Stenting the Upper/Cervical Oesophagus with a Proximal Deployment Cervical Oesophageal Stent: Technique and Outcomes.

INTRODUCTION: Proximal oesophageal stent deployment continues to provide challenges due to the proximity of the upper oesophageal sphincter and the associated subsequent complications such as globus sensation and stent migration. Patients with cervical oesophageal cancer have previously had limited stenting options available to them with a paucity of the literature describing the radiological technique for successfully placing these high-risk stents. In this paper, we present our experience using the Taewoong Niti-S CERVICAL Oesophageal Stent. MATERIALS AND METHODS: We describe our method for stent deployment highlighting the importance of pre-procedural planning in ensuring an adequate proximal landing zone for the short proximal flare of the stent. Furthermore, we outline how we have adapted our placement technique to incorporate a routine pre-dilatation stage which has optimised retrieval of the proximal to distal deployment system. RESULTS: We have placed eight cervical oesophageal stents within our institution. Contrast swallows in all the patients following stent deployment have demonstrated free flow of contrast to the stomach with all patients reporting symptomatic relief and no foreign body/globus sensation. There has been one episode of stent migration but no incidence of oesophageal perforation or haemorrhage. DISCUSSION: Evolution of stenting technique and the properties of the stents themselves are improving accuracy of stent placement in relation to the important landmark of the upper oesophageal sphincter. CONCLUSION: Stenting of cervical oesophageal malignancy has proved successful in our institution and provided symptom relief for a subset of palliative patients who were previously unable to benefit from oesophageal stenting.

Percutaneous Antegrade Colonic Stent Insertion Using a Proximal Trans-peritoneal Colopexy Technique.

INTRODUCTION: Conventionally, colonic stents are inserted with a retrograde trans-anal approach-however, stenting of right-sided or proximal transverse colon lesions may pose a challenge due to tortuosity or long distances. We report three successful cases of percutaneous antegrade colonic stenting in patients using a proximal trans-peritoneal colopexy technique. MATERIALS AND METHODS: Three patients underwent a proximal trans-peritoneal colopexy technique for antegrade colonic stent placement. The patients included three males, ages 89, 92 and 55, who were unsuitable for conventional methods. All patients had a colopexy with the aid of three gastropexy sutures performed under CT or fluoroscopic guidance and subsequent colonic access, followed by the crossing lesion and subsequent deployment of an uncovered colonic stent. A 10-Fr pigtail catheter was exchanged for the sheath, capped and left in place along with the colopexy suture anchors. RESULTS: Percutaneous antegrade colonic stent placement was technically successful in all patients with no complications. Follow-up at 10 days, a tubogram confirmed stent patency. The pigtail drain and suture anchors were subsequently removed. CONCLUSION: Antegrade colonic stenting with the use of a three point colopexy is a straightforward well-tolerated procedure and is a useful technique in a cohort of patients in whom conventional stenting has failed/is unsuitable. Additionally, we believe we have reported the first two cases involving transverse colon access for stenting.

Ultrasound-guided percutaneous retrieval of a dropped gallstone following laparoscopic cholecystectomy.

Removal of intraabdominal dropped gallstones remains a challenging problem for both surgeon and radiologist. We describe in this report a novel, minimally invasive technique to successfully remove a dropped gallstone, causing recurrent intra-abdominal infection, from a patient who had undergone laparoscopic cholecystectomy.

Self-expanding metal stents in palliative malignant oesophageal dysplasia.

Oesophageal cancer is the sixth leading cause of cancer-related death worldwide. At the time of presentation, more than half of patients with oesophageal cancer have advanced disease not eligible for curative resection. Due to this, the treatment of oesophageal malignancy is usually palliative, with the main aim to relieve dysphagia, maintain nutritional intake and occlusion of tracheoesophageal fistulas. Palliative surgery offers the optimal alleviation for oesophageal obstruction symptoms such as dysphagia and vomiting. However, due to the poor prognosis, the short survival time, the significant morbidity and mortality rate for surgical intervention, this treatment option cannot be justified to less invasive non-surgical techniques such as oesophageal stenting. Oesophageal stenting has now become the treatment option of choice for palliative oesophageal malignancy. The previously used covered plastic stents were related with high migration rates and nowadays have been superseded by self-expandable metal stents (SEMS) which comparably have significantly lower migration rates, whilst at the same time provide safe, rapid and effective symptomatic relief. Herein, we present an up to date review of the current literature regarding malignant oesophageal stenting. In particular, the authors will detail important factors in patient selection, indications, contraindications, procedural steps, complications and stent design.

Anal carcinomas: the role of endoanal ultrasound and magnetic resonance imaging in staging, response evaluation and follow-up.

Anal carcinoma is an important but rare condition, managed in specialist centres. Both endoanal ultrasound and magnetic resonance imaging (MRI) can be used in the locoregional staging and follow-up of patients with anal cancer, and both may assist in treatment planning and prognosis. Recent guidelines published by the European Society for Medical Oncology have recommended MRI as the technique of choice for assessment of locoregional disease. This paper describes the techniques for both endoanal ultrasound and MRI, and compares the relative merits and disadvantages of each in the local assessment of anal carcinoma.

Male breast carcinoma and the use of MRI.

MRI is well established in the diagnosis of female breast cancer, with an important role as a problem-solving tool in the postoperative breast and in implant evaluation. Little in the literature mentions the use of MRI in male breast cancer, with there is no clear role for its use at present. We present an unusual case of bilateral male breast carcinoma and demonstrate a similar enhancement pattern to that described in female breast cancer; we also suggest other potential applications of MRI for the male breast.

