Reappraisal of screening strategy in hepatitis B surface antigen-negative blood donors: Correlation with hepatitis B virus-DNA quantification.

BACKGROUND: In spite of screening for hepatitis B surface antigen (HBsAg), transfusion-associated hepatitis B virus (TAHBV) infection remains a serious public health problem due to transmission of HBV in window period and occult HBV infection. To avoid TAHBV infection, some health-care facilities have started Hepatitis B core antibody test along with HBsAg, but this leads to a lot of potential donor rejection who are not HBV infected. Our aim is to find a new protocol of donor screening to prevent TAHBV without compromising blood availability. MATERIALS AND METHODS: A total of 88 HBsAg-negative anti-HBc total positive blood donors were included in this study. All samples were also tested for anti-HBs by enzyme immunoassay and for the presence of HBV-DNA viral load by real-time polymerase chain reaction. RESULTS: A total of 88 HBsAg negative and anti-HBc, total positive blood donors were tested for anti-HBs and HBV-DNA (Qn.). Among them, 76 donors (86.4%) (males 73 and females 3) were found to be positive for anti-HBs, while rest 12 (13.6%) showed no detectable antibody against HBsAg. HBV-DNA was found to be positive in 4 (7.7%) donor samples among 52 (60%) who have anti-HBs level <100 mIU/ml, while 36 (40%) donor samples were found to have >100 mIU/ml anti-HBs antibody with no detectable HBV-DNA. CONCLUSION: HBV-DNA should be implemented as a screening test of the blood donors to prevent TAHBV infection without potential donor rejection.

Is interval appendectomy indicated after non-operative management of acute appendicitis in patients with cancer? A retrospective review from a single institution.

Interval appendectomy (IA) is a controversial subject, with little consensus on its use in patients undergoing treatment for malignancy. We sought to determine the frequency of recurrent appendicitis in cancer patients managed nonoperatively (NOM) during index hospitalization (IHA) for acute appendicitis (AA). Clinical presentation, cancer treatment, and follow-up were collected from electronic medical records of patients with CT scan-confirmed AA treated at a single institution between August 1999 and August 2009. Seventy-two of 109 AA patients underwent appendectomy during IHA; 34 of these 109 were NOM during IHA. Median index length of NOM patients' stay was six days (0-55), median age was 59 (18-80) years. Indications for NOM were presence of abscess or phlegmon (14), mild symptoms (13), high surgical risk (3), end-stage cancer (3), and patient declining surgery (1). Eight NOM patients underwent percutaneous drainage of abdominal abscess (median total duration of intravenous + oral antibiotics = 12 days [0-55]). There were six deaths (1 IHA, 5 NOM): four sepsis and two cancer progression. At a median of 19-month follow-up (range 1-103), four NOM patients surviving IHA had recurrent AA (11.7%) at two (n = 2) and three months (n = 2) after the first episode. Overall, six had IA (17.6%) one to seven months post AA; 25 remained asymptomatic, without IA. In conclusion, among NOM patients at a cancer center at IHA for AA, recurrent AA was early (<4 months) but uncommon. IA should be offered to those with recurrent symptoms, but appears to have a very limited role after several months of asymptomatic follow-up.

Lymph node yield after colectomy for cancer: is absence of mismatch repair a factor?

BACKGROUND: Nodal staging is crucial in determining the use of adjuvant chemotherapy for colon cancer. The number of metastatic lymph nodes has been positively correlated with the number of lymph nodes examined. Current guidelines recommend that at minimum 12 to 14 lymph nodes be assessed. In some studies, mismatch repair deficiency has been associated with lymph node yield. OBJECTIVE: The purpose of this work was to determine whether mismatch repair-deficient colorectal tumors are associated with increased lymph node yield. DESIGN: We queried an institutional database to analyze colectomy specimens with immunohistochemistry for mismatch repair genes in patients treated for colorectal cancer between 1999 and 2012. Before 2006, immunohistochemistry was performed at the request of an oncologist or surgeon. After 2006, it was routinely performed for patients <50 years of age. We measured the association of clinical and pathologic features with lymph node quantity. Fourteen predictors and confounders were jointly analyzed in a multivariable linear regression model. SETTINGS: The study was conducted at a single tertiary care institution. PATIENTS: Tissue specimens from 256 patients were reviewed. MAIN OUTCOME MEASURES: The correlation of tumor, patient, and operative variables to the yield of mesenteric lymph nodes was measured. RESULTS: Of 256 colectomy specimens reviewed, 94 had mismatch repair deficiency. On univariate analysis, mismatch repair deficiency was associated with lower lymph node yield, older patient age, right-sided tumors, and poor differentiation. The linear regression model identified 5 variables with independent relationships to lymph node yield, including patient age, specimen length, lymph node ratio, perineural invasion, and tumor size. A positive correlation was observed with tumor size, specimen length, and perineural invasion. Tumor location had a more complex, nonlinear, quadratic relationship with lymph node yield; proximal tumors were associated with a higher yield than more distal lesions. Mismatch repair deficiency was not independently associated with lymph node yield. LIMITATIONS: Mismatch repair immunohistochemistry based on patient age, family history, and pathologic features may reduce the generalizability of these results. Our sample size was too small to identify variables with small measures of effect. The retrospective nature of the study did not permit a true assessment of the extent of mesenteric resection. CONCLUSIONS: Patient age, length of bowel resected, lymph node ratio, perineural invasion, tumor size, and tumor location were significant predictors of lymph node yield. However, when controlling for surgical and pathologic factors, mismatch repair protein expression did not predict lymph node yield.

