Polylactide bioabsorbable struts for chest wall reconstruction in a pediatric patient.

Chest wall reconstruction after pediatric tumor resection is challenging. Children have unique characteristics related to growth and prosthetic material for reconstruction must be chosen carefully. Poly-L-Lactide (PLA), a bioabsorbable prosthetic material, has been used in the plate form for reconstruction after tumor resection in children. Recently developed PLA struts have been successfully used to reconstruct pediatric chest wall deformities. This is the first description of the use of PLA rib struts to reconstruct chest wall defects after a pediatric chest wall tumor resection.

Cecal bascule herniation into the lesser sac.

Cecal bascule is a rare cause of bowel obstruction in which a mobile cecum folds anteriorly and superiorly over the ascending colon. Herein, we present the first case of internal herniation of a cecal bascule into the lesser sac through the foramen of winslow, aiming at discussing radiological findings, differential diagnosis, and surgical management of this uncommon condition. A 75-year-old female presented to the emergency room with an 18-h history of sudden onset sharp, progressively worsening abdominal pain associated with vomiting. Physical exam revealed abdominal distention and epigastric tenderness while initial laboratory tests were unremarkable. Computed tomography of her abdomen and pelvis showed a loop of distended colon within lesser sac without signs of bowel ischemia or perforation. On exploratory laparotomy, a cecal bascule was found herniating into lesser sac via foramen of winslow. Upon reduction, the cecum appeared viable therefore a cecopexy was performed without bowel resection. Unlike cecal volvulus, cecal bascule consists of no axial rotation of the bowel with no mesenteric vascular compromise and therefore ischemia would only occur from intraluminal tension or extraluminal compression from the borders of foramen of winslow. The management of internal herniation of a cecal bascule is always surgical including anatomic resection or cecopexy.

Pancreatic intraepithelial neoplasia arising from an ectopic pancreas in the small bowel.

BACKGROUND: Ectopic pancreatic tissue is relatively uncommon, and is characterized as pancreatic tissue with no contact with the normal pancreas, and with its own ductal system and blood supply. It is usually asymptomatic, and can be incidentally diagnosed by conventional imaging studies. METHOD: A 69-year-old woman with a prior history of bilateral breast carcinoma presented with ectopic pancreatic intraepithelial neoplasia (PanIN) that was identified incidentally in the small bowel during an oncological resection of a synchronous primary pancreatic adenocarcinoma, and renal cell carcinoma. RESULTS: The patient underwent subtotal pancreatectomy with splenectomy, regional lymphadenectomy, radical left nephrectomy, and small bowel resection with primary anastomosis of ectopic PanIN-2. She had an uneventful hospitalization and was discharged home on postoperative day 7. CONCLUSIONS: The occurrence of ectopic PanIN is extremely unusual with only few cases previously reported in the literature. The need for negative margins after surgical resection of ectopic PanIN lesions remains controversial.

Colorectal hepatic metastasis: Evolving therapies.

The approach for colorectal hepatic metastasis has advanced tremendously over the past decade. Multidrug chemotherapy regimens have been successfully introduced with improved outcomes. Concurrently, adjunct multimodal therapies have improved survival rates, and increased the number of patients eligible for curative liver resection. Herein, we described major advancements of surgical and oncologic management of such lesions, thereby discussing modern chemotherapeutic regimens, adjunct therapies and surgical aspects of liver resection.

Surgery for diverticulitis: a re-evaluation of the changing trends.

The surgical management of diverticulitis continues to evolve but recent literature has not qualified just how different current practice is compared with the previous era. This study aims to update the seminal paper by Rodkey and Welch regarding indications and operation types performed for diverticulitis by comparing their findings with present practice at a community based institution. The charts of 407 patients admitted with "diverticular disease" between 2005 and 2010 were identified. For each admission, patients' demographics, presentations and management were recorded. Direct comparisons were made with results from the study by Rodkey and Welch. Of the 407 admissions studied, the distribution was 335 emergency and 72 elective. Medical management alone treated 90% of emergency admissions, while 4% required additional radiologic intervention. Emergency surgery was necessary in only 6% of cases with Hartmann's procedure being the most common procedure. Recurrent diverticulitis was a prime indication for elective surgery with 96% of cases undergoing a 1-staged procedure. Compared with the previous era, the nonoperative approach to managing acute diverticulitis is now applied for the vast majority of admissions. Improved success in medically temporizing patients in the present era has allowed for a higher percentage of successful single-staged elective surgeries.

Colonoscopic perforation management by laparoendoscopy: an algorithm.

BACKGROUND AND OBJECTIVES: The role of laparoscopy in the management of iatrogenic colonoscopic injuries has increased with surgeons becoming facile with minimally invasive methods. However, with a limited number of reported cases of successful laparoscopic repair, the exact role of this modality is still being defined. Drawing from previous literature and our own experiences, we have formulated a simple algorithm that has helped us treat colonoscopic perforations. METHODS: A retrospective review was undertaken of patients treated for colonoscopic perforations since the algorithm's introduction. For each patient, initial clinical assessment, management, and postoperative recovery were carefully documented. A Medline search was performed, incorporating the following search words: colonoscopy, perforation, and laparoscopy. Twenty-three articles involving 106 patients were identified and reviewed. RESULTS: Between May 2009 and August 2012, 7 consecutive patients with colonoscopic perforations were managed by 2 surgeons using the algorithm. There were no complications and no deaths, with a mean length of stay of 4.43 days (range, 2-7 days). Of the 7 patients, 6 required surgery. A single patient was managed conservatively and later underwent an elective colon resection. CONCLUSIONS: Traditionally, laparotomy was the preferred method for treating colonoscopic perforations. Our initial experience reinforces previous views that laparoendoscopic surgery is a safe and effective alternative to traditional surgery for managing this complication. We have formulated a simple algorithm that we have found helpful for surgeons considering a laparoscopic approach to managing this condition.

Water as a contrast medium: a re-evaluation using the multidetector-row computed tomography.

Water as an intraluminal negative contrast medium produces improved image quality with reduced artefact. However, rapid absorption of oral water in the bowel relative to speed and timing of image capturing has limited its clinical application. These findings predate advances in multidetector-row computed tomography (CT). To re-evaluate differences in image quality, we studied image clarity and luminal distention between the same group of patients who received both a pancreas protocol CT (PPCT) that uses oral water and a conventional positive oral contrast scan. We reviewed 66 patients who had previously undergone both a PPCT and an oral contrast abdominal CT. CT images were independently reviewed by two board-certified radiologists who scored degree of hollow viscus distention and visualization of mural detail using a Likert 5-point scale. Results were evaluated by using the Wilcoxon-signed rank test. Student's t test was applied to evaluate the differences in radiation dosage and Spearman's correlational test was used to evaluate interrater correlation between the radiologists. In comparing the mean radiation dosage, there was no statistical difference between the two protocols, and there was good interrater association with ratios of 0.595 and 0.51 achieved for the PPCT and conventional oral scan, respectively. The Wilcoxon signed-rank test showed statistical differences in the stomach (P < 0.001) for both clarity (P < 0.001) and distention (P < 0.001), the duodenum for both clarity (P < 0.001) and distention (P = 0.02), and the ileum for distention (P = 0.02) with the PPCT having a better median score for organ clarity in the stomach and duodenum and better luminal distention in the stomach, equal distention in the duodenum, and slightly worse distention in the ileum. For the remainder of the bowel and organs evaluated, there was no statistically significant difference in the ratings between the two protocols. Using present CT scan technology, water can be an effective contrast medium causing better or equal distention in the bowel and better or equal clarity than routine barium contrast. This calls for a need to reconsider the use of water as a contrast medium in clinical practice.

A true orthotopic gastric cancer murine model using electrocoagulation.

