Thomas A. Stellato

Percutaneous approaches to enteral alimentation

Feeding gastrostomy and jejunostomy provide effective access for long-term enteral nutrition. Traditional operative techniques for the performance of these procedures requires laparotomy and often, general anesthesia. This report describes our experience with two relatively new methods, percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy. Results of percutaneous gastrostomy and jejunostomy to date in 323 cases include a morbidity of 5.9 percent and a 0.3 percent operative mortality. Percutaneous endoscopic gastrostomy and jejunostomy should become the procedures of choice for the establishment of enteral access in patients requiring long-term enteral alimentation.

Growth stimulation by coexpression of transforming growth factor-alpha and epidermal growth factor-receptor in normal and adenomatous human colon epithelium.

Autocrine stimulation of the epidermal growth factor receptor (EGF-R), by coexpression of transforming growth factor-alpha (TGF-alpha), causes malignant transformation of some fibroblast cell lines. TGF-alpha and EGF-R are both known to be expressed in colon carcinoma tissue and have been shown coexpressed in colon carcinoma cell lines. TGF-alpha autocrine activation of EGF-R has been suggested as a potential mechanism contributing to abnormal growth control in colon cancer. We now report coexpression of TGF-alpha and EGF-R transcripts in morphologically normal colonic epithelium from five individuals, in colonic adenomas from three individuals, and in a nontumorigenic colon adenoma cell line, VACO-330. Functional studies demonstrate VACO-330 growth is stimulated by exogenous TGF-alpha and is completely abolished by a blocking anti-EGF-R antibody. Autocrine stimulation of EGF-R by TGF-alpha is therefore required for growth of the adenoma cell line. Autocrine stimulation of EGF-R by TGF-alpha does not cause malignant transformation of the colonic epithelial cell. In normal and adenomatous human colon TGF-alpha, via either an autocrine or paracrine mechanism, is likely an important physiologic stimulant of epithelial proliferation.

Role of surgery in antibiotic-induced pseudomembranous enterocolitis

With the increased use of prophylactic and broad-spectrum antibiotics, pseudomembranous colitis has emerged as a significant clinical problem. Management with specific anti-Clostridium difficile therapy (vancomycin or metronidazole) has reduced mortality to less than 2%. Nevertheless, the disease may progress to a fulminant toxic colitis or colonic perforation. Additionally, another subset of patients will present with a dramatic clinical picture, suggesting acute peritonitis, eventuating in unnecessary laparotomy. This report reviews both the medical and surgical literature during the past 15 years of patients treated for pseudomembranous colitis. Analysis of this clinical data has provided us with the opportunity to both define the role of surgery in this disorder and illustrate the necessity for a combined medical and surgical cooperative approach in the early management of this iatrogenic disease.

Transverse testicular ectopia

In transverse or crossed testicular ectopia, the affected gonad lies in the same canal as the normally descended testis. During a 5-yr span, three children with this form of ectopia were seen. All presented with a symptomatic right inguinal hernia and an empty scrotum on the left side. The ages at operation were 1, 3, and 5 mo. Only the first patient was reoperated. In this child, the diagnosis of transverse testicular ectopia was made during the herniorrhaphy and the ectopic, but otherwise normal, gonad returned to the abdominal cavity. A subsequent left orchidopexy through a celiotomy was done. In the last two patients, the correct diagnosis was made preoperatively. Both gonads were of equal size and normal, occupying the same hemiscrotum. A herniorrhaphy with fixation of the ectopic gonad to the opposite hemiscrotum was done in both. All three children are otherwise normal. Cases collected from the literature are discussed. The condition should be suspected if a unilateral hernia is associated with a contralateral, nonpalpable testis and may not be as rare as formerly thought.

