemical components studied by FTIR. The utilization of FTIR-MSP is proposed for diagnosis of abnormal metabolism at the molecular level of histologically completely normal-looking crypts, especially from those biopsies that are taken from sites far away from cancer.

CONCLUSIONS

This method could give rise to a reduction in false-negative results during examination of biopsies using the conventional histopathological methods. The present method may be complementary to existing methods for precise demarcation of the zone of colostomy prior to colon cancer surgery.

Lycopene in serum, skin and adipose tissues after tomato-oleoresin supplementation in patients undergoing haemorrhoidectomy or peri-anal fistulotomy

Lycopene, the main carotenoid found in tomatoes and tomato-based products, has been reported to be protective against several types of cancer. Assessment of changes in plasma concentration of carotenoids following ingestion of lycopene-rich food sources does not necessarily predict changes in lycopene concentration or distribution of its isomers in other body tissues. Our aim was to determine the relationship between concentrations of lycopene and other tomato carotenoids in human serum and body tissues after tomato-oleoresin supplementation. Tomato lycopene oleoresin (30 mg/d) or a placebo was administered for 1 to 7 weeks to seventy-five volunteers undergoing elective haemorrhoidectomy or peri-anal fistulotomy. Carotenoid concentration and isomer distribution in blood and in the surgically removed skin and adipose tissues was measured by HPLC. The serum concentration of lycopene increased after supplementation from 0.26 (SD 0.12) to 0.52 (SD 0.25) micromol/l (n 35; P<0.0001). In the placebo group (n 40), lycopene serum concentration did not change significantly. Serum lycopene concentration after treatment was 2.2-fold greater in the lycopene group than in the placebo group, a slightly higher ratio than that found in skin and adipose tissue (1.6- and 1.4-fold higher than the placebo, respectively). A significant correlation between serum and tissue concentrations was found for both beta-carotene and lycopene in the placebo group, whereas in the lycopene-supplemented group the correlation between serum and tissues remained the same for beta-carotene but for lycopene was weak. Lycopene supplementation did not significantly change the proportion of all-trans v. cis isomers in the serum and tissues, despite the fact that more than 90 % of the supplemented lycopene was in the all-trans form. These results show that tomato-oleoresin supplementation increases lycopene concentrations in serum and in adipose tissue and skin. The ability to increase lycopene levels in tissues is one of the prerequisites for using it as a food supplement with health benefits.

Diamond-shaped optical fiber delivery system

OBJECTIVE

Physicians who use laser systems are looking for new fiberoptic delivery systems with better performance. We searched for a delivery system with high power and with a tip of high durability that may be reused many times.

SUMMARY BACKGROUND DATA

The delivery systems currently found on the market can burn and break easily. The surgeon may either finish the surgery with a damaged delivery system, or have to switch to a new one during surgery, thus increasing the inconvenience and cost of the surgery.

METHODS

Distal tips of fibers used with Nd:YAG and diode lasers have been shaped and polished according to their specific function, including excision, vaporization, and coagulation of tissue.

RESULTS

We have developed several prototypes of optical fiber delivery systems, and in particular, we have developed a prototype of a delivery system, called the Diamond-Shaped Optical Fiber Delivery System, or Diamond. By making the tip of an optical fiber diamond shaped, we are able to obtain greater mechanical resistance than that of other delivery systems that were tested in our laboratory. In the Colorectal Unit, we applied it in surgical procedures such as perianal fistulectomy, hemorrhoidectomy, and excision of condilomata acuminata and pilonidal cyst and sinuses. During cutting and coagulating, the system performed well with no technical problems.

CONCLUSIONS

A new delivery system (Diamond) gave satisfactory performance during surgical operations. Its main component, the diamond-shaped distal end, provided high durability and was reused many times, thus improving the quality of operations and reducing expenses greatly.

Twelve-year survival after the diagnosis of locally advanced carcinoma of the pancreas: A case report

The long-term survival rate of patients with carcinoma of the pancreas is low. Even more so, long-term survival of patients with metastatic pancreatic carcinoma is extremely rare. In this case report, we describe a patient with an unusual course of disease. This patient was diagnosed with locoregional carcinoma of the pancreas and therefore underwent gastroenterostomy and cholecystojeojenostomy without resection of the primary tumor. Later he was treated with radiotherapy and chemotherapy and survived 12 years, during 11 of which he had no evidence of disease. He died 12 years after the initial diagnosis from peritoneal dissemination of poorly differentiated carcinoma complicated with obstructive jaundice and sepsis. To our knowledge, this patient had the longest reported survival with locally advanced pancreas carcinoma that was not resected. The case is presented and discussed in this article.

