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ABSTRACT: Although blunt trauma to a hernia-containing bowel is known to cause bowel perforation, this report documents the first incident of a small bowel transection following a non-traumatic event.
We report the case of a 49-year-old African American man with a chronic incarcerated inguinal hernia awaiting elective repair. He presented to the Emergency Department with abdominal pain following an episode of coughing. On examination, he was found to have peritonitis. He underwent exploratory laparotomy, and had a complete small bowel transection. A bowel resection with primary anastomosis was performed, as well an inguinal hernia repair.
Chronic hernia incarceration can lead to weakening and ischemia of the bowel, and minimal trauma can lead to perforation of the weakened segment. In such presentations, bowel resection and repair of the defect with a biological material is safe and feasible.
Journal of Medical Case Reports 01/2013; 7(1):47.
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ABSTRACT: To evaluate the risk of gallbladder cancer (GBC) in patients with a porcelain gallbladder (PGB).
Retrospective analysis of our institutional experience and a systematic review of the literature.
Academic teaching facility, Parkland Memorial Hospital, and the Dallas Veterans Affairs Medical Center (all in Dallas, Texas).
Medical records of 1200 cholecystectomies performed between 2008 and 2009 at Parkland Memorial Hospital, The University of Texas Southwestern Medical Center, and the Dallas Veterans Affairs Medical Center were reviewed. Patients with radiologic or histologic evidence of PGB or GBC were included.
The risk of GBC in patients with a PGB was assessed by contingency table analysis.
We identified 13 patients with a PGB among 1200 cholecystectomies (1.1%). Most of these patients had concomitant gallstones (n = 9). None of the patients with a PGB had evidence of carcinoma. We also reviewed the histologic analysis results of 35 cases of GBC operated on between 1997 and 2009; none of these had gallbladder wall calcifications. Most patients underwent a laparoscopic cholecystectomy without any postoperative complications. We reviewed 7 published series that included 60,665 cholecystectomies. The overall incidence of PGB was 0.2%, and GBC occurred in 15% of the PGB cases. Most cases of GBC occurring in PGB were found in the older literature; in the contemporary series, there were few reports of GBC associated with a PGB.
Porcelain gallbladder is only weakly associated with GBC. Prophylactic cholecystectomy is not indicated for PGB alone and should be performed only in patients with conventional indications for cholecystectomy. A laparoscopic approach is appropriate for most patients with a PGB.
Archives of surgery (Chicago, Ill.: 1960) 10/2011; 146(10):1143-7. · 4.32 Impact Factor
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Sergio Huerta
Journal of Gastrointestinal Surgery 07/2011; 15(7):1292; author reply 1293. · 2.83 Impact Factor
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ABSTRACT: A process was developed to use a nontraditional operative day (Saturday) to increase the number of inguinal herniorrhaphies (IHs) performed. The purpose of this analysis was to compare operating times and outcomes between patients undergoing IH on Saturday versus the weekday. A retrospective review was conducted that included patients who underwent IH from October 2008 to January 2010. This cohort was divided based on the day on which surgery occurred. The outcome measures were operative times, room turnover time, and complication rates. Operative time was shorter for Saturday IHs (50.7 vs. 67.8 min, P ≤ 0.001). The greatest difference between the two groups occurred in turnover times. We considered Saturday turnover time to be zero, which was possible because of multiple support teams and additional room availability. Turnover times during the week averaged 40.5 ± 2 minutes. There was no difference in complication rates for the two groups (Saturday IHs 17.6% vs. 20.9% for weekday IHs, P = 0.75). Elective cases can be accomplished more rapidly during nontraditional operating times if there are multiple support teams and rooms available.
The American surgeon 05/2011; 77(5):597-601. · 1.28 Impact Factor
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Sergio Huerta
Anti-cancer drugs 02/2011; 22(4):305-7. · 2.23 Impact Factor
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ABSTRACT: A murine orthotopic model for the study of colon cancer has been described earlier. However, for the study of rectal cancer, three issues remain: (i) the relative sensitivity of the implanted tumors to ionizing radiation (IR); (ii) the location of the tumor for the delivery of external beam IR; and (iii) the assessment of a given modality over time before necropsy. In this protocol, we have modified an orthotopic model for colon cancer described earlier for the specific assessment of chemoradiation in rectal cancer by (i) cecal transplantation of tumors with a known response to IR; (ii) securing the tumor to the lateral abdominal wall with a permanent suture for the administration of IR; and (iii) transfection of cells with luciferase before tumor implantation for the assessment of the chemoradiotherapeutic interventions over time by bioluminescence imaging before the end on the study. This technique allows targeted delivery of IR in an intraperitoneal tumor. Imaging throughout the course of the treatment is possible such that the timing of chemoradiation can be determined and permits comparison between groups before the end of the treatment. This model represents a modified technique that allows the assessment of chemoradiotherapeutic interventions in rectal cancer.
