Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience

AIM

Rectal carcinoids are often inadequately resected by snare excision during colonoscopy. Transanal endoscopic microsurgery is a minimally invasive procedure with low morbidity that offers full-thickness excision with a low rate of negative margins. It presents an excellent alternative to radical surgery for mid and proximally located lesions. We report the largest United States (US) experience in the use of transanal endoscopic microsurgery for rectal carcinoids.

METHOD

Data of patients who had undergone transanal endoscopic microsurgery for rectal carcinoids were prospectively collected and retrospectively analyzed. Patient and tumour characteristics, operative and perioperative details, as well as oncological outcomes were reviewed.

RESULTS

Over a 12-year period, 24 patients underwent transanal endoscopic microsurgery for rectal carcinoids. Of these, six (25%) were primary surgical resections and 18 (75%) were performed after incomplete snare excisions during colonoscopy. Three (17%) patients who underwent full-thickness resection after snare excision had residual tumour on histopathological examination. Negative margins were obtained in all cases. No recurrences were noted.

CONCLUSION

Transanal endoscopic microsurgery is effective and safe for the surgical resection of rectal carcinoids<2 cm in diameter, with typical features and located more than 5 cm from the anal verge. Transanal endoscopic microsurgery can be used for primary resection or for resection after incomplete colonoscopic snare excision.

Use of sentinel node lymphoscintigraphy in malignant melanoma

Lymphoscintigraphy is a sensitive, inexpensive, relatively noninvasive method of identifying lymphatic drainage patterns and sentinel lymph nodes in patients with malignant melanoma. Lymphoscintigraphy with filtered technetium-99m sulfur colloid allows prompt visualization of the lymphatic system, produces high-quality images, and delivers a low radiation dose to the patient. In addition, good regional lymph node retention is seen with filtered Tc-99m sulfur colloid, improving the success rate of intraoperative gamma probe localization. In combination with surgical localization, lymphoscintigraphy allows preoperative and intraoperative identification of the sentinel node in patients with intermediate thickness melanomatous lesions, obviating radical lymph node dissection in most patients and possibly prolonging their survival. Variables such as tumor location, type and preparation of radiopharmaceutical, injection technique, imaging technique, and prior surgical intervention influence the efficacy of lymphoscintigraphy. Nevertheless, lymphoscintigraphy is recommended as a cost-effective preoperative procedure in all patients planning to undergo elective lymph node dissection. Because of the unpredictability of lymphatic drainage, preoperative scintigraphic findings may lead to changes in surgical management.

Characteristics of Minnesota dairy farms that significantly increased milk production from 1989-1993

This study evaluated factors that affected decision making and changes within the Minnesota dairy industry. The 50 herds selected for this study had at least 75 cows registered with the Dairy Herd Improvement Association in 1993 and were selected based on the total percentage increase in milk production on the farm from 1989 to 1993. These 50 herds had a mean herd size of 131 cows and a mean milk production of 8807 kg per cow in 1993. On average, from 1989 to 1993, the surveyed herds increased their total milk output by 90%, increased their herd size by 51 cows, and increased mean herd milk production by 926 kg. Of the farms, 50% were partnerships or family corporations, and 50% were owned by a single family. The surveyed producers were 39 yr of age on average. During the period studied, the use of free-stall housing increased from 36 to 48%, use of the milking parlor increased from 32 to 54%, and use of tie stalls decreased from 42 to 28%. The daily hauling of manure decreased from 34 to 20% on these farms. The use of hired labor increased by a mean of 0.61 full-time workers and 0.34 part-time workers. Strategies for herd growth included internal growth (no purchased animals), 24%; the purchase of cows, 24%; and the purchase of springers, 52%. Over 90% of the producers were very satisfied or somewhat satisfied with dairy farming operations, but only 33% of the spouses were very or somewhat satisfied. Satisfaction levels were positively associated with overall production levels on the farms. Although there is no single established pattern for the expansion of herds, practices utilized by those producers surveyed can be scrutinized by others who are contemplating expansions to determine what might be efficient for their operations.

