Major vascular and pancreatic penetrating trauma in patient with pre-existing MALS.

We report a case regarding a 24-year-old male with severe intraabdominal complex vascular lesions involving the superior mesenteric vein (SMV), portal vein (PV), inferior vena cava (IVC), the Common Hepatic and Gastroduodenal arteries (CHA and GDA) in combination with a total transection of the pancreatic neck following a single penetrating trauma to the upper abdomen. The management of the splanchnic vascular lesions were further complicated by the patient having pre-existing vascular condition known as Median Arcuate Ligament Syndrome (MALS). The MALS aspect makes this case unique and interesting to all trauma surgeons. Furthermore, this case report also reflects on the management of severe pancreatic trauma in the setting of the aforementioned vascular lesions.

[Uterine arterial embolisation in cases with bleeding non-tubal ectopic pregnancy as a new acute treatment].

Ectopic pregnancy is a potential lifethreatening condition and can be treated conservatively, with methotrexat or acute surgery depending upon the patient's condition. A 38-year-old woman was brought to the gynaecological acute ward with an ectopic pregnancy. However, the woman had a previous history of major abdominal surgery and many adhesions. In a multidisciplinary effort it was decided to perform an embolisation of the uterine artery with a good result. This case study depicts that an embolisation can be a valid treatment of an ectopic pregnancy.

Differential Impact of Anastomotic Leak in Patients With Stage IV Colonic or Rectal Cancer: A Nationwide Cohort Study.

BACKGROUND: Anastomotic leak has a negative impact on the prognosis of patients who undergo colorectal cancer resection. However, data on anastomotic leak are limited for stage IV colorectal cancers. OBJECTIVE: The purpose of this study was to investigate the impact of anastomotic leak on survival and the decision to administer chemotherapy and/or metastasectomy after elective surgery for stage IV colorectal cancer. DESIGN: This was a nationwide, retrospective cohort study. SETTINGS: Data were obtained from the Danish Colorectal Cancer Group, the Danish Pathology Registry, and the National Patient Registry. PATIENTS: Patients who were diagnosed with stage IV colorectal cancer between 2009 and 2013 and underwent elective resection of their primary tumors were included. MAIN OUTCOME MEASURES: The primary outcome was all-cause mortality depending on the occurrence of anastomotic leak. Secondary outcomes were the administration of and time to adjuvant chemotherapy, metastasectomy rate, and risk factors for leak. RESULTS: Of the 774 patients with stage IV colorectal cancer who were included, 71 (9.2%) developed anastomotic leaks. Anastomotic leak had a significant impact on the long-term survival of patients with colon cancer (p = 0.04) but not on those with rectal cancer (p = 0.91). Anastomotic leak was followed by the decreased administration of adjuvant chemotherapy in patients with colon cancer (p = 0.007) but not in patients with rectal cancer (p = 0.47). Finally, anastomotic leak had a detrimental impact on metastasectomy rates after colon cancer but not on resection rates of rectal cancer. LIMITATIONS: Retrospective data on the selection criteria for primary tumor resection and metastatic tumor load were unavailable. CONCLUSIONS: The impact of anastomotic leak on patients differed between stage IV colon and rectal cancers. Survival and eligibility to receive chemotherapy and metastasectomy differed between patients with colon and rectal cancers. When planning for primary tumor resection, these factors should be considered.

Comparison of "Nil by Mouth" Versus Early Oral Intake in Three Different Diet Regimens Following Esophagectomy.

BACKGROUND: The literature on oral intake after esophagectomy and its influence on anastomotic leakage and complications is sparse. METHODS: This retrospective study included 359 patients undergoing esophagectomy between January 2011 and August 2015. Three oral intake protocols were evaluated: regimen 1, nil by mouth until postoperative day (POD) 7 followed by a normal diet; regimen 2, oral intake of clear fluids from POD 1 followed by a normal diet; regimen 3, nil by mouth until POD 7 followed by a slow increase to a blended diet. The outcome endpoints were: (1) anastomotic leakage, (2) complications [severity and number described using the Dindo-Clavien Classification and Comprehensive Complication Index (CCI)] and (3) length of stay. A multivariate logistic regression model was obtained for CCI and anastomotic leakage using Wald's stepwise selection. RESULTS: CCI was significantly lower in regimen 3 (16 vs. 22 and 26 in regimen 1 and 2, p = 0.027). Additionally, significantly fewer patients in regimen 3 suffered from severe complications of Dindo-Clavien grade IIIb-IV (p = 0.025). The incidence of anastomotic leakage reached its lowest in regimen 3, 2%, compared to 7-9%. Multivariate analyses revealed that high American Society of Anesthesiologist score was a predicting factor for both CCI and anastomotic leakage. CONCLUSION: The study indicates that nil by mouth until postoperative day 7 followed by a slow increase to a blended diet after esophagectomy results in less severe complications and a tendency of fewer anastomotic leakages. Multiple comorbidities proved to be an important predictive factor of the postoperative course.

