Association Between the Most Frequent Complications After Surgery for Stage I-III Colon Cancer and Short-Term Survival, Long-Term Survival, and Recurrences.

BACKGROUND: The purpose of this study was to identify the ten most frequent complications after surgery for stage I-III colon cancer and to assess the association between these complications and overall survival, conditional overall survival, and recurrences. METHODS: All patients who underwent surgery for stage I-III colon cancer in five hospitals in the Western region of the Netherlands were identified. Crude and adjusted Cox proportional hazards models were used to study the association between complications and 1-year overall survival, 5-year overall survival, 5-year conditional overall survival, and 5-year disease-free period. RESULTS: Data from 761 patients were used for the analyses. Complications were associated with decreased 1-year overall survival (hazard ratio (HR) 2.87, 95 % confidence interval (CI) 1.82-4.51; p < 0.001), 5-year overall survival (HR 1.59, 95 % CI 1.25-2.04; p < 0.001), and 5-year conditional overall survival (HR 1.34, 95 % CI 1.06-1.69; p = 0.016), whereas an increasing number of complications had no additional impact. Anastomotic leakage, excessive blood loss, and (abdominal) sepsis were associated with reduced 1-year overall survival, anastomotic leakage, delirium, abscess, and (abdominal) sepsis with reduced 5-year overall survival, and anastomotic leakage, delirium, and abscess with reduced 5-year conditional overall survival. Anastomotic leakage, electrolyte disorders, and abscess were risk factors for recurrence within five years. CONCLUSIONS: Our results demonstrate the serious impact of the most frequent complications after surgery for colon cancer on short-term and long-term outcomes. This study confirms the prolonged impact of surgery and demonstrates that complications result not only in reduced 1-year survival, but also in reduced long-term outcomes.

H. influenza Panaritium Tendineum. A Rare Pathogen.

Panaritium tendineum is a severe infection of the hand in most cases caused by infection with staphylococcal or streptococcal species. In this article, a case of panaritium tendineum caused by Haemophilus influenzae is described. In the literature, no cases of H. influenzae causing a panaritium tendineum are described before. The patient in this case was treated by repeated surgical incision and drainage, local antiseptic treatment, intravenous antibiotics, and 2 months of physiotherapy after which there remained some loss of function of the left hand.

Adenocarcinoma Arising within a Colonic Diverticulum in a Patient with Recurrent Diverticulitis.

In 2006, while admitted in our hospital for surgical treatment of recurrent diverticulitis, a 54-year-old man was found to have an adenocarcinoma arising within a colonic diverticulum. Computed tomography, during this episode of diverticulitis, showed a thickened wall of the sigmoid and inflammatory induration of the pericolonic fat. Colonoscopy could be performed up to no more then 25 cm from the anus due to mucosal edema. A sigmoid resection was performed. Histopathological examination of the resected specimen showed an inflamed diverticulum with a submucosal adenocarcinoma of the intestinal type within its wall. The surrounding flat colonic mucosa was not involved by the cancerous process. Due to lymph node involvement the patient received adjuvant chemotherapy and remained disease free during follow up.

The Eindhoven laparoscopic cholecystectomy training course--improving operating room performance using virtual reality training: results from the first E.A.E.S. accredited virtual reality trainings curriculum.

BACKGROUND: This study was undertaken to investigate operating room performance of surgical residents, after participating in the Eindhoven virtual reality laparoscopic cholecystectomy training course. This course is the first formal surgical resident trainings course, using a variety of complementary virtual reality (VR) skills training simulation in order to prepare surgical residents for their first laparoscopic cholecystectomy. The course was granted EAES certification. METHODS: The four-day course is based on multimedia and multimodality approach. A variety of increasingly difficult simulation training sessions, next to intimate focus-group "knowledge sessions" are included. Both basic and procedural VR simulation is featured, using MIST-VR and the Xitacts' LapChol simulation software. The operating room performance of twelve surgical residents who participated in the course and twelve case-control counterparts were compared. The case-control group was matched for clinical number laparoscopic cholecystectomy performance (maximum of 4 procedures). Two observers analyzed a randomly mixed videotape, featuring the part of the "clip-and-cut" procedure of the laparoscopic cholecystectomy, and were blinded for participants' group status. Structured questionnaires including multiple observation scales were used to assess performance. RESULTS: Residents of both the experimental and control group did not differ in demographic parameters, except for number of laparoscopic cholecystectomies in favor of the control group (p-value 0.008). Both observers judge the experimental group to perform significantly better (p-value 0.004 and 0.013). Experimental group residents valued their course highly in terms of their laparoscopic surgical skills improvement and the use of VR simulators in the surgical curriculum. CONCLUSIONS: The Eindhoven Virtual Reality laparoscopic cholecystectomy training course improves surgical skill in the operating room above the level of residents trained by a variety of other training methods.

