Imaging Characteristics and Management of Infected Hepatic Hemangioma: Case-in Discussion

Hepatic hemangiomas are the most common type of benign liver tumors. We present a case of an infected hepatic hemangioma, which posed a diagnostic challenge. A 43-year-old female presented with right upper quadrant pain after blunt force trauma and intentional weight loss. CT and MRI were done, showing a posterior right lobe liver mass. Imaging characteristics were thought to be suggestive of metastatic disease, with a differential diagnosis of abscess. Drainage and biopsy of the mass revealed Streptococcus sp. infection, and pathology showed a cavernous hemangioma with inflammation. Patients presenting with systemic symptoms and an indeterminate liver mass on imaging should be evaluated for infected hepatic hemangiomas. Biopsy may be needed to rule out cancer. Management may include surgical resection; however, antibiotics and percutaneous drainage can suffice, as in this case.

Bouveret syndrome: A series of cases that illustrates a rare complication of chronic cholelithiasis

Bouveret syndrome is defined as gastric outlet obstruction secondary to the impaction of a large gallstone in the proximal gastrointestinal tract. The obstruction occurs as result of a bilio-enteric or bilio-gastric fistula. This clinical entity is a rare variant of the more commonly recognized gallstone ileus, which tends to cause small bowel obstruction of the terminal ileum. The typical presentation of Bouveret syndrome consists of nausea, vomiting and abdominal pain secondary to obstruction. Diagnosis often requires radiographic imaging with computed tomography, which typically shows pneumobilia or a cholecystoduodenal fistula. Herein is a series consisting of three cases of Bouveret syndrome involving a bilioenteric, cholecystoduodenal, and choledochoduodenal fistula, respectfully, all of which required operative management. A discussion of the current literature regarding management of this rare syndrome follows.

The use of tamsulosin to prevent postoperative urinary retention in laparoscopic inguinal hernia repair: a randomized double-blind placebo-controlled study

PURPOSE

The rate of postoperative urinary retention (POUR) in laparoscopic inguinal hernia repairs is 1-22%. POUR may cause patient anxiety, discomfort, and increased hospital costs. Currently there is no standard prophylaxis for POUR. Preoperative administration of tamsulosin has been shown to decrease POUR rates in urologic studies. This study aims to evaluate the efficacy of tamsulosin on the incidence of POUR in patients undergoing totally extraperitoneal (TEP) LIHR.

METHODS

A randomized, double-blinded, placebo-controlled trial was initiated and accrued patients from 2017 to 2019. A total of 169 males undergoing elective TEP LIHR were included. Patients were administered tamsulosin 2 h before surgery and followed for up to 24 h postoperatively for episodes of POUR. Analysis was performed to quantify the association between patient, surgical, and perioperative factors with POUR.

RESULTS

The overall rate of POUR was 9%. There was no difference in the rate of POUR between the placebo (9.9%) and tamsulosin groups (7.9%) (p = 0.433). Univariate analysis showed a trend toward POUR in patients with history of benign prostatic hypertrophy (BPH) (p = 0.058). Previously reported risk factors of older age, total IVF, length of procedure and opioid use were not associated with increased rates of POUR. Tamsulosin reduced the time to discharge by 4 to 68 min when compared to placebo.

CONCLUSIONS

This study suggests that preoperative administration of tamsulosin may not reduce the risk of POUR in males undergoing elective TEP LIHR. Further study with a larger sample size may be needed to show a statistically significant difference.

Hypervascular neck mass as the initial presentation of papillary thyroid cancer: A case report and review of current literature

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Papillary thyroid cancer can present as an unusual hypervascular neck mass.

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Metastasis to regional lymph nodes is a common mechanism of thyroid cancer.

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FNA can be inconclusive in majority of case reports.

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CT, angio and MRI can be very helpful in narrowing the diagnosis of thyroid cancer.

Background

Papillary Thyroid Carcinoma presenting initially as a hypervascular mass is exceedingly rare. The objective of this paper was to present the rare pathology along with the utilization of multimodal imaging to establish a correct diagnosis along with current management and review of literature.

Case presentation

We describe a 33 year old male who presented with a left-sided neck mass. CT with contrast of the neck revealed a hypervascular, ring enhancing, complex cystic lesion in the left sub-clavicular and supraclavicular neck deep to the SCM, with accompanying edema. The differential diagnosis was broad and difficult to achieve given the fine needle aspiration biopsy was inconclusive. Eventually, the patient underwent a total thyroidectomy with a left modified radical neck dissection, central neck dissection, and partial resection of sternocleidomastoid muscle.

Conclusion

A large hypervascular mass presenting as a papillary thyroid carcinoma is difficult to discern but with combination of ultrasonography, soft tissue CT and angiography imaging, along with fine needle aspiration, and possible use of MRI would be successful in narrowing down the differential list to the final diagnosis of papillary thyroid carcinoma, supporting the need for punctual surgical intervention.