Current applications of interventional radiology.

Interventional radiology uses a range of radiological techniques to precisely and accurately diagnose and treat pathologies. This article discusses patient preparation and selection and highlights its strengths and weaknesses as well as introducing its use in each of the systems of the body.

Is there a role for pre-operative thrombocytosis in the management of colorectal cancer?

BACKGROUND: High circulating platelet counts have been associated with poor prognosis in a variety of solid tumours such as breast, renal and lung cancer. We investigated the significance of a high pre-operative platelet count on overall survival in patients with stages I-IV colorectal cancer. PATIENTS AND METHODS: 630 Consecutive patients who colorectal cancer resection between 2004 and 2007 with a full blood count taken 14 days prior to the surgery were assessed. Male:female 7:5, median (range) age 73 (40-99 years). Thrombocytosis was defined as platelet count of ≥450 × 10(9)/L. The relationship between platelet count, pathological features and overall survival was assessed. RESULTS: : Mantel-Cox regression showed that platelet count does not predict survival on multivariate analysis (p = 0.067). Thrombocytosis was present in 51/627 (8.1%) of cases. There was no statistically significant difference in mean survival (p = 0.067) observed in patients with platelet count <450 × 10(9)/L (n = 576; 95%CI: 1550.5-1405.4 SE 37.0) versus ≥450 × 10(9)/L (n = 51, CI: 1261.6-955.0, SE 78.2). There was also no correlation between Dukes stage and thrombocytosis. CONCLUSION(S): In our study, pre-operative thrombocytosis is not a prognostic indicator of survival in colorectal cancer patients regardless of pathological stage.

Rectus sheath haematoma or leaking aortic aneurysm - a diagnostic challenge: a case report.

INTRODUCTION: A rectus sheath haematoma is a rare condition that arises from the accumulation of blood within the rectus sheath from either muscular tear or rupture of the epigastric vessels. It is a known complication of either blunt abdominal trauma, anticoagulation therapy or the repetitive contraction of the rectus muscle such as paroxysms of coughing. It remains an uncommon and elusive entity and is often clinically misdiagnosed. CASE PRESENTATION: An 80-year-old British man with a known aortic aneurysm was admitted with sudden onset of right iliac fossa pain. The patient was hemodynamically stable and underwent a computed tomography scan which revealed an intact aorta and an acute rectus sheath hematoma. CONCLUSION: To the best of our knowledge, no case has previously been reported involving the diagnostic challenge of a rectus sheath hematoma in a patient with a known aortic aneurysm. Here we discuss the symptoms and signs of a rectus sheath hematoma, as well as the radiological modalities that could be utilized to reach the diagnosis.

Clostridium difficile enteritis in a patient after total proctocolectomy.

Clostridium difficile infection is associated with antibiotic therapy and usually limited to the colonic mucosa. However, it is also a rare cause of enteritis, with only a few cases reported in the literature. In the present report, the case of a 30-year-old woman with Clostridium difficile enteritis who previously had a panproctocolectomy with end ileostomy for severe ulcerative colitis is described. Previously reported cases of Clostridium difficile enteritis are also reviewed. Previous antibiotic therapy had been present in all cases and appears causative, major colonic resection is a precipitating factor. Small bowel Clostridium difficile infection should be considered in any patient with ileostomy flux/diarrhoea after major colonic surgery. If recognised early and treated aggressively the high mortality associated with Clostridium difficile enteritis may be avoided.

An unusual differential diagnosis of a left iliac fossa mass.

We present a case of decompensated alcoholic liver cirrhosis with widespread porto-systemic anastamoses that resulted in varices within the rectus muscle. A literature review reveals only two similar cases previously. Intramuscular varices may predispose to local haemorrhage, especially in those with underlying coagulopathy as a result of liver cirrhosis. Management options include optimising medical management of the underlying condition, simple analgesics, and for those at high risk of bleeding, decompression by transjugular intrahepatic porto-systemic shunting. Interim monitoring by ultrasonography is also helpful in detecting rapid increases in vascular size. In our case the patient continued to drink heavily and developed hepatic encephalopathy. Her prognosis remains poor and is currently a poor candidate for any surgical intervention.

Osseous metaplasia in an ulcerating tubular adenoma of the colon: a case report.

INTRODUCTION: Heterotopic bone is rarely found in the gastrointestinal tract. Here we report a rare case of metaplastic ossification within a benign ulcerating adenoma and review the literature concerning the aetiology. CASE PRESENTATION: A 63-year-old woman, who presented with a history of melaena, was found at colonoscopy to have a pedunculated ulcerating polyp. Histological examination demonstrated multiple areas of osseous metaplasia within the polyp stroma. CONCLUSION: Heterotopic ossification in colonic adenomas is a particularly rare phenomenon, with the majority of cases occurring within malignant lesions. The suggested mechanisms for its aetiology still remain unclear.

Large bowel obstruction due to sesame seed bezoar: a case report.

We report a case of a 79 year old man with a known benign anastomotic stricture presenting with large bowel obstruction. At laparotomy the obstruction was found to be caused by a large sesame seed bezoar. Seed bezoars are well known to cause impaction in the rectum but have never been previously reported to cause large bowel obstruction. We recommend that patients with known large bowel strictures should be advised not to eat seeds as this could ultimately lead to obstruction, ischaemia or perforation.