Effects of ethnicity and socioeconomic status on surgical outcomes from inflammatory bowel disease.

PURPOSE: Evidence suggests that ethnicity and socioeconomic status of patients with chronic diseases influence their healthcare outcomes. The aim of this study was to assess the impact of these factors on the surgical outcome of patients with inflammatory bowel disease (IBD) over a 15-year period. METHODS: A retrospective observational study investigated IBD patients operated on at an NHS Trust between 2000-2015, with follow-up data until 2020. Logistic regression models were used to determine the relationship between ethnic minority background and Index of Multiple Deprivation (IMD) on outcomes including requirement for intra-abdominal surgery, permanent stoma, re-do surgery and surgical complications, accounting for age, gender, smoking history and biologic treatment. RESULTS: There were 1,620 patients (56.7% ulcerative colitis (UC) and 43.3% Crohn's disease (CD)). Median age was 32 years, and 49.6% were female. Patients with an ethnic minority background accounted for 20.6%. Within 5 years of first presentation, 369 patients required intra-abdominal surgery, 95 permanent stomas and 107 re-do surgery. For CD patients, younger age at diagnosis, female patients, those with an ethnic minority background, higher IMD quintile, smoking history and biologic treatment were more likely to have intra-abdominal surgery. Ethnic minority background and higher IMD score were further associated with surgical complications for CD but not UC patients. CONCLUSION: Ethnic minority status and socioeconomic deprivation were associated with worse surgical outcomes within our cohort of IBD patients. These findings may stimulate discourse regarding the strategic planning of equitable healthcare services.

A feasibility study of circulating melanoma cells in the perioperative context of hyperthermic isolated limb perfusion (HILP) in 20 patients.

INTRODUCTION: Hyperthermic Ιsolated Limb Perfusion using melphalan and TNFα (TM-HILP) is a regional chemotherapy method for advanced melanoma. PURPOSE: To explore the feasibility of the study of Circulating Melanoma Cells (CMCs) in the context of acute physiological changes induced by TM-HILP and their association with oncological outcomes. METHODS: The study included 20 patients undergoing TM-HILP for unresectable in-transit melanoma of the limbs, stage III(B/C/D). CMCs in the peripheral blood were analyzed at 5-time points from the preoperative day until day 7 from surgery using the following biomarkers: MITF, Tyrosinase mRNA, Melan-A and S100b, through quantitative RT-PCR. RESULTS: No CMCs according to Tyrosinase and Melan-A biomarkers were found in any sample. Friedman test showed significant alterations perioperatively for MITF (p < .001) and S100b (p = .001). Pairwise tests showed a significant increase of MITF levels on postoperative day 7 compared with postoperative day 1, intraoperative and preoperative levels (p < .05). Pairwise tests for S100b showed a significant difference between intraoperative sample and postoperative day 7 (p < .0001). Patients who experienced a complete response to TM-HILP (n = 12) had higher mean levels of MITF and the difference was significant at the time point immediately after the operation (0.29 ± 0.27 vs. 0.06 ± 0.06, p = .014) and on postoperative day 1 (1.48 ± 2.24 vs. 0.41 ± 0.65, p = .046). There was no association of MITF or S100b levels with 4-year disease specific survival. CONCLUSION: TM-HILP is associated with increased levels of CMCs, but there was no association of this increase with survival. Patients with complete response to HILP demonstrate higher values of MITF shortly after the operation.

Spontaneous adrenal hemorrhage. Report of two cases and review of pathogenesis, diagnosis and management.

Adrenal hemorrhage represents a relatively rare condition, usually associated with meningococcal septicemia. It is an underestimated cause of acute decompensation, multiorgan failure and death, usually diagnosed post-mortem. Depending on its etiology adrenal hemorrhage is categorized as traumatic and non-traumatic. The technical advancement of imaging modalities, has made diagnosis and management more efficient. Assessment of hemodynamic stability, exclusion of a hormonal active adrenal tumor and assessment for adrenal insuffi¬ciency, are of cardinal importance. Angiographic embolization has contributed significantly in better outcomes as emergency laparotomy is associated with high morbidity and mortality rates. Hereby we present two cases of spontaneous adrenal hemorrhage associated with extensive retroperitoneal bleeding and hemodynamic instability. Both underwent angiography with one requiring embolization with favorable outcome. Investigation for exclusion of underlying adrenal tumor, adrenal insufficiency and follow-up imaging are presented in detail for both cases.

