Wafi Attaallah

Enterostomy closure site hernias: a clinical and ultrasonographic evaluation

BackgroundParastomal hernia with a reported incidence of up to 50% is a major problem after ostomy formation. Hernias at the closure site may be a problem after the closure of the enterostomy. In this study, in addition to physical examination, we used ultrasonography (USG) in order to find the true incidence of ostomy closure site and laparotomy incisional hernias.MethodsWe examined patients with closed enterostomy sites by both physical examination and USG for the detection of hernias. Risk factors for hernia formation, such as age, gender, body mass index (BMI), ostomy type, and surgical site infections, were determined.ResultsThe evaluation of 31 patients with ostomies resulted in a 32% incidence of closed ostomy site hernias when patient medical history, physical examination, and ultrasonographic examination were used together. With physical examination and USG, incisional hernias at the laparotomy incision were found in 58% of cases. USG was able to detect hernias which were not clinically evident at the ostomy closure site and the laparotomy wound. BMI, age, gender, ostomy type, and surgical site infection did not have a significant effect on hernia formation.ConclusionOstomy closure site and laparotomy incisional hernias are important clinical problems with a high incidence after ostomies are closed. Closure of the enterostomy site should be regarded as a hernia repair rather than a simple fascial closure. USG is a valuable clinical tool in combination with physical examination for the detection of minor defects.

Whey Protein Versus Whey Protein Hydrolyzate for the Protection of Azoxymethane and Dextran Sodium Sulfate Induced Colonic Tumors in Rats

Recent studies have shown that whey protein has many useful effects including its anti-cancer effect. In this study we have compared the protective effect of dietary whey protein with whey protein hydrolyzate against azoxymethane and dextran sodium sulfate induced colon cancer in rats. We used a rat model of the colon cancer induced by administration of azoxymethane followed by repeated dextran sodium sulfate ingestion which causes multiple tumor development. Colon tissues were analyzed histologically in addition to biochemical analyses performed by measuring lipid peroxidation, protein oxidation and glutathione levels in both of colon and liver tissues of rats after sacrification. Macroscopic and microscopic tumors were identified in all groups that received azoxymethane followed by repeated dextran sodium sulfate. Group fed with whey protein hydrolyzate showed significantly less macroscopic and microscopic tumor development compared with group fed with whey protein. The protocol applied to generate an appropriate model of colon cancer was successful. Whey protein hydrolyzate was found to be more effective in preventing colon tumor development compared with whey protein.

Spontaneous rupture of extraluminal jejunal gastrointestinal stromal tumor causing acute abdomen and hemoperitoneum.

Tumor perforation is accepted as an important prognostic factor along with tumor size and mitotic index in gastrointestinal stromal tumors (GIST). The prognosis is worse in patients with tumor perforation or rupture. A few case reports of small bowel GIST presenting with rupture have been published in the medical literature. We report an unusual case of a 7.5 cm GIST of the jejunum that presented with spontaneous rupture. A previously healthy 46-year-old male patient presented with sudden abdominal pain. Physical examination revealed overt peritonitis, and computed tomography showed a heterogeneous solid mass measuring approximately 6 cm × 5.5 cm arising from the jejunum and massive fluid in the peritoneum. The mass was diagnosed as a GIST originating from the gastrointestinal tract. Emergency laparotomy was performed and intraoperative findings showed massive hemoperitoneum and an outgrowing mass at the jejunum, 50 cm distal to the Treitz ligament. The tumor had ruptured near the wall of the small intestine and it was actively bleeding. Surgical resection of the tumor was performed and the patient was discharged home uneventfully on the third postoperative day. The immunohistochemical characteristics of the tumor revealed it to be a GIST.

Prognostic Impact of the Metastatic Lymph Node Ratio on Survival in Rectal Cancer

Purpose Lymph-node metastasis is the most important predictor of survival in stage III rectal cancer. The number of metastatic lymph nodes may vary depending on the level of specimen dissection and the total number of lymph nodes harvested. The aim of this study was to evaluate whether the lymph node ratio (LNR) is a prognostic parameter for patients with rectal cancer. Methods A retrospective review of a database of rectal cancer patients was performed to determine the effect of the LNR on the disease-free survival (DFS) and the overall survival. Of the total 228 patients with rectal cancer, 55 patients with stage III cancer were eligible for analysis. Survival curves were estimated using the Kaplan-Meier method. Cox regression analyses, after adjustments for potential confounders, were used to evaluate the relationship between the LNR and survival. Results According to the cutoff point 0.15 (15%), the 2-year DFS was 95.2% among patients with a LNR < 0.15 compared with 67.6% for those with LNR ≥ 0.15 (P = 0.02). In stratified and multivariate analyses adjusted for age, gender, histology and tumor status, a higher LNR was independently associated with worse DFS. Conclusion This study showed the prognostic significance of ratio-based staging for rectal cancer and may help in developing better staging systems. LNR 0.15 (15%) was shown to be a cutoff point for determining survival and prognosis in rectal cancer cases.

HER-2 incidence in gastric cancer, its association with prognosis and clinicopathological parameters.

OBJECTIVE Human epidermal growth factor-2 (HER-2) overexpression has prognostic value in breast cancer. However, the significance of HER-2 positivity in gastric cancer is controversial. In this study, we investigated the frequency of overexpression of HER-2 and its relationship with clinicopathological findings and impact on survival in gastric cancer. MATERIAL AND METHODS Gastric cancer patients, operated in Marmara University Faculty of Medicine, Pendik Training and Research Hospital, General Surgery Department, between January 2012-December 2013 were enrolled in this study. Medical records were retrospectively evaluated. Tissue samples were stained by immunohistochemistry (IHC) method, and were followed by fluorescence in situ hybridization (FISH) in those with positive results. HER-2 expression rates and its association with other histopathological features and survival have been analyzed. RESULTS 135 patients were enrolled in the study, with 88 (65%) male and 47 (35%) female patients. The median age was 61 (29-84) years. Only 11 patients (8%) were positive for HER-2. HER-2 positive patients were similar to negative patients in terms of age, gender, tumor size, tumor location, tumor T stage, lymph node metastasis, histological type, differentiation, lymphovascular invasion, perinodal, perineural invasion and stage. No significant difference was detected on 1 and 2-year overall and disease-free survival rates between receptor positive and negative groups. CONCLUSION Consistent with the literature data, HER-2 positivity rate in this study was approximately 8%, but this positivity has not been found to be associated with either clinical and pathological parameters or overall and disease-free survival.

Should we consider topical silver nitrate irrigation as a definitive nonsurgical treatment for perianal fistula

BACKGROUND: Surgery is currently the sole treatment modality for anal fistulas. However, surgery is associated with complications such as permanent incontinence, which reduces quality of life. OBJECTIVE: To determine the rate of complete clinical healing of anal fistulas after irrigation of the fistula tract with silver nitrate solution as a nonsurgical treatment. DESIGN: Prospective single arm study. SETTING: Tertiary university hospital PATIENTS: Adult patients with symptomatic perianal fistula presenting between June 2012 and January 2013. INTERVENTION: Irrigation of the fistula tract with 1% silver nitrate solution. Irrigation was repeated every 2 weeks when necessary. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of complete clinical healing. RESULTS: Fifty-six consecutive patients with anal fistula were analyzed. Of those, 29 (52%) had complete clinical healing without recurrence for a median of 10 months. The median number of irrigations needed for complete clinical healing was 4 (1–10). The level of satisfaction was excellent in patients with complete clinical healing. The frequency of complaints was the only independent factor that had an impact on healing; patients with intermittent discharge had a significantly higher rate of complete clinical healing (67%) than those with continuous discharge (40%). There were no notable complications. LIMITATIONS: Short follow-up, small sample size, and no comparisons. CONCLUSION: This study demonstrates that the application of silver nitrate solution often produces a favorable outcome in the treatment of anal fistula. This method may be considered as a first-line treatment for the disease because it is simple, performed on an outpatient basis, minimally invasive, and lacks the complications encountered with current conventional surgical modalities.

Gallstones and Concomitant Gastric Helicobacter pylori Infection.

Background. The association of gallstones with Helicobacter pylori has been investigated but not clearly demonstrated. In this study, the presence of H. pylori in the gallbladder mucosa of patients with symptomatic gallstones was investigated. Method. Ninety-four consecutive patients with symptomatic gallstone disease were enrolled for the study. Gastroscopy and gastric H. pylori urease test were done before cholecystectomy to all patients who accepted. After cholecystectomy, the gallbladder tissue was investigated in terms of H. pylori by urease test, Giemsa, and immunohistochemical stain. Results. Overall 35 patients (37%) gallbladder mucosa tested positive for H. pylori with any of the three tests. Correlation of the three tests Giemsa, IHC, and rapid urease test was significant (r s: 0590, P > 0.001). Rapid urease test was positive in the gastric mucosa in 47 (58.7%) patients, and it was positive in the gallbladder mucosa in 21 patients (22%). In 15 patients both gastric and gallbladder tested positive with the urease test. There was significant correlation of rapid urease test in both of gallbladder and gastric mucosa (P = 0.0001). Conclusion. Study demonstrates the presence of H. pylori in the gallbladders of 37% of patients with symptomatic gallstones.