Perianal and gluteal burns as a complication of hot water bottle treatment for anal fissure

Contact with hot objects and surfaces often causes burns. We present a case of burns to the buttock and perineum caused by use of a hot water bottle to relieve the pain caused by an anal fissure.

Sigmoid colon carcinoma metastatic to the myometrium

Metastases to the uterus from extragenital cancers are significantly rarer than metastases to the ovaries. Of the approximately 200 cases of metastases to the uterus from extragenital cancers that have been reported in the literature, more than half are cases of metastases from breast carcinoma and only 16 are cases of metastases from colorectal carcinoma. A case of isolated metastases restricted to the myometrium of the right uterine comu from sigmoid colon carcinoma, without involvement of the ovaries, is described. The patient who six months previously had surgery for sigmoid colon carcinoma presented with right lower abdominal pain and a palpable mass in the region of the right uterine cornu. The diagnosis of isolated metastases restricted to the myometrium of the right uterine cornu was confirmed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. This case illustrates that a growing uterine mass in a patient with a history of primary extragenital cancer, regardless of whether abnormal uterine bleeding is present or absent, should alert the physician to consider the possibility of uterine metastases.

[Adjuvant therapy of colon cancer stage C MAC. Adverse effects and efficacy in the Department of Oncology, Soroka Medical Center in the years 1991-1994]

The National Institutes of Health (NIH) held a consensus conference which recommended 5-FU and levamisole as adjuvant chemotherapy for colon cancer MAC (Modified Astler Coller) stage C. From 1991-1994, 37 such patients diagnosed here were treated with 5-FU (intravenous dose of 450/mg/m2/d for 5 days and from day 29, once a week for 48 weeks) and oral levamisole (50 mg 3 times/d. for 3 days, every 2 weeks for a year), as suggested by NIH guidelines. 16 patients were males and 21 were females, mean age was 62 years and median 64. Cancer locations were: right colon (in 16, 43%), left colon (19, 51%), multiple colon primaries (2, 1%). 25 (68%) had 1-3 positive lymph nodes and 12 (32%) had 4 or more positive lymph nodes. Only 20 (54%) finished treatment as prescribed. In the others, 1 or both drugs caused side-effects for which the drugs had to be stopped. 6 patients relapsed while on treatment. The most common side-effects were diarrhea, stomatitis and bone marrow suppression. 3 were hospitalized due to neutropenic fever. 5-year actuarial survival of all patients was 61%; 5-year relapse-free survival was 61%; 5-year relapse-free survival of right versus left colon was 41% and 82%, respectively (p < 0.01). There was no significant difference in 5-year survival of those with 1-3 positive lymph nodes as compared to those with 4 or more (62% and 56%, respectively). 5-year survival in those who finished or did not finish treatment (excluding those who stopped treatment because of progressive disease) was 83% and 70%, respectively (NS). The 5-year survival of our series was similar to that of patients treated similarly elsewhere. The 5-FU and levamisole treatment was not tolerated well by our study population. It has recently been replaced in our service by a 5-FU and leucovorin regimen given for 6 months.

Double seton--a new modified approach to high transsphincteric anal fistula

Despite the fact that complicated extrasphincteric anal fistulas have been recognized and treated for many years, there is still a lack of consensus among colorectal surgeons as to the optimum surgical approach. We have devised a modification of the seton technique, which we used in 23 patients without complications or recurrence.

Effects of oleic acid lung injury and positive end-expiratory pressure on central hemodynamics and regional blood flow

The objective of our study was to investigate the influence on central and regional circulation of the application of positive end-expiratory pressure (PEEP=P) in a canine model of low hydrostatic pulmonary edema. Eight mongrel dogs with oleic acid-induced pulmonary edema were artificially ventilated with and without PEEP. Regional blood flow was determined using radioactive microspheres directly injected into the left ventricle. Regional blood flow to the brain was maintained under all experimental conditions, while the blood flow to the gastric fundal mucosa and to the pancreas significantly decreased following PEEP, oleic acid injection (OA) and with PEEP and oleic acid combination (P+OA). The renal blood flow decreased only during the P+OA phase. We conclude that the observed decrease in blood flow to the gastrointestinal mucosa and renal circulation in this acute low hydrostatic pressure pulmonary edema may correlate with the increased incidence of gastrointestinal and renal complications that accompany critically ill patients.

