Laparoscopic parastomal hernia repair using a nonslit mesh technique.

BACKGROUND: The management of parastomal hernia is associated with high morbidity and recurrence rates (20-70%). This study investigated a novel laparoscopic approach and evaluated its outcomes. METHODS: A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence. RESULTS: A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2-38 months), 4% (1/25) of the patients experienced recurrence. CONCLUSION: On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

Laparoscopic splenectomy in the elderly: a morbid procedure?

BACKGROUND: Laparoscopic splenectomy has emerged as the gold standard for elective splenectomy. Few reports have critically evaluated the results of laparoscopic splenectomy in elderly patients. METHODS: All laparoscopic splenectomies performed between August 19, 1998 and June 8, 2004 were reviewed retrospectively. RESULTS: Of 235 splenectomies, 188 were performed for patients younger than age 65 years (group 1), and 45 were performed for patients 65 years of age or older (group 2). The groups were demographically similar, except for the average age and the American Society of Anesthesiology (ASA) classification. Operative characteristics were similar, but the average length of hospital stay differed: 2.2 days for group 1 and 3.9 days for group 2 (p < 0.03). Complications occurred for 8.5% of group 1 and 17.8% of group 2, but the percentages were similar by ASA class. CONCLUSIONS: Elderly patients have a higher rate of complications after laparoscopic splenectomy. The complications are similar when matched for ASA class, but a larger percentage of elderly patients fall into higher ASA class ratings.

Primary signet-ring cell carcinoma mimicking segmental Crohn's colitis.

Primary signet-ring cell carcinoma of the colon is a rare entity with a dismal prognosis, mainly due to a delay in diagnosis. Here, we present a case of a 30-year-old Filipino woman who presented with symptoms mimicking inflammatory bowel disease. A barium enema and colonoscopy demonstrated a stricture in the rectosigmoid region. A biopsy revealed granulomatous changes indicative of inflammatory bowel disease. Despite initial improvement of her symptoms on total parenteral nutrition and steroids, the patient relapsed several weeks later with recurrent left lower quadrant pain. A subsequent biopsy revealed poorly differentiated signet-ring cell carcinoma of the colon. She was treated surgically with a left hemi-colectomy and primary repair. A high degree of suspicion is necessary to correctly diagnose these, often young, patients with primary signet-ring cell carcinoma early and have a positive impact on survival. The literature on primary signet-ring cell carcinoma is reviewed.

Controlled ovarian hyperstimulation. Relationship of early serum E2 levels to the ultimate response of oocyte donors.

OBJECTIVE: To assess the predictive value of measuring serum day 5 E2 and in vitro fertilization (IVF) cycle outcome of oocyte donors undergoing controlled ovarian hyperstimulation (COH). STUDY DESIGN: Retrospective data analysis. RESULTS: Day 5 E2 significantly correlated with the peak serum E2 and number of retrieved mature oocytes. The pregnancy rates associated with stimulated day 5 E2 > 70 pg/mL were significantly greater than in cycles with levels < 70 pg/mL (58%, 71/123, versus 25%, 15/60; P < .05). CONCLUSION: The cycle performance of an oocyte donor can be predicted by measuring cycle day 5 serum E2 during COH. Poor-prognosis cycles can be identified and discontinued, saving patients and the program unnecessary exspense.

Complications of endoscopy.

BACKGROUND: Although most gastrointestinal endoscopic procedures are performed by gastroenterologists, surgeons often assist in the management of patients with complications. This review provides an introduction to the incidence, prevention, and treatment of complications that may occur after upper endoscopy, colonoscopy, percutaneous endoscopic gastrostomy, and endoscopic retrograde cholangiopancreatography. METHODS: Systematic review of the literature. RESULTS: Preprocedural complications include medication effects and adverse effects of bowel preparation. Major procedural complications consist primarily of perforation and hemorrhage. Percutaneous endoscopic gastrostomy tube placement may be complicated by fistula and obstruction. There is also a risk of infectious disease transmission, both to and from the patient. CONCLUSIONS: Endoscopy, like all invasive procedures, carries significant potential risks for the patient. In practiced hands, and with awareness of the problems that may arise, many complications may be avoided and others successfully managed.

Oocyte donation treats infertility in survivors of malignancies: ten-year experience.

Women who are survivors of malignancy may achieve pregnancy through oocyte donation. The largest obstacle to successful reproduction in cancer patients relates to iatrogenic damage to the primary reproductive organs associated with their primary oncology treatment. Reactive damage from surgery, radiation, or chemotherapy may render these organs nonfunctional and irreparable. In cases where the ovary is primarily affected, oocyte donation provides a logical alternative for childbearing.

Environmental factors of temperature, humidity, serum accumulation, and cell seeding increase colon cancer cell adhesion in vitro, with partial characterization of the serum component responsible for pressure-stimulated adhesion.