Microvessel density and endothelial cell proliferation levels in colorectal liver metastases from patients given neo-adjuvant cytotoxic chemotherapy and bevacizumab.

The treatment of patients with colorectal liver metastasis has improved significantly and first line therapy is often combined chemotherapy and bevacizumab, although it is unknown who responds to this regimen. Colorectal liver metastases grow in different histological growth patterns showing differences in angiogenesis. To identify possible response markers, histological markers of angiogenesis were assessed. Patients who underwent resection of colorectal liver metastasis at Rigshospitalet, Copenhagen, Denmark from 2007 to 2011 were included (n = 254) including untreated and patients treated with chemotherapy or chemotherapy plus bevacizumab. The resected liver metastases were characterised with respect to growth pattern, endothelial and tumour cell proliferation as well as microvessel density and tumour regression. Tumour regression grade of liver metastases differed significantly between untreated/chemotherapy treated patients in comparison to chemotherapy plus bevacizumab treated patients (both p < 0.0001). Microvessel density was decreased in liver metastases from patients treated with bevacizumab in comparison to those from untreated/chemotherapy-treated patients (p = 0.006/p = 0.002). Tumour cell proliferation assessed by Ki67 expression correlated to a shorter recurrence free survival in the total patient cohort. In conclusion, liver metastases from patients treated with neo-adjuvant chemotherapy and bevacizumab had significantly lower microvessel densities and tumour regression grades when compared to liver metastases from untreated or chemotherapy treated patients. This may indicate that bevacizumab treatment results in altered vascular biology and tumour viability, with possible tumour reducing effect.

The Prognostic and Predictive Value of Soluble Type IV Collagen in Colorectal Cancer: A Retrospective Multicenter Study.

PURPOSE: To investigate the prognostic and predictive biomarker value of type IV collagen in colorectal cancer. EXPERIMENTAL DESIGN: Retrospective evaluation of two independent cohorts of patients with colorectal cancer included prospectively in 2004-2005 (training set) and 2006-2008 (validation set). Plasma samples were available from 297 (training set) and 482 (validation set) patients. Type IV collagen determinations were performed using an ELISA. From the training set, 222 tumors were available for IHC. Clinical and follow-up data were retrieved from patient files and national registries. RESULTS: High levels of type IV collagen showed independent prognostic significance in both cohorts with hazard ratios (HRs; for a one-unit change on the log base 2 scale) of 2.25 [95% confidence intervals (CIs), 1.78-2.84; P < 0.0001] and 2.24 (95% CI, 1.75-2.86; P < 0.0001) for the training and validation set, respectively. The prognostic impact was present both in patients with metastatic and nonmetastatic disease. The predictive value of the marker was investigated in stage II and III patients. In the training set, type IV collagen was prognostic both in the subsets of patients receiving and not receiving adjuvant antineoplastic therapy. However, in the validation set, the prognostic effect of the marker vanished when looking at patients who received adjuvant antineoplatic therapy (HR 0.90; 95% CI, 0.42-1.93) but was still present in the group not receiving adjuvant chemotherapy (HR 2.88; 95% CI, 1.98-4.21). CONCLUSIONS: The results indicate clinical validity of type IV collagen as a prognostic biomarker in colorectal cancer, although the suggested predictive role of the marker should be validated. Clin Cancer Res; 22(10); 2427-34. ©2015 AACR.

Good results after repeated resection for colorectal liver metastases.

