George Mathew

Prevention of parastomal hernia using preperitoneal mesh: a prospective observational study

Objective  Parastomal hernia is a common complication after stoma formation. The objective of the study was to see whether placing prophylactic preperitoneal mesh could reduce the incidence of parastomal hernia.

Parastomal hernia: is prevention better than cure? Use of preperitoneal polypropylene mesh at the time of stoma formation

BackgroundThis is a prospective study of prophylactic mesh placement in the preperitoneal space at the time of stoma formation to prevent parastomal hernia.MethodsPatients undergoing elective permanent stoma formation and resiting of a stoma were included. Patients with peritoneal contamination were excluded. A 6×6-cm polypropylene mesh was placed in the preperitoneal space (no stitches), and a circular hole was made to let the bowel come through with ease and the stoma was constructed. At follow-up, the patients were examined standing and lying down for parastomal hernia. In the event of clinical uncertainty, a CT scan was done.ResultsA total of 42 patients (20 women, 22 men, mean age 61 years) were eligible for the study. The patients were followed up for a mean of 31 months (range 9–68 months). There were 29 end-colostomies and 8 end-ileostomies and 5 stomas resited. Four parastomal hernias were detected during the follow-up period (9.52%). One required repair due to an ill-fitting stoma bag and leakage. The other three were asymptomatic. One patient developed stomal necrosis which required a new segment of bowel to be brought out through the same opening and the underlying mesh was left undisturbed.ConclusionsThe results of the 2-year follow-up in this study (incidence of parastomal herniation 9.5%) along with available evidence in the literature (incidence 0–8.3%), compared to the results of repair make a strong case for the use of a mesh at the time of initial surgery for the formation of any permanent stoma to prevent parastomal herniation.

Toponome imaging system in situ protein network mapping in normal and cancerous colon from the same patient reveals more than five-thousand cancer specific protein clusters and their subcellular annotation by using a three symbol code

In a proof of principle study, we have applied an automated fluorescence toponome imaging system (TIS) to examine whether TIS can find protein network structures, distinguishing cancerous from normal colon tissue present in a surgical sample from the same patient. By using a three symbol code and a power of combinatorial molecular discrimination (PCMD) of 2(21) per subcellular data point in one single tissue section, we demonstrate an in situ protein network structure, visualized as a mosaic of 6813 protein clusters (combinatorial molecular phenotype or CMPs), in the cancerous part of the colon. By contrast, in the histologically normal colon, TIS identifies nearly 5 times the number of protein clusters as compared to the cancerous part (32 009). By subcellular visualization procedures, we found that many cell surface membrane molecules were closely associated with the cell cytoskeleton as unique CMPs in the normal part of the colon, while the same molecules were disassembled in the cancerous part, suggesting the presence of dysfunctional cytoskeleton-membrane complexes. As expected, glandular and stromal cell signatures were found, but interestingly also found were potentially TIS signatures identifying a very restricted subset of cells expressing several putative stem cell markers, all restricted to the cancerous tissue. The detection of these signatures is based on the extreme searching depth, high degree of dimensionality, and subcellular resolution capacity of TIS. These findings provide the technological rationale for the feasibility of a complete colon cancer toponome to be established by massive parallel high throughput/high content TIS mapping.

Intrahepatic perforation of the gall bladder presenting as liver abscess: case report, review of literature and Niemeier's classification.

Liver abscess formation is a rare complication of gall bladder perforation with cholecystohepatic communication. We describe a patient who presented with right upper quadrant pain and progressive confusion, and was found to have an intrahepatic perforation of the gall bladder. We discuss the diagnostic work-up and the management of this rare entity. In particular, we look at the increasing role of interventional radiology and the limits of laparoscopic cholecystectomy in the management of such cases. The discrepancies and the modifications in the classification of gall bladder perforation (Niemeiers classification) are also discussed.

Melaena with Peutz-Jeghers syndrome: a case report.

IntroductionPeutz-Jeghers syndrome (PJS) is a rare familial disorder characterised by mucocutaneous pigmentation, gastrointestinal and extragastrointestinal hamartomatous polyps and an increased risk of malignancy. Peutz-Jeghers polyps in the bowel may result in intussusception. This complication usually manifests with abdominal pain and signs of intestinal obstruction.Case PresentationWe report the case of a 24-year-old Caucasian male who presented with melaena. Pigmentation of the buccal mucosa was noted but he was pain-free and examination of the abdomen was unremarkable. Upper gastrointestinal endoscopy revealed multiple polyps. An urgent abdominal computed tomography (CT) scan revealed multiple small bowel intussusceptions. Laparotomy was undertaken on our patient, reducing the intussusceptions and removing the polyps by enterotomies. Bowel resection was not needed.ConclusionMelaena in PJS needs to be urgently investigated through a CT scan even in the absence of abdominal pain and when clinical examination of the abdomen shows normal findings. Although rare, the underlying cause could be intussusception, which if missed could result in grave consequences.

Primary Carcinosarcoma of the Spleen: Case Report of a Rare Tumor and Review of The Literature

Carcinosarcoma of extragenital organs is rare. In this article, a case of primary carcinosarcoma of the spleen, which presented as painful splenomegaly is reported. To the best of our knowledge, this is the second reported case of primary splenic carcinosarcoma in English literature. The pathogenesis of these tumors is incompletely understood. No specific treatment guidelines exist for these aggressive tumors, surgery being the mainstay of treatment. The prognosis remains poor regardless of the adjuvant therapy used.

Carcinosarcoma of the spleen: literature review of a very rare tumour

Carcinosarcomas are rare tumours, which have both epithelial, and connective tissue elements. They are most commonly seen in the female genital tract. Rarely they arise from the gastrointestinal tract. We report a case of Carcinosarcoma arising as a primary in the spleen of a male aged 60yrs. The most unique feature of this tumour is the presence of osteosarcomatous element. This report highlights the importance of clinical awareness of such rare tumours and gives a brief overview on presentation, probable aetiology, diagnosis and management with literature review of carcinosarcoma.

Detection and survival of colorectal cancer from a 2 week wait service

AIM To determine detection strategies for colorectal cancer (CRC) and to analyse subsequent survival from a 2 week wait (2WW) service. METHOD Retrospective analysis of 2WW and hospital CRC databases from January 2006 to July 2009. Survival was assessed using Kaplan Meier survival curves and Coxs proportional hazard models. Proximal cancers were those proximal to and including the splenic flexure. RESULTS From 1725 patients seen in a 2WW clinic, 108 were identified with CRC. Median follow-up in survivors was 514 days (interquartile range 160-788 days). Of 23 patients investigated for iron deficient anaemia and/or abdominal mass, 78% (18) were found to have proximal cancers. Of 85 patients with symptoms of change in bowel habit, rectal bleeding or abdominal pain, 15% (13) were found to have proximal cancers. Age, haemoglobin and mean corpuscular volumes between these 13 patients and the 72 distal cancers in this group were not significantly different. Multivariable analysis showed that survival was lower for those presenting with proximal cancers (hazard ratio 2.912, 95% confidence interval 1.361-6.227, p=0.006) and for those with increasing Dukes stage (p<0.001). CONCLUSIONS Flexible sigmoidoscopy would have missed 15% of cancers in those presenting with symptoms alone. Patients with proximal tumours had a worse prognosis. Further research is needed to identify those presenting with symptoms alone who are at high risk of having proximal tumours and thus requiring whole colonic imaging.

Six years survival on imatinib with no disease progression after diagnosis of metastatic duodenal gastrointestinal stromal tumour: a case report

IntroductionA duodenal Gastrointestinal Stromal Tumour (GIST) is a rare finding and until recently advanced disease had a poor prognosis. A PubMed search revealed no reports of more than five years survival of inoperable GIST on chemotherapy with WHO performance status zero.Case PresentationA 68 year old female was diagnosed with unresectable GIST in the duodenum with metastasis to liver, pancreas and omentum in November 2001. She was commenced on imatinib mesylate (Glivec) chemotherapy. This case report was prepared from the medical records and radiology reports. She had good tolerance with stable disease. After six years her CT scan showed no disease progression and her WHO performance status was zero.ConclusionThis report supports the view that imatinib is a safe and effective drug in controlling disease progression in advanced metastatic GIST and plays an important role in improving the patients quality of life.

Multiple synchronous intestinal tumors

Synchronous cancer in small and large bowel is rare. We present a 83 years old woman with synchronous primary cancers of terminal ileum, sigmoid and upper rectum. Billroth first described multiple primary malignancies in a single patient in 1879 [1]. During the past century, numerous series and case reports in the literature have cited similar occurrences involving a single organ or multiple organ systems. The majority of multiple primary malignancies involving multiple organs are metachronous lesions, with synchronous lesions occurring less frequently. More than two primary synchronous malignancies involving two or more organs are extremely rare. A 83 year-old woman presented with lower abdominal pain, urinary retention and constipation. There was no history of vomiting. There was no history of change in bowel habits, bleeding per rectum or melena.The abdomen was tender in right iliac fossa but soft. Per rectal examination showed a stenosing tumor in rectum.CT scan done showed fluid in the right iliac fossa which was drained under CT guidance and found out to be pus.Laparatomy done showed pus collection in right iliac fossa and a diagnosis of appendicular abscess was made.Defunctioning loop ileostomy was done for rectal carcinoma. Post operative period was uneventful. Later,laparatomy was undertaken in view to do anterior resection in this patient. During laparatomy, tumor was found to be unresectable because of the perirectal spread and two more tumors were found. Adjuvant radio-chemotherapy was given and third laparatomy was done. Three tumors were found including a stenosing tumor in terminal ileum proximal to loop ileostomy, polypoid mass in upper rectum and another possible tumor in rectum. Terminal ileum tumor was