A Rare Case of Spontaneous Intussusception in an Elderly Patient.

Intussusception is an uncommon pathology in the adult population. Most intussusception cases result from an underlying pathological lead point, oftentimes a malignant neoplasm. We report a case of intussusception in an adult male patient who presented with abdominal pain and currant jelly diarrhea. The patient underwent laparoscopic right hemicolectomy and the biopsy of the affected colon did not show any pathological lead point. Intussusception remains an important differential diagnosis in patients presenting with abdominal pain and bloody diarrhea.

Doing more with less: our decade of experience with laparo-endoscopic single site Heller myotomy supports its application.

BACKGROUND: Achalasia is a rare esophageal motility disorder that affects 1 in 100,000 individuals. Currently, laparoscopic Heller myotomy with anterior fundoplication is the 'gold standard' therapy for achalasia, alleviating symptoms by de-functionalizing the lower esophageal sphincter mechanism. The advent of the Laparo-Endoscopic Single Site (LESS) technique provides a more minimally invasive approach to Heller myotomy. METHODS: With IRB approval, 179 patients who underwent LESS Heller myotomy with anterior fundoplication since 2007 have been prospectively followed. Patients self-assessed symptom frequency and severity preoperatively and postoperatively using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients scored their scar satisfaction (1 = revolting to 10 = beautiful). Data are presented as median (mean ± SD). Significance was accepted with 95% probability. RESULTS: Fifty-one percent of patients were men, of age 55 (53 ± 17) years and BMI of 25 (25 ± 6.1) kg/m2. Patients had an operative time of 134 (135 ± 34.3) minutes with an estimated blood loss (EBL) of 50 mL. Postoperative complications occurred in 18% of patients (e.g., urinary retention, capnothorax). Length of stay was 1 (2 ± 2.1) day. Preoperatively, symptoms (e.g., dysphagia, regurgitation) were frequent and severe; following myotomy, all symptoms queried were significantly less frequent and severe with follow-up of 28 (34 ± 18.4) months (p < 0.0001 for all, paired Student's t test). Eighty-seven percent of patients reported they were 'very satisfied' or 'satisfied' with their experience and 95% of patients would undergo the operation again knowing what they know now. Patients scored their satisfaction with their scar as 10 (9 ± 1.6). CONCLUSION: Heller myotomy with anterior fundoplication undertaken via the LESS approach provides efficacious, satisfactory, and durable amelioration of symptoms. Patients reported significant symptom resolution as well as satisfaction with their overall experience. Our decade of experience documenting the salutary benefits of LESS Heller myotomy should be more than enough to encourage surgeons to incorporate the approach into their armamentarium.

The Evolving Landscape of Esophageal Cancer: A Four-Decade Analysis.

The incidence of esophageal cancer in the United States seems to have significantly increased since the 1970s. In undertaking this study, we sought to describe changes in the incidence, histologic type, and presenting stage of esophageal cancer over the past four decades. With Institutional Review Board approval, the Surveillance, Epidemiology, and End Results database of the National Cancer Institute was queried. Regression analysis was used to analyze data, and significance was accepted with 95 per cent probability. Forty-two thousand seven hundred thirty-nine patients had squamous cell carcinoma or adenocarcinoma located in their upper, middle, and/or lower esophagus from 1973 through 2010, reflecting a 7.5-fold annual increase from 1973 through 2010. Squamous cell carcinoma increased annually 2.5-fold (P < 0.001) and esophageal adenocarcinoma increased annually 57-fold from 1973 through 2010 (P < 0.001), whereas the overall population in the United States increased only 43 per cent (215,092,900 to 308,745,538) in the same period. From 1973 through 2010, there was a significant increase in the incidence of esophageal cancer in the United States. This increase was much greater than the increase in the population in the United States. The incidence of adenocarcinoma increased much more than that of squamous cell carcinoma of the esophagus from 1973 through 2010.

Single-Institution Early Experience and Learning Curve with Robotic Liver Resections.

Robotic liver resection is being introduced with its potential to overcome limitations of conventional laparoscopy. This study was undertaken to document early experience and learning curve of robotic liver resection in our institution. All patients undergoing liver resection between 2013 and 2017 were prospectively followed. Patients were divided into three consecutive tertiles (cohort I-III). Thirty-three patients underwent robotic liver resection within the study period. Twenty-four per cent of patients underwent formal right or left hemihepatectomy, 21 per cent underwent sectionectomy, 6 per cent underwent central hepatectomy, and the remainder underwent nonanatomical liver resection. Formal hemihepatectomy and right posterosuperior segment resection were undertaken in two patients in cohort I, four patients in cohort II, and four patients in cohort III. Two cases were converted to "open" operation. Operative time was 172 (194.5 ± 65.1) minutes in cohort I, 222 (247.8 ± 109.8) minutes in cohort II, and 280 (302.5 ± 84.9) minutes in cohort III, reflecting increasing degree of technical complexity. Estimated blood loss decreased significantly throughout the cohorts, being 400 mL, 200 mL, and 100 mL in cohorts I to III, respectively. Major intraoperative complications were not seen. Three patients experienced postoperative complications, resulting in a single mortality. Length of hospital stay was three days, with two patients being readmitted within 30 days. Robotic technique for liver resection is feasible and safe. It offers good short-term clinical outcomes, including for patients who require major liver resection. As the proficiency developed, a notable improvement in technically ability to undertake more complex resections with decreasing blood loss and minimal morbidity was seen.

