J. Alexander Palesty

The efficacy of x-rays after chest tube removal

BACKGROUNDnThe insertion and subsequent removal of chest tubes are frequently performed procedures. We hypothesize that routine chest radiographs obtained after chest tube removal to confirm the absence of any post-procedure complications have little impact on clinical management.nnnMATERIALS AND METHODSnA 5-year retrospective study of 73 patients with tube thoracotomies was performed in a level II trauma centers intensive care unit. Patients were identified from billing records for chest tube placement. Medical records and official chest x-ray film reports, both before and after removal, were reviewed, and demographic data were collected.nnnRESULTSnOf the 73 patients examined, only 8 had postprocedure reports that differed from the preprocedure reports. Two of these 8 patients required reinsertion of a chest tube to treat the recurrence of a significant pneumothorax. However, the decision to reinsert the chest tube was based on the patients clinical appearance rather than on the x-ray findings.nnnCONCLUSIONnChest radiography following the removal of chest tubes should not be a routinely performed procedure, but should preferably be based on the good clinical judgement and discrimination of the surgeon.

Routine chest radiographs following central venous recatheterization over a wire are not justified.

BACKGROUNDnSubclavian vein central venous catheterization and the subsequent exchange of subclavian catheters over a guidewire are frequently performed procedures. We hypothesized that the policy of obtaining a routine postprocedure chest radiograph to confirm appropriate catheter placement and to rule out complications after exchanging central venous catheters over a wire was no longer justifiable.nnnMETHODSnA retrospective study of 295 patients with Swan-Ganz catheters (SGC) was performed between July 1, 1994 and June 30, 1996. One hundred fourteen of these SGCs were exchanged over a guidewire for a central venous catheter (CVC). Postexchange chest radiograph and associated radiologists report, as well as age, gender, and duration of catheter placement were all recorded. Since July 1996, this study has been extended prospectively.nnnRESULTSnOf the 380 documented over-a-wire exchanges, none has resulted in a complication, including catheter malposition.nnnCONCLUSIONnWe conclude from these data that a routine chest radiograph following the replacement of a CVC over a guidewire is not necessary when good clinical judgment and discrimination are used in a monitored setting.

Nd:YAG laser surgery for the excision of pilonidal cysts: A comparison with traditional techniques

Nd:YAG laser photothermal ablation has been accepted as a treatment modality for hemorrhoidal disease. There is little reported on its use in treating pilonidal disease. We hypothesized that laser would be an excellent tool for pilonidal cystectomy, facilitating improved outcome and patient satisfaction.

Laparoscopic Splenectomy for Traumatic Splenic Injury after Screening Colonoscopy

Colonoscopy is a widespread diagnostic and therapeutic procedure. The most common complications include bleeding and perforation. Splenic rupture following colonoscopy is rarely encountered and is most likely secondary to traction on the splenocolic ligament. Exploratory laparotomy and splenectomy is the most commonly employed therapeutic intervention for this injury reported in the literature. We present the case of a patient with this potentially fatal complication who was treated successfully at our institution. To our knowledge it is the first report in the literature of laparoscopic splenectomy as a successful minimally invasive treatment of splenic rupture following colonoscopy. The patient was a 62-year-old female who underwent screening colonoscopy with polypectomies at the cecum, descending colon and rectum. Immediately following the procedure she developed abdominal pain and had a syncopal episode. Clinical, laboratory and imaging findings were suggestive of hemoperitoneum and a ruptured spleen. A diagnostic laparoscopy was emergently performed and revealed a grade IV splenic laceration and hemoperitoneum. Laparoscopic splenectomy was completed safely and effectively. The patient’s postoperative recovery was uneventful. We conclude that splenic rupture after colonoscopy is a rare but dangerous complication. A high index of suspicion is required to recognize it early. Awareness of this potential complication can lead to optimal patient outcome. Laparoscopic splenectomy may be a feasible treatment option.

Is Gender Related to the Stage of Colorectal Cancer at Initial Presentation in Young Patients

BACKGROUNDnThe incidence of colorectal cancer (CRC) in young adults is rising, and young age is a predictor of poor survival. The purpose of this study was to examine factors leading to increased mortality in patients ≤ 50 years of age, and to examine this population for characteristics that could lead to benefit from CRC screening.nnnMETHODSnCharts of patients 50 years of age and under, diagnosed with CRC from 1998 through 2007, at our community teaching hospital, were reviewed retrospectively. Demographics, social and family history, staging, treatment and death were evaluated. Mann Whitney, Fisher Exact, and χ(2) tests were used with P <0.05 considered statistically significant.nnnRESULTSnForty-five young patients with CRC were identified. Twenty-five patients were female and 20 male; the mean age was 43.6 y. Most patients presented with rectal bleeding. Right-sided cancers had a higher presenting stage (P < 0.05). Men had both a higher presenting stage (P = 0.35) and a higher incidence of smoking compared with women (P = 0.001). Female patients were more likely to have left-sided CRC (65%) compared with men (35%). Ninety-six percent of patients underwent surgical resection; 14 patients died.nnnCONCLUSIONSnCRC in young adults is not common, but is often advanced when discovered. Diagnostic efforts should be aggressive in young patients who have rectal bleeding, especially young male smokers. Sigmoidoscopy is not adequate for comprehensive diagnosis of CRC in young patients, as the majority have right-sided colon cancers, which often result in subsequent presentation of the disease at a higher stage, risk, and mortality rate.

Hybrid Verrucous—Squamous Cell Carcinoma of the Ovary With Synchronous Squamous Cell Carcinoma of the Endometrium

Verrucous carcinoma, a variant of well-differentiated squamous cell carcinoma, is usually described in the literature as arising in the oral cavity, skin, and larynx. The reports on verrucous carcinoma arising in the genital tract, usually originating in the vagina, vulva, or uterine cervix, are few. Verrucous carcinoma arising in the ovary has not been previously reported. In this article, a unique hybrid carcinoma, a large aggressive verrucous carcinoma in combination with squamous carcinoma of the left ovary and synchronously occurring with a squamous cell carcinoma in the endometrium, is presented. This unique case of a hybrid carcinoma includes the first-known case of this type of carcinoma involving the ovary. The negative cervical evaluation findings, together with the histologic patterns of the tumors in the uterus and the ovary, support the conclusion that these 2 carcinomas are synchronous, one arising in the left ovary and the other arising in the uterus.

Overexpression of Thioredoxin1 enhances functional recovery in a mouse model of hind limb ischemia

BACKGROUNDnThere is keen interest in finding nonsurgical treatments for peripheral vascular disease (PVD). Previously, we demonstrated that selective activation of Thioredoxin1 (Trx1), a 12-kDa cytosolic protein, initiates redox-dependent signaling and promotes neovascularization after ischemic heart disease. Therefore, Trx1 might possess immense potential to not only treat murine hind limb ischemia (HLI) through effective angiogenesis but also provide PVD patients with nonsurgical therapy to enhance neovascularization and improve blood perfusion.nnnMETHODSnTo determine whether activation of Trx1 increases blood perfusion in HLI, two different strategies were used-gene therapy and transgenic model system. In adenoviral-mediated gene therapy, 8- to 12-wk-old mice were divided into two groups: (1) control Adeno-LacZ (Ad-LacZ) and (2) Adeno-Thiroedoxin1 (Ad-Trx1). The mice underwent surgical intervention to induce right HLI followed by injection with Ad-LacZ or Ad-Trx1, respectively. In the second strategy, we used wild-type and transgenic mice overexpressing Trx1 (Trx1Tg/+). All the animals underwent Doppler imaging for the assessment of limb perfusion followed by immunohistochemistry and Western blot analysis.nnnRESULTSnSignificant increases in perfusion ratio were observed in all the Trx1 overexpressed groups compared with their corresponding controls. Expressions of heme oxygenase-1, vascular endothelial growth factor, and the vascular endothelial growth factor receptors Flk-1 and Flt-1 were increased in Trx1 overexpressed mice compared with their respective controls. Blood perfusion in the ischemic limb gradually improved and significantly recovered in Trx1Tg/+ and Ad-Trx1 groups compared with their corresponding controls. The capillary and arteriolar density in the ischemic zone were found to be higher in Trx1Tg/+ group compared with wild type.nnnCONCLUSIONSnThe overall outcomes of our study demonstrate that Trx1 enhances blood perfusion and increases angiogenic protein expression in a rodent HLI model. These results suggest that Trx1 is a potential target for clinical trials and drug therapy for the treatment of PVD.

Thioredoxin-1 augments wound healing and promote angiogenesis in a murine ischemic full-thickness wound model

Background Nonhealing wounds are a continuing health problem in the United States. Overproduction of reactive oxygen species is a major causative factor behind delayed wound healing. Previously we reported that thioredoxin‐1 treatment could alleviate oxidative stress under ischemic conditions, such as myocardial infarction and hindlimb ischemia. In this study, we explored the potential for thioredoxin‐1 gene therapy to effectively aid wound healing through improved angiogenesis in a murine ischemic wound model. Methods Full‐thickness, cutaneous, ischemic wounds were created in the dorsum skin flap of 8‐ to 12‐week‐old CD1 mice. Nonischemic wounds created lateral to the ischemic skin flap served as internal controls. Mice with both ischemic wounds and nonischemic wounds were treated with Adeno‐LacZ (1 × 109 pfu) or Adeno‐thioredoxin‐1 (1 × 109 pfu), injected intradermally around the wound. Digital imaging was performed on days 0, 3, 6, and 9 to assess the rate of wound closure. Tissue samples collected at predetermined time intervals were processed for immunohistochemical analysis. Results No significant differences in wound closure were identified among the nonischemic wounds control, nonischemic wounds‐LacZ, and nonischemic wounds–thioredoxin‐1 groups. Hence, only mice with ischemic wounds were further analyzed. The ischemic wounds–thioredoxin‐1 group had significant improvement in wound closure on days 6 and 9 after surgery compared with the ischemic wounds control and ischemic wounds‐LacZ groups. Immunohistochemical analysis indicated increased thioredoxin‐1, vascular endothelial cell growth factor, and &bgr;‐catenin levels in the ischemic wounds–thioredoxin‐1 group compared with the ischemic wounds control and ischemic wounds‐LacZ groups, as well as increased capillary density and cell proliferation, as represented by Ki‐67 staining. Conclusion Taken together, thioredoxin‐1 gene therapy promotes vascular endothelial cell growth factor signaling and re‐epithelialization and activates wound closure in mice with ischemic wounds.