The occurrence of diabetic ketoacidosis in adults.

OBJECTIVE: To analyze the occurrence of DKA in Chinese adults. METHODS AND PATIENTS: We retrospectively reviewed the medical records of adults presenting with DKA in a tertiary referral center from January 1992 to December 1997. We classified these patients into 3 groups: type 1, type 2 and new-onset diabetes. Clinical features and follow-up treatment were analyzed. RESULTS: One hundred and twenty patients with 141 episodes of DKA were included; 77 episodes (54.6%) were classified as being caused by type 2, 32 (22.7%) by type 1 and 32 (22.7%) by new-onset DM. The average age of type 2 patients was significantly higher. Of the 25 new-onset patients with follow-up for at least 12 months, 11 were not taking insulin. Of these 11 patients, 6 had a family history of DM and 5 had BMI greater than 26.4 kg/m2. The fasting plasma C-peptide values at various times of follow-up varied from 2.3 to 9.5 ng/ml in 6 of the 11 DKA-onset patients. CONCLUSION: In type 2 patients, the occurrence of DKA is usually associated with old age and another severe illness. "DKA-onset type 2 DM" reported in African-Americans and in Japanese is also observed in Chinese.

Family aggregation and maternal inheritance of Chinese type 2 diabetes mellitus in Taiwan.

BACKGROUND: Type 2 diabetes mellitus (DM) is a well-known familial disease, although the genetics of this complex condition remains unclear. Recent evidence suggests the significance of maternal inheritance. However, the pattern of family aggregation and the influence of other family relatives on the mode of transmission in Chinese patients with diabetes are lacking. METHODS: We interviewed 449 patients (151 men and 298 women) with type 2 DM who were aged between 35 and 74 years with a mean age of 58 +/- 1 years in a referral hospital in central Taiwan. We recorded a detailed family history of diabetes for each patient. RESULTS: Overall, 60% of diabetic patients had at least one diabetic family member. Among these index patients, 22.5% had a diabetic mother compared with 12.0% who had a diabetic father (p < 0.001). Approximately 29% of diabetic patients had at least one diabetic sister compared with 24% who had at least one diabetic brother (p = 0.13). A total of 27% of diabetic men had a diabetic mother, compared with 20% of diabetic women. Women with diabetes had more diabetic sisters than did diabetic men. In contrast, diabetic men had a significantly increased percentage of diabetic family members on the maternal side or paternal uncles or aunts than did diabetic women. The percentage of diabetic patients who had a diabetic mother decreased as their age increased. The maternal effect disappeared in the diabetic patients who were over 65 years old. Statistical differences between diabetic fathers and mothers were observed when DM was diagnosed in patients under 65 years of age. CONCLUSIONS: We documented the presence of family aggregation and significant maternal inheritance in Chinese patients with type 2 DM in Taiwan. Further prospective study is needed to monitor the offspring of diabetic parents and other relatives in order to clarify the true mode of family aggregation and maternal transmission of type 2 DM.

Port-site metastases. Impact of local tissue trauma and gas leakage.

BACKGROUND: Port-site metastases after laparoscopic procedures in patients with digestive malignancies have evoked concern. The pathogenesis of port-site metastases remains unclear. Two experiments in rats were performed to determine the impact of both tissue trauma and leakage of CO2 along trocars (chimney effect) in the development of port-site metastases. METHODS: Experiment I: Ten WAG rats had four 5-mm incisions in all abdominal quadrants. The incisions on the right side were crushed to induce tissue trauma. After inserting 5-mm trocars in all incisions, a pneumoperitoneum was created, and CC-531 tumor cells were injected intraperitoneally. CO2 was insufflated for 20 min. Experiment II: Ten WAG rats had 5-mm incisions in the left and right abdominal upper quadrant. A 5-mm trocar was inserted in the incision in the left upper quadrant, and a 2-mm trocar was inserted in the incision in the right upper quadrant. After insufflating the abdomen, CC-531 tumor cells were injected intraperitoneally. Total leakage of CO2 along the trocar in the right quadrant was 10 liters. After 4 weeks, in both experiments, the tumor deposits at the trocar sites were assessed. Statistical analysis was performed by the Wilcoxon matched-pairs test. RESULTS: Experiment I: The median weight of tumor deposits at the trocar sites without induced tissue trauma was 22 mg. At the traumatic port sites, median weight of tumor deposits was 316 mg (p = 0.007). Experiment II: The median weight of tumor deposits at the leaking trocar sites was 478 mg and at the control sites 153 mg (p = 0.009). CONCLUSION: Tissue trauma at trocar sites and leakage of CO2 along a trocar appear to promote implantation and growth of tumor cells at port sites.

