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PubMed1995

Anomalous origins of colic arteries.

The topography of the celiac trunk and superior and inferior mesenteric arteries was studied by dissection in 27 embalmed cadavers. Variant vascular patterns were noted in four subjects. These consisted of: (1) an accessory right hepatic artery from the superior mesenteric artery, (2) an anomalous middle colic artery from the proximal segment of the splenic artery, and (3) two instances of an accessory left colic artery originating from the superior mesenteric artery. The precarious course of the middle colic artery (coming from the splenic artery) and its dominance in the formation of the marginal artery were thought to predispose the ascending and transverse colon to an increased risk of vascular damage. These cases also illustrate two variant patterns of formation of the marginal artery. In the case of the anomalous middle colic artery, the only contribution of the superior mesenteric artery to the marginal artery was through the anastomosis of its ileocolic branch with the right branch of the aberrant middle colic artery. In subjects with accessory left colic arteries, the superior mesenteric artery played a dominant role in the formation of the marginal artery by contributing the accessory left colic artery, which supplied the splenic flexure and the proximal part of the descending colon. These arterial variations underscore the importance of doing vascular studies prior to major abdominal surgery.

Arteries↗
PubMed2006

Cancer incidence after localized therapy for prostate cancer.

BACKGROUND: Second cancers may occur in patients who have undergone radiation therapy. The risk for these adverse events after therapy is uncertain. In this study, the authors examined the size and significance of the observed association between occurrences of secondary cancers 5 years after radiotherapy in a large population of men with incident prostate cancer. METHODS: Men with incident prostate cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) registry and were distinguished by the type of treatment received, tumor stage, tumor grade, and age at diagnosis. SEER data also were used to identify occurrences of secondary cancer beginning 5 years after the date patients were diagnosed with prostate cancer. Multivariate logistic regression analysis was used to estimate the adjusted odds of the subsequent occurrence of other cancers associated with types of radiation therapy received and was adjusted for the type of surgery, tumor grade, stage, and patient age. RESULTS: Compared with men who received no prostate cancer-directed radiation, men who received external beam radiation therapy (EBRT) as their only form of radiation therapy had statistically significant increased odds of developing secondary cancers at several sites potentially related to radiation therapy, including the bladder (odds ratio [OR], 1.63; 95% confidence interval [95% CI], 1.44-1.84) and rectum (OR, 1.60; 95% CI, 1.29-1.99). Men who received EBRT also had statistically significant higher odds of developing secondary cancers at sites in the upper body and other areas not potentially related to radiation therapy, including the cecum (OR, 1.63; 95% CI, 1.10-1.70), transverse colon (OR, 1.85; 95% CI, 1.30-2.63), brain (OR, 1.83; 95% CI, 1.22-2.75), stomach (OR, 1.38; 95% CI, 1.09-1.75), melanoma (OR, 1.29; 95% CI, 1.09-1.53), and lung and bronchus (OR, 1.25; 95% CI, 1.13-1.37) compared with the odds among men who received no radiation therapy. Men who received radiation therapy in the form of radioactive implants or isotopes, either in isolation or combined with beam radiation, did not have significantly different odds of secondary cancer occurring at any of the 20 most common sites. CONCLUSIONS: Patients who received with EBRT had significantly higher odds of developing second cancers both overall and in the areas that were exposed to radiation. It is noteworthy that, to the authors' knowledge, this report shows for the first time that, despite the higher doses of radiation delivered, patients who received radioactive implants had the lowest odds of developing second cancers.

Brachytherapy↗
PubMed1990

Prognostic significance of alpha-1-antitrypsin in early stage of colorectal carcinomas.