INTRODUCTION: Our study aim was to evaluate the perioperative events, postoperative events and survival after a second liver resection due to colorectal liver metastases (CLM), compared with a matched control group that had only undergone primary liver resection due to CLM. MATERIAL AND METHODS: Retrospective review of charts from patients having undergone a second liver resection due to CLM. A control group was identified by selecting the first liver resection due to CLM occurring after a second resection due to CLM. Twenty-four patients were hereby included in both the primary resection group (PRG) and the second resection group (SRG). The groups were compared statistically with regard to demographics, primary tumour and hepatic involvement. RESULTS: No significant differences between the groups were noted in terms of perioperative events, although there was a trend towards PRG resections involving more liver segments than SRG resections (p = 0.08). The rate of postoperative surgical complications was 17.4% in the PRG and 4% in the SRG (p = 0.18). The admission time was 10.6 days in the PRG and 8.4 days in the SRG (p = 0.71). 30-day mortality was 4% in the PRG and 0% in the SRG (p = 0.41). The five-year survival was 36% in the PRG and 42% in the SRG (p = 0.17) CONCLUSION: This study shows that a second hepatic resection due to recurrent CLM is safe and feasible. It also shows that patients undergoing a second liver resection due to CLM have five-year survival rates comparable to those of patients who have only undergone one hepatic resection due to CLM. FUNDING: Not relevant. TRIAL REGISTRATION: Not relevant.

Clinical findings confirm national guidelines regarding primary gastroscopy for upper gastrointestinal symptoms.

INTRODUCTION: This study describes unsedated transnasal oesophagogastroduodenoscopy (UT-OGD) in the office setting. Evaluation of national guidelines regarding primary endoscopy for the investigation of upper gastrointestinal (GI) symptoms was also a focus of this study. MATERIAL AND METHODS: Retrospective registration of 2,000 cases regarding demographics, symptoms, pre-endoscopic treatment, feasibility and findings. RESULTS: The proportion of males was 42%. 19% of the patients were referred due to alarm symptoms. The transnasal feasibility was 97%. Endoscopic findings: No abnormal findings (NAF) 53%, hiatal hernia 25%, oesophagitis 11%, gastric inflammation 11%, ulcer 10%, cancer 1% and others 1%. Alarm symptoms (AS) versus non-alarm symptoms (NAS): 35% of patients with AS had NAF versus 58% in the NAS group (p < 0.001). Cancer was present in 4% of the cases in the AS group versus 0.1% in the NAS group (p < 0.001). < 45 years versus ≥ 45 years: 69% of patients < 45 years had NAF versus 45% of patients ≥ 45 years (p < 0.001). Cancer was present in 0% of the cases in those < 45 years versus 1.4% in those ≥ 45 years (p = 0.002). CONCLUSION: UT-OGD in private practice had a higher proportion of females than similar procedures performed in hospital settings. Feasibility was high. Endoscopic findings were comparable to those reported by other studies, except for a lower prevalence of oesophagitis. Age < 45 years and absence of alarm symptoms were strong negative predictors for the presence upper GI cancer. Our data thus seem to confirm the Danish guideline regarding primary endoscopy for the investigation of upper GI symptoms.

[Mesenteric panniculitis is a rare inflammation of the mesenteric adipose tissue]. / Mesenterial pannikulitis er en sjælden inflammatorisk proces i mesenteriets fedtvæv.

Mesenteric panniculitis (MP) is a rare condition affecting the mesentery of the small bowel and/or colon. Obtaining a diagnosis is dependent on radiological and histological findings. With the increasing use of abdominal CT, more cases of MP will be discovered. We report a case of MP accidentally found at CT in a 64 year-old woman who was evaluated for upper abdominal discomfort. Percutaneous ultrasonography guided biopsy secured the diagnosis. There is no consensus on the treatment and management of MP. An approach guided by the patient's symptoms seems suitable.

[Intravenous or oral N acetylcysteine therapy in paracetamol poisoned patients. Should treatment guidelines be reviewed?]. / Intravenøs eller oral N-acetylcysteinbehandling til paracetamolforgiftede patienter. Er det tid til at revurdere behandlingsinstruksen?

Danish paracetamol (PCM) poisoned patients are treated with N-acetylcysteine (NAC) intravenously for 36 hours. This probably leads to overtreatment. Today, patients with poor prognoses can be identified and, in addition, NAC may have serious side effects. We reviewed the literature (route of administration, duration and timing of treatment) and found that intravenous NAC often leads to side effects (some serious), primarily when serum paracetamol is low. These patients are often only mildly poisoned and they may therefore benefit from a shorter, orally administered regimen (equally efficient and with fewer side effects than intravenously administered NAC).