CARCINOMA OF THE RECTUM—Low Abdominal Tranverse Incision for Resection with End-to-End Anastomosis

On the basis of published studies of the lymphatic spread of carcinoma of the rectum, tumors lying as low as the anterior peritoneal reflection may be treated by segmental resection with end-to-end anastomosis. Statistics of five-year survivals in these published studies indicate that for tumors in such locations, a segmental resection offers the same chance for cure as an abdominoperineal resection.The transverse low abdominal incision previously described by the author permits better exposure, facilitates the performance of anastomosis which can be made at a greater depth, and thus enables the surgeon to resect a wider margin distal to the tumor.     

The effects of tapering and artery wall stiffness on treatments for Coarctation of the Aorta

Coarctation of the Aorta is a congenital narrowing of the aorta. Two commonly used treatments are resection and end-to-end anastomosis, and stent placements. We simulate blood flow through one-dimensional models of aortas. Different artery stiffnesses, due to treatments, are included in our model, and used to compare blood flow properties in the treated aortas. We expand our previously published model to include the natural tapering of aortas. We look at change in aorta wall radius, blood pressure and blood flow velocity, and find that, of the two treatments, the resection and end-to-end anastomosis treatment more closely matches healthy aortas.     

Surgical treatment of hepato-pancreato-biliary disease in China: the Tongji experience

Hepato-pancreato-biliary (HPB) tumors are common in China. However, these tumors are often diagnosed at intermediate/ advanced stages because of the lack of a systemic surveillance program in China. This situation creates many technical challenges for surgeons and increases the incidence of postoperative complications. Therefore, Dr. Xiao-Ping Chen has made many important technical improvements, such as Chen’s hepatic portal occlusion method, the anterior approach for liver resection of large HCC tumors, the modified technique of Belghiti’s liver-hanging maneuver, inserting biliary-enteric anastomosis technique, and invaginated pancreaticojujunostomy with transpancreatic U-sutures. These techniques are simple, practical, and easy to learn. Owing to these advantages, complicated surgical procedures can be simplified, and the curative effects are greatly improved. These improved techniques have been widely applied in China and will benefit many additional patients. In this review, we introduce our experience of surgically treating intermediate/advanced hepatocellular carcinoma (HCC), hilar cholangiocarcinoma (HC), and pancreatic carcinoma, mainly focusing on technical innovations established by Dr. Chen in HPB surgery.     

Functional aspects of ano-rectal vascularity

The blood supply of the ano-rectum has been studied in cadaveric specimens by angiographic methods. The vascular anastomosis between the middle rectal and superior rectal vessels was found to be demonstrable on one side only. There appears to be a midline paucity of vessels in both the posterior and anterior rectal walls, and this may be important in the aetiology of anastomotic dehiscence in low anterior resection.     

The Diagnosis and Treatment of Arterial Injuries

Repair of arterial injuries has decreased the amputation rate to 15% from 50%, which was prevalent when ligation was practised. Methods of treatment include lateral repair, resection of damaged area with end-to-end anastomosis, and resection and graft, with or without the assistance of partial or complete cardiopulmonary bypass. Lacerations of large arteries (aorta, iliac) may be treated by lateral repair. Lacerations of smaller arteries are best treated by resection and anastomosis, or by resection and graft. True and false aneurysms and arteriovenous fistulas are best treated by resection and restoration of blood flow. “Spasm” in an artery is frequently due to intimal rupture or subintimal hemorrhage, and likewise requires resection and anastomosis in many instances. Clinical examples of each type of injury are presented. Angiography is of great value in establishing the precise abnormality present, its location, the degree of collateral circulation, and the result achieved by surgery.     

Management of colonic and rectal injuries.

In managing a colonic or rectal injury the surgeon must decide whether it is acceptable to have feces passing over a suture line or anastomosis. If it is, resection and anastomosis or simple oversewing of the bowel can be done. If it is not, there are four choices: (a) closure of the wound, drainage and proximal diversion; (b) primary closure or resection and anastomosis of the wound with exteriorization; (c) formation of a double-barrelled colostomy; and (d) resection of the injured colon with formation of an end-colostomy and a mucosal fistula or a Hartmann procedure. The surgeon''s choice should be dictated by the severity of the injury, the degree of fecal contamination and the general condition of the patient.     