We have previously shown that human colorectal carcinoma cell lines, RCM-1 and CoCM-1, synthesize alpha-1-antitrypsin (alpha 1-AT) in culture. We have studied immunohistochemically the incidence of alpha 1-AT on histologic sections from paraffin-embedded tissues of surgically resected colorectal carcinomas and their metastatic foci, polypectomized adenomas, and normal mucosae. alpha 1-AT was detected in 89 (61%) of 145 carcinomas (including 14 carcinomas in adenoma), and 12 (39%) of 31 adenomas. But only 2 (4%) of 55 normal colorectal mucosae were positive for alpha 1-AT. In metastatic tumor cells of colorectal carcinomas in lymph nodes and other organs, alpha 1-AT positivity was 60% and 82%, respectively. The incidence of alpha 1-AT was markedly higher in advanced adenocarcinomas than in early ones and more frequent in adenocarcinomas of right side (including transverse colon) than those of left side and rectum, regardless of their histological malignancy grades. In mucinous carcinomas the frequency was greater (8 of 9 cases) than in conventional adenocarcinomas. Clinical follow-up of the patients with colorectal carcinomas suggested that alpha 1-AT positivity in Dukes' stage A/B tends to correlate with unfavorable prognosis irrespective of the grade of histologic differentiation of carcinoma, but there is no significant relation in Dukes' stage C/D. Our findings suggest that alpha 1-AT in colorectal carcinoma is related to the invasive and metastatic capacity. It may thus serve as a biologic marker for prognosis of colorectal carcinomas at relatively early stages (Dukes' stage A/B).

Adenoma↗
PubMed2004

Two colons-two cancers: paradigm shift and clinical implications.

Embryological and physiological data suggest that proximal (in relation to the splenic flexure) and distal parts of the colon represent distinct anatomical and functional entities. Since 1990, molecular biologists have identified two distinct pathways, microsatellite instability (MSI) and chromosomal instability (CIN), which are involved in the pathogenesis of colon cancer (CC). Thus, a new paradigm has emerged with the discovery that CC is a heterogeneous disease; furthermore recent data have demonstrated that these two distinct pathways in colorectal carcinogenesis are characterized by a different clinical outcome. The implications for the clinicians are twofold; (1) tumors originating from the proximal colon have a better prognosis due to a high percentage of MSI-positive lesions; and (2) location of the neoplasm in reference to the splenic flexure should be documented before group stratification in ongoing trials of adjuvant chemotherapy for CC. In the future, clinical decision-making regarding adjuvant chemotherapy might be stratified according to the MSI status of cancers located proximally to the splenic flexure.

Chemotherapy, Adjuvant↗
PubMed1995

Incidence and management of major urinary complications after pelvic exenteration for gynecological malignancies.

Urinary fistulae and obstruction following pelvic exenteration are frequent and life-threatening complications. They increase the mortality and morbidity rates of large exereses performed during pelvic exenteration for gynecological cancers. From a series of 97 patients who underwent pelvic exenteration for gynecological cancers we report the incidence, risk factors, and management of major urinary complications. Eighty patients had had previous surgery and/or pelvic radiation therapy at the time of pelvic exenteration. A urinary diversion was performed in 63 patients. Major early urinary complications were: urinary fistula in seven patients and ureteral obstruction in four patients (11.3% of the patients). Ten patients had a late urinary complication: stenosis of the cutaneous ureteral meatus (five), stenosis of the ureteroileal anastomosis following ileal loop (two), and urinary fistulae (three). Cancer recurrence was found in 4 of these 10 cases. Major early urinary complications were significantly increased in patients who had received previous pelvic radiation therapy (P < 0.05) and in patients who had had an intestinal conduit for urinary diversion (P < 0.05). Reoperation was done in six of seven cases of early urinary fistula (urinary undiversion four, nephrectomy one, ureteral reimplantation one). Three of four ureteral obstructions were managed with percutaneous nephrostomy and ureteral stent. We recommend the use of nonirradiated bowel segment for urinary diversion as transverse colon or jejunal conduit in patients who have received previous high doses of pelvic radiotherapy. For the management of urinary complications post pelvic exenteration, reoperation is required for most urinary fistula but ureteral obstructions can be managed with percutaneous nephrostomy and ureteral stent.

Adult↗
PubMed2006

Prenatal diagnosis of a large de novo terminal deletion of chromosome 11q.

OBJECTIVE: To describe the prenatal phenotype of the 11q deletion syndrome (Jacobsen syndrome) and present the molecular characterization of the deletion in the case presented. CASE: Ultrasound at 18 and 20 weeks of gestation, on a 34-year-old woman who presented for amniocentesis, revealed slow movements, oligohydramnios and dilatation of the cerebral ventricles in the fetus. Maternal and paternal ages were 34 and 38 years, respectively. RESULTS: Prenatal karyotyping of cultured amniotic fluid cells revealed an 11q terminal deletion, 46,XX,del(11)(q23) (Jacobsen syndrome). Real-time quantitative PCR analysis was used to identify and map the breakpoint physically to a 45-kb region located 14.5 Mb from the 11q telomere. Polymorphic DNA marker analysis showed that DNA sequences on the paternally derived chromosome are deleted. At autopsy, facial dysmorphism without major malformations was recorded. Examination of the internal organs disclosed the following abnormalities: a Meckels' diverticulum of 4-mm length, adhesion between the gall bladder and the transverse colon, and bilaterally bilobed lungs without further situs anomalies. CONCLUSION: Our case demonstrates significant phenotypic variability of Jacobsen syndrome at midtrimester pregnancy; the syndrome may be manifested at this stage only by mild to moderate ventriculomegaly of the brain.

Abnormalities, Multiple↗
PubMed1994

The stapled continent ileocecal urinary reservoir in the surgical management of gynecologic malignancy.

Total cystectomy at the time of radical pelvic surgery for gynecologic malignancies is not uncommon. Many techniques have been developed for urinary diversion including the continent ileocecal urinary reservoir. Twenty-nine patients underwent construction of a continent ileocecal urinary reservoir during the reconstructive phase of an exenterative procedure or for the relief of urinary tract fistula between 1990 and 1993. All procedures were performed using the mechanical stapling devices using metal staples. The right and proximal transverse colon were mobilized to a length of 24 cm. The ileum was divided 8 cm proximal to the ileocecal valve and plicated using the stapling technique. The colonic segment was opened on its antimesenteric border and the reservoir was created by stapling in a fashion to reapproximate the distal ends to each other. The ureters were stented and implanted without tunneling. A large Malecot drain was placed in all the pouches for irrigation of the colonic mucosa in the postoperative period. The ileal stoma was fixed to the anterior abdominal wall as was the anterior surface of the pouch. Operative time ranged from 50 to 150 min for the pouch construction. All patients underwent retrograde contrast study of the pouch 7-10 days postoperatively to verify lack of anastomatic leaks. After recovery, all patients successfully self-catheterized the pouch three to five times daily without difficulty. Of the 29 patients, 17 (59%) had received prior radiation as part of therapy. All patients remained continent at the end of observation. One developed a fistula to the perineum after intraoperative placement of 125I seeds on the pelvic wall. One patient developed pouch stones; endoscopic evaluation of this pouch revealed no evidence of stones at the staple lines and metabolic workup demonstrated hypocitremia as the etiology for the stones. Mean reservoir volume was 550 ml. Mean follow-up is 15.8 months; 5 have expired due to recurrent disease and 19 (83%) remain alive. Only two patients have been admitted for urosepsis due to reflux pyelonephritis. The stapled continent ileocecal reservoir offers benefits to patients undergoing total cystectomy. Using the mechanical stapling devices decreases the operative time and has not resulted in stone formation or pouch leakage. The complications of the procedure are acceptable.

Adult↗
PubMed1996

What is the role of reassessment laparoscopy in the management of gynecologic cancers in 1995?

One hundred fifty-four patients with a diagnosis of ovarian, primary peritoneal, or fallopian tube carcinoma underwent 181 reassessment procedures to detect persistent or recurrent disease between January 1, 1989 and December 31, 1994 at Cedars-Sinai Medical Center. One hundred four laparoscopic procedures were performed. Eleven of these procedures were converted to laparotomy due to severe adhesions. Therefore, a total of 88 reassessment laparotomies were performed during the study period. Fifty-seven of 93 laparoscopies and 69 of 88 laparotomies were done as second-look procedures. There was no significant difference between the two groups with respect to patient age, tumor histology, degree of primary cytoreduction, and tumor stage or grade. Significant differences were found between laparoscopy and laparotomy groups in the following outcome variables evaluated: estimated blood loss (33.9 ml vs 164.9 ml, P = 0.0001), operative time (81.3 min vs 130.4 min, P = 0.0001), days of hospitalization (0.3 days vs 6.8 days, P = 0.0001), and direct cost/case ($2765 vs $5420, P = 0.0001). Despite obtaining 50% fewer biopsies with laparoscopy than laparotomy, the ability to detect disease was similar between these two groups: 47.3% vs 55.7% for all procedures and 52.6% vs 53.6% in the patients undergoing second-look procedures. Major complications in the laparoscopy group included transverse colon perforation (1), small bowel perforation (2), enterocutaneous fistula (1), and a retroperitoneal hematoma (1). Major complications in the laparotomy group included cystotomy (1), left ureteral injury (1), enterotomy (2), and SBO (4). Laparoscopy, when technically feasible, appears equally as effective as laparotomy in detecting persistent or recurrent malignant disease with less blood loss, less days spent in the hospital, less financial burden, and no increase in patient morbidity.

Evaluation Studies as Topic↗
PubMed2000

Vaginal reconstruction using the bladder and/or rectal walls in patients with radiation-induced fistulas.

OBJECTIVE: In irreparable or recurrent vesicovaginal fistulas and cloacal defects following high-dose irradiation therapy for gynecological malignancies, urinary diversion is the last resort to achieve a socially acceptable solution. In a select group of young and tumor-free patients, additional vaginal reconstruction may be indicated. Multiple operative procedures are available, but the results are often disappointing in the previously irradiated area. MATERIALS AND METHODS: In six such patients with large radiogenic vesicovaginal defects (n = 5) or a cloacal fistula (n = 1), a continent reservoir using the transverse colon with an umbilical stoma was performed. At the end of the operation, the bladder was incorporated into a neovagina by incising the urethra, anterior vaginal wall, and the posterior bladder wall with electrocautery from the urethral meatus to the dome of the fistula. RESULTS: No postoperative complications related to the vaginal reconstruction occurred. After a mean follow-up of 4.7 years, all patients had a capacious vagina and a wide introitus; the neovagina measured a mean of 18 cm in length. Five patients with a partner reported a normal sexual life. No dyspareunia or discomfort from bladder or urethral mucosa during intercourse was reported. CONCLUSIONS: Following continent urinary diversion due to irreparable vesicovaginal fistulas, a neovagina can be created by simple dissection of the posterior bladder and anterior vaginal wall. When a colostomy is present, the neovagina can additionally be augmented with a bowel flap of the Hartmann stump or by incising the rectovaginal septum. The technique affords good functional and cosmetic results.

Cloaca↗
PubMed2000

Rapid progression of primary vaginal squamous cell carcinoma in a young HIV-infected woman.

BACKGROUND: The association of human immunodeficiency virus (HIV) infection with rapid progression of cervical and anal squamous cell carcinoma has been clearly established by several studies. Human papilloma virus (HPV) infection of the anogenital tract is believed to be the causative agent of cervical, anal, vaginal, and vulvar squamous cell carcinoma. While a myriad of reports exist in the literature pertaining to the rapid progression of cervical and anal carcinoma in HIV-infected patients, no association of HIV infection and vaginal carcinoma has been reported. We present an unusual case of a young woman infected with HIV who was diagnosed with advanced vaginal carcinoma and succumbed to her disease shortly thereafter despite aggressive treatment. CASE: A 40-year-old woman with a 2-year history of HIV infection presented with Stage IVA squamous cell carcinoma of the vagina and a large vesicovaginal fistula from the tumor eroding through the posterior bladder wall. Computed tomography (CT) of the abdomen and pelvis revealed a large tumor replacing the vagina with mild hydronephrosis and diffuse pelvic and inguinal lymphadenopathy. She underwent urinary diversion with a transverse colon conduit followed by pelvic radiation with weekly cisplatin chemosensitization. A repeat CT scan of the abdomen and pelvis upon completion of her treatment revealed progression of disease with multiple liver metastases and gastrohepatic ligament adenopathy. She subsequently died of advanced metastatic vaginal carcinoma 2 months after completion of treatment. CONCLUSION: Due to the rarity of primary vaginal carcinoma, the clinical behavior of this neoplasm in the HIV-infected patient is poorly understood. Our case indicates that, although vaginal carcinoma is a disease of the elderly, young women infected with HIV and HPV are predisposed not only to develop cervical or anal carcinoma but also may be at increased risk for vaginal carcinoma with more aggressive and less responsive disease. Furthermore, although vaginal carcinoma is usually a slow-growing neoplasm, this case illustrates the aggressive behavior of such a tumor when associated with HIV infection.

