Endoscopic repair of a complete post-radiation esophageal obstruction.

We describe a 64-year-old man with squamous cell carcinoma of the esophagus who presented with an obstruction of the esophagus following radiation therapy and chemotherapy. Initial upper gastrointestinal barium swallow studies showed a complete stoppage of the barium column, not unlike that of a congenital esophageal atresia. Therapeutic endoscopy was performed using a two-endoscope, two-operator system that reestablished patency of the esophagus. Repeated endoscopy was then used to continue esophageal dilation with eventual placement of a permanent stent. A video and a comprehensive review of the literature regarding combined antegrade-retrograde dilation techniques used to date are also provided.

Timing of intervention does not affect outcome in acute appendicitis in a large community practice.

BACKGROUND: Surgical management of acute appendicitis remains one of the most frequent problems faced by gastrointestinal surgeons. Traditional management has emphasized urgent surgical care. Recent literature suggests delayed surgery for acute appendicitis does not affect outcome. The outcomes of patients undergoing urgent and delayed appendectomy in a large community surgical practice are compared. METHODS: All patients undergoing appendectomy between August 2002 and May 2007 were reviewed retrospectively. The data were gathered from a large community surgical practice. Patient demographics, treatment times, and surgical, pathologic, and postsurgical outcomes were documented. RESULTS: A total of 1,198 patients underwent appendectomy (575 female/623 male). The mean time to surgical intervention was 7.1 hours (range, 1-24 h). The percentage of patients undergoing laparoscopy versus open versus surgical conversion was 63%, 33%, and 4%, respectively. The percentage of patients with acute appendicitis versus perforated acute appendicitis versus negative exploration was 77%, 14%, and 8.5%, respectively. Postoperative wound or intra-abdominal septic complications were observed in 5.3% and 2.6% of patients, respectively. There was no correlation between the duration of symptoms or time to surgical intervention and surgical approach, pathologic outcome, length of stay, or postoperative septic complications. CONCLUSIONS: Outcome variables documented in this study were independent of duration of symptoms or time to surgical intervention. This would suggest that short delays in surgical intervention for acute appendicitis are well tolerated. Outcome is related more clearly to the severity of the acute appendicitis at presentation.

Viability of endoscopic and excisional treatment of early rectal carcinoids.

With the advent of endoscopy, the incidence of rectal carcinoid tumors has not only risen, but the majority are localized at presentation. This has led to excisional and/or ablative therapy in lieu of radical resections. A single institute's experience with rectal carcinoids was reviewed to determine the impact this approach has had on outcomes, and evaluate any selection criteria for optimizing patient survival. A single institute's tumor registry was retrospectively queried, identifying 14 patients with rectal carcinoid tumors over a 28-year period. The mean age at diagnosis was 52.1 +/- 14.4 years. Six of the 14 patients were female. Presenting symptoms included a change in bowel habits in six (38%), rectal bleeding in six (38%), and abdominal pain or distention in five (31%) patients. No patient had symptoms consistent with carcinoid syndrome. The rectal carcinoids were a mean 9.2 +/- 3.4 cm from the anal verge and a mean 9 +/- 6 mm in size. Endoscopic and/or transanal excision/fulguration techniques treated 11 (79%) patients, whereas two (14%) patients underwent a low anterior resection (LAR). Surveillance entailed periodic endoscopy for a median 65 months (range 8-281). No patient developed recurrent carcinoid disease for a 20-year overall survival of 70%.

Genetic conditions associated with intestinal juvenile polyps.

Juvenile polyps are hamartomatous polyps found primarily in infants and children, and in association with juvenile polyposis (JP; OMIM #174900), Cowden syndrome (CS; OMIM #158350), and Bannayan-Riley-Ruvalcaba syndrome (BRRS; OMIM# 153480). Although solitary juvenile polyps are benign lesions, when present in JP patients they may lead to gastrointestinal cancers. Germline mutations in MADH4 and BMPR1A predispose to JP, and both genes are involved in TGF-beta superfamily signaling pathways. In CS and BRRS, juvenile polyps are a less consistent feature, and CS patients are at risk for breast and thyroid cancers. Mutations of the tumor suppressor gene PTEN have been found in the germline of both CS and BRRS patients. Despite different underlying genetic mechanisms, these and other syndromes share the same phenotypic feature of juvenile polyps.

Laparoscopic splenectomy for treatment of splenomegaly.

BACKGROUND: Laparoscopic splenectomy presents an advantage over open splenectomy, resulting in shorter hospital stay, decreased blood loss, and fewer operative and postoperative complications. Splenomegaly has long been considered a contraindication for laparoscopic splenectomy; however, in the hands of an experienced surgeon, this technique can be effectively applied to the treatment of splenomegaly. METHODS: Records for patients undergoing laparoscopic splenectomy for splenomegaly between 2000 and 2003, performed by a single surgeon in three community-based hospitals, were reviewed and demographic, operative, and postoperative data compiled. Preoperative diagnoses included B cell lymphoma, hemolytic anemia, and chronic lymphocytic leukemia. RESULTS: Seven patients underwent laparoscopic and hand-assisted laparoscopic splenectomy for splenomegaly during this time period. Splenic weights ranged from 410 to 3,100 g, and average operative time was 86.6 minutes. Estimated blood loss ranged from 50 to 350 ml; average hospital stay was 4.4 days. Two postoperative complications, ie, postoperative bleeding and superficial wound breakdown, were noted. CONCLUSIONS: Laparoscopic and hand-assisted laparoscopic splenectomy are effective methods for treatment of splenomegaly.

Mechanisms of impaired gallbladder contractile response in chronic acalculous cholecystitis.

The mechanisms involved in the impaired gallbladder contractile response in chronic acalculous cholecystitis are unknown. To determine the mechanisms that may lead to impaired gallbladder emptying in chronic acalculous cholecystitis, gallbladder specimens removed during hepatic resection (controls) and after cholecystectomy for chronic acalculous cholecystitis were attached to force transducers and placed in tissue baths with oxygenated Krebs solution. Electrical field stimulation (EFS) (1 to 10 Hz, 0.1 msec, 70 V) or the contractile agonists, CCK-8 (10(-9) to 10(-5)) or K(+) (80 mmol/L), were placed separately in the tissue baths and changes in tension were determined. Patients with chronic acalculous cholecystitis had a mean gallbladder ejection fraction of 12% +/- 4%. Pathologic examination of all gallbladders removed for chronic acalculous cholecystitis revealed chronic cholecystitis. Spontaneous contractile activity was present in gallbladder strips in 83% of control specimens but only 29% of gallbladder strips from patients with chronic acalculous cholecystitis (P < 0.05 vs. controls). CCK-8 contractions were decreased by 54% and EFS-stimulated contractions were decreased by 50% in the presence of chronic acalculous cholecystitis (P < 0.05 vs. controls). K(+)-induced contractions were similar between control and chronic acalculous cholecystitis gallbladder strips. The impaired gallbladder emptying in chronic acalculous cholecystitis appears to be due to diminished spontaneous contractile activity and decreased contractile responsiveness to both CCK and EFS.