Surgical Duodenotomy Following Untreated Bouveret Syndrome

Bouveret syndrome is caused by the impaction of a gallstone into the duodenum through a cholecystoduodenal fistula. This is typically followed by pyloric obstruction via retrograde migration of the stone, as opposed to anterograde migration, which can result in gallstone ileus. Bouveret syndrome usually presents with nausea, vomiting, and abdominal pain. Pneumobilia is seen on radiographic imaging. Herein, we describe a case of Bouveret syndrome where the diagnosis and treatment were delayed due to the initial patient desire for surgical intervention. Ultimately, duodenotomy was performed after several failed attempts of endoscopic stone extraction.

Prevention of Postoperative Pneumonia in Noncardiac Surgical Patients: A Prospective Study Using the National Surgical Quality Improvement Program Database

Postoperative pneumonia increases morbidity, length of stay, and hospital readmission rates. Current data support the use of perioperative chlorhexidine gluconate in elective cardiac surgery patients to prevent postoperative pneumonia. The objectives of this study were to implement a resident-driven quality improvement project and determine the efficacy of an oral care bundle in preventing postoperative pneumonia among noncardiac surgical patients. A retrospective review of postoperative pneumonia occurrences at our hospital captured by the NSQIP database from 2014 to 2016 was conducted. A pre- and postoperative pulmonary care bundle was implemented in all surgical patients undergoing general anesthesia and outcomes were tracked by NSQIP for up to 90 days postoperatively for calendar year 2017. The NSQIP-reported incidence of postoperative pneumonia at our hospital was reduced from 0.8 to 0 per cent (P = 0). The risk-adjusted smoothed rate fell from 1.17 (95% confidence interval 0.77-1.66) in 2014 to 0.33 (95% confidence interval 0.03-0.98) in 2017. We encountered multiple systematic issues while conducting this study, which led to an imbalanced compliance to the preoperative (90%) and postoperative (31%) bundle; however, there was no significant difference between these two groups. Successful implementation of a resident-driven quality project resulted in a decreased rate of postoperative pneumonia.

Prevention of Postoperative Pneumonia in Noncardiac Surgical Patients: A Prospective Study Using the National Surgical Quality Improvement Program Database

Postoperative pneumonia increases morbidity, length of stay, and hospital readmission rates. Current data support the use of perioperative chlorhexidine gluconate in elective cardiac surgery patients to prevent postoperative pneumonia. The objectives of this study were to implement a resident-driven quality improvement project and determine the efficacy of an oral care bundle in preventing postoperative pneumonia among noncardiac surgical patients. A retrospective review of postoperative pneumonia occurrences at our hospital captured by the NSQIP database from 2014 to 2016 was conducted. A pre- and postoperative pulmonary care bundle was implemented in all surgical patients undergoing general anesthesia and outcomes were tracked by NSQIP for up to 90 days postoperatively for calendar year 2017. The NSQIP-reported incidence of postoperative pneumonia at our hospital was reduced from 0.8 to 0 per cent (P = 0). The risk-adjusted smoothed rate fell from 1.17 (95% confidence interval 0.77–1.66) in 2014 to 0.33 (95% confidence interval 0.03–0.98) in 2017. We encountered multiple systematic issues while conducting this study, which led to an imbalanced compliance to the preoperative (90%) and postoperative (31%) bundle; however, there was no significant difference between these two groups. Successful implementation of a resident-driven quality project resulted in a decreased rate of postoperative pneumonia.

Eccrine Porocarcinoma Presenting as a Hand Cyst

Eccrine porocarcinoma is a rare tumor that arises from the epithelium of the eccrine ducts, with a tendency for metastatic spread and a high rate of local recurrence after excision. It was first described in 1963 by Pinkus and Mehregan and can present clinically as a nodule, erosive plaque or a polypoid growth that may ulcerate. The variable clinical appearance of these lesions can make diagnosis challenging and could delay appropriate treatment. If metastasis occurs the prognosis is poor, with a reported mortality rate of up to 80%. We report an uncommon presentation of porocarcinoma as a cyst on the dorsum of the right hand in a 37-year-old man. Only 8% of porocarcinomas occur in the upper extremity and only 3% are on the hand. Furthermore, the tumor is more common in females and mean age at diagnosis is 67 years. Treatment is with wide local excision with free tumor borders confirmed by biopsy, which has been shown to be curative in 70% to 80% of patients.

Metastatic recurrence to a solitary lymph node four years after hepatic lobectomy for primary hepatocellular carcinoma

This report describes a patient that developed recurrent metastatic hepatocellular carcinoma (HCC) to a suprapancreatic lymph node four years after being treated for primary HCC via complete left hepatectomy. Metastatic HCC was proven by pathologic confirmation. The report addresses the role of surgical resection as a treatment modality for recurrent HCC to solitary lymph nodes. The role of biological chemotherapy as adjuvant treatment is also addressed.