Adult↗
PubMed2000

A case of rapidly growing ovarian squamous cell carcinoma successfully controlled by weekly paclitaxel-carboplatin administration.

BACKGROUND: Primary squamous cell carcinoma of the ovary is uncommon and has a poor prognosis. Because of its rarity, the effective postoperative treatment is unknown. We describe a remarkable response of this tumor to weekly paclitaxel-carboplatin administration. CASE: A 53-year-old woman had rapidly growing primary squamous cell carcinoma of the ovary that metastasized to the abdominal wall and transverse colon after maximum cytoreductive surgery. The tumor was resistant to primary chemotherapy with cisplatin, vincristine, mitomycin C, and bleomycin. A combination of paclitaxel and carboplatin was used for second-line chemotherapy and was repeated every week. The patient tolerated the chemotherapy well and demonstrated a pathological complete response in the abdominal metastases following the five courses of chemotherapy. CONCLUSION: Weekly paclitaxel-carboplatin administration may be a safe and effective treatment for advanced and rapidly growing ovarian squamous cell carcinoma with primary resistance to chemotherapy.

Abdominal Neoplasms↗
PubMed2002

Functional outcomes and complications of continent urinary diversions in patients with gynecologic malignancies.

OBJECTIVE: The purpose of this study was to review our experience with continent urinary diversions in patients with gynecologic malignancies and evaluate the presentation and management of early and late complications. METHODS: A retrospective chart review was performed of all patients who underwent a continent urinary diversion on the Gynecologic Oncology Service at The University of Texas M. D. Anderson Cancer Center during the period January 1988 to March 2001. We analyzed our data to evaluate potential risk factors for complications. Renal status, conduit integrity, and overall patient outcomes were also studied. RESULTS: We identified 40 patients who underwent a continent urinary diversion using an ileocolonic segment (Miami pouch technique). All patients had a history of gynecologic malignancies. The median age at the time of the procedure was 50 years (range 24 to 76 years), and the median weight was 69.6 kg (range 47 to 125 kg). A total of 39 patients (98%) had a history of radiotherapy. Continent urinary diversion was performed as part of an anterior pelvic exenteration in 12 patients (30%), in conjunction with a total pelvic exenteration in 18 patients (45%), and as the main procedure in 10 patients (25%). The median estimated blood loss was 2100 ml (range 200 to 8500 ml). The median length of hospitalization was 19.5 days (range 7 to 56 days). A total of 24 patients (60.0%) had a postoperative complications unrelated to the reservoir. Complications directly related to the continent urinary diversion were seen in 26 (65.0%) of 40 patients. None of the patients in this study group developed chronic renal failure, and there were no perioperative deaths. At last evaluation, 36 (90%) of 40 patients reported normal continent conduit function. CONCLUSIONS: Continent urinary diversion using an ileocolonic segment is a reasonable alternative to the ileal and transverse colon conduit in bladder reconstruction in patients undergoing radical pelvic surgery. The routine use of postoperative total parenteral nutrition, the chronic use of antibiotics after discharge from the hospital, and the routine use of imaging studies remain controversial. In this group of patients, the majority of complications may be successfully managed conservatively.

Adult↗
PubMed2002

Small intestinal volvulus following laparotomy for endometrial clear cell carcinoma in a woman with a past history of total gastrectomy and Roux-en-Y anastomosis for gastric carcinoma.

BACKGROUND: Small intestinal volvulus is a rare complication following Roux-en-Y anastomosis. CASE REPORT: A 63-year-old woman was diagnosed with small intestinal volvulus following laparotomy for clear cell carcinoma of the endometrium. Her past medical history included a total gastrectomy and antecolic Roux-en-Y anastomosis for Duke's B gastric carcinoma. Operative findings were of transmesenteric herniation of the ileum through the Roux-en-Y small intestinal mesenteric window, with metastatic deposits fixing the hernia at its base to create a volvulus. The proximal transverse colon was very dilated and thin due to partial obstruction by the volvulus. Her treatment involved adhesiolysis and unraveling of the small intestinal volvulus. CONCLUSIONS: This is the first case report of a small intestinal volvulus following a Roux-en-Y anastomosis involving a metastatic gynacological malignancy.

Adenocarcinoma, Clear Cell↗
PubMed1985

Small bowel esophagoplasty with vascular microanastomoses in the neck for treatment of esophageal burns in childhood.

Replacement of the esophagus may become mandatory in esophageal burns if dilatation treatment is unsuccessful. Normally, the isoperistaltic transverse colon placed in the neck is used for this purpose. The use of the major curvature of the stomach, according to Gavriliu, may also be considered. In two of our patients, these techniques could not be applied, and we transplanted a portion of the small bowel into the neck, with the blood supply to the pedicule being provided by vascular microanastomosis in the cervical region. The functional results were very satisfying in both cases, despite of the bent appearance of the grafts. At long-term follow-up, there have been no major, particularly peptic, complications. The two cases and the technique applied are described.

Burns, Chemical↗
PubMed1995

Treatment of cholecystocolonic fistula by laparoscopy.

Cholecystocolonic fistula is an unusual complication of biliary tract disease. Many of the signs and symptoms of these fistulas are nonspecific, so the diagnosis is often not suspected preoperatively. It is important to make the diagnosis then to prevent fecal contamination when the fistula is divided. We recently encountered a patient who, while undergoing laparoscopic cholecystectomy, was found to have a fistula between the gallbladder and the proximal transverse colon. Important features in the management of this case are (1) maintaining a high index of suspicion for the presence of this complication, (2) use of cholecystography to establish the diagnosis, and (3) use of laparoscopic stapling techniques to divide the fistula while preventing fecal soilage.

Aged↗
PubMedDate not supplied

Percutaneous feeding gastrostomy in patients with a partial gastrectomy: transhepatic approach with CT guidance.

BACKGROUND: Percutaneous gastrostomy in patients with a partial gastrectomy is rarely performed because the gastric remnants are generally small, positioned high subcostally, and overlaid by the transverse colon and the left lobe of the liver. METHODS: We performed percutaneous transhepatic feeding gastrostomy in four patients with a partial gastrectomy whose conditions precluded oral feeding. The gastric remnant was punctured with a 22-gauge percutaneous transhepatic cholangiography needle through the left lobe of the liver with computed tomography guidance and following tract dilation over the guidewire 8 or 9F. Cope loop catheters were fluoroscopically placed. RESULTS: No obvious complications were encountered during the procedures. The catheter feedings were continued for 2 to 7 months without any serious problems. CONCLUSIONS: We conclude this technique can be performed easily and may be safe because of the presence of the adhesion between the remnant and the liver, which prevents a massive hemorrhage or the displacement of the catheters.

Aged↗
PubMed1993

Esophago-jejuno-duodenal anastomoses with an ultra-short duodenum.

Reconstruction following total gastrectomy usually requires one of the various methods of esophagojejunal anastomosis. We present herein the case of a 78-year-old woman with gastric carcinoma involving the adjacent organs for which resection of the whole stomach, distal pancreas, transverse colon, and distal duodenum was performed. Reconstruction was carried out with an esophagojejunostomy, followed by a side-to-side anastomosis between the raised jejunal limb and the residual short duodenum. Her postoperative course was uneventful and she was able to lead a relatively comfortable life at home until she died after tumor recurrence caused GI bleeding 1 year postoperatively. This new modified Roux-en-Y with an ultra-short duodenum can be applied for such contiguously invasive gastric carcinoma to achieve a better quality of life, when conventional reconstruction techniques after total gastrectomy are not indicated.

Adenocarcinoma↗