Anti-cancer drugs 01/2011; 22(4):371-6. · 2.23 Impact Factor
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ABSTRACT: The efficacy of oxaliplatin monotherapy against several solid tumors and its relative lack of nephrotoxicity and myelosupression, coupled with results of the Multicenter International Study of Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjuvant Treatment of Colon Cancer trial, led to a great deal of interest for the implementation of this chemotherapeutic agent in the preoperative setting for the management of adenocarcinoma of the rectum. Despite limited in-vitro and in-vivo data with regard to the radiosensitizing properties of oxaliplatin in rectal cancer, it rapidly entered phase I-III clinical trials. This study reviews the results of these trials and the current status of oxaliplatin as a radiosensitizing agent in the neoadjuvant management of rectal cancer.
Anti-cancer drugs 01/2011; 22(4):317-23. · 2.23 Impact Factor
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ABSTRACT: To determine if an evidence-based practice bundle would result in a significantly lower rate of surgical site infections (SSIs) when compared with standard practice.
Single-institution, randomized controlled trial with blinded assessment of main outcome. The trial opened in April 2007 and was closed in January 2010.
Veterans Administration teaching hospital.
Patients who required elective transabdominal colorectal surgery were eligible. A total of 241 subjects were approached, 211 subjects were randomly allocated to 1 of 2 interventions, and 197 were included in an intention-to-treat analysis.
Subjects received either a combination of 5 evidenced-based practices (extended arm) or were treated according to our current practice (standard arm). The interventions in the extended arm included (1) omission of mechanical bowel preparation; (2) preoperative and intraoperative warming; (3) supplemental oxygen during and immediately after surgery; (4) intraoperative intravenous fluid restriction; and (5) use of a surgical wound protector.
Overall SSI rate at 30 days assessed by blinded infection control coordinators using standardized definitions.
The overall rate of SSI was 45% in the extended arm of the study and 24% in the standard arm (P = .003). Most of the increased number of infections in the extended arm were superficial incisional SSIs (36% extended arm vs 19% standard arm; P = .004). Multivariate analysis suggested that allocation to the extended arm of the trial conferred a 2.49-fold risk (95% confidence interval, 1.36-4.56; P = .003) independent of other factors traditionally associated with SSI.
An evidence-based intervention bundle did not reduce SSIs. The bundling of interventions, even when the constituent interventions have been individually tested, does not have a predictable effect on outcome. Formal testing of bundled approaches should occur prior to implementation.
Archives of surgery (Chicago, Ill.: 1960) 11/2010; 146(3):263-9. · 4.32 Impact Factor
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Journal of the American College of Surgeons 10/2010; 211(6):812-22. · 4.55 Impact Factor
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ABSTRACT: The response to neoadjuvant chemoradiation in rectal cancer is variable and unpredictable. Resistance to chemoradiation has been directly correlated with the levels of the inhibitors of apoptosis (IAPs) in several malignancies. Because smac-DIABLO is a pro-apoptotic gene product that directly inhibits the activity of the IAPs, molecules with similar activity might radiosensitize rectal tumors with phenotypes that express high levels of IAPs. This study was undertaken to assess the radiosensitizing properties of the smac mimetic JP-1201 in radioresistant HT-29 colorectal cancer cells in vitro and established xenografts in SCID mice.
Survival was determined by clonogenic assays. PARP-1, caspase-8 cleavage, and IAP levels were assessed by Western blot analysis. SCID mice bearing HT-29 xenografts were treated with ionizing radiation: 2.0 Gy x 5; (n = 6), JP-1201 (5.0 mg/Kg i.p., n = 5) or combination treatment (n = 7) and compared to control (n = 8). DNA repair mechanisms were interrogated by gammaH2AX positive foci.
Pretreatment of HT-29 cells with JP-1201 (5.0 microM) prior to ionizing radiation (IR) significantly decreased the survival of these cells. SCID mice bearing HT-29 xenografts demonstrated no difference in tumor load in the group receiving exclusively JP-1201 versus control. At the end of the treatment (day 40), a 46% reduction of tumor load was observed in the IR+JP-1201-treated group compared to the IR-only treated group. Radiosensitization was achieved with a substantial elevation of cleaved PARP-1 in JP-1201- treated HT-29 cells versus control cells with a concomitant decrease of XIAP, but not of survivin or cIAP1/2. JP-1201-treated HT-29 cells had a reduced ability to repair double-stranded DNA breaks (DSBs).