Reestablishment of sensitivity in the latissimus dorsi transplant through anastomosis of the thoracodorsal nerve with sensitive nerves

The question as to whether anastomosis of sensory nerves is recommended for free transplants of the myocutaneous latissimus dorsi flap, reanastomosed by microvascular surgery, remains a controversial issue. In this study, a microsurgical nerve anastomosis was performed to sensitize a latissimus dorsi transplant. To determine sensation in the transplanted tissue, six patients were examined clinically. All patients had free transplants of latissimus dorsi flaps reanastomosed by microvascular surgery after tumor resection in the oral cavity. An anastomosis of the sensible auricular magnus nerve with the motor thoracodorsalis nerve was performed. Resulting sensation was determined clinically by testing for pain, temperature, pressure, two-point discrimination, and vibration. All patients showed sensation in the latissimus dorsi flap beginning between the third and the fifth month postoperatively. Therefore, resensitization of a large and voluminous myocutaneous latissimus dorsi flap should be attempted by a nerve anastomosis in this transplant.     

Spontaneous retroperitoneal hemorrhage caused by segmental arterial mediolysis

Spontaneous retroperitoneal hemorrhage is a rare clinical entity; signs and symptoms include pain, hematuria, and shock. Spontaneous retroperitoneal hemorrhage can be caused by tumors, such as renal cell carcinoma and angiomyolipoma; polyarteritis nodosa; and nephritis. The least common cause is segmental arterial mediolysis. Although computed tomography is used for the diagnosis of spontaneous retroperitoneal hemorrhage, it can miss segmental arterial mediolysis as the cause of the hemorrhage. The diagnosis of segmental arterial mediolysis as a cause of spontaneous retroperitoneal hemorrhage requires angiography, with pathologic confirmation for a definitive diagnosis.     

A study of small bowel tumors; with special emphasis on clinical aspects

Ninety-eight patients with 100 different tumors of the small bowel were studied. There were more malignant than benign tumors. Adenocarcinoma was the commonest lesion and the ileum the most frequent anatomical site of all tumors. Except for carcinoid tumors, the lesions were observed more often in male than in female patients. The average age of patients in this series was higher than that reported in most other series. Loss of weight, and abdominal pain were the most constant symptoms. Clinical syndromes of anemia and bleeding, small bowel obstruction, biliary obstruction, perforation with peritonitis, abdominal tumor, melanosis with small bowel polyposis, and cutaneous von Recklinghausen's disease with small bowel neurofibromatosis were encountered either alone or in combination. In the group operated upon, a resection of the involved segment with end-to-end anastomosis was done when feasible. None of the patients operated upon before 1946 lived as much as five years after operation. The most common causes of death were extension of the primary tumor and metastasis, peritonitis due to perforation, associated bronchopneumonia, and hemorrhage.     

Tuberculous Enteritis

Tuberculous enteritis occurs in about 2 percent of patients with pulmonary tuberculosis. Although it is uncommon in the United States, tuberculous enteritis should be considered in any patient with active pulmonary tuberculosis and abdominal complaints.Eight cases of T. enteritis have been treated at Harbor General Hospital in the last 25 years. Associated pulmonary disease was shown radiologically to be present in seven of eight patients. Findings on contrast studies of the gastrointestinal tract showed disease in six of six patients examined.In five patients, surgical operation was required for diagnosis or complications. Resection of diseased bowel with primary anastomosis was done in five patients. Although medical therapy is the mainstay in the treatment of both pulmonary and intestinal tuberculosis, one staged resection of diseased bowel with primary anastomosis is the procedure of choice for complications such as obstruction, hemorrhage or perforation.     

Our technique of combined renal and segmental pancreas transplantation

This case, however, confirms our hypothesis that intraperitoneal positioning of a segmental pancreatic graft into the Douglas' pouch and an end to side arterial anastomosis bring several advantages as far as venous thrombosis and tryptic lesions are concerned.     

Ganglia formation of the peripheral nervous system.

Embryologic studies have shown that the ganglions of the peripheral nervous system are formed by the neuroblasts from the central nervous system. The histotopography of the neurons and their segmental communications with the central nervous system are established experimentally (segmental section of the ventral roots and resection of the spinal nodes: 100 experiments). It is proved that the neurons, which communicate with the definite segment of the spinal cord, are diffusely distributed in the ganglion mass.     

Dormancy signatures and metastasis in estrogen receptor positive and negative breast cancer

Breast cancers can recur after removal of the primary tumor and treatment to eliminate remaining tumor cells. Recurrence may occur after long periods of time during which there are no clinical symptoms. Tumor cell dormancy may explain these prolonged periods of asymptomatic residual disease and treatment resistance. We generated a dormancy gene signature from published experimental models and applied it to both breast cancer cell line expression data as well as four published clinical studies of primary breast cancers. We found that estrogen receptor (ER) positive breast cell lines and primary tumors have significantly higher dormancy signature scores (P<0.0000001) than ER- cell lines and tumors. In addition, a stratified analysis combining all ER+ tumors in four studies indicated 2.1 times higher hazard of recurrence among patients whose tumors had low dormancy scores (LDS) compared to those whose tumors had high dormancy scores (HDS) (p<0.000005). The trend was shown in all four individual studies. Suppression of two dormancy genes, BHLHE41 and NR2F1, resulted in increased in vivo growth of ER positive MCF7 cells. The patient data analysis suggests that disseminated ER positive tumor cells carrying a dormancy signature are more likely to undergo prolonged dormancy before resuming metastatic growth. Furthermore, genes identified with this approach might provide insight into the mechanisms of dormancy onset and maintenance as well as dormancy models using human breast cancer cell lines.     

A STUDY OF SMALL BOWEL TUMORS—With Special Emphasis on Clinical Aspects

Ninety-eight patients with 100 different tumors of the small bowel were studied. There were more malignant than benign tumors. Adenocarcinoma was the commonest lesion and the ileum the most frequent anatomical site of all tumors. Except for carcinoid tumors, the lesions were observed more often in male than in female patients. The average age of patients in this series was higher than that reported in most other series. Loss of weight, and abdominal pain were the most constant symptoms. Clinical syndromes of anemia and bleeding, small bowel obstruction, biliary obstruction, perforation with peritonitis, abdominal tumor, melanosis with small bowel polyposis, and cutaneous von Recklinghausen''s disease with small bowel neurofibromatosis were encountered either alone or in combination.In the group operated upon, a resection of the involved segment with end-to-end anastomosis was done when feasible. None of the patients operated upon before 1946 lived as much as five years after operation. The most common causes of death were extension of the primary tumor and metastasis, peritonitis due to perforation, associated bronchopneumonia, and hemorrhage.     

Submandibular gland resection and bilateral parotid duct ligation as a management for chronic drooling in cerebral palsy

The control of chronic drooling in cerebral palsy has been difficult in the past. Previous methods to control drooling include the Wilkie procedure, which diverts the salivary flow from the parotid glands by means of surgically created tunnels to the tonsillar fossa, along with submandibular gland resection. An alternative is submandibular gland resection with bilateral parotid duct ligation. Previous published studies using this method have resulted in good to excellent results, but population sizes were felt to be too small to be conclusive. Since 1979, a total of 58 patients have been treated by parotid duct ligation with submandibular gland resection, and 86 percent have shown good to excellent results. These results compare favorably with those published by Wilkie. Also, parotid duct ligation is technically easier, associated with less postoperative morbidity, and has shown a decreased duration of hospitalization compared to parotid duct transposition.     

Klatskin tumor--results of surgical therapy

Between January 1st 1990 and December 31st 1999, 24 patients affected by Klatskin tumor underwent operation in our department of surgery. According to Bismuth's classification, there were 0 (0%) type I, 5 (21%) type II, 6 (25%) type IIIa, 4 (17%) type IIIb and 9 (37%) type IV tumors. Five patients (21%) were treated by curative resection (group I) while in 14 patients (58%) palliative surgical procedure was performed (group II). In 5 cases (21%) the extension of malignancy did not allowed any procedure (group III). Curative resection for malignant tumors of the hepatic duct bifurcation included wide tumor excision and bile duct resection at the liver hilum (with wedge hepatic resection in one patient) and creation of biliary-enteric anastomosis. Palliative surgical procedure included stent insertion. Jaundice was completely relieved in all patients undergoing resection, since 3 patients (21%) after stenting hadn't satisfactory biliary drainage. There was 1 (20%) perioperative death in the group 1, while in group 2, 5 patients (36%) died postoperatively. In this series, the mean postoperative survival of all patients was 16 months. The mean postoperative survival of patients undergoing localized tumor resection with curative intent was 38 months, in contrast to 10 months for those undergoing operative stent insertion. in addition, only 1 patient from group III, in whom only exploratory surgery were performed survived 7 months, while other 4 patients died in the hospital. This retrospective review suggests that aggressive surgical treatment could improve survival and quality of life in patients suffering from Klatskin tumor.     