Hyperthermic isolated limb perfusion. The switch from Steinmann pins to Omni-tract assisted isolation.

BACKGROUND: Hyperthermic isolated limb perfusion (HILP) represents an alternative to amputation for patients with either in-transit melanoma or unresectable soft tissue sarcoma, entailing delivery of high-dose chemotherapy after isolation of the extremity, under hyperthermic conditions. Stabilization of the Esmarch elastic bandage is so far performed with the use of Steinmann pins. In this study, we presented our experience with HILP and demonstrated an alternative technique for limb isolation using an Omni-tract retractor instead of the traditional Steinmann pin, while comparing the two methods. METHODS: Forty patients, 28 with recurrent in-transit melanoma and 12 with locally advanced/recurrent sarcoma of the limbs, underwent HILP in a single institution and were included in the study. The Steinmann pin was applied in the first 23 cases, whereas the Omni-tract retractor was applied in the latter 17 patients. RESULTS: The median follow-up for the whole study group was 17.5 mo, whereas the overall response rate was 92.9% for melanoma and 75% for sarcoma patients. Both overall survival and local progression-free survival differed significantly between patients with complete response and those with partial response, stable disease or progressive disease. The use of the Omni-tract retractor was advantageous in every examined field, with the overall complication rate, duration of analgesic administration, and total opioid and paracetamol dose, being significantly less in the Omni-tract patient group. CONCLUSIONS: Although this study was not a randomized trial, we consider that the noninvasive application of the Omni-tract retractor will gain significant acceptance, by contributing to the reduction of HILP complications.

Large presacral tailgut cyst with a carcinoid tumor in a male: report of a case.

Tailgut cysts are developmental hamartomas found in the presacral space. They are usually detected incidentally during physical examinations or imaging studies. However, they may cause symptoms due to compression of nearby organs. Due to their potential malignant transformation, surgical resection is warranted, while routine biopsy is considered controversial because of the concern about infection of the tailgut cyst and needle-track implantation of malignant cells. The co-existence of a carcinoid in a tailgut cyst is extremely rare. Only 16 cases have been reported previously, the vast majority of which were found in females. We herein present the case of a carcinoid in a tailgut cyst found in a male patient, discuss the potential pathogenesis of tailgut carcinoids, and underline the fact that their previous consideration of the condition as a female-restricted entity should be rejected.

Obturator hernia revisited: surgical anatomy, embryology, diagnosis, and technique of repair.

Obturator hernia is the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator canal. The first case was published by de Ronsil in 1724. Obturator hernia is more common in older malnourished women due to loss of supporting connective tissue and the wider female pelvis. The hernia sac usually contains small bowel, especially ileum. It may follow the anterior or posterior division of the obturator nerve. In most cases, obturator hernia presents with intestinal obstruction of unknown cause. It may present with obturator neuralgia, as a palpable mass or, in cases of bowel necrosis, as ecchymosis of the thigh. A correct diagnosis is made in 20 to 30 per cent of cases. CT scan is considered the gold standard for diagnosis, whereas ultrasonography, contrast studies, herniography and plain films are less specific. Surgery is the only treatment option for obturator hernia. Hesitancy to intervene surgically for chronically ill patients results in high mortality. Transabdominal approach is indicated in cases of complete bowel obstruction or suspected peritonitis. The extra-abdominal approach is used in preoperatively diagnosed cases and in absence of bowel strangulation. The laparoscopic approach is minimally invasive and effectively reduces morbidity. The defect is closed using sutures, tissue flaps, or prosthetic mesh.

Perineal hernia: surgical anatomy, embryology, and technique of repair.