The smac mimetic JP-1201 decreased the survival of HT-29 cells and tumor growth by an additive effect in apoptosis and a reduction in the level of XIAP and an impairment of DNA repair mechanisms. The pathways leading to this response need to be further investigated.
Surgery 08/2010; 148(2):346-53. · 3.10 Impact Factor
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ABSTRACT: The continuous infusion of ropivacaine is effective in controlling pain for a wide variety of surgical procedures and reducing opioid adverse effects and dependency. The present study assessed the efficacy of ropivacaine infusion using the I-Flow dual Soaker Catheter system at the surgical site for bariatric surgery recovery at the Dallas Veterans Affairs Medical Center Hospital (Dallas, TX). We hypothesized that patients receiving ropivacaine would report lower levels of morphine requirement and pain, would have shorter hospital stays, and would return to ambulating faster than patients in the control group.
A total of 45 patients undergoing Roux-en-Y gastric bypass surgery were randomized to 1 of 2 treatment groups, with a target study population of 50 patients, receiving either .2% ropivacaine (n = 24) or saline solution (n = 21). Before incision closure, the surgeon infiltrated the surrounding tissues with 30 mL of ropivacaine (.5%) or saline solution. The catheter was then placed in both the subfascial space and subcutaneously. Next, the infusion pump was connected to the Soaker Catheters to complete the system design and deliver solution to the surgical site.
No significant differences were found in the pain scores, morphine requirement, or length of stay between the 2 groups. The ropivacaine group interval to sitting up was one half day shorter than that of patients receiving saline (P = .038).
Patients receiving ropivacaine were found to ambulate much more quickly than did the control group patients. This could be very beneficial in reducing the complications from blood clots and improving patient recovery and overall well-being after surgery by assisting with a quicker return to activities of daily living and reducing the dependence on the nursing staff.
Surgery for Obesity and Related Diseases 03/2010; 6(2):181-4. · 3.93 Impact Factor
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ABSTRACT: PurposeTo identify, using tissue microarray (TMA), an immunohistochemical panel predictive of response to ionizing radiation (IR) in rectal cancer.MethodsTMA constructs were prepared from archived stage II/III rectal tumors and matching adjacent mucosa (n = 38) from patients treated with pre-operative chemoradiation. Immunohistochemistry (IHC) was performed for MIB, Cyclin E, p21, p27, p53, survivin, Bcl-2, and BAX. Immunoreactivity along with clinical variables was subjected to univariate and forward stepwise logistic regression analyses.ResultsPathological complete response (pCR) was 23.9%. The number of positive lymph nodes obtained in the resected specimen was associated with pCR. Immunoreactivity for MIB (Sn 15%, Sp 65%, OR 0.33), p53 (Sn 3%, Sp 84%, OR 0.16), Bcl-2 (Sn 11%, Sp 74%, OR 0.35), and BAX (Sn 92%, Sp 80%, OR 46) was associated with pathological response (all p's < 0.001). Forward stepwise logistic regression analysis demonstrated that MIB was an independent predictor of a response to chemoradiation (p = 0.001).ConclusionsA combined panel of mediators of apoptosis alone or combined with clinical factors is a feasible approach that can be applied to rectal tumor biopsies to predict a response to chemoradiation. The most sensitive factor was BAX; while MIB independently predicted a response to chemoradiation.
Digestive and Liver Disease 03/2010; · 3.05 Impact Factor
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Sergio Huerta
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ABSTRACT: Neoadjuvant chemoradiation is used as a preoperative standard treatment for the majority of patients with Stage II/III rectal cancers and, in attempt to facilitate surgical intervention, reduce the rate of local recurrence and improve overall outcomes in patients suffering from this malignancy. However, this modality results in a wide range of clinical responses. In many cases, a pathological complete response is achieved, while in others, receiving the same form of treatment, the tumor continues to grow. The specific phenotype of the tumor plays a major role in rendering tumor cells a survival advantage to the cytotoxic effects of chemoradiation. Several factors participating in proliferation, cell cycle, apoptosis and hypoxiahave been investigated under a variety of conditions in pre-irradiated tissues and post-irradiated tumors. Mutations in the genes of these pathways have shown to lead to resistance to chemoradiation. This chapter describes colon cancer with emphasis on the molecular mechanisms that may lead to chemoradio-resistance of cells with cytotoxically induced DNA injury in rectal cancer.