[Uncommon presentation of perforated colonic diverticuli]

Diverticulosis of the colon is common in the sigmoid, but much less so in the cecum, ascending or transverse colon. We report 2 patients who presented with clinical findings of perforated diverticulitis of the transverse and left colon. A 42- and a 46-year-old man underwent extended right and left hemicolectomies, respectively. The first patient ran an excellent postoperative course. In the second, in whom a double-barrelled colostomy was formed, the proximal colostomy had to be redone because of stomal retraction, but both stomata eventually were closed. On follow-up both patients are symptom-free. The diagnosis of diverticulitis with complications should be considered in patients who present with intra-abdominal masses. Preoperatively, the condition often cannot be differentiated from carcinoma.

[Circumcision of new immigrants]

Recent immigration from eastern Europe to Israel (1990-1992) has brought to the Negev many uncircumcised newcomers. The rationale for circumcising healthy children has been a matter of controversy, not yet settled. Healthy adults are not usually circumcised except for ritual reasons. In the past 3 years we circumcised 2857 males 1-64 years old, mostly of Russian origin. All were operated on as outpatients on a 1-day, ambulatory service. 75% of the newcomers were operated on during the first 6 months after immigration. 86% of the circumcisions were done under general anesthesia and the rest under local. After stretching the prepuce backwards, the foreskin was excised. Hemostasis was achieved with the aid of electrocautery and the skin was approximated with in absorbable sutures. All patients were re examined 1 week later. There were complications in 50 (1.75%), consisting mostly of postoperative bleeding and wound infections. We conclude that ritual circumcision is a safe procedure in normal adults.

[Laparoscopic-assisted colectomy]

After gaining experience in laparoscopic cholecystectomy, laparoscopic appendectomy and other laparoscopic procedures, we decided to perform laparoscopic-assisted colectomy. During July 1992 to February 1993 we performed 14 such procedures. Ages ranged from 46-83 years (mean, 68). In all cases the indication for surgery was neoplasm of the colon. 8 of the tumors were located in the right colon and 6 in the sigmoid. Procedures performed were laparoscopic-assisted right hemicolectomy with a biofragmentable anastomotic ring or laparoscopic-assisted sigmoidectomy with end-to-end anastomosis. In 1 operation we combined laparoscopic cholecystectomy with laparoscopic right hemicolectomy. Operation time varied from 90-130 min (mean, 100 min). In our opinion the procedure is as radical as standard laparotomy with the number of lymph nodes per specimen ranging from 4-10 (mean, 7); the surgical margins were free of tumor in all cases. There was less pain in the postoperative period than with the standard procedure and the average time from operation to discharge was 7 days (range, 5-9). Complications included 1 fatality due to postoperative myocardial infarction, and 1 case of duodenal perforation which was sutured during the operation. We conclude that laparoscopic-assisted right hemicolectomy and laparoscopic sigmoidectomy are feasible for carcinoma, and that recovery is quicker and with less pain. However, we need a larger series and long-term follow-up to conclude whether the laparoscopic assisted technic is an adequate operation in cases of cancer.

[Nd:YAG laser for anorectal surgery: initial experience in Israel]

The use of laser in gastrointestinal diseases started in the mid-70's. The 3 types of laser in use today are CO2, argon and Nd:YAG. We present the first clinical results in Israel of the use of the Nd:YAG laser in anorectal surgery. Between Oct. '91-Dec. '92, 275 patients with anorectal diseases (mostly hemorrhoids, anal fissures and fistulas) and 67 with various perineal lesions were operated on. Within an hour of the end of the operation, most patients were discharged to home with detailed follow-up instructions. 8 needed an extra day of observation in hospital. Postoperative complications included: bleeding (8 patients), wound infection (4) and urinary retention after hemorrhoidectomy (8). 1 patient complained of anal laxity after sphincterotomy, and 4 of recurrence of anal fissure. It is our impression that after laser hemorrhoidectomy patients return quickly to their normal lives; that the rate of complications is not greater than after other accepted techniques; and that the laser method for anal fistulectomy is most efficacious.