Colonic diverticulitis in chemotherapy patients: should operative indications change? A retrospective cohort study.

INTRODUCTION: Management of the immunosuppressed patient with diverticular disease remains controversial. We report the largest series of colon cancer patients undergoing chemotherapy and hospitalized for acute diverticulitis, to determine whether recent treatment with systemic chemotherapy is associated with increased risk for/increased severity of recurrent diverticulitis. METHODS: Retrospective cohort study of adult patients hospitalized for an initial episode of acute colonic diverticulitis at Memorial Sloan Kettering Cancer Center, 1988-2004. Outcomes in patients receiving systemic chemotherapy within one month of admission for diverticulitis ("Chemo") were compared to outcomes of patients not receiving chemotherapy within the past month ("No-chemo"). RESULTS: A total 131 patients met inclusion criteria. Chemo patients did not differ significantly from No-chemo group in terms of severity of acute diverticulitis at index admission (13.2% vs. 4.4%, respectively, p = 0.12), resumption of chemotherapy (median 2 months), failure of non-operative management (13.2% vs 4.4%, respectively, p = 0.12), frequency of recurrence (20.5% vs 18.5%), hospital length of stay (p = 0.08), and likelihood of interval resection (24.0% vs. 16.2%, respectively, p = 0.39). Chemo patients recurred with more severe disease, were more likely to undergo emergent surgery (75.0% vs. 23.5%, respectively, p = 0.03), and were more likely to be diverted (100.0% vs. 25.0%, respectively, p = 0.03). Chemo patients were significantly more likely to incur a postoperative complication (100% vs 9.1% p < 0.01) following interval resection. Overall mortality was significantly higher in the Chemo vs. No-chemo group. Median survival in Chemo patients was 3.4 years; in No-chemo patients, median survival was not reached at 10 years. CONCLUSION: Our data do not support routine elective surgery for acute diverticulitis in patients receiving chemotherapy. Non-operative management in the acute or interval setting appears preferable whenever possible.

Immunohistochemical detection of ARID1A in colorectal carcinoma: loss of staining is associated with sporadic microsatellite unstable tumors with medullary histology and high TNM stage.

AT-rich interactive domain-containing protein 1A (ARID1A), a chromatin remodeling gene recently discovered to be a tumor suppressor in ovarian cancers, has been found to be mutated at low frequencies in many other tumors including colorectal carcinoma (CRC). An association between ARID1A alteration and DNA mismatch repair (MMR) deficiency has been implicated; understanding this association may facilitate the understanding of the role of ARID1A in the various tumors. In this pilot study, we analyzed the immunohistochemical expression of ARID1A in a consecutive series of 257 CRCs that fulfilled a set of relaxed criteria for Lynch syndrome screening; 59 (23%) were MMR deficient by immunohistochemistry (44 MLH1/PMS2 deficient, 9 MSH2/MSH6 deficient, 4 MSH6 deficient, and 2 PMS2 deficient). ARID1A loss was observed in 9% (22/257) of the cohort: 24% of MMR-deficient tumors (14/59, 13 of the 14 being MLH1/PMS2 deficient) and 4% of MMR-normal tumors (8/198) (P < .05). MLH1 (mutL homolog 1) promoter hypermethylation was observed in 10 of the 13 MLH1/PMS2-deficient/ARID1A-loss tumors, indicating an association between ARID1A loss and sporadic microsatellite unstable CRCs. Among the MMR-deficient cases, ARID1A loss correlated with old age (P = .04), poor tumor differentiation (P < .01), medullary histology (P < .01), and an increased rate of nodal and distant metastasis (P = .03); these patients also trended toward a worse 5-year overall survival. Among MMR-normal tumors, no differences in clinicopathological features were detected between the groups stratified by ARID1A. In conclusion, our results suggest that ARID1A loss may be linked to a specific subset of sporadic microsatellite unstable CRCs that may be medullary but is more likely to present with metastatic disease, warranting further investigation.