Percutaneous endoscopic gastrostomy following previous abdominal surgery

During a 36-month period, 89 patients have undergone percutaneous endoscopic gastrostomy without mortality. Of these patients, 25 (13 infants and children, 12 adults) had prior abdominal procedures that increased their risk for the endoscopic procedure. With two exceptions, all gastrostomies were performed utilizing local anesthesia. There was one major complication, a gastrocolic fistula, which was successfully managed by repeating the endoscopic gastrostomy procedure at a location more cephalad in the stomach. Twenty-two of the gastrostomies were placed for feeding purposes and all of these patients were able to leave the hospital with alimentation accomplished via the tube. Three of the endoscopically placed gastrostomies were for gastrointestinal tract decompression. A total of 255 patient months have been accumulated in these patients with the endoscopically placed gastrostomy in situ. The technique can be safely performed in patients with prior abdominal surgery and in the majority of cases is the technique of choice for establishing a tube gastrostomy.

Should bariatric revisional surgery be avoided secondary to increased morbidity and mortality

BACKGROUND Revisional bariatric surgery may be necessary due to inadequate weight loss or postoperative complications of the primary operation. We sought to identify the reasons for revision, characteristics of the surgery, and outcomes. We hypothesize that revisional surgery, although technically challenging, can produce desirable outcomes. METHODS Patients undergoing bariatric surgery at our institution between 1998 and 2007 were reviewed from a prospective database. Patients who had revisional surgery were compared to those who had primary surgery. RESULTS We have identified 46 of 1,038 patients who underwent revisional surgery. Twenty of 46 had a primary Roux-en-Y gastric bypass. The most common indication for revisions is inadequate weight loss secondary to gastrogastric fistula (15/20). Leaks occurred more frequently following revisional surgeries (11% vs 1.2%), but intensive care unit (ICU) utilization was less (11% vs 4.4%) and mortality was lower (0% vs .3%) with bariatric revision surgery. CONCLUSIONS Although we saw a 9-fold increase in leaks, a 2-5 fold increase in ICU utilization, and 1.5-fold increase in length of stay, our mortality rate was zero. In experienced hands, bariatric revision surgery can be performed to produce desirable outcomes.

Carcinoembryonic antigen in human colonic aberrant crypt foci

BACKGROUND/AIMS Aberrant crypt foci are putative preneoplastic lesions that, by definition, are identified microscopically in whole-mount preparations of colonic mucosa. Because the identification of hexosaminidase as a marker for rat aberrant crypt foci in histological sections facilitated their characterization, a similar marker for human foci in histological sections was sought. METHODS Human aberrant crypt foci were marked in whole-mount preparations, embedded in paraffin, and evaluated for their expression of carcinoembryonic antigen with two monoclonal antibodies. RESULTS Elevated expression of carcinoembryonic antigen was detected in 39 of 42 (93%) aberrant crypt foci from 15 patients. The expression of carcinoembryonic antigen assisted in the evaluation of longitudinal sections of foci, where dysplasia is more readily detected in these small lesions. The expression of carcinoembryonic antigen was related to the sizes of the foci (P = 0.0085, generalized Fishers Exact Test) but not to the presence or degree of dysplasia. CONCLUSIONS The overexpression of immunohistochemically demonstrable carcinoembryonic antigen is, to date, the only described alteration in most of these putative precursors of human colon cancer that differs from the expression in contiguous, normal crypts at the histological level and thus facilitates the identification of aberrant crypts in histological sections for further characterization.

The impact of resection margin status and postoperative CA19-9 levels on survival and patterns of recurrence after postoperative high-dose radiotherapy with 5-FU-based concurrent chemotherapy for resectable pancreatic cancer.