Pelvic pouch emptying scan: an evaluation of scintigraphic assessment of the neorectum

Although scintigraphic pelvic pouch emptying scans have been used to evaluate neorectal function in patients who have undergone colectomy, mucosal proctectomy, and ileoanal pouch anastomosis, previous reports have not documented the reliability of this test in measuring pouch volume and emptying. Thus, this study was undertaken to determine: (1) the reliability of this test in patients with stable functional results and, (2) whether the emptying fraction correlates with the volume of the pouch. Ten patients who had stable functional results had 99m Tc-sulphur colloid pouch emptying scans performed on two occasions, one week apart. The average volume of artificial stool that was instilled was 338 +/- 104 cc. The mean difference in the volume instilled between the initial and repeat scans was 78 +/- 26 cc and the mean absolute difference in the percentage evacuated was 12 +/- 9 percent. These inter-test differences were not statistically significant (p greater than 0.05). There was no correlation between the volume of artificial stool instilled into the pelvic pouch and the fraction spontaneously emptied (r = -0.1). Our results suggest that the 99m Tc-sulphur colloid pelvic pouch emptying scan is reliable in patients with stable functional results. Pouch emptying fraction is independent of pouch volume.

Cancer in an ileoanal reservoir: a new late complication?

The functional success rate of the ileoanal reservoir procedure for ulcerative colitis is quite high. Despite the few early and late complications described there is now wide-spread acceptance of this procedure in the management of ulcerative colitis. We report a patient who developed an adenocarcinoma in the rectal cuff four years after having a pelvic pouch procedure. This new late complication brings to light several points including the importance of a radical total mucosectomy. The purpose of this paper is to discuss concern as to whether or not this procedure is indicated in colitis patients in whom severe dysplasia is the primary indication for surgery.

Use of Nd-Yag laser ablation in colorectal obstruction and palliation in high-risk patients

Conventional treatment for colonic obstruction due to cancer or benign anastomotic strictures in high-risk patients or unresectable cases in some form of colostomy. This procedure has the negative aspects of requiring a general anesthetic and leaves the infirm patient with a stoma that they cannot easily attend to. Ablation of tumor by Nd-Yag laser has been available for several years, with passage of the laser fiber through a colonoscope. To evaluate the role of laser photocoagulation in the palliation of colorectal tumors or benign strictures, the authors summarized their initial experience, trying to define the indications, various methods of treatment, and complication rate in these patients. This technique is difficult to perform and has the added risk of intestinal perforation but does obviate anesthetic and surgical risks. Seven patients with recurrent metastatic colorectal obstruction, three patients with benign colonic strictures, and two patients with large villous tumors were treated with Nd-Yag laser passed via the colonoscope. The mean age was 71 years (range, 52 to 86 years). Five patients received sedatives only, six patients received epidural anesthetic, and one had a general anesthetic. The average total energy used was 3702 joules on noncontact fibers, and the average number of pulses was 126. Distance of the lesion from the anal margin ranged from 0.5 to 30 cm. Ten of twelve tumors were within 15 cm of the dentate line. In the most distal lesions, manual debulking with biopsy forceps facilitated the laser treatment. Symptomatic relief was achieved in all patients. One patient required a colostomy one month after treatment because of incontinence. Another patient needed a resection of a benign stricture after three laser treatments. Other than one case of microperforation, treated conservatively with antibiotics, no other complications occurred and there was no mortality. The authors believed that the Nd-Yag laser plays a specific role in the treatment of high-risk patients.

Pancreatic structure and glucose tolerance in a longitudinal study of experimental pancreatitis-induced diabetes

Chronic pancreatitis is associated with glucose intolerance and resultant pancreatogenic diabetes. Using the canine pancreatic duct-ligated model of pancreatitis, we serially evaluated pancreatic histology and electron microscopy, tolerance to intravenous and oral glucose, and insulin response to glucose loading. Pancreatic duct ligation caused microscopic evidence of acute pancreatitis at 1 week, progressing to acinar loss and fibrosis consistent with chronic pancreatitis at time periods up to 6 months. The islets of Langerhans showed degranulation early and appeared to be structurally preserved late. Calculated K values indicated a progressive significant deterioration in intravenous glucose tolerance, falling significantly from 3.46 +/- 0.23 basally to 1.51 +/- 0.17 at 6 months after duct ligation (p less than 0.0001). Oral glucose tolerance deteriorated significantly, with the integrated glucose response rising from 23.7 +/- 1.2 g/dl.minute basally to 32.3 +/- 2.8 g/dl.minute at 6 months after duct ligation (p less than 0.05). Integrated insulin response to both intravenous and oral glucose deteriorated with pancreatitis. Pancreatitis-induced glucose intolerance is a consistent feature of this duct-ligated model. Glucose intolerance stabilizes between 4 and 6 months after duct ligation and is associated with pancreatic acinar fibrosis and pancreatic endocrine structural preservation. While the mechanism of altered glucose tolerance may involve mechanical, neural, humoral, or vascular events, our data clearly support the conclusion that pancreatic ductal stenosis with resultant pancreatic fibrosis and chronic pancreatitis is associated with abnormal islet responsiveness leading to circulating insulin deficiency and glucose intolerance, despite histologic and ultrastructural evidence of intact islets of Langerhans.

Use of thoracoabdominal incision for cancer of the splenic flexure in the obese patient

The thoracoabdominal incision is not a common incision in colonic surgery. However, it may be of unique benefit in tumors of the splenic flexure in which adequate mobilization and adequate lateral resection margins may otherwise be difficult to achieve. These tumors are believed to carry a poorer prognosis in part because of reduced accessibility. Specifically, exposure in short, obese patients with locally advanced lesions may be improved significantly with a thoracoabdominal incision. This report presents a patient with a tumor of the splenic flexure invading the diaphragm, greater curvature of the stomach, splenic hilum, and tail of the pancreas. The exposure provided by this incision made a radical cancer operation possible, which would not have been possible with an abdominal incision.

Role of prostanoids in experimental duodenal ulcer in rat

The purposes of this study were to determine whether inhibition of cyclooxygenase is a mechanism by which cysteamine and mepirizole produce duodenal ulcers, identify qualitative or quantitative differences in prostanoid production between gastric mucosa and duodenum, and determine whether differences in cyclooxygenase sensitivity to inhibition by aspirin exist between these two tissues. In fed female rats, gastric mucosal prostaglandin E2 (PGE2) and prostacyclin (PGI2) generation was 235 +/- 25 and 832 +/- 40 ng/g/min, respectively, whereas full-thickness duodenal PGE2 and PGI2 generation was 665 +/- 46 and 662 +/- 49 ng/g/min, respectively. Over an intraperitoneal dose range of 0-25 mg/kg, aspirin-induced cyclooxygenase inhibition was dose-dependent and similar for the two tissues. Duodenal ulceration (16.7 mm2) produced by cysteamine, 425 mg/kg, was associated with a 46% reduction in duodenal PGE2 generation, while having no effect on PGI2 generation; however, cysteamine, 213 mg/kg, produced no visible duodenal mucosa injury yet reduced duodenal PGE2 generation 39% compared to control values. In fed male rats, gastric mucosal PGE2 and PGI2 generation was 179 +/- 18 and 813 +/- 61 ng/g/min, respectively, whereas duodenal PGE2 and PGI2 generation was 321 +/- 27 and 454 +/- 38 ng/g/min, respectively. Duodenal ulceration (7.7 +/- 2.3 mm2) produced by oral mepirizole was associated with a 63% reduction in duodenal PGE2 generation compared to control values, while having no effect on PGI2 generation. Subcutaneous aspirin, 100 mg/kg, which reduced duodenal PGE2 generation to a greater degree than either ulcerogen, given in conjunction with pentagastrin, did not produce visible duodenal ulceration.(ABSTRACT TRUNCATED AT 250 WORDS)

Circumcision complications and indications for ritual recircumcision--clinical experience and review of the literature

The aim of this work is to review the complications of circumcision in the literature of medicine and Jewish law. One of the problems discussed in Jewish law concerns a remnant of the prepuce covering the corona, thus causing the circumcision to be incomplete. There is a controversy in Jewish law sources regarding the definition of the corona--whether it is all the glans penis, or only the cord surrounding the base of the glans. During the last 8 years, our center has been consulted about recircumcision for 60 children and about treatment for another group who had developed complications due to circumcision, often as a result of "nonprofessional" circumcision.

Benign hamartoma of the lung presenting as massive hemoptysis

A case is presented of benign pulmonary hamartoma causing episodes of hemoptysis. This is an extremely unusual manner of presentation for such lesions.