BACKGROUND: Orthotopic mouse models of human gastric cancer represent an important in vivo tool for testing chemotherapeutic agents and for studying intraluminal factors. Currently, orthotopic mouse models of gastric cancer require an operative procedure involving either injection or implantation of tumor cells in stomach layers. The resultant tumor does not grow from the stomach's mucosal surface, so it does not mimic the human disease process. STUDY DESIGN: A low-dose gastric mucosal coagulation was done transorally in the body of stomach using a specially designed polyethylene catheter in 16 female severe combined immunodeficient mice. This was followed by the instillation of SNU-16 human gastric cancer tumor cells (1 × 10(6) cells). Five mice each were euthanized at 1 and 2 months, and 6 mice were euthanized at 3 months. Three control mice underwent electrocoagulation alone and 3 mice underwent cell line instillation alone. RESULTS: Tumors were detected in 11 of 16 experimental mice, but not in the control mice. Tumors were noted in mice at 1 month. Over time, there was an increase in tumor growth and metastasis to lymph nodes and surrounding organs. Histopathologic evaluation showed that the tumors grew from the gastric mucosa. CONCLUSIONS: Our model is easy to create and overcomes the limitations of the existing models, as the tumor arises from the stomach's mucosal layer and mimics the human disease in terms of morphology and biologic behavior. This is the first report of a true orthotopic gastric cancer murine model. This model opens new doors for additional studies that were not possible earlier.

Phosphodiesterase 5 inhibitors for lower urinary tract symptoms secondary to benign prostatic hyperplasia: a systematic review.

OBJECTIVE: • To review the evidence in support of the effectiveness of phosphodiesterase 5 inhibitors in lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). METHODS: • Relevant studies were identified by performing a literature search using MEDLINE® and The Cochrane Library®. The criteria used during the search included randomized, placebo-controlled trials of treatment for LUTS secondary to BPH using the International Prostate Symptom Score as an outcome measure. RESULTS: • Four trials that included a total of 1928 patients met the inclusion criteria. All four studies showed a statistically significant difference in the International Prostate Symptom Score, quality of life and erectile function in favour of phosphodiesterase 5 inhibitors. • No study showed a statistically significant improvement of the maximum urinary flow. • Meta-analysis of the results was not possible because of heterogeneity across the studies. CONCLUSIONS: • Phosphodiesterase 5 inhibitors used in the clinical setting can significantly improve LUTS secondary to BPH, erectile function and quality of life. Maximum urinary flow improvement is not statistically significant. • Future research should focus on pathophysiological principles and cost analysis.

Is routine nasoendoscopy warranted in epistaxis patients after removal of nasal packing?

Fiberoptic nasoendoscopy (FNE) is a powerful investigative tool in ear, nose, and throat practice in which its use in the management of epistaxis is varied among clinicians. The practice of assessing the nasal cavity after removal of nasal packs is common but its usefulness has not been evaluated. Therefore, we assessed the benefits of routine FNE after removal of nasal packs in epistaxis patients. Our study was performed retrospectively involving 62 adult patients admitted over a 6-month period between 2005 and 2006. Data regarding the emergent management of epistaxis cases on presentation, the use of FNE, and the final diagnosis and outcome of each patient were specifically investigated during the study. Anterior rhinoscopy was performed in 27 patients at initial presentation, of whom 45% (10/27) had anterior bleeding points identified. FNE examination after removal of nasal packs in eight patients yielded evidence of a posterior bleeding point in only one case (12.5%). Of those patients in whom anterior rhinoscopy revealed no anterior bleeding point at presentation (17/27), 12 patients went on to have FNE after removal of their nasal packs, and of these, 33% (4/12) of patients were found to have a posterior bleeding vessel. Overall, FNE was performed in 24 patients, of whom only 1 (1/24) had an active posterior bleeding vessel needing nasal repacking. Four patients (4/24) had prominent posterior vessels that required no intervention, 1 patient (1/24) had new pathology identified, and in the remaining 18 cases (18/24), FNE yielded no additional information to modify management. The routine performance of FNE in all epistaxis patients after pack removal does not appear to convey any additional benefit. We advocate the use of FNE when anterior bleeding has been excluded or bleeding is persistent and that careful nasal examination by anterior rhinoscopy should be the cornerstone of assessment.

Trichoptysis: a hairy presentation of a rare tumour.

We describe the case of a 17-year-old hairdresser who presented with haemoptysis and trichoptysis due to benign intrapulmonary teratoma and her surgical management. The clinical and radiological features of this rare tumour are reviewed and the symptom of trichoptysis discussed.