Intra-arterial Versus Intravenous Adoptive Cell Therapy in a Mouse Tumor Model.

Adoptive cell transfer therapy for cancer has existed for decades and is experiencing a resurgence in popularity that has been facilitated by improved methods of production, techniques for genetic modification, and host preconditioning. The trafficking of adoptively transferred lymphocytes and infiltration into the tumor microenvironment is sine qua non for successful tumor eradication; however, the paradox of extremely poor trafficking of lymphocytes into the tumor microenvironment raises the issue of how best to deliver these cells to optimize entry into tumor tissue. We examined the route of administration as a potential modifier of both trafficking and antitumor efficacy. Femoral artery cannulation and tail vein injection for the intra-arterial (IA) and IV delivery, respectively, were utilized in the B16-OVA/OT-I mouse model system. Both IV and IA infusions showed decreased tumor growth and prolonged survival. However, although significantly increased T-cell tumor infiltration was observed in IA mice, tumor growth and survival were not improved as compared with IV mice. These studies suggest that IA administration produces increased early lymphocyte trafficking, but a discernable survival benefit was not seen in the murine model examined.

Preclinical Validation of a Single-Treatment Infusion Modality That Can Eradicate Extremity Melanomas.

Isolated limb perfusion (ILP) with the chemotherapeutic agent melphalan is an effective treatment option for extremity in-transit melanoma but is toxic and technically challenging to deliver locoregionally. CBL0137 is an experimental clinical drug with broad anticancer activity in animal models, owing to its ability to bind DNA in a nongenotoxic manner and inactivate the FACT chromatin modulator essential for tumor cell viability. Here, we report that CBL0137 delivered by ILP in a murine melanoma model is as efficacious as melphalan, displaying antitumor activity at doses corresponding to only a fraction of the systemic MTD of CBL0137. The ability to bind DNA quickly combined with a favorable safety profile made it possible to substitute CBL0137 in the ILP protocol, using an intra-arterial infusion method, to safely achieve effective tumor suppression. Our findings of a preclinical proof of concept for CBL0137 and its administration via intra-arterial infusion as a superior treatment compared with melphalan ILP allows for locoregional treatment anywhere a catheter can be placed. Cancer Res; 76(22); 6620-30. ©2016 AACR.

A murine model of targeted infusion for intracranial tumors.

Historically, intra-arterial (IA) drug administration for malignant brain tumors including glioblastoma multiforme (GBM) was performed as an attempt to improve drug delivery. With the advent of percutaneous neuorovascular techniques and modern microcatheters, intracranial drug delivery is readily feasible; however, the question remains whether IA administration is safe and more effective compared to other delivery modalities such as intravenous (IV) or oral administrations. Preclinical large animal models allow for comparisons between treatment routes and to test novel agents, but can be expensive and difficult to generate large numbers and rapid results. Accordingly, we developed a murine model of IA drug delivery for GBM that is reproducible with clear readouts of tumor response and neurotoxicities. Herein, we describe a novel mouse model of IA drug delivery accessing the internal carotid artery to treat ipsilateral implanted GBM tumors that is consistent and reproducible with minimal experience. The intent of establishing this unique platform is to efficiently interrogate targeted anti-tumor agents that may be designed to take advantage of a directed, regional therapy approach for brain tumors.

Duodenal Adenocarcinoma: Profile and Predictors of Survival Outcomes.

Duodenal adenocarcinoma is rare. We aimed to evaluate survival outcome and prognostic factors for survival in patients with duodenal adenocarcinoma in recent years, marked by advancement in chemotherapy for gastrointestinal cancers. All patients treated for duodenal adenocarcinoma at our institution between January 2000 and July 2013 were reviewed. Thirty-nine patients were identified: 27 operative patients [21(53.8%) curative and 6 (15.4%) palliative operations] and 12 nonoperative patients [primary systemic chemotherapy, 4 (10.3%), palliative radiotherapy, 1 (2.6%), and no treatment, 7 (17.9%)]. Curative resections included 13 pancreaticoduodenectomies and eight segmental resections. Median overall survival (OS) for entire cohort was 14.4 months. Median OS and one-, three-, and five-year OS were operative group (41.4 months; 79.1%, 50.6%, and 10.6%, respectively); nonoperative group (7.4 months; 25.0%, 8.3%, and 0%, respectively); curative surgery (45.4 months; 92.9%, 62.5%, and 16.7%, respectively) and palliative surgery (5.4 months; 33.3%, 16.7%, and 0%, respectively). Female gender (P = 0.04), curative resection (P = 0.03), nodal metastasis (P = 0.047) and advanced T stage (P = 0.047) were predictive of OS. Two factors were independently predictive of OS--female gender and curative resection. Overall survival still hinges on curative resection. This favors early detection. Adjuvant treatment modalities such as chemotherapy and radiation require further investigation.