Advances in experimental medicine and biology 01/2010; 685:124-33. · 1.09 Impact Factor
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ABSTRACT: Metastatic disease to the gallbladder is unusual. The most common malignancy metastatic to the gallbladder is melanoma, followed by renal cell carcinoma (RCC) and breast cancer. Due to the unusual nature of the disease, there are no trials available for review. Thus, the management for these patients has been based on institutional experience and review of case series. The indications for surgical intervention for melanoma are metastatic disease discrete to the gallbladder and biliary symptoms, which are uncommon for melanoma, but might occur due to cystic duct obstruction culminating in cholecystitis. Laparoscopic cholecystectomy without a lymphadenectomy is emerging as the preferred approach for this metastatic deposit. The vast majority of patients with metastases to the gallbladder from RCC carry a good prognosis and a laparoscopic cholecystectomy should be considered. Patients with metastases to the gallbladder from the breast classically present with biliary symptoms and commonly undergo a laparoscopic cholecystectomy, which invariably demonstrates a deposit in the gallbladder from lobular breast cancer. In the present report, we review the indications for surgical intervention from various malignancies metastatic to the gallbladder and the current consensus for the laparoscopic approach from the diverse metastatic deposits to the gallbladder.
World Journal of Surgical Oncology 01/2010; 8:80. · 1.12 Impact Factor
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ABSTRACT: Adenoid cystic carcinoma (ACC) of the larynx is a rare malignancy characterized by an indolent course and late pulmonary metastases. Metastases from the larynx to the spleen are an unusual event. In the present report, we discuss a patient with adenoid cystic carcinoma of the larynx metastatic to the spleen. A review of the literature did not yield any other such incidents. We review the clinical presentation and course of adenoid cystic carcinoma, as well as the role of splenectomy for metastases.
We present a case of laryngeal adenoid cystic carcinoma in a 26-year-old Caucasian man treated with total laryngectomy and ionizing radiation. He initially developed asynchronous pulmonary metastases, which were resected. Our patient subsequently presented with a symptomatic splenic lesion consistent with metastatic disease, for which he underwent laparoscopic splenectomy.
Splenectomy might be indicated for isolated metastases. A splenectomy effectively addresses symptoms and serves as a cytoreduction modality.
Journal of Medical Case Reports 01/2010; 4:207.
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ABSTRACT: The management of rectal cancer has drastically evolved over the past two decades as a result of implementation of circular stapling devices and the introduction of neoadjuvant chemoradiation. In spite of current aggressive multimodality treatments, the recurrence rate remains unacceptably high and the expected 5-year survival in patients who develop recurrent disease is dismal. The management of rectal cancer must involve a multidisciplinary approach. An understanding of the biology of rectal tumours may allow for selection of patients who may have an aggressive phenotype allowing for alterations in the operative and neoadjuvant planning. Efforts to improve local control and survival in rectal cancer are the focus of multiple current clinical and preclinical research efforts. Preoperative chemoradiation for and surgical management of rectal cancer, including the laparoscopic approach are areas of dynamic progression. In the present report, we review the current evidence in the new strategies pertaining to the multimodality approach in the management of rectal cancer.
Indian Journal of Surgery 12/2009; 71(6):356-62. · 0.08 Impact Factor
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ABSTRACT: This study was undertaken to determine the feasibility of an inpatient low-calorie program for a substantial decrease of preoperative weight (>10 points in BMI) in superobese patients.
Five patients were hospitalized for an average of 11 weeks and were placed on a low-calorie liquid diet (<900 kcal/day) and an exercise program. Following a drop of ten points in BMI, they underwent a Roux-en-Y gastric bypass (RYGB). Hemoglobin A1c and lipid profiles were obtained at the beginning of the diet, prior to surgery and at the last follow-up appointment. Our results were compared to the National Surgical Quality Improvement Program (NSQIP) database, which included 1,046 bariatric operations performed at VA centers between October 1999 and August 2007.