Three-dimensional models of the abdominal vasculature based on helical CT: usefulness in patients with pancreatic neoplasms

Three-dimensional (3D) rendering of helical (spiral) CT data is used increasingly to show abnormalities of the vascular system [1]. Abdominal applications have focused mainly on the arterial system, but the portal venous system also can be depicted effectively with this technique. In patients with pancreaticobiliary neoplasms, axial display of helical CT images generally allows accurate staging of the lesion [2, 3]. Many surgeons, however, continue to request arteriography to specifically look for evidence of vascular encasement that would preclude surgery or vascular anomalies that would alter the surgical approach [4, 5]. The purpose of this essay is to illustrate the value of 3D rendering of CT data in providing useful information for surgical planning and showing the extent of vascular involvement by tumor.

Sphincter-saving alternatives in the management of adenocarcinoma involving the distal rectum. 5-year follow-up results in 40 patients

We reviewed the treatment outcome in 40 patients undergoing full-thickness local excision (seven patients) or electrocoagulation (33 patients) for adenocarcinoma of the rectum. Patients were followed up for a minimum of 5 years or until death (mean follow-up, 7.6 years). Twenty-two patients (55%) survived 5 years free of disease or were free of disease at the time of death due to other causes following local treatment. Eight (62%) of 13 patients with persistent or locally recurrent disease were successfully treated with additional local therapy, rectal resection, or combined radiation therapy and chemotherapy. Overall, 30 (75%) of 40 patients embarking on a program of local treatment for carcinoma of the rectum survived 5 years free of disease or were free of disease at the time of death due to other causes.

Sphincter-saving alternatives for treatment of adenocarcinoma involving distal rectum

In reviewing the results achieved with local treatment of carcinoma of the rectum, it becomes apparent that no single approach to the treatment of carcinoma of the rectum is optimal for all patients. As is true in patients with carcinoma of the breast and other malignant lesions, selection of the appropriate treatment alternatives for a patient with carcinoma confined to the distal rectum requires accurate preoperative staging of the disease. Physicians interested in treating patients with carcinoma of the rectum should have the full spectrum of treatment alternatives available.

Crohn's disease and carcinoma: increasing justification for surveillance?

Carcinoma of the colon that arises in patients with Crohn's disease is being reported with increasing frequency. To help clarify the nature of this association, records of 25 patients with Crohn's disease and colorectal carcinoma seen from 1957 through 1989 were reviewed. One patient had leiomyosarcoma of the rectum, and two patients had the onset of Crohn's disease after the diagnosis and treatment of colorectal carcinoma. Therefore, 22 patients were available for complete retrospective analysis. The median age at diagnosis of Crohn's disease was 37 years (range, 15-67 years), and the median age at diagnosis of carcinoma was 54.5 years (range, 32-76 years). The median duration of symptoms preceding the discovery of colorectal carcinoma was 18.5 years (range, 0-32 years). Carcinoma arose in colonic segments with known Crohn's disease in 77 percent of patients, and six patients (27 percent) had associated colonic mucosal dysplasia. One lesion was classified as Dukes A, nine lesions were Dukes B, five lesions were Dukes C, and seven lesions were Dukes D. Patients with an onset of Crohn's disease before the age of 40 years had primarily Dukes C or D lesions and consequently poor survival. Most patients presented with nonspecific signs and symptoms, with nothing to distinguish the activity of the Crohn's disease from the presence of colorectal neoplasm. Younger patients with long-standing Crohn's disease should be considered for colonic surveillance to permit earlier diagnosis and treatment of potential colorectal carcinoma.

Office management of common anorectal problems

Common anorectal problems can often be treated in the office setting. Hemorrhoids are usually relieved with use of bulk laxatives or stool softeners; if this fails, coagulation or rubber band ligation may be effective. Surgical therapy is still preferred for third- and fourth-degree hemorrhoids. Perirectal and perianal abscesses are treated by drainage, but in up to 30% of cases a fistula occurs following treatment. Surgical evaluation is appropriate when a fistula is suspected. Acute anal fissures often heal with conservative management; sphincterotomy may be needed for chronic fissures. Anal warts tend to recur and require several treatment sessions with use of ablative techniques.