Prospective randomized comparison of oral sodium phosphate and sennoside A+B calcium lavage for colonoscopy preparation.

Purpose The aim of this study is to assess 2 different bowel-cleansing agents. Methods The patients were prospectively randomized to 2 arms of sodium phosphate versus Sennoside A+B calcium preparation. Laboratory assessment, body weight, height, and vital signs were obtained at baseline and before colonoscopy. A self-administered questionnaire was completed by the patients. The time taken to complete the colonoscopy and the segment of the colon examined were recorded. Results The patients in the Sennoside A+B calcium group were more comfortable with the taste of the solution. Patients using sodium phosphate faced more nausea and significantly lower Ca levels and P values. The pulse rate was significantly higher in this group. Patients in the sennoside group had better grades of bowel cleansing in sigmoid and descending segments of the colon. Conclusions Sennoside A+B calcium is more effective in some of the colonic segmental cleansing, causes fewer changes on serum electrolyte levels, and is better tolerated.

Endoscopic snare excision of adenoma of the papilla of Vater without prophylactic pancreatic-duct stent.

CONTEXT The endoscopic excision of adenomas of the papilla of Vater has gained increased popularity in the recent years. Temporary pancreatic drainage has been advised to accompany snare papillectomy in order to prevent ductal obstruction and serious pancreatitis. OBJECTIVES We evaluated treatment outcome of patients who had undergone endoscopic papillectomy without pancreatic drainage. METHODS Three consecutive adult patients with adenomas of the papilla of Vater presented with jaundice and pain were treated by endoscopic snare excision between October 2013 and February 2014 in a single center. ERCP procedures revealed papillary tumors and endoscopic biopsy specimens revealed tubular adenoma the papilla of Vater. Adenomas were treated by snare papillectomy method and a biliary stent was inserted as a prophylactic procedure immediately after excision of the adenoma in each case. In addition to physical examination, laboratory tests were repeated in the follow-up period after papillectomy in order to document if there is any complication particularly pancreatitis. RESULTS None of the patients experienced an immediate complication, including pancreatitis after papillectomy. Also neither patient experienced abnormal fluctuations of laboratory tests during the follow-up. Histopathologic evaluation of the resection specimens revealed a tubular adenoma with low grade dysplasia in the first two patients and a tubular adenoma with high-grade dysplasia in the third one. Endoscopy and pathologic evaluation revealed no recurrent/residual disease during the follow-up period of these patients. CONCLUSION Endoscopic snare resection of adenoma of the major papilla of the duodenum is a safe and minimal invasive alternative to surgical therapy. Biliary stent is sufficient to prevent biliary ductal patency and pancreatic stenting might not be necessary to prevent pancreatitis.

Locally Advanced Pseudopapillary Neoplasm of the Pancreas in a Male Patient: A Case Report

CONTEXT Solid pseudopapillary tumor of the pancreas is a rare neoplasm, predominantly observed in young women and with greatest incidence in the second and third decade. Although large at the time of diagnosis, it has clinically good behavior. The occurrence of infiltrating varieties of solid pseudopapillary tumors is very rare. CASE REPORT We report the case of a 48-year-old man with a giant mass in the pancreas, incidentally discovered during an abdominal ultrasonography. The mass was later investigated using multidetector computed tomography and magnetic resonance imaging. The lobulated lesion had cystic-necrotic appearances which lead the radiologists to suggest the possibility of either a gastrointestinal stromal tumor or a pancreatic cancer. The patient was operated. Operative signs showed that the tumor invaded the splenic hilum and mesentery of transverse colon. En-block resection of pancreas, spleen and transverse colon was performed as the mass was thought to be a locally advanced pancreas tumor. Pathological diagnosis reported a solid pseudopapillary tumor. CONCLUSION Although solid pseudopapillary tumor is considered a rare tumor, with a very rare rate of locally infiltrating variety, and rarely presents in males, it must be kept in mind while making the differential diagnosis of cystic pancreatic lesions to begin appropriate clinical management.