Reversal of abnormal glucose metabolism in chronic pancreatitis by administration of pancreatic polypeptide

Chronic pancreatitis, induced in dogs by pancreatic duct ligation, is associated with glucose intolerance due to insulin deficiency, reduced hepatic sensitivity to insulin, and a marked deficiency of pancreatic polypeptide. Treatment with a 14 day continuous subcutaneous infusion of pancreatic polypeptide resulted in improved oral glucose tolerance and improved hepatic glucose responses to insulin in dogs with chronic pancreatitis. No effect of continuous subcutaneous infusion of pancreatic polypeptide was seen in the control dogs. The time course of the effect of continuous subcutaneous infusion on the hepatic response to insulin was relatively immediate, whereas the effects on improvement in oral glucose tolerance were prolonged. We conclude that pancreatic polypeptide may function physiologically to enhance the hepatic glucose response to insulin and that alterations in glucose metabolism seen in chronic pancreatitis may be due, in part, to a deficiency in pancreatic polypeptide. Since treatment with continuous subcutaneous infusion of pancreatic polypeptide restored the hepatic response to insulin and oral glucose tolerance to more normal levels in our animal model, administration of pancreatic polypeptide may play a therapeutic role in the treatment of certain forms of pancreatogenic diabetes.

Smooth muscle tumors of the small bowel: a case report and review of the literature

We report a rare case of peritonitis caused by perforation of smooth muscle tumor of the jejunum. In spite of having all the reported presenting symptoms of these tumors, the diagnosis was not made preoperatively. Although histopathologically diagnosis was that of a benign tumor, the subsequent course was rapid and malignant. A complete review of the literature is presented.

Sexual satisfaction among middle-aged couples: correlation with frequency of intercourse and health status

The central hypothesis of this investigation is that the greater the sexual satisfaction that a couple reports from their sexual relationship, the better will be their adjustment to the changes that occur during middle age, as reflected in their reported health status and health behaviour. Forty-seven married couples, of North African Jewish origin, were investigated, the women being in the age range 48-53 yr. The findings regarding reported frequency of sexual intercourse and sexual satisfaction of women and men separately showed that a great majority of both men (87%) and women (74%) reported a decrease in sexual activity over the 5 yr preceding the study. Most of the men (56%) said the change was due to the aging process, whereas the women's responses were more varied and included aging, worries and decrease in sexual interest or desire. Eighty percent of the men reported satisfaction in their sexual relationship with their wives, but only 43% of the women stated that they were satisfied. A significant correlation was found, for women only, between the degree of satisfaction and the change in frequency of intercourse. Among the women there was also a positive correlation between general life satisfaction and sexual satisfaction. The hypothesis in regard to mutual (couple) sexual satisfaction was not confirmed in the men. It was validated in the women in regard to only two of the four criteria used - their perception of their health status and of their well-being. The women perceived the sexual satisfaction of their husbands much more accurately than the husbands perceived that of their wives.

Relationship between biological changes and symptoms and health behaviour during the climacteric

The object of this investigation was to assess the impact of biological (hormonal) changes during the climacteric on self-reported health status and health behaviour in a group of middle-aged women. The central research question was whether or not the menopausal phase (pre, peri, post) affects the number and frequency of the symptoms a women reports, the frequency of her visits to the primary-care clinic and her perception of her general state of health. The subjects comprised a random sample of 47 women aged 48-53 yr who were judged by their family doctors to be healthy or to be suffering from a chronic disease which was inactive at the time the study was carried out. The women were chosen from among a population of married couples under investigation in a larger study. The sample was homogeneous both ethnically (all subjects born in North Africa) and in terms of social class (lower to lower-middle class). No relationships were found between menopausal phase and any of the health criteria considered. The number and frequency of symptoms was low for all the women. Only a small number of women (2-10%) reported a frequent occurrence even of symptoms that are considered to be direct consequences of hormonal changes. These findings conflict with those deriving from studies of women attending gynaecological clinics, but confirm those of other community (non-clinic) studies. The results of this study bear out the general theoretical conclusion that climacteric symptoms are 'psychological and cultural artifacts' rather than consequences of biological changes.

Coping with a threat to life: a longitudinal study of self-concept, social support, and psychological distress

The relationship of self-concept (self-esteem and mastery) and social support to psychological distress was studied among 68 Israeli women immediately prior to undergoing biopsy for suspected cancer (acute stress) and 3 months later for the noncancer group (everyday stress). It was predicted that women with stronger self-concepts and more social support would experience less state depression and state anxiety during the acute crisis than women with weaker self-concepts and less social support. It was further predicted that self-concept would be more critical than social support due to the acute nature of the event. Finally, self-concept was predicted to be related to psychological distress both during the acute and everyday stress situations (a direct effect), while social support was predicted to be related to psychological distress only during the acute stress situation (a buffering effect). The hypotheses were generally confirmed. However, self-concept and social support were seen as complexly related to psychological distress during the acute phase, one not necessarily being more critical than the other. The selective employment of available resistance resources to fit the situation and implications for preventive intervention were discussed.