Central role of liver in anticancer and radioprotective activities of Toll-like receptor 5 agonist

Vertebrate Toll-like receptor 5 (TLR5) recognizes bacterial flagellin proteins and activates innate immune responses to motile bacteria. In addition, activation of TLR5 signaling can inhibit growth of TLR5-expressing tumors and protect normal tissues from radiation and ischemia-reperfusion injuries. To understand the mechanisms behind these phenomena at the organismal level, we assessed nuclear factor kappa B (NF-κB) activation (indicative of TLR5 signaling) in tissues and cells of mice treated with CBLB502, a pharmacologically optimized flagellin derivative. This identified the liver and gastrointestinal tract as primary CBLB502 target organs. In particular, liver hepatocytes were the main cell type directly and specifically responding to systemic administration of CBLB502 but not to that of the TLR4 agonist LPS. To assess CBLB502 impact on other pathways, we created multireporter mice with hepatocytes transduced in vivo with reporters for 46 inducible transcription factor families and found that along with NF-κB, CBLB502 strongly activated STAT3-, phenobarbital-responsive enhancer module (PREM), and activator protein 1 (AP-1-) -driven pathways. Livers of CBLB502-treated mice displayed induction of numerous immunomodulatory factors and massive recruitment of various types of immune cells. This led to inhibition of growth of liver metastases of multiple tumors regardless of their TLR5 status. The changed liver microenvironment was not, however, hepatotoxic, because CBLB502 induced resistance to Fas-mediated apoptosis in normal liver cells. Temporary occlusion of liver blood circulation prevented CBLB502 from protecting hematopoietic progenitors in lethally irradiated mice, indicating involvement of a factor secreted by responding liver cells. These results define the liver as the key mediator of TLR5-dependent effects in vivo and suggest clinical applications for TLR5 agonists as hepatoprotective and antimetastatic agents.

Abstract 4398: Liver is a major primary target for the Toll-like receptor-5 agonist CBLB502 providing radioprotective, antimicrobial and antitumor responses

We have previously shown that activation of Toll-like receptor 5 (TLR5) by bacterial flagellin and by pharmacologically optimized flagellin derivative CBLB502 protects mice and monkeys from lethal radiation injury to the hematopoietic and gastrointestinal systems. Here, we report that the liver is a major primary CBLB502 target organ in mice, with hepatocytes specifically showing rapid and strong NF-kB and STAT3 activation. Livers from CBLB502-treated mice showed up-regulation of numerous downstream genes encoding intracellular and secreted proteins with anti-apoptotic, anti-microbial and immunomodulatory activities. Unlike the TLR4 agonist LPS, the liver response to TLR5 agonists appears to be direct and does not involve high levels of proinflammatory cytokines. Thus, while LPS is toxic, TLR5 agonists have strong clinical potential. The importance of liver for CBLB502 radioprotective activity was confirmed by temporary occlusion of liver blood circulation which completely abrogated the protective effect of CBLB502 on hematopoietic precursor cells in irradiated mice. CBLB502 also protected liver tissue itself, increasing mouse resistance to lethal Salmonella tiphymurium liver infection and to hepatotoxic Fas agonistic antibodies. By testing CBLB502 in combination with radiation treatment of experimental mouse tumors in vivo, we demonstrated that its tissue protection properties are limited to normal tissues with no tumor protection detected in any of numerous mouse tumor models. Moreover, direct antitumor effects of CBLB502 treatment was observed in several tumor models. Comparison of the effect of CBLB502 on in vivo growth of isogenic pairs of tumor cell lines differing in their TLR5 status showed that the antitumor effect of the TLR5 agonist is TLR5 dependent and is associated with tumor infiltration by immunocytes, presumably attracted following activation of TLR5 signaling in the tumor cells. Remarkably, CBLB502 caused an immunotherapeutic effect in TLR5-negative tumors (CT26 colon adenocarcinoma and A20 lymphoma) growing as experimental liver metastases. Based on these results, we project clinical applications of CBLB502 as an anticancer immunotherapeutic drug against liver metastases independently on TLR5 status and TLR5-expressing tumors in other locations as well as supporting care drug to reduce adverse hepatotoxicity from radiation and chemotherapy.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4398. doi:1538-7445.AM2012-4398

Abstract A63: TLR5 agonist CBLB502 protects mice from Fas-mediated liver damage without protecting tumors

