Magnets and children: a dangerous combination

BACKGROUND

Accidental ingestion of foreign bodies is a common problem in children. Fortunately, the gastrointestinal tract is quite resilient to foreign bodies. On the other hand, the ingestion of magnets can result in enormous morbidity. Because of their natural tendency to firmly adhere they can cause intestinal obstruction, pressure necrosis, fistula formation or perforation. With this case report, we aim to raise awareness of the risks that these magnets pose to children.

METHODS

We describe a case of intestinal perforation caused by the separate ingestion of multiple magnets from a children's toy (buckyballs, Neodymium spheres) by a two-year-old boy. A search in the Pubmed database showed some publications and varied management guidelines.

RESULTS

The boy was treated with an exploratory laparoscopy converted to a mini-laparotomy. We removed the four magnets through separate enterotomies. Postoperative recovery was uneventful. The boy was discharged on a postoperative day five and had no complications at three months follow-ups.

CONCLUSION

Accidental ingestion of multiple magnets is rare but can create a life-threatening situation in children. If the magnets are still in the stomach, endoscopic retrieval is needed. If they are beyond the stomach, in asymptomatic cases close clinical and radiographic vigilance is mandatory. When symptomatic we advise urgent removal. If treated on time, the surgical outcome is good and fast recovery is expected.

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection

INTRODUCTION

Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure.

METHODS

A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes.

CONCLUSION

LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

Vasodilation of rat skeletal muscle arteries by the novel BK channel opener GoSlo is mediated by the simultaneous activation of BK and Kv 7 channels

Background and Purpose

BK channels play important roles in various physiological and pathophysiological processes and thus have been the target of several drug development programmes focused on creating new efficacious BK channel openers, such as the GoSlo‐SR compounds. However, the effect of GoSlo‐SR compounds on vascular smooth muscle has not been studied. Therefore, we tested the hypothesis that GoSlo‐SR compounds dilate arteries exclusively by activating BK channels.

Experimental Approach

Experiments were performed on rat Gracilis muscle, saphenous, mesenteric and tail arteries using isobaric and isometric myography, sharp microelectrodes, digital droplet PCR and the patch‐clamp technique.

Key Results

GoSlo‐SR compounds dilated isobaric and relaxed and hyperpolarised isometric vessel preparations and their effects were abolished after (a) functionally eliminating K⁺ channels by pre‐constriction with 50 mM KCl or (b) blocking all K⁺ channels known to be expressed in vascular smooth muscle. However, these effects were not blocked when BK channels were inhibited. Surprisingly, the K_v7 channel inhibitor XE991 reduced their effects considerably, but neither K_v1 nor K_v2 channel blockers altered the inhibitory effects of GoSlo‐SR. However, the combined blockade of BK and K_v7 channels abolished the GoSlo‐SR‐induced relaxation. GoSlo‐SR compounds also activated K_v7.4 and K_v7.5 channels expressed in HEK 293 cells.

Conclusion and Implications

This study shows that GoSlo‐SR compounds are effective relaxants in vascular smooth muscle and mediate their effects by a combined activation of BK and K_v7.4/K_v7.5 channels. Activation of K_v1, K_v2 or K_v7.1 channels or other vasodilator pathways seems not to be involved.

Salvage parenchymal liver transection for patients with insufficient volume increase after portal vein occlusion -- an extension of the ALPPS approach

BACKGROUND

Portal vein ligation (PVL) or embolization (PVE) are standard approaches to induce liver hypertrophy of the future liver remnant (FLR) prior to hepatectomy in primarily non-resectable liver tumors. However, this approach fails in about one third of patients. Recently, the new "ALPPS" approach has been described that combines PVL with parenchymal transection to induce rapid liver hypertrophy. This series explores whether isolated parenchymal transection boosts liver hypertrophy in scenarios of failed PVL/PVE.

METHODS

A multicenter database with 170 patients undergoing portal vein manipulation to increase the size of the FLR was screened for patients undergoing isolated parenchymal transection as a salvage procedure. Three patients who underwent PVL/PVE with subsequent insufficient volume gain and subsequently underwent parenchymal liver transection as a salvage procedure were identified. Patient characteristics, volume increase, postoperative complications and outcomes were analyzed.

RESULTS

The first patient underwent liver transection 16 weeks after failed PVL with a standardized FLR (sFLR) of 30%, which increased to 47% in 7 days. The second patient showed a sFLR of 25% 28 weeks after PVL and subsequent PVE of segment IV, which increased to 41% in 7 days after transection. The third patient underwent liver partition 8 weeks after PVE with a sFLR of 19%, which increased to 37% in six days. All patients underwent a R0 resection.

