Severe small intestinal bacterial overgrowth syndrome after jejunal feeding requiring surgical intervention: a case report and review of the literature.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is a condition of unknown prevalence characterized by an excessive amount of bacteria in the small bowel, typically resulting in vague gastrointestinal symptoms with bloating being most commonly reported. Here we describe a severe case of SIBO leading to small bowel necrosis requiring surgical intervention. CASE PRESENTATION: A 55-year-old Hispanic female with gastric outlet obstruction secondary to a newly diagnosed gastric adenocarcinoma, receiving neoadjuvant chemotherapy, developed bloody gastrostomy output and rapidly progressing nausea and abdominal distention 3 days after jejunostomy tube placement and initiation of jejunal enteral nutrition. Imaging revealed diffuse pneumatosis and portal venous gas. Surgical exploration confirmed segmental bowel necrosis requiring resection. Histologic findings were consistent with SIBO. CONCLUSIONS: Presentation of severe SIBO in the setting of intestinal stasis secondary to gastric outlet after initiation of enteral feeds is a rare phenomenon. Early recognition and diagnosis of SIBO is critical in minimizing patient morbidity and mortality.

Plasmoblastic lymphoma as cause of perianal fistula: a case report and literature review.

We report the case of a 33-year-old HIV-infected man who presented with a recurrent, nonhealing perianal fistula. After multiple benign biopsies, the diagnosis of plasmablastic lymphoma (PBL) eventually was made. The patient underwent chemotherapy and radiation with a complete response. Perianal fistulas are frequent in HIV-positive patients, but PBL as a cause is extremely rare. This often delays the diagnosis and treatment of this highly aggressive disease. We review the literature and discuss the pitfalls in the diagnosis and management of the disease.

Predictors of margin status after breast-conserving operations in an underscreened population.

PURPOSE: Negative margins after lumpectomy remain a prominent issue in breast surgery. The current study was performed to evaluate patient-related variables that affect risk for positive margins in an underscreened population. METHODS: A retrospective review was performed of all patients who underwent breast-conserving operations from 2001 to 2010. Sociodemographic, clinical, and treatment variables were evaluated. One millimeter from tumor to inked margin was considered a negative margin. Univariate and multivariate analyses were performed to identify variables which affect margin status after a lumpectomy. RESULTS: Over the time period evaluated, 69 patients had positive margins (31 %) and 155 (69 %) had negative margins. Overall use of screening mammography was poor (36 %). In unadjusted analysis, patients with positive margins were less likely to have undergone screening mammography (p = 0.003) and presented with a palpable mass (p = 0.01). Histopathologic variables which predicted increased risk for positive margins included larger pathologic size, greater number of pathologically involved lymph nodes, higher pathologic stage, presence of lymphovascular invasion (LVI) and extensive intraductal component (EIC), p < 0.05. In multivariate analysis, clinical stage, poor histologic grade, LVI, and EIC were associated with positive margins (p < 0.05). By contrast, use of preoperative chemotherapy was associated with attaining negative margins (p < 0.05). CONCLUSIONS: Factors associated with positive margins after lumpectomy included poor histologic grade, LVI, and EIC. Use of preoperative chemotherapy was the strongest independent predictor of lower risk for positive margins.

Intraoperative touch imprint and frozen section analysis of sentinel lymph nodes after neoadjuvant chemotherapy for breast cancer.

OBJECTIVE: To evaluate the accuracy of touch imprint and frozen section analysis of sentinel nodes after neoadjuvant chemotherapy. SUMMARY BACKGROUND DATA: Intraoperative evaluation of the sentinel node can determine the need for axillary dissection at the time of initial operation and therefore spare the patient a second operation. Little data, however, exists on the accuracy of intraoperative evaluation of sentinel nodes after neoadjuvant chemotherapy. METHODS: A retrospective chart review was performed of all sentinel node procedures for breast cancer from 2004 to 2008 at a single institution. The sentinel node procedure was done before (no-NACT) chemotherapy in 107 patients and 37 had the procedure after neoadjuvant (NACT) chemotherapy. Intraoperative analysis of sentinel nodes was performed using touch imprint and frozen section techniques. RESULTS: In the no-NACT group, intraoperative assessment by touch imprint analysis had 61% sensitivity, 100% specificity, and 87% accuracy. Frozen section analysis was similar with 74% sensitivity, 100% specificity, and 90% accuracy. In the NACT group, touch imprint analysis had 79% sensitivity, 100% specificity, and 90% accuracy. Frozen section analysis was again similar with 74% sensitivity, 100% specificity, and 83% accuracy. When the no-NACT group and the NACT group were compared, both frozen section and touch imprint analysis had similar sensitivity, specificity, and accuracy. CONCLUSIONS: Intraoperative evaluation of sentinel nodes with touch imprint and frozen section analysis in patients treated with neoadjuvant chemotherapy showed acceptable sensitivity, specificity, and accuracy. Nearly all of the misses in intraoperative evaluation were in patients with micrometastases.