We have previously shown the strong radioprotective properties of the Toll-like receptor 5 (TLR5) agonist flagellin and its derivative CBLB502 in both mouse and non-human primate models (Burdelya et al., 2008, Science 320: 226–230). Because no protection has been observed in any in vitro cell model regardless of the TLR5 status of the cells, we hypothesized that the radioprotective effects of the TLR5 agonist are indirect and mediated by factors produced by primary cells responding to flagellin in the organism. Using a combination of tools, including NF-kB-responsive reporter mice and immunohistochemical determination of tissues responding to CBLB502 by NF-kB activation, we defined liver hepatocytes as the primary pharmacological targets of flagellin. Surgical exclusion of the liver from the blood circulation completely abolished radioprotection of the bone marrow hematopoietic progenitor cells by CBLB502 suggesting that the liver acts as a mediator of at least some of the effects of the TLR5 agonist. Since the induction of NF-kB is known to activate multiple pro-survival mechanisms, we further hypothesized that administration of the TLR5 agonist can result in liver resistance to otherwise toxic conditions. Mice treated with Fas agonistic antibodies were employed as a model of acute hepatotoxicity. Injection of CBLB502 showed a strong preventive effect against Fas-mediated injury rescuing all of the injected mice in contrast to complete lethality in the control groups. The ability of CBLB502 to protect the liver was also demonstrated via reduced levels of liver enzymes in the peripheral blood and caspase activation in liver extracts of mice treated with Fas agonistic antibodies. Using two syngeneic tumor models, colon adenocarcinoma CT26 and lymphoma A20, growing as liver metastases in mice, we found that CBLB502 injections not only prevented liver damage, but also suppressed tumor appearance and growth when injected with or without anti-Fas antibodies. Thus, TLR5 agonist has potential to become a new agent for liver protection and suppression of liver metastasis.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the Second AACR International Conference on Frontiers in Basic Cancer Research; 2011 Sep 14-18; San Francisco, CA. Philadelphia (PA): AACR; Cancer Res 2011;71(18 Suppl):Abstract nr A63.

Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: experience at a community based level I trauma center

INTRODUCTION

Early identification of pneumothorax is crucial to reduce the mortality in critically injured patients. The objective of our study is to investigate the utility of surgeon performed extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax.

METHODS

We prospectively analysed 204 trauma patients in our level I trauma center over a period of 12 (06/2007-05/2008) months in whom EFAST was performed. The patients' demographics, type of injury, clinical examination findings (decreased air entry), CXR, EFAST and CT scan findings were entered into the data base. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated.

RESULTS

Of 204 patients (mean age--43.01+/-19.5 years, sex--male 152, female 52) 21 (10.3%) patients had pneumothorax. Of 21 patients who had pneumothorax 12 were due to blunt trauma and 9 were due to penetrating trauma. The diagnosis of pneumothorax in 204 patients demonstrated the following: clinical examination was positive in 17 patients (true positive in 13/21, 62%; 4 were false positive and 8 were false negative), CXR was positive in 16 (true positive in 15/19, 79%; 1 false positive, 4 missed and 2 CXR not performed before chest tube) patients and EFAST was positive in 21 patients (20 were true positive [95.2%], 1 false positive and 1 false negative). In diagnosing pneumothorax EFAST has significantly higher sensitivity compared to the CXR (P=0.02).

CONCLUSIONS

Surgeon performed trauma room extended FAST is simple and has higher sensitivity compared to the chest X-ray and clinical examination in detecting pneumothorax.

Establishment of a definitive protocol for the diagnosis and management of body packers (drug mules)

BACKGROUND

'Mules' or body packers are people who transport illegal drugs by packet ingestion into the gastrointestinal tract. These people are otherwise healthy and their management should maintain minimal morbidity. In this study, experience with body packers is presented and an algorithm for conservative and surgical management is provided.

METHODS

The clinical patient database for all body packer admissions at Mary Immaculate Hospital of the Caritas Health Care Inc. from 1993 to 2005 was interrogated. 56 patients (4.5%) required admission out of a total of 1250 subjects confirmed to be body packers and apprehended by United State Customs officials at JFK International Airport, New York. The retrieved patient data were analysed retrospectively.

RESULTS

70% of the body packers were men, with a male to female ratio of 2.8 to 1. The mean age was 33 years and 52% were from Columbia. Heroin was the most common illegally transported substance (73%). 25 patients (45%) required surgical intervention, whereas 31 patients (55%) were successfully managed conservatively. Indications for intervention included: bowel obstruction, packet rupture/toxicity, and delayed progression of packet transit on conservative management. Multiple intraoperative manoeuvres were used to remove the foreign bodies: gastrotomy, enterotomy and colotomy. Wound infection was the most common complication and is associated with distal enterotomy and colotomy.

CONCLUSIONS

Men were more likely to present as body packers than women. Proximal enterotomies are preferred and multiple enterotomies should be avoided. A confirmatory radiological study is needed to demonstrate complete clearance of packets. A systematic protocol for the management of body packers results in minimal morbidity and no mortality.