Use of Sodium Hyaluronate/Carboxymethylcellulose Bioresorbable Membrane in Loop Ileostomy Construction Facilitates Stoma Closure.

BACKGROUND: Loop ileostomy is a common adjunct to surgical procedures for low rectal cancers and inflammatory bowel disease. Ileostomy closure through a limited incision can be technically challenging. We hypothesized that placing a sodium hyaluronate/carboxymethylcellulose (SH/CMC) bioresorbable membrane at loop ileostomy creation would decrease stoma closure time without increasing morbidity. METHODS: In a retrospective review at a single institution with 6 board-certified colorectal surgeons, patients with loop ileostomy creation and closure between September 1999 and December 2011 were grouped based on SH/CMC placement at ileostomy creation. Data were abstracted for age, sex, body mass index (BMI), primary diagnosis, length of surgery, staff surgeon, interval between surgeries, and postoperative morbidity. The primary endpoint was the length of the surgery for ileostomy closure. Secondary outcome measures were length of stay, wound infection rate, and other complications. RESULTS: A total of 293 patients were identified. Group 1 (with SH/CMC) included 146 patients, and Group 2 (without SH/CMC) included 147 patients. The groups were matched according to age, sex, BMI, interval between creation and closure, and indication for surgery. The average surgical time for closure was significantly shorter in Group 1 (46.4 minutes ± 2.7) compared to Group 2 (60 minutes ± 2.3) (P=0.0001). We found no difference between the groups in length of stay, wound infection rate, or complication rate. CONCLUSION: The use of SH/CMC in loop ileostomy creation significantly decreases the operative time required for stoma closure with no increase in the complication rate.

Protecting Nipple Perfusion by Devascularization and Surgical Delay in Patients at Risk for Ischemic Complications During Nipple-Sparing Mastectomies.

BACKGROUND: Indications for nipple-sparing mastectomy (NSM) are expanding; however, high-risk patients have more ischemic complications. Surgical devascularization of the nipple-areolar complex (NAC) prior to NSM can reduce complications. This study reports perfusion patterns and complications in high-risk patients undergoing 2-stage NSM. METHODS: Surgical devascularization of the NAC was performed 3-6 weeks prior to NSM in 28 women. Risk factors included ptosis, obesity, smoking, prior breast surgery, and radiation. Using indocyanine green (ICG)-based fluorescence and an infrared camera, blood inflow was visualized intraoperatively. NAC perfusion patterns were classified as: V1, underlying breast; V2, surrounding skin; V3 = V1 + V2, or V4, capillary fill following devascularization. Ischemic complications were analyzed. RESULTS: Baseline perfusion for 54 breasts was 35 % V1, 32 % V2, and 33 % V3. Increasing ptosis was associated with V1 pattern: 86 % for grade 3, 31 % for grade 2, and 18 % for grade 1. Postdevascularization epidermolysis was observed in 63 % of V1 baseline, 41 % of V2, and 22 % of V3 (P = .042) and after NSM in 26 % for V1, 7 % for V2, and 6 % for V3 (P = .131). Ptosis was significantly associated with epidermolysis postdevascularization (P = .002) and NSM (P = .002). Smoking and BMI ≥30 were related to increased ischemic complications. Two or more risk factors were associated with postdevascularization ischemic changes (P = .026), but were not significant after NSM. Nipple loss was not observed, but 2 patients underwent partial areolar resection. CONCLUSION: Adaptive circulatory changes after devascularization allow tissues to tolerate the additional ischemic challenge of mastectomy. Our findings support extending 2-staged operations to high-risk women previously considered unsuitable for NSM.

Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies.

The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.

The critical roles of tumor-initiating cells and the lymph node stromal microenvironment in human colorectal cancer extranodal metastasis using a unique humanized orthotopic mouse model.

Colorectal cancer (CRC) is the second-most common cause of cancer-related mortality. The most important prognostic factors are lymph node (LN) involvement and extranodal metastasis. Our objective is to investigate the interactions between CD133(+)CXCR4(+) (CXC receptor 4) colorectal cancer tumor-initiating cells (Co-TICs) and the LN stromal microenvironment in human CRC extranodal metastasis. We established a unique humanized orthotopic xenograft model. Luciferase-tagged CRC cell lines and human cancer cells were injected intrarectally into nonobese diabetic/SCID mice. Mesenteric LN stromal cells, stromal cell line HK, or CXCL12 knockdown HK (HK-KD-A3) cells were coinoculated with CRC cells. Tumor growth and metastasis were monitored by bioluminescent imaging and immunohistochemistry. We found that this model mimics the human CRC metastatic pattern with CRC cell lines or patient specimens. Adding LN stromal cells promotes CRC tumor growth and extranodal metastasis (P < 0.001). Knocking down CXCL12 impaired HK cell support of CRC tumor formation and extranodal metastasis. When HK cells were added, sorted CD133(+)CXCR4(+) Co-TICs showed increased tumor formation and extranodal metastasis capacities compared to unseparated and non-Co-TIC populations. In conclusion, both Co-TIC and LN stromal factors play crucial roles in CRC metastasis through the CXCL12/CXCR4 axis. Blocking Co-TIC/LN-stromal interactions may lead to effective therapy to prevent extranodal metastasis.