Physical characteristics of surgical wounds and viable tumor cells shed may differ between open and laparoscopic procedures. Because environmental factors may vary between the laparoscopic milieu and that of open surgical procedures, we sought to characterize the effect of these factors on tumor cell adhesion, an early step in the process of wound implantation. Human SW620 colon cancer cells were placed in matrix-precoated dishes for 30 min at concentrations of 90,000-540,000 cells/well, at 25-37 degrees C, in the native state of the matrix proteins and after drying for 60 min, and in 0-10% serum. As increased pressure has previously been reported to stimulate colon cancer cell adhesion synergistically with serum, we then further partially characterized the serum components responsible for this potentiating effect. The number of adherent cells varied linearly with cells seeded. Adhesion was temperature-dependent, and also was dependent on the matrix conformation. Less adhesion occurred to dry matrix proteins. Serum dose-dependently potentiated SW620 pressure-stimulated adhesion, with a maximal increase in adhesion compared with ambient pressure conditions at 5% serum concentration. Heat inactivating the serum at 60 degrees C for 30 min ablated the effect. Filtration to remove molecules over 10 kDa produced no change in adhesion relative to ambient conditions, but filtration to 100 kDa preserved the serum effect. When the serum was passed over a gelatin-Sepharose column, which binds numerous proteins including fibronectin, the serum effect was lost. Addition of fibronectin to serum-free media did not reconstitute the effect. The environmental factors of warm temperature, moisture, and serum accumulation may contribute to increased colon cancer cell adhesion. However, the most important determinant of malignant adhesion to surgical wounds, laparoscopic or open, is likely to be the size of the tumor cell inoculum. Pressure stimulation of colon cancer cell adhesion is potentiated by heat-labile serum components of molecular weight 10-100 kDa which bind gelatin-Sepharose, and is not fibronectin alone. Irrigating serum from surgical wounds may decrease tumor implantation.

Operative hysteroscopy in the office setting.

STUDY OBJECTIVE: To describe the feasibility of operative hysteroscopy in the office setting. DESIGN. Descriptive study (Canadian Task Force classification II-2). SETTING: University-based private practice. PATIENTS: Women undergoing assisted reproduction in whom diagnostic evaluation revealed uterine cavity pathology. INTERVENTION: Patients were offered office hysteroscopy and allowed to choose between paracervical block anesthesia supplemented with mild intravenous sedation or full conscious sedation, administered by an anesthesiologist. A MicroSpan Hysteroscopy system or HysteroSys Flexible Hysteroscope system was used for diagnostic purposes. When pathology was identified, resection was performed with 2-mm operative instruments or a VersaPoint hysteroscopic electrosurgical electrode using bipolar coagulation through an expandable operating channel. MEASUREMENTS AND MAIN RESULTS: Of 69 women with abnormal sonohysterographic and hysterosalpingogram studies, 44 agreed to office hysteroscopy. Thirty-three (48%) underwent VersaPoint resection and/or scissors resection, which was successfully accomplished in 32 (97%). Significant cervical stenosis in one woman precluded resection because of concern of creating a false passage. Concomitant diagnostic laparoscopy and operative hysteroscopy was performed in one patient. Average operating and anesthesia times were 45.2 +/- 20.3 minutes and 67.2 +/- 28.4 minutes, respectively. One uterine perforation occurred (3.3%) during resection of intrauterine adhesions. CONCLUSION: Office hysteroscopy is a time-efficient and cost-effective procedure, made possible by the development of small instruments. Proper patient selection and training of office personnel are mandatory to minimize complications and maximize efficacy.

Case studies in cholera: lessons in medical history and science.

Cholera, a prototypical secretory diarrheal disease, is an ancient scourge that has both wrought great suffering and taught many valuable lessons, from basic sanitation to molecular signal transduction. Victims experience the voluminous loss of bicarbonate-rich isotonic saline at a rate that may lead to hypovolemic shock, metabolic acidosis, and death within afew hours. Intravenous solution therapy as we know it was first developed in an attempt to provide life-saving volume replacement for cholera patients. Breakthroughs in epithelial membrane transport physiology, such as the discovery of sugar and salt cotransport, have paved the way for oral replacement therapy in areas of the world where intravenous replacement is not readily available. In addition, the discovery of the cholera toxin has yielded vital information about toxigenic infectious diseases, providing a framework in which to study fundamental elements of intracellular signal transduction pathways, such as G-proteins. Cholera may even shed light on the evolution and pathophysiology of cystic fibrosis, the most commonly inherited disease among Caucasians. The goal of this paper is to review, using case studies, some of the lessons learned from cholera throughout the ages, acknowledging those pioneers whose seminal work led to our understanding of many basic concepts in medical epidemiology, microbiology, physiology, and therapeutics.