CONCLUSION

Failed PVE or PVL appears to represent a good indication for the isolated parenchymal liver transection according to the newly developed ALPPS approach.

The prognostic relevance of tumor hypoxia markers in resected carcinoma of the gallbladder

BACKGROUND

Intratumoral hypoxia has been suggested to drive more aggressive tumor behavior. Our aim was to define whether markers of tumor hypoxia are predictors of outcome in patients with gallbladder carcinoma.

PATIENTS AND METHODS

From 1996 to 2006, 34 patients underwent resection for gallbladder carcinoma. The median follow-up was 12.6 months. Immunohistochemical stains for VEGF, HIF1α, GLUT1, GLUT3, CA9 and EGFR were performed on archival tissue. Immunohistochemical results were correlated with clinical and histopathological parameters. Cumulative overall survival (OS) rates were estimated using the Kaplan-Meier method. Multivariable Cox regression models were used to identify predictors of OS.

RESULTS

The median OS was 11.9 (IQR: 3.4-22.0) months. Ubiquitous VEGF staining was observed in all gallbladder carcinomas. High (>50% of tumor cells) EGFR expression was associated with worse OS (p0.03). CA9 expression was less prevalent in poorly differentiated tumors (p0.02). GLUT3, GLUT1 and HIF1α expression were not associated with survival, but did correlate with the presence of lymph node metastasis (p0.02), tumor differentiation (p0.04) and tumor stage (p0.03) respectively. High EGFR expression, TNM stage and preoperative serum CA19.9 were retained as independent predictors of OS in multivariable analysis.

CONCLUSION

In gallbladder cancer high expression of EGFR is an independent predictor of survival.

Rho-associated kinase plays a role in rabbit urethral smooth muscle contraction, but not via enhanced myosin light chain phosphorylation

The involvement of Rho-associated kinase (ROK) in activation of rabbit urethral smooth muscle contraction was investigated by examining the effects of two structurally distinct inhibitors of ROK, Y27632 and H1152, on the contractile response to electric field stimulation, membrane depolarization with KCl, and α1-adrenoceptor stimulation with phenylephrine. Both compounds inhibited contractions elicited by all three stimuli. The protein kinase C inhibitor GF109203X, on the other hand, had no effect. Urethral smooth muscle strips were analyzed for phosphorylation of three potential direct or indirect substrates of ROK: 1) myosin regulatory light chains (LC20) at S19, 2) the myosin-targeting subunit of myosin light chain phosphatase (MYPT1) at T697 and T855, and 3) cofilin at S3. The following results were obtained: 1) under resting tension, LC20 was phosphorylated to 0.65±0.02 mol Pi/mol LC20 (n=21) at S19; 2) LC20 phosphorylation did not change in response to KCl or phenylephrine; 3) ROK inhibition had no effect on LC20 phosphorylation in the absence or presence of contractile stimuli; 4) under resting conditions, MYPT1 was partially phosphorylated at T697 and T855 and cofilin at S3; 5) phosphorylation of MYPT1 and cofilin was unaffected by KCl or phenylephrine; and 6) KCl- and phenylephrine-induced contraction-relaxation cycles did not correlate with actin polymerization-depolymerization. We conclude that ROK plays an important role in urethral smooth muscle contraction, but not via inhibition of MLCP or polymerization of actin.

Patterns of recurrence after curative resection of pancreatic ductal adenocarcinoma

AIMS

Despite curative surgery for pancreatic ductal adenocarcinoma (PDAC), most patients develop cancer recurrence and die from metastatic disease. Understanding of the patterns of failure after surgery can lead to new insights for novel therapeutic modalities. The aim of the present study is to describe the patterns of recurrence after curative resection of PDAC.

METHODS

A retrospective analysis was performed of 145 consecutive resections for PDAC between 1998 and 2005 (M/F 75/70; median (range) age 67 years (32-85 y)). The location of the first and consecutive recurrences, and the time interval to cancer recurrence after surgical resection was studied. The magnitude of tumour-free margin was less than a millimetre in 48 patients, whereas a positive surgical margin was observed in 27 patients. The median duration of follow-up was 18.5 (range 0.3-116.8) months.

RESULTS

Cancer recurrence was observed in 110 patients. The first location of recurrence was locoregional in 19, extra-pancreatic in 66, and combined locoregional and extra-pancreatic in 25 patients. Extra-pancreatic recurrence developed in the liver in 57, peritoneal in 35, pulmonary in 15, and retroperitoneal in 5 patients. The median (95% CI) overall (OS) and disease-free (DFS) survival was 18.7 (15.7-23.5) and 9.8 (7.5-12.4) months, respectively. The type of cancer recurrence did not significantly influence OS, while the resection margin status had a prognostic effect.