Imaging in rectal cancer: magnetic resonance imaging versus endorectal ultrasonography.

Over the past several decades there have been tremendous improvements in the outcomes of patients with rectal cancer. Imaging modalities such as endorectal ultrasonography (ERUS), magnetic resonance imaging (MRI), and computed tomography scanning play a pivotal role in evaluating rectal cancer preoperatively, planning surgical procedures, and selecting patients for neoadjuvant therapy. This article provides an overview of rectal anatomy and pelvic structures relevant to preoperative assessment and surgical treatment. The technical aspects, applications, and limitations of the imaging tools currently in use are examined, focusing on MRI and ERUS.

Complications of spilled gallstones following laparoscopic cholecystectomy: a case report and literature overview.

INTRODUCTION: Gallbladder perforation is common and occurs in 6 to 40% of laparoscopic cholecystectomy procedures. In up to a third of these cases, stones are not retrieved and complications can arise many years post-operatively. Diagnosis can be difficult and patients may present to many specialties within medicine and surgery. We seek to present our case and review the literature on prevention and management of "lost" stones. CASE PRESENTATION: Our patient is a 77-year-old woman who presented to the urology clinic with a loin abscess that developed five years after laparoscopic cholecystectomy. Radiological studies showed retained abdominal gallstones and an associated abscess formation. These were drained under ultrasound guidance on several occasions and the patient now suffers from chronic sinusitis. Due to her age and comorbidities, she has declined definitive surgical intervention to remove the stones. CONCLUSION: Gallbladder perforation during laparoscopic cholecystectomy is a reasonably common problem and may result in spilled and lost gallstones. Though uncommon, these stones may lead to early or late complications, which can be a diagnostic challenge and cause significant morbidity to the patient. Clear documentation and patient awareness of lost gallstones is of utmost importance, as this may enable prompt recognition and treatment of any complications.

Patient experience with gallstone disease in a national health service district hospital.

BACKGROUND: The prevalence of gallstone disease in the community makes it an important area of service in district general hospitals. Laparoscopic surgical techniques in synergy with modern imaging and endoscopic and interventional techniques have revolutionized the treatment of gallstone disease, making it possible to provide prompt and definitive care to patients. METHODS: Patients with gallstone disease were treated based on a predetermined protocol by a special-interest team depending on the patient's mode of presentation. Data were collected and analyzed prospectively. RESULTS: Our team treated 1332 patients with gallstone disease between September 1999 and December 2007. Patients (249) with acute symptoms presented through Accident and Emergency (A&E). Despite varied presentations, laparoscopic treatment was possible in all but 8 patients. The study comprised 696 patients who underwent laparoscopic cholecystectomy (LC) as in-hospital (23 hour) cases in a stand-alone center, and 257 outpatients and 379 inpatients. Sixty-seven patients with acute cholecystitis had their surgery within 96 hours of acute presentation. Seventy patients had laparoscopic subtotal cholecystectomy. The overall morbidity was 2.33% with 3 patients having residual common bile duct stones; 3 patients had biliary leak from cystic or accessory duct stumps and one had idiopathic right segmental liver atrophy; 19 had wound infections, 5 had port-site hernia. No mortalities occurred during the 30-day follow-up. CONCLUSION: We believe that prompt investigation with imaging and endoscopic intervention if needed along with LC at the earliest safe opportunity by a specialized dedicated team represents an effective method for treating gallstone disease in district general hospitals. Our experience with over 1000 patients has offered us the courage of conviction to say that justice is finally here for gallstone sufferers.

An apricot story: view through a keyhole.

BACKGROUND: Very few cases of small bowel obstruction due to ingested fruits have been described in literature, and most of these have managed by a laparotomy. Laparoscopic assisted surgery can effectively deal with such impacted foreign bodies, thereby avoiding a formal laparotomy. CASE PRESENTATION: A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. Investigations were suggestive of acute small bowel obstruction. On laparoscopy, there was an area of sudden change in calibre of small bowel with dilated proximal and collapsed distal segment in distal jejunum. A foreign body, dried undigested apricot, was extracted by mini-laparotomy. DISCUSSION: Small bowel obstruction is a frequent cause of emergency surgery, and aetiology may include food bolus obstruction. Diagnosis is usually confirmed intra-operatively. Foreign body impacted in small bowel can be removed by open or laparoscopic methods. CONCLUSION: Generally, laparotomy is performed for diagnosis and management in acute bowel obstruction, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach.