Reza Gamagami

Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis

PURPOSE: Improved functional results can be obtained by construction of a colonic J-pouch after coloanal anastomosis. Variability in pouch size following coloanal anastomosis is prevalent in current literature. In this study, the authors compare clinical bowel function after complete rectal excision with coloanal anastomosis for patients with rectal carcinoma using either a small 6-cm or a large 10-cm colonic J-pouch anastomosis. The clinical outcome is assessed both at short-term and long-term follow-up. METHODS: Fifty-nine consecutive patients with rectal cancers 4 to 8 cm from the anal verge were recruited into the study. Patients were randomized intraoperatively to either a 6-cm J-pouch group or a 10-cm J-pouch group. Clinical assessments were performed prospectively at 3, 6, 12, and 24 months postoperatively, following colostomy closure. Clinical parameters such as frequency, urgency, continence, and laxative and enema use were assessed and compared between the two groups. RESULTS: There was no statistical differences in the mean defecation frequency, urgency, and fecal continence between the two groups at 3, 6, 12, and 24 months. In the first year, laxative and enema use between the two groups was negligible; however at two years, 30 percent of patients with a large reservoir compared with 10 percent of patients in the small-pouch group required laxative and/or enema for constipation and evacuation of bowels. CONCLUSION: Similar clinical results can be expected from patients with either small or large reservoirs at one year. However, with long-term follow-up, patients with a large reservoir are more likely to require medication for constipation and evacuation. To avoid these inconveniences a small reservoir is advocated for patients undergoing coloanal anastomosis.

Residual human immunodeficiency virus (HIV) Type 1 RNA and DNA in lymph nodes and HIV RNA in genital secretions and in cerebrospinal fluid after suppression of viremia for 2 years.

Residual viral replication persists in a significant proportion of human immunodeficiency virus (HIV)-infected patients receiving potent antiretroviral therapy. To determine the source of this virus, levels of HIV RNA and DNA from lymphoid tissues and levels of viral RNA in serum, cerebrospinal fluid (CSF), and genital secretions in 28 patients treated for < or =2.5 years with indinavir, zidovudine, and lamivudine were examined. Both HIV RNA and DNA remained detectable in all lymph nodes. In contrast, HIV RNA was not detected in 20 of 23 genital secretions or in any of 13 CSF samples after 2 years of treatment. HIV envelope sequence data from plasma and lymph nodes from 4 patients demonstrated sequence divergence, which suggests varying degrees of residual viral replication in 3 and absence in 1 patient. In patients receiving potent antiretroviral therapy, the greatest virus burden may continue to be in lymphoid tissues rather than in central nervous system or genitourinary compartments.

Factors influencing survival after resection for periampullary neoplasms

BACKGROUND The purpose of this study was to determine predictors of survival after resection for periampullary neoplasms. METHODS Over a 15-year period, 208 patients underwent laparotomy for periampullary neoplasms. Data were analyzed to assess predictors of survival. RESULTS Pathologic examination showed pancreatic cancer (n = 136; 65%), ampullary cancer (n = 28; 13%), distal common bile duct cancer (n = 10; 5%), duodenal cancer (n = 4; 2%), neuroendocrine tumor (n = 11; 5%), cystadenocarcinoma (n = 4; 2%), cystadenoma (n = 5; 2%), and other (n = 10; 5%). A total of 129 patients underwent pancreatic resection (71 Whipples, 35 total pancreatectomies, 21 distal pancreatectomies, and 2 partial pancreatectomies) whereas 79 patients were found to be unresectable and underwent palliative bypass and/or biopsy. Median survival was 20.4 months for resectable patients versus 4.5 months for unresectable patients (P<0.001). Of the 129 resected patients, factors significantly (P<0.05) favoring long-term survival on univariate analysis included well-differentiated histology, common bile duct or ampullary adenocarcinoma, early stage, tumor diameter <2 cm, negative margins, and absence of lymph node metastases, perineural, or vascular invasion. Age, sex, race, and type of procedure had no influence on survival. On multivariate analysis, only tumor differentiation appeared independently related to survival. Using Kendalls tau analysis, tumor type and grade correlated significantly with all other predictors. CONCLUSIONS Of all variables studied, tumor type and poor tumor differentiation in periampullary neoplasms appear to be markers that predict a constellation of other adverse findings.

Value of Three-dimensional US for Optimizing Guidance for Ablating Focal Liver Tumors

PURPOSE To determine if three-dimensional ultrasound (3D US), by nature of its ability to simultaneously evaluate structures in three orthogonal planes and to study relationships of devices to tumor(s) and surrounding anatomic structures from any desired orientation, adds significant additional information to real-time 2D US used for placement of devices for ablation of focal liver tumors. MATERIALS AND METHODS Sixteen patients underwent focal ablation of 23 liver tumors during two intraoperative cryoablation (CA) procedures, three intraoperative radiofrequency ablation (RFA) procedures, 11 percutaneous ethanol injections (PEI) procedures, and six percutaneous RFA procedures. After satisfactory placement of the ablative device(s) with 2D US guidance, 3D US was used to reevaluate adequacy to device position. Information added by 3D US and resultant alterations in device deployment were tabulated. RESULTS 3D US added information in 20 of 22 (91%) procedures and caused the operator to readjust the number or position of ablative devices in 10 of 22 (45%) of procedures. Specifically, 3D US improved visualization and confident localization of devices in 13 of 22 (59%) procedures, detected unacceptable device placement in 10 of 22 (45%), and determined that 2D US had incorrectly predicted device orientation to a tumor in three of 22 (14%). CONCLUSIONS Compared to conventional 2D US, 3D US provides additional relationship information for improved placement and optimal distribution of ablative agents for treatment of focal liver malignancy.

Diagnosis and Staging of Pancreatic Neoplasms

The relative value of current approaches to the diagnosis and staging of pancreatic cancer is discussed. A rational sequence of testing is recommended based on the clinical presentation of the patient and the local institutional expertise and facilities that are available.

FOURNIER'S GANGRENE: AN UNUSUAL PRESENTATION FOR RECTAL CARCINOMA

We report a case of a large perforated adenocarcinoma of the rectum manifesting as an ischiorectal abscess progressing to Fourniers gangrene in an insulin-dependent diabetic man. Recognition and management of this rare syndrome in the setting of a common disease is discussed.

Is rectal intussusception a cause of idiopathic incontinence

PURPOSE: The cause of rectal intussusception in patients primarily dominated by symptoms of anal incontinence has not been fully elucidated, especially for patients with idiopathic incontinence. METHODS: Between 1991 and 1996, 51 patients referred with a diagnosis of idiopathic incontinence were prospectively evaluated by standard questionnaire, clinical examination, defecography, and anal manometry. Fourteen female patients were identified with rectal intussusception and were treated by transabdominal rectopexy. Postoperatively, clinical assessment and anal manometry were performed at regular intervals. RESULTS: Continence was improved after rectopexy (P<0.01). The postoperative increases in the anal resting pressure, maximum squeeze pressure, and maximum tolerated volume were not statistically significant. CONCLUSIONS: Rectopexy improved anal incontinence in patients with rectal intussusception. The cause of rectal intussusception in anal incontinence could not be explained by functional improvement of the internal anal sphincter tone or an increase in the maximum tolerated volume. Rectal intussusception may be a cause of idiopathic incontinence in patients; however, larger prospective studies are required to support this concept.

Cimetidine: An inhibitor or promoter of tumor growth?

Cimetidine, a histamine type 2 (H 2) receptor antagonist, is a commonly prescribed medication for the treatment of gastroesophageal reflux disease (GERD) as well as for gastric and duodenal ulcer disease. In addition, cimetidine has been shown to have immunomodulatory effects. This has led investigators to study the effects of cimetidine in the treatment of various neoplasms. Chemotherapy for colon cancer is based on fluorouracil, which has only minimal activity on high-stage disease. Pharmacologic agents that can improve survival in patients with colon cancer will have profound impact in the treatment of this condition. Cimetidine was first reported to have antitumor effects in 1979 (Armitage and Sidnez, 1979). This anecdotal case presentation was followed by a report of immunomodulation by cimetidine (Osbandet al., 1981). Studies involving cimetidine on xenograft mouse models have been reported (Gifford et al., 1981; Tutton and Steel, 1979; Watson et al., 1993; Adamset al.,1994; Suonioet al.,1994). The majority of these studies (Giffordet al., 1981; Tutton and Steel, 1979; Watsonet al.,1993; Adamset al.,1994) describe an antitumor effect of cimetidine. In addition, there have been several clinical trials with equivocal results (Svendsen t al.,1995; Linkset al., 1995; Matsumoto, 1995). The xenograft models that were previously used to test cimetidine involved human tumor cell line implantation in the subcutaneous (s.c.) space (Gifford et al., 1981; Tutton and Steel, 1979; Watson et al.,1993; Adamset al.,1994) and the subrenal capsule (Suonio et al., 1994). We have previously developed a ‘‘patient-like’’ tumor model using surgical orthotopic implantation (SOI) of histologically intact tumor tissue for human colon cancer (Fuet al., 1991) as well as many other tumor types (Hoffman, 1994). Tumor growth and progression after s.c. implantation, where metastasis rarely occurs, differ greatly when compared with orthotopic implantation, which can allow for a high metastatic potential correlating with the clinical course of the disease (Hoffman, 1994). In addition, different drug responses on tumor growth have been reported for the s.c. vs. orthotopic site (Kuo et al.,1993). These significant differences suggest that orthotopic implantation is a more clinically relevant tumor model. This study was designed to examine the effıcacy of cimetidine on human colon carcinomas that were implanted by SOI compared with s.c.

Symptomatic post-traumatic cyst of the liver: treatment by laparoscopic surgery.

We report a case of a large post-traumatic liver cyst in a symptomatic patient treated by laparoscopic excision in an ambulatory setting. This rare lesion can be treated safely by this alternative modality on an outpatient basis, with minimal morbidity.

Rectal excision with coloanal anastomosis for superficial distal third rectal cancer: survival and local recurrence.

Appropriate surgical treatment of distal third rectal cancer limited to bowel wall (i.e. T1 or T2) in medically operable patients is controversial. Transanal excision can deprive some patients of accurate pathological staging, prognosis and cure. In contrast abdominoperineal resection has considerable practical and psychosocial problems largely related to a permanent colostomy. We hypothesize that superficial distal rectal tumours can be effectively treated with rectal excision and coloanal anastomosis.