Effects of carbon dioxide pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy on body weight and tumor growth.

BACKGROUND: The oncologic consequences of intraperitoneal carbon dioxide (CO2) insufflation during the laparoscopic resection of cancer are under debate. The effect of other insufflating gases or gasless laparoscopy on cancer requires study. OBJECTIVE: To study body weight and tumor growth in rats after CO2 pneumoperitoneum, air pneumoperitoneum, and gasless laparoscopy. METHODS: On day 1, an 8-mg bolus of ROS-1 tumor was placed under the renal capsule of both kidneys in rats. In experiment A, rats had either CO2 insufflation (n=10) or a gasless laparoscopic bowel resection (n=10) on day 3 and were humanely killed after 7 days. In experiment B, rats had either a laparoscopic bowel resection with CO2 insufflation (n=11) or insufflation with air (n=11) on day 3 and were killed after 7 days. In both experiments, postoperative weight loss and tumor growth were measured, and the differences were tested with an analysis of covariance. RESULTS: Renal subcapsular tumor growth in the group having gasless laparoscopy was less than that in the group having CO2 pneumoperitoneum (P=.04). Postoperative weight loss in these groups showed no differences (P=.55). No differences in tumor growth or weight loss were found between rats having insufflation with CO2 and those having insufflation with air (P=.61 and P=.68, respectively). CONCLUSIONS: The restoration of body weight after a laparoscopic surgical procedure was similar with CO2, air, or gasless laparoscopy. Gasless laparoscopy was associated with less renal subcapsular tumor growth than was insufflation with CO2. Therefore, the application of gasless techniques in laparoscopic oncologic surgical treatment demands further study.

Laparoscopic vs conventional bowel resection in the rat. Earlier restoration of serum insulin-like growth factor 1 levels.

BACKGROUND: The role of laparoscopic surgery in the treatment of colorectal disease is still controversial. To assess the metabolic consequences of laparoscopic and open bowel surgery, we studied serum levels of insulin-like growth factor 1 (IGF-1), an anabolic and mitogeneic peptide, in rats. MATERIALS AND METHODS: In experiment 1, the serum IGF-1 levels of 10 rats undergoing laparoscopic small bowel resections (group I) and 10 rats undergoing conventional small bowel resections (group II) were determined before surgery and on days 1, 2, and 7. Experiment 2 compared five rats that had CO2 pneumoperitoneum (group III), five rats that underwent laparotomy (group IV), and five rats that received anesthesia only (group V). Differences in IGF-1 levels were tested with analysis of covariance. RESULTS: In experiment 1, preoperative IGF-1 levels were similar in groups I and II (87.9 +/- 6.1 nmol/L versus 90.5 +/- 8.1 nmol/L). One day after surgery IGF-1 was 54.6 +/- 10.5 in group I versus 41.6 +/- 8.3 in group II (p = 0.006). Two days after surgery, IGF-1 was 79.4 +/- 9.2 in group I versus 59.0 +/- 10.5 in group II (p < 0.001). Seven days after both types of surgery, IGF-1 levels had returned to almost normal levels. In experiment 2, no significant differences were found between the rats with CO2 pneumoperitoneum (group III) and those with laparotomy only (group IV). Rats that had anaesthesia only showed a significant decrease in IGF-1 levels between days 0 and 1 (p < 0.018). CONCLUSION: Our study indicates that laparoscopic bowel surgery is associated with a better postoperative anabolic state (i.e., less catabolism) than conventional surgery. This finding reflects a potential benefit of laparoscopy in bowel surgery.

Minimising the risks of PUVA treatment.