All five patients were massively obese men (body mass index (BMI) = 64.3 +/- 2.1 kg/m(2); 54.7 +/- 2.6 years old; four of five were white) with multiple comorbid conditions, which placed them in a substantially higher risk for bariatric surgery. Of the four diabetic patients, two were insulin dependent. There was an average decrease in BMI by 12.7 points (85.8 +/- 6.0 lb) during the preoperative diet period (11 weeks). All patients underwent RYGB without complications. This cohort of patients further decreased their BMI by 10.6 points (88.4 +/- 29.4 lb) following surgical intervention. The total combined preoperative and postoperative excess body weight loss was 89% (10.6-month average follow-up). Sleep apnea resolved following gastric bypass but did not improve during the preoperative weight loss period. Hypertension, osteoarthritis, and dyslipidemia all improved following surgical intervention. Hemoglobin A1c decreased by 1.9% during diet-induced weight loss with no further improvement being noted after surgery. The two insulin-dependent diabetic patients discontinued insulin therapy following surgery. The NSQIP database contained 77 patients with similar characteristics to our cohort of patients. The 30-day mortality for this cohort of patients was 3.9% with a complication rate of 33.8%.
Massive preoperative weight loss is possible to achieve with a liquid protein diet in superobese patients greatly facilitating gastric bypass surgery in an otherwise high-risk patient population.
Obesity Surgery 10/2009; 20(2):173-80. · 3.29 Impact Factor
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ABSTRACT: While patients with breast cancers are not subjected to the adverse side effects of tamoxifen or trastuzumab if their tumors are negative for estrogen, progesterone or Her-2/Neu, neoadjuvant ionizing radiation with concurrent chemotherapeutic agents is administered almost universally to patients with stage II/III rectal cancers. There is, however, a tremendously wide range of response to this preoperative modality from complete pathological response to continuous tumor growth in patients receiving the same form of treatment. The specific phenotype of the tumor plays a major role in rendering tumor cells survival advantage to the cytotoxic effects of chemoradiation. Pathways such as proliferation, cell cycle, apoptosis and hypoxia have been investigated under a variety of conditions in preirradiated tissues and postirradiated tumors. This article reviews the current evidence available to identify a molecular profile predictive of the best response to ionizing radiation.
Expert Review of Molecular Diagnostics 08/2009; 9(5):469-80. · 4.86 Impact Factor
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ABSTRACT: Mechanisms of radioresistance in rectal cancer remain unclear.
To determine mechanisms of radioresistance in rectal cancer cells and to assess the role of the nitric oxide donor DETANONOate as a radiosensitizing agent.
Survival was determined by clonogenic assays, apoptosis by PARP-1 cleavage, and phenotypic differences by Western blot analysis. SCID mice bearing HT-29 xenografts were treated with ionizing radiation (IR) [2.0 Gy x 5], DETANONOate [0.4 mg/kg i.p.], or combination treatment.
Colorectal cancer HT-29-p53-null cells were resistant and HCT-116-p53 wild-type cells sensitive to IR, which correlated with cleaved PARP-1. Increased levels of p21 occurred in HCT-116 cells, while Bcl-2 and survivin were elevated in HT-29 cells. Radiosensitization was achieved with a substantial elevation of cleaved PARP-1 in DETANONOate-HT-29-treated versus control cells, which was accompanied by elevation of p21, p27, and BAX, and a concomitant decrease in Bcl-2. SCID mice bearing HT-29 xenografts demonstrated a 37.6%, 51.1%, and 70.1% inhibition in tumor growth in mice receiving IR, DETANONOate, and combination treatment versus control, respectively.
Radioresistant HT-29 cells are p53-null and have substantially decreased levels of p21. DETANONOate radiosensitized HT-29 cells in vitro and in vivo by an additive effect in apoptosis.
Journal of Surgical Oncology 07/2009; 100(2):149-58. · 2.10 Impact Factor
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ABSTRACT: The recent discovery of Smac and the elucidation of its structure and function have led to the rapid development of Smac mimetics, comprising Smac derivative and mimicking molecules, for use in cancer treatment. Smac is an endogenous proapoptotic protein that resides in the mitochondria and is released when a cell is triggered to undergo programmed cell death. One of the mechanisms by which Smac promotes apoptosis is through its ability to inhibit inhibitors of apoptosis (IAPs), by direct inhibition and/or proteasomal degradation of some members of the IAP family, and therefore disinhibit caspases. Thus, the use of Smac mimetics as anticancer agents follows a rational approach in cancer therapeutics. This approach directly targets dysregulated, neoplastic cells that overexpress IAPs or underexpress Smac. Although Smac mimetics are able to elicit an anticancer response when used alone, these molecules can also function effectively and synergistically when combined with other therapeutic agents. A variety of Smac mimetic types comprising peptides, polynucleotides, and compounds have been studied both in vitro and in vivo. This discussion addresses the current status of Smac mimetics in cancer research.
Anti-cancer drugs 07/2009; 20(8):646-58. · 2.23 Impact Factor