CONCLUSION

The vast majority of patients who undergo potentially curative surgery for PDAC develop cancer recurrence located in the abdominal cavity. Surgical resection margins with tumour involvement and tumour-free margins of less then 1mm are negative prognostic factors. Further research on better local surgical control, peri-operative locoregional treatment, and more effective adjuvant systemic therapy is necessary to improve long-term survival of patients with curable PDAC.

Incisional surgical site infections after colorectal surgery: time to appraise its true incidence

BACKGROUND

Surgical site infections (SSI) are the leading cause of complications in surgical patients. For colorectal surgery the reported incidence of SSI varies between 10 and 15%. This incidence however, has been challenged recently. In this study, we evaluated the incidence of incisional SSI after colorectal surgery in our department.

METHODS

We performed a retrospective analysis of 115 non-laparoscopic colorectal resections between July 1st 2004 and July 31st 2005. After exclusion, 101 patients were retained. Demographic, clinical and operative variables were collected. Univariable and multivariable analysis were performed to identify risk factors for the development of incisional SSI.

RESULTS

21 SSI were diagnosed (20.7%). Seventeen cases were incisional SSI (16.8%). Multivariable analysis identified longer operation time (p = 0.014), pre-operative obstructive lung disease (p = 0.02) and fewer postoperative days on TPN (p = 0.04) as independent predictors of incisional SSI.

CONCLUSION

In comparison with recent publications, the incidence of SSI in our series was higher compared to what is generally reported.

Origin of spontaneous rhythmicity in smooth muscle

Rhythmic electrical activity is a feature of most smooth muscles but the mechanical consequences can vary from regular rapid phasic contractions to sustained contracture. For many years it was thought that spontaneous electrical activity originated in smooth muscle cells but recently it has become apparent that there are specialized pacemaker cells in many organs that are morphologically and functionally distinct from smooth muscle and that the former cells are the source of spontaneous electrical activity. Such a pacemaker function is well documented for the ICC of the gastrointestinal tract but evidence is accumulating that ICC-like cells play a similar role in other types of smooth muscle. We have recently shown that there are specialized pacemaking cells in the rabbit urethra which are spontaneously active when freshly isolated, readily distinguishable from smooth muscle cells under bright field illumination and relatively easy to study using patch-clamp and confocal imaging techniques. Recent results suggest that calcium oscillations in isolated rabbit urethral interstitial cells are initiated by calcium release from ryanodine sensitive intracellular stores, that oscillation frequency is very sensitive to the external calcium concentration and that conversion of the primary oscillation to a propagated calcium wave depends upon IP3-induced calcium release.

Recurrent flank pain caused by eosinophilic ureteritis mimicking urinary stone disease: a case report

Flank pain is caused by a variety of pathologies of which urinary stone disease is the most frequent. Eosinophilic ureteritis is a rare stenosing condition of the ureter. Eosinophilic ureteritis can cause flank pain and/or unilateral hydronephrosis. On pathological examination it is characterised by a marked infiltration of the submucosal layers by eosinophils. A relationship of this condition with atopy, hypereosinophilic syndrome and prior ureteral trauma has been described. Surgical resection of the stenosing segment with end-to-end anastomosis is usually a successful treatment. In some cases of proximal disease total nephro-ureterectomy has been performed. One author describes remission of disease after a prolonged oral corticosteroid regimen. In this article we report another case of eosinophilic ureteritis and discuss different treatment strategies.

Neurovascular compression by a subpectoral lipoma. A case report of a rare cause of thoracic outlet syndrome

BACKGROUND

Lipomas are benign soft tissue tumours, progressively expanding in volume. Beside frequent aesthetic consequences, lipomas can also exert pressure on surrounding tissues and structures.

MATERIALS AND METHODS

A case of a subpectoral infraclavicular lipoma compressing the axillo-subclavicular neurovascular bundle, produced unilateral brachialgia, thereby simulating a Thoracic Outlet Syndrome. The expansive, but non-infiltrative, nature of the lipoma allowed local excision in the vicinity of the brachial plexus and infraclavicular vascular structures.

RESULTS

Surgical removal of the lipoma resulted in complete remission of symptoms in the left arm and hand.

CONCLUSIONS

In the presence of unilateral brachialgia, a subpectoral tumour causing a Thoracic Outlet Syndrome should always be excluded in the absence of other relevant pathology.