Sepsis-induced diastolic dysfunction in chronic canine peritonitis

A chronic canine model of hyperdynamic sepsis was achieved by cecal ligation and puncture (SEP) in conjunction with continuous high-volume fluid resuscitation. Cardiac function was evaluated using ultrasonic cardiac crystals placed across the major, minor, and wall thickness axes of the left ventricle, together with simultaneous arterial and ventricular pressure measurement. Seven to 10 days after crystal implantation, animals were randomized to either SEP (n = 10) or sham laparotomy control (n = 7). SEP dogs became febrile and lethargic, with elevated leukocyte counts and positive blood cultures for enteric organisms. They were also hyperdynamic, with significant increases in heart rate and cardiac output and a fall in systemic vascular resistance. Systolic blood pressure, stroke volume, and ejection fraction remained stable. Relative to control, the SEP group demonstrated a significant reduction in intrinsic contractility during systole, as measured by the heart rate and load-independent index of left ventricular performance Emax (P less than 0.01), confirming the observations of others. In addition, however, diastolic function also became markedly abnormal with a progressive increase in unstressed and end-diastolic ventricular volumes (P less than 0.05) and a significant decrease in myocardial compliance as quantitated by transmural pressure vs. volume-strain analysis. It is hypothesized that this increase in diastolic volume helps to maintain global cardiac performance during the hyperdynamic response to sepsis in the presence of adequate volume support.

Giant inguinal hernia in a 5-year-old boy with hydrocephalus: a case report

A case of giant left inguinal hernia in a 5-year-old boy is presented. The patient had multiple neurosurgical procedures performed in the neonatal period for spina bifida and hydrocephalus, including the placement of a ventriculoperitoneal shunt. The hernia was first noted during this period but was not repaired, and the child was lost to follow-up until age 5. The hernia underwent progressive enlargement over this interval, and the eventual development of gastrointestinal symptoms prompted the "rediscovery" of the defect. The majority of the child's intestines were within the hernia, with at least partial loss of domain. The unique preoperative and postoperative management of this difficult problem is described.

Cardiac beta-adrenergic responsiveness is well preserved in moderate protein calorie malnutrition from semistarvation

Twenty-one dogs underwent instrumentation of the left ventricle with ultrasonic dimension to study the effects of acute protein-calorie malnutrition on the adrenergic responsiveness of the heart. This study allowed a chronic and dynamic measurement of the major cardiac axes and the ventricular wall thickness, which in turn can be used to derive sophisticated measurements of global and intrinsic left ventricular function. Of the 21 dogs, 11 received a protein- and calorie-deficient diet designed to achieve a mean weight loss from a baseline of 20-25% over a 4-week period. The other 10 dogs received a normal diet. Dogs were also randomized to receive either acute propranolol beta-receptor blockade (n = 9) or acute isoproterenol beta-receptor stimulation (n = 12) during their baseline studies. Of the nine dogs given propranolol, five were subsequently malnourished and four served as controls. Of the 12 given isoproterenol, six were rendered malnourished and six were controls. All dogs were studied at both baseline and 4 weeks and received drugs in an identical fashion during both studies. The significant changes with malnutrition consisted of decreases in heart rate, cardiac mass, and left ventricular wall thickness. The degree of change in stroke volume, ejection fraction, cardiac output, dp/dt, and Emax (index of left ventricular contractility), with the administration of propranolol or isoproterenol was unaltered by malnutrition. These data support the contention that moderate protein-calorie malnutrition is well tolerated in instrumented, unstessed dogs and that the left ventricle's capacity to respond to beta-stimulation and to tolerate beta-blockade is largely unimpaired.

Papillary thyroid cancer in identical twins

The cases of a set of 19-year old monozygotic twins are presented--the first report of thyroid cancer of follicular origin occurring in identical twins. This report includes a brief review of reports of cancer of various sites in twins. Several studies and reports emphasize genetic factors influencing the concurrence of cancer. Other reports downgrade the likelihood of genetic influence in cancer.

Partial biliary obstruction caused by chronic pancreatitis. An appraisal of indications for surgical biliary drainage

This paper presents a retrospective review of 38 patients with intrapancreatic bile duct strictures secondary to chronic alcoholic pancreatitis. The strictures were identified by endoscopic retrograde cholangiopancreatography (ERCP). All patients with pancreatic cancer and gallstone pancreatitis were excluded. The mean alkaline phosphatase and total bilirubin values were 344 +/- 57 IU/dl and 4.4 +/- 0.7 mg/dl, respectively. The mean stricture length was 3.9 +/- 0.5 cm, and the mean common bile duct (CBD) diameter was 1.8 +/- 0.2 cm. The degree of bilirubin and alkaline phosphatase elevation did not correlate with stricture length or the severity of bile duct dilatation. Eighteen of the 38 patients received surgical biliary drainage (BD) as part of their initial therapy, and 20 patients did not. Liver function tests, intrapancreatic stricture length, and the degree of proximal CBD dilation were comparable in these two groups. Patients not undergoing BD did well clinically as only one patient required BD over an average follow-up period of 3.8 years. In conclusion, bypass of these strictures is usually unnecessary, and most patients may be safely treated without operation.

Left ventricular function in malnutrition

Twenty-one dogs were chronically instrumented with ultrasonic left ventricular dimension transducers and micromanometers to elucidate the effects of acute protein-calorie malnutrition on cardiac function. Ten dogs received a regular diet for 3 wk, whereas 11 dogs received a protein-calorie-deficient diet designed to achieve a mean weight loss of 20-25% over a 3-wk period. Studies of cardiac function were performed in awake intact animals at base line (1 wk postoperatively) and after 3 wk. In the malnourished dogs, cardiac mass was lost in proportion to total body mass loss. Mean cardiac mass fell from 115 to 91 g. This was largely due to wall thinning in this group. Heart rate dropped from 125 to 79 beats/min with malnutrition and ejection fraction increased from 29.8 to 34.6%. Cardiac output fell from 2.98 to 2.38 l/min, but cardiac index normalized to body surface area was unchanged. No significant changes in hemodynamics were observed in the control group. In the malnutrition group, global ventricular contractility, as measured by the load-independent index of systolic function or the slope of linear relationship between end-systolic pressure and end-systolic volume (EmaxPV), decreased slightly from 3.56 to 2.81 mmHg/ml (P = 0.07). However, Emax calculated from circumferential stress and strain data was unchanged. This indicates that depressed contractility was due to loss of cardiac muscle mass rather than any change in the myocardium per se. Response to beta-adrenergic stimulation was unchanged with starvation. Acute protein-calorie malnutrition causes significant cardiac atrophy that is reflected in decreased cardiac output and slightly reduced contractility but not in intrinsic properties of the myocardium.

Modus operandi for a picture archiving and communication system

The authors describe their 18 month experience operating an all digital nuclear medicine department, which led to the development of a system that allows multiple users to access patient reports and images through terminals located in various parts of the hospital. All user interactions are mediated through protocols that automatically acquire, process, display, and archive data. This approach offers distinct advantages over film and paper methods and is applicable in theory to any digital image format.

Radioimmunoassay and the hormones of thyroid function

Radioimmunoassay (RIA) has provided the tools for wide-reaching investigations that have changed and continue to change many important concepts of thyroid physiology and pathosphysiology. The RIA vor human thyrotropin (TSH) was developed in 1965; development of the RIA for triiodothyronine (T3), thyroxine (T4), thyroxine-binding globulin (TBG), and, recently, thyrothropin-releasing hormone (TRH) and thyroglobulin (Tg) followed. The capacity to measure nanogram and picogram concentrations with relative ease and speed has permitted the demonstration of dynamic relationships of the intrathyroidal and circulating thyroid hormones to each other and to the pituitary and hypothalamic regulating hormones. Evidence for the presence of cross-influences between TRH and other hypothalamic regulating hormones on the secretion of pituitary hormones has accumulated. The impact of the new information on clinical practice is now becoming evident. There is new appreciation of the value of assaying serum T3 and TSH concentrations in the clinical management of patients with disturbed function of the thyroid, pituitary, or hypothalamus. The necessary components for RIA performance can be purchansed separately or in kit form from commercial sources. With appropriate quality-control procedures, precise, sensitive, and reliable data can be generated. Awareness of the specific technical problems relating to the RIA of these hormones is absolutely necessary to assure reliable results. The availability of kits or their components permits the performance of these studies in the community hospital and in reliable commercial-service laboratories.