胆管癌的光动力疗法

胆管癌(Cholangiocarcinoma CC)是一种罕见的胆道原发性恶性肿瘤,预后较差。根治性手术只适用于一小部分早期诊断的患者。姑息性的经皮或内镜下支架置入胆管引流术能通过减轻瘙痒,疼痛,和胆管炎的程度从而提高生活质量,但对于延长生存时间作用甚微。光动力疗法(PDT)是对于不能手术切除的CC的一种较新颖的局部微创性的姑息疗法。其原理是PDT中使用的光敏性分子能特异性的聚集在增生组织如肿瘤,在特定波长的光照下光敏剂激活生成活性氧类物质,从而选择性的导致肿瘤细胞的死亡。经过初步的可行性性研究和充满前景的前瞻性II期临床研究后,关于研究比较胆管支架置入联合光动力治疗与单纯胆管内支架置入的两组前瞻性随机对照试验已经发表。其中一组试验结果显示PDT组(493天)与非PDT组(98天)相比在中位生存期方面的显著优势(P0.0001),且PDT组患者的体力状态也明显改善。另一组试验也进一步明确了PDT治疗对于提高生存率方面的优势(PDT组630天而单纯支架置入组210天,P0.01)。整个治疗过程耐受性良好。有报道称PDT作为CC的辅助或新辅助疗法已取得了令人满意的结果,因此PDT可以被看作是治疗不能手术切除的胆管癌的一种标准性姑息治疗方法。     

Mutation Discovery in Regions of Segmental Cancer Genome Amplifications with CoNAn-SNV: A Mixture Model for Next Generation Sequencing of Tumors

Next generation sequencing has now enabled a cost-effective enumeration of the full mutational complement of a tumor genome-in particular single nucleotide variants (SNVs). Most current computational and statistical models for analyzing next generation sequencing data, however, do not account for cancer-specific biological properties, including somatic segmental copy number alterations (CNAs)-which require special treatment of the data. Here we present CoNAn-SNV (Copy Number Annotated SNV): a novel algorithm for the inference of single nucleotide variants (SNVs) that overlap copy number alterations. The method is based on modelling the notion that genomic regions of segmental duplication and amplification induce an extended genotype space where a subset of genotypes will exhibit heavily skewed allelic distributions in SNVs (and therefore render them undetectable by methods that assume diploidy). We introduce the concept of modelling allelic counts from sequencing data using a panel of Binomial mixture models where the number of mixtures for a given locus in the genome is informed by a discrete copy number state given as input. We applied CoNAn-SNV to a previously published whole genome shotgun data set obtained from a lobular breast cancer and show that it is able to discover 21 experimentally revalidated somatic non-synonymous mutations in a lobular breast cancer genome that were not detected using copy number insensitive SNV detection algorithms. Importantly, ROC analysis shows that the increased sensitivity of CoNAn-SNV does not result in disproportionate loss of specificity. This was also supported by analysis of a recently published lymphoma genome with a relatively quiescent karyotype, where CoNAn-SNV showed similar results to other callers except in regions of copy number gain where increased sensitivity was conferred. Our results indicate that in genomically unstable tumors, copy number annotation for SNV detection will be critical to fully characterize the mutational landscape of cancer genomes.     

MANAGEMENT OF RESECTABLE LESIONS OF THE SMALL BOWEL

During a 12-year period at the Los Angeles County General Hospital there were 364 cases of resection and anastomosis of the small intestine which were classified and studied. Particular attention was paid to the methods of anastomosis. There were more wound infections, fistulas and otherwise faulty anastomosis with the open than with the closed technique. In the presence of a peritoneal cavity not previously contaminated by bowel content, a closed anastomosis is better and safer than an open anastomosis.