Objectives:To analyze the impact of surgical margins and other clinicopathological data on treatment outcomes on 75 patients treated from 1999 to 2006 by initial potentially curative surgery (±intraoperative radiotherapy), followed by high-dose 3-dimensional conformal radiation therapy and concomitant fluoropyrimidine-based chemoradiotherapy. Materials and Methods:All clinical and pathologic data on this patient cohort were analyzed by actuarial Kaplan-Meier survival methodology and by univariate and multivariate Cox proportional hazards methods to measure effects on survival and patterns of failure. Results:With a median follow-up of 28 months, the median, 2-year and 5-year overall survival (OS) rates were 18.1 month, 41% and 23.6%, respectively. Disease-free survival (DFS) rates were of 11.4 months, 35% and 20%, respectively. Only 2 clinicopathological features, positive (≤1 mm) surgical margins (P < 0.05) and a 2-fold (>70 U/mL) elevation of the postoperative serum CA19-9 (P < 0.001) impacted OS and disease-free survival. In patients with negative (>1 mm) surgical margins and a low (≤70 U/mL) postoperative CA19-9, the projected 2- and 5-year OS were 80% and 65%, respectively, compared with 40% and 10% with positive surgical margins and a low CA19-9 and to 10% and 0% with positive or negative surgical margins and a high (>70 U/mL) CA19-9. Positive surgical margins (P < 0.001) and an elevated postoperative CA19-9 (P < 0.001) also predicted early development of distant metastases, whereas isolated loco-regional failure was less common and not affected by these or other clinicopathological features. Conclusions:Using this fluoropyrimidine-based chemoradiotherapy regimen after surgical resection (±intraoperative radiotherapy), positive surgical margins and an elevated (2-fold) postoperative serum CA19-9 level predicted for reduced survival and early development of distant metastatic disease.

Adjuvant therapy of stage II breast cancer

SummaryA prospective, randomized clinical trial of adjuvant treatment of 318 stage II breast cancer patients, using chemotherapy, the antiestrogen tamoxifen, and immunotherapy is reported at 48 months follow-up.Women whose primary tumors have no estrogen receptors fall into a significantly poorer prognostic group than those whose tumors contain estrogen receptors. None of the adjuvant regimens appeared to offer any clear-cut advantage for the estrogen receptor negative patients.Those women whose primary tumor contains estrogen receptors appear to be in a prognostically favorable group, when their treatment regimen included the antiestrogen, tamoxifen. The adjuvant use of BCG immunotherapy does not appear to offer additional benefit, but the follow-up period of these treated patients is too brief to be conclusive.A longer period of observation is needed to determine whether this systemic treatment in estrogen receptor positive patients is preventing recurrence or merely delaying it.

The utility of computed tomography in colonic diverticulitis.

Forty-one patients admitted to our hospital during an 18-month period with the clinical diagnosis of colonie diverticulitis were analyzed to evaluate the utility of computed tomography (CT). Abdominal pain and leukocytosis were the most common presenting manifestations, 75 and 66%, respectively. Just over one-half of the patients also demonstrated hematuria. Twenty patients required surgical intervention, most commonly for failure to improve despite medical management. Preoperative studies included 10 sigmoidoscopies, 30 plain abdominal roentgenograms, 20 barium enemas (BE), and 24 CT scans. Two CT scans were also obtained after operation for successful percutaneous drainage of intra-abdominal abscesses. Abdominal roentgenograms were most commonly obtained but least helpful, with only one third demonstrating any abnormality whatsoever. Sigmoidoscopy was least commonly performed but almost universally abnormal. Specificity was low, however, in that spasm with inability to advance the endoscope was the most common finding. Of the 20 barium enemas obtained, 60% had findings consistent with diverticulitis, most commonly localized perforation or fixed narrow segment. Sixty-three per cent of CT scans were abnormal. The most frequent findings were localized thickening of the colonie wall and increased density in the pericolic fat. Diverticular abscess, which may be inferred by other studies, was definitely diagnosed in one third of the patients with abnormal CT scans. CT also provided the ability to identify extracolonic intra-abdominal pathology. The study demonstrates that both barium enema and CT are effective in diagnosing diverticulitis, although CT can be performed without risk. CT played no therapeutic role before operation, although two patients benefited after operation by CT-guided drainage of intra-abdominal abscesses. The decision for surgery was most frequently dependent on clinical examination and never solely on the basis of either the barium enema or CT in this study. The major benefit of CT appears to be its ability to identify both gross and subtle changes indicative of diverticular disease and extracolonic pathology in a relatively noninvasive manner.