Perineal hernia is the protrusion into the perineum of intraperitoneal or extraperitoneal contents through a congenital or acquired defect of the pelvic diaphragm. The first case was reported by de Garangeot in 1743. Perineal hernias may occur anteriorly or posteriorly to the superficial transverse perineal muscles. Congenital perineal hernia is a rare entity. Failure of regression of the peritoneal cul de sac of the embryo is considered a predisposing factor for hernia formation. Acquired perineal hernias are primary or secondary. Primarily acquired perineal hernias are caused by factors associated with increased intra-abdominal pressure. They are more common in females as a result of the broader female pelvis and the attenuation of the pelvic floor during pregnancy and childbirth. Secondarily acquired perineal hernias are incisional hernias associated with extensive pelvic operations such as abdominoperineal resection of the anorectum and pelvic exenteration. Pain in the perineal area, intestinal obstruction, topical skin erosion, and difficulty with urination necessitate the surgical repair of a perineal hernia. This can be accomplished through transabdominal, perineal, or combined abdominoperineal approaches. The defect in the muscles of the pelvic diaphragm may be closed either with direct suturing or by using autogenous tissues or synthetic mesh.

Lumbar hernia: surgical anatomy, embryology, and technique of repair.

Lumbar hernia is the protrusion of intraperitoneal or extraperitoneal contents through a defect of the posterolateral abdominal wall. Barbette was the first, in 1672, to suggest the existence of lumbar hernias. The first case was reported by Garangeot in 1731. Petit and Grynfeltt delineated the boundaries of the inferior and superior lumbar triangles in 1783 and 1866, respectively. These two anatomical sites account for about 95 per cent of lumbar hernias. Approximately 20 per cent of lumbar hernias are congenital. The rest are either primarily or secondarily acquired. The most common cause of primarily acquired lumbar hernias is increased intra-abdominal pressure. Secondarily acquired lumbar hernias are associated with prior surgical incisions, trauma, and abscess formation. During embryologic development, weakening of the area of the aponeuroses of the layered abdominal muscles that derive from somitic mesoderm, which invades the somatopleure, may potentially lead to lumbar hernias. Repair of lumbar hernias should be performed as early as possible to avoid incarceration and strangulation. The classic repair technique uses the open approach, where closure of the defect is performed either directly or using prosthetic mesh. The laparoscopic approach, either transabdominal or extraperitoneal, is an alternative.

Global gene expression profiling of end-stage dilated cardiomyopathy using a human cardiovascular-based cDNA microarray.

To obtain a genomic portrait of heart failure derived from end-stage dilated cardiomyopathy (DCM), we explored expression analysis using the CardioChip, a nonredundant 10,848-element human cardiovascular-based expressed sequence tag glass slide cDNA microarray constructed in-house. RNA was extracted from the left ventricular free wall of seven patients undergoing transplantation, and five nonfailing heart samples. Cy3- and Cy5-labeled (and reverse dye-labeled) cDNA probes were synthesized from individual diseased or nonfailing adult heart RNA, and hybridized to the array. More than 100 transcripts were consistently differentially expressed in DCM >1.5-fold (versus pooled nonfailing heart, P < 0.05). Atrial natriuretic peptide was found to be up-regulated in DCM (19-fold compared to nonfailing, P < 0.05), as well as numerous sarcomeric and cytoskeletal proteins (eg, cardiac troponin, tropomyosin), stress response proteins (eg, HSP 40, HSP 70), and transcription/translation regulators (eg, CCAAT box binding factor, eIF-1AY). Down-regulation was most prominently observed with cell-signaling channels and mediators, particularly those involved in Ca(2+) pathways (Ca(2+)/calmodulin-dependent kinase, inositol 1,4,5-trisphosphate receptor, SERCA). Most intriguing was the co-expression of several novel, cardiac-enriched expressed sequence tags. Quantitative real-time reverse transcriptase-polymerase chain reaction of a selection of these clones verified expression. Our study provides a preliminary molecular profile of DCM using the largest human heart-specific cDNA microarray to date.