Background
Postesophagectomy diaphragmatic hernia (DH) is an uncommon problem but an important one to recognize and treat because of the risk of significant complications such as incarceration and ...strangulation. Diaphragmatic hