Richard T. Zera

Stapled versus hand sewn anastomoses in patients with small bowel injury: a changing perspective.

INTRODUCTION Recent studies indicate that trauma patients with hollow viscus injuries requiring anastomosis who are managed with stapling have a higher rate of complications than do those in whom a hand-sewn anastomosis is used. We undertook this study to determine whether this finding applied to patients with small bowel trauma at our institution. METHODS Records of patients with small bowel injuries were retrospectively reviewed. Demographics, severity of injury, injury management, and outcome data were collected. RESULTS Patients who had their small bowel injuries managed by hand-sewn repair versus resection and stapled anastomosis demonstrated a nonsignificant decrease in overall complication rate (35% vs. 44%) and rate of intra-abdominal complication (10% vs. 18%). Yet the rate of intra-abdominal abscess formation was significantly lower with hand-sewn repair than with resection and stapled anastomosis (4% vs. 13%). However, when hand-sewn primary repairs were excluded from the analysis and injuries that required resection and either stapled or hand-sewn anastomosis were compared, there was a similar overall complication rate (41% vs. 41%) and rate of intra-abdominal complications (17% vs. 21%). CONCLUSION The rate of intra-abdominal complications did not differ significantly between patients requiring small bowel resection and reanastomosis managed by either a stapled or hand-sewn technique. In our experience, surgical stapling devices appear to be safe for use in repairing traumatic small bowel injury.

Efficacy of radioprotective agents in preventing small and large bowel radiation injury

PURPOSE: A variety of adjuvant treatments and cytoprotective agents have been proposed to lessen the toxicity of radiation therapy. The following study was designed to evaluate the benefit of six agents or combinations using anastomotic bursting strength as a measure of transmural radiation injury. METHODS: The 40-Gy study consisted of the following. Seventy-two male Sprague-Dawley rats were divided into eight equal groups: nonradiated control, radiated untreated control, and six radiated treated groups. The radioprotective treatments included ribose-cysteine (RibCys), WR-2721, glutamine, vitamin E, MgCl2/adenosine triphosphate, and RibCys/glutamine in combination. Radiated animals received 40 Gy to the abdomen. Two weeks after radiation, all animals underwent small bowel and colonic resection with primary anastomosis. Animals were sacrificed one week postoperatively, at which time anastomoses were evaluated and bursting strengths determined. The 70-Gy study consisted of the following. The same protocol was repeated for five groups of nine rats divided into nonradiated, radiated untreated, and three radiated treated groups receiving RibCys (8 mmol/kg), RibCys (20 mmol/kg), and WR-2721. All radiated animals received 70-Gy doses. RESULTS: In the 40-Gy group, there were 10 radiation-related deaths and 6 anastomotic leaks among 70 rats studied. None of the differences between groups were significant. Nonradiated control group small bowel and large bowel anastomotic bursting pressures were significantly elevated compared with all radiated groups. Compared with radiated controls, there were significant improvements in small bowel bursting strength in the RibCys, WR-2721, RibCys-glutamine, and vitamin E groups and significant improvement in colonic bursting strength in MgCl2/adenosine triphosphate, WR-2721, and RibCys groups. In the 70-Gy group, all nine nonradiated control rats survived. All eight untreated radiated control rats died, four of eight WR-2721 animals died (P=0.03), all RibCys (8 mmol/kg) animals died (P=0.03), and three of nine treated with RibCys (20 mmol/kg) survived (P=0.08). CONCLUSIONS: WR-2721 and RibCys gave consistent protection against large and small bowel radiation injury. The lower incidence of treatment-related toxicity and potentially equal or greater radioprotective effects may make RibCys more clinically useful than WR-2721.

Civilian rectal trauma: A changing perspective

BACKGROUND Recently the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma developed a Rectal Injury Scaling System (RISS). Little data exist regarding its clinical utility. METHODS We retrospectively reviewed 45 patients with rectal injuries to assess the impact of the RISS on patient management and outcome. We compared RISS grade I patients (group I, partial-thickness injury) with patients with grades 2, 3, and 4 injuries (group II, full-thickness injury). RESULTS Group II underwent distal rectal washout and repair of the injury twice as often and had a significantly higher rate of diversion of the fecal stream. This was associated with a 3-fold increase in complications. The only complications in group I were in patients managed with diversion of the fecal stream and distal rectal washout. CONCLUSIONS Our data suggest that aggressive surgical management for RISS grade I injury may not be necessary. Implementation of therapy based on the RISS may improve outcomes of civilian rectal trauma.

A review of technical aspects of sentinel lymph node identification for breast cancer

The management of lymph nodes in breast cancer has undergone significant changes over the past century. In the Halsted radical mastectomy, axillary lymph nodes were removed en bloc with the breast and pectoralis muscles. After World War II, Waangensteen and others advocated removing the supraclavicular and internal mammary lymph nodes and the axillary nodes. More recently, others have suggested that removing clinically normal axillary lymph nodes is not therapeutic, so is unnecessary. But the status of the axillary lymph node basin remains the most powerful predictor of longterm survival in patients with breast cancer. Furthermore, pathologic analysis of the axillary nodes provides essential information for determining adjuvant therapies. Until recently, a level I/II axillary lymph node dissection (ALND) was the recommended method for identifying nodal metastases. But ALND is associated with numerous side effects, including arm numbness and pain, fluid collections, infections, and lymphedema. Because most breast cancer patients today do not have lymph node metastases, ALND offers no benefit, and may, in fact, do harm to many patients. Sentinel lymph node (SLN) biopsy has been proposed as a substitute for routine ALND in patients with clinically normal axillary basins. The SLN, the first node to receive primary lymphatic drainage from the breast, may be used to predict the status of the remainder of the axilla. A patient with a negative SLN biopsy may be spared the risks of unnecessary ALND. Early investigators attempted to identify the SLN using peritumoral injections of either blue dye or radioactive colloid, or both. In preliminary studies, SLN biopsy was followed by ALND to determine the accuracy of the biopsy results. SLN biopsy results are assessed by identification rates and false-negative rates. If the SLN is not identified, an ALND should be performed. So a high identification rate is desired to reduce unnecessary ALNDs. A falsenegative result in a patient with breast cancer is especially troublesome; cancerous lymph nodes can be left untreated in the axilla, and, more important, appropriate adjuvant therapy might not be implemented. Overall, identification rates and false-negative rates vary considerably among surgeons and might be related to the lack of a standardized technique to identify the SLN. Despite the widespread use of SLN biopsy, a number of technical questions remain: Where should the tracer be injected? What volume of radioactive colloid should be used? Is the use of dual agents better than a single agent? What is the value of preoperative lymphoscintigraphy? Should internal mammary lymph nodes be removed? Is filtered radioactive colloid better than unfiltered? When should the tracer agents be injected? The literature now includes several hundred publications with more than 10,000 patients undergoing SLN biopsy using various techniques. In many cases, individual authors advocate the particular technique used at their own institution. An overview analysis is limited by retrospective studies, various degrees of surgeon experience, conflicting indications for the procedure, and the evolution of technology over the past several years. Nevertheless, a critical and objective review is important to provide the practicing general surgeon guidelines for accurate SLN identification.

Percutaneous endoscopic gastrostomy (PEG) in cancer patients

SummaryNinety-nine cancer patients underwent PEG placement attempt at Rosewell Park Cancer Institute between January 1, 1985, and December 1, 1987. Ninety-eight of these were successful and were retrospectively reviewed to determine if cancer patients constitute a high-risk group for PEG placement. Procedure-related mortality was 2% and morbidity was 19%. Morbidity of 17% was noted at less than 30 days and 2% had late complications. Six complications were considered serious with peritonitis in 3 and tube loss in 3 patients; an additional 4 patients had a failure of adequate GI tract decompression which was the indication for their PEG placement. Ascites was a major factor in morbidity with 4 of 5 patients with ascites having complications including the 2 deaths. Overall major morbidity was not increased in cancer patients without ascites including a group of patients with carcinomatosis (18 patients) and 22 patients requiring preoperative dilatation and/or tumor ablative procedures. We conclude that morbidity in cancer patients is not increased if one excludes those with ascites from the procedure

Comparative surgical and colonoscopic appearance of colon anastomoses constructed with sutures, staples, and the biofragmentable anastomotic ring

SummaryThe following animal study was undertaken to compare and assess the endoscopic gross appearance and histology of colonic anastomoses constructed with sutures, staples, and the biofragmentable anastomotic ring (BAR).Methods: Three anastomoses—1 BAR, 1 stapled, and 1 sutured—were placed in each of 48 dogs and colonoscopy and anastomotic evaluation were done.Results: No leaks were found by air insufflation at surgery. Grossly, the BAR had serosal hematomas in 27/48 anatomoses vs 7/48 for stapled and 1/48 for sutured (BAR vs stapledP<0.0005 and sutured vs stapledP=0.07). Adhesions were significantly greater for BAR (35/36) and sutured (34/36) compared to stapled (26/36) (BAR vs stapledP=0.01 and sutured vs. stapledP=0.04). Colonoscopic exams at days 3, 7, and 28 showed no significant difference among groups with respect to bleeding, ulceration, necrosis, granulation, or contour. Sutured anastomoses were more stenotic (24/31) than stapled (4/31) or BAR (3/31) ones (BAR vs sutured and sutured vs stapledP<0.005). At 28 days, 10/10 sutured vs 2/10 stapled vs 3/10 BAR were stenotic (BAR vs suturedP=0.02, sutured vs stapledP=0.01). Inflammation on histologic exam at 28 days was not significantly different: sutured (12/12), stapled (12/12), or BAR (9/12). Fibrosis was more prominent in sutured (12/12) than in stapled (5/12) or BAR (4/12) anastomoses (BAR vs suturedP=0.001, sutured vs stapledP=0.004, and BAR vs stapledP=1.00). All anastomoses healed primarily without necrosis or obstruction.Conclusions: (1) Colonoscopy to evaluate anastomoses can be done safely even in the early postoperative period. (2) The BAR anastomoses had the most serosal hematomas; BAR and sutured had more adhesions than stapled anastomoses; and sutured anastomoses had the most stenosis and fibrosis. None of these differences was of clinical significance.

Protective effect of RibCys following high-dose irradiation of the rectosigmoid.

Ribose-cysteine (RibCys) is a prodrug ofl-cysteine that stimulates glutathione biosynthesis. Increased glutathione levels have been shown to have a protective effect against radiation-induced injury and oxidative stress. Surface oximetry has previously been used successfully to predict anastomotic leakage. PURPOSE: The following study was done to evaluate the protective effect of RibCys and the predictive value of PtO2 determinations in a swine model. METHODS: Domestic swine were divided into three groups: Group A served as a nonradiated control; Group B received 6,000 to 6,500 rad to the rectosigmoid; and Group C received RibCys (1 g/kg) prior to receiving 6,000 to 6,500 rad. Radiated animals and controls underwent rectosigmoid resection after a three-week rest period. Intraoperative anastomotic PtO2 was checked with a modified Clark electrode. Anastomoses were evaluated radiographically at three and seven days; animals were sacrificed, and bursting strength was recorded at 10 days. RESULTS: Mean bursting pressures were 243.8±59.4, 199.5±37.8, and 209.5±54.9 mmHg (NS) for Groups A, B, and C, respectively. Anastomotic PtO2 ranged from 19 to 98 mmHg and could not be correlated with anastomotic leaks or bursting pressure. There were 11/15 radiation-related deaths and leaks (eight deaths and three leaks) in the radiated group and 4/12 radiation-related deaths and leaks (three deaths and one leak) in the group receiving radiation and RibCys (P < 0.04). CONCLUSIONS: 1) RibCys protected animals against radiation-related deaths and anastomotic leaks following high doses of pelvic irradiation; 2) anastomotic PtO2 levels did not correlate with anastomotic healing in this model.

L-Cysteine prodrug protects against cyclophosphamide urotoxicity without compromising therapeutic activity

Summary2(R,S)-d-ribo-(1′,2′,3′,4′-Tetrahydroxybutyl)-thiazolidine-4(R)-carboxylic acid (RibCys) is a prodrug ofL-cysteine that releases the sulfhydryl amino acid after monenzymatic ring opening and hydrolysis. TheL-cysteine then elevates glutathione (GSH) levels by stimulating its biosynthesis. RibCys was investigated for its ability to protect CDF1 mice from the potent urotoxicity of cyclophosphamide (CTX) without compromising the therapeutic utility of the drug. RibCys induced a significant reduction in weight loss of the animals and in bladder inflammation at 48 h after CTX administration; however, bladder tissue remained inflamed as compared with that in controls. Bladder histology also showed some pathological changes in the presence of RibCys. In contrast, all parameters of toxicity (body weight loss, bladder inflammation, and pathological abnormalities) had been virtually reversed by day 21 after administration. In tests against 1210 leukemia, RibCys did not interfere with CTX anti-cancer activity. From these preliminary studies, RibCys appears to be a likely candidate for protecting against long-term CTX toxicity, perhaps reversing the original damage caused by a very high dose, without compromising the therapeutic utility of the alkylating agent.

A Case of Fat Necrosis of the Breasts Associated with Central Venous Occlusion Related to Dialysis Access.

A 33-year-old female presented with severe bilateral breast pain and palpable masses. Complex past medical history included diabetes, obesity, history of heparin-induced thrombocytopenic thrombosis, deep vein thrombosis on chronic anticoagulation with warfarin, end stage renal disease, failed living donor related transplant and on dialysis. She suffered from multiple clotted central venous access catheters, the last occurred 3 months prior to presentation. Prior breast history included multiple breast abscesses that required incision and drainage. On exam, she appeared obese and older than stated age. Her breasts appeared pendulous with prominent cutaneous varicosities and were markedly tender bilaterally. She had a 5 cm mass on the right and a 10–12 cm mass on the left (Fig. 1a). Ultrasound revealed only soft tissue edema without evidence of mass or fluid collection. Breast Magnetic Resonance Imaging (MRI) without contrast showed findings consistent with mastitis on the left and no significant abnormalities on the right. The patient was treated as an outpatient with a course of antibiotics for presumed mastitis. At follow-up, her symptoms had failed to resolve. Ultrasound of the left breast was suggestive of hematoma. Breast MRI with contrast revealed very prominent collateral venous outflow and lumps in bilateral breasts (Fig. 1b). A needle biopsy revealed fat necrosis of the beast without evidence of malignancy. She continued to suffer significant pain and was hospitalized twice for pain management. A pain management