Psoralen photochemotherapy (PUVA) is a combination of orally administered psoralen and long wave ultraviolet-A radiation (UVA), and is one of the most effective forms of therapy for psoriasis. The unwanted effects of PUVA therapy can be divided into short and long term adverse effects. The short term adverse effects include erythema, pruritus, nausea and headache. While short term adverse effects are limited and reversible after discontinuation of treatment, potential long term adverse effects such as chronic actinic skin damage, dyskeratotic and precancerous skin conditions, nonmelanoma skin cancer, immunological alterations and cataract formation are of greater concern. Long term risks associated with PUVA therapy can be minimised by several measures. Careful patient selection is mandatory; for example, patients with chronic actinic damage and a history of skin cancer may bear a higher risk for the development of new cancers, and previous arsenic intake and ionising radiation also increase the risk of nonmelanoma skin cancers. Certain drug combinations make it possible to lower the UVA dose, which is important because of the dose-dependent increase in the incidence of squamous cell carcinomas in patients treated with PUVA. It has been demonstrated that 200 treatments or a total UVA dose of 1200 J/cm2 seems to be the threshold for development of nonmelanoma skin cancer. Shielding male genitalia during PUVA treatment is essential because of the increased risk of genital squamous cell carcinomas. Yearly dermatological examination to detect skin cancer at an early stage is highly advisable. Sunscreen use, protective clothing and avoidance of sun exposure reduce the uncontrolled dose of solar UV radiation. Other psoralens with a less carcinogenic potential can be used. UVA-opaque sunglasses during the entire period of increased photosensitivity after psoralen ingestion help avoid cataract formation. Assignment to PUVA ought to be based on the risk-benefit ratio for the individual patient and should be limited to those who can be monitored and controlled by informed, competent and conscientious physicians.

[Diabetic foot infections: a preliminary report].

Foot infection is a common cause of hospitalization for diabetic patients. Our study aimed to analyze patients' age, sex, the primary sites of infection, presenting features, outcome, bacteriologic studies and their clinical significance in diabetic foot infections. The age of our diabetic patients with foot infections ranged from 43 to 82 years, with a mean of 62.5 years; fifty-two of them were males and twenty-eight were females. The male to female ratio was 1.9:1, but there was no statistically significant difference between the sexes (p greater than 0.05). The commonest age group was the seventh decade of life (47.5%), followed by the sixth decade (32.5%). The commonest primary site of infection was the toes (53.8%), followed by foot area other than toe (25%) and the leg area was the least frequent (21.2%). Cellulitis combined with other foot lesions presented in 78.8% of these patients, foot ulcers in 75% of them, gangrenous change in 68%, necrotizing cellulitis or fasciitis in 16.3%, abscess formation in 12.5% and osteomyelitis in 7.5%. The legs were amputated in 53 patients (66.3%), usually below the knee (in 47.5%). We found that patients with a long history of DM had statistically significantly higher rate of amputation (p less than 0.01) than patients with only a brief history. Bacterial cultures from the infected foot lesions yielded numerous organisms in 58.8% of cases and a single organism in 31.1% of cases. Proteus mirabilis was the commonest organism isolated, followed by E. coli, Pseudomonas aeruginosa. The commonest month of the onset of diabetic foot infection was January, followed by February.

Serotonin (5-HT1c) receptors in pig choroid plexus.

It is very important to find suitable reaction conditions to attain a high specific binding (specific/total binding) in the receptor binding study. Membrane homogenates of pig choroid plexus are known to have exclusively serotonin (5-hydroxytryptamine, 5-HT) receptor of the subtype 5-HT1c. In this study, we used the membrane preparation of pig choroid plexus tissue and the specific binding of [3H]5-HT was 72-84% to serotonin receptor subtype 5-HT1c, as defined by the inhibition of 1 uM 5-HT, when a radioligand concentration of 0.5 nM of [3H]5-HT was used in the assay. Analysis of the properties of specific [3H]5-HT binding in pig choroid plexus tissue membrane preparation revealed linear Scatchard plots. In Tris-HCl buffer without CaCl2, pargyline or ascorbic acid, high average of affinity dissociation constant (Kd) of 1.3 +/- 0.2 nM (SEM, n = 4) and also a high average of receptor density (Bmax) of 284 +/- 12 fmol/mg of protein were found. Pig choroid plexus proves to be a good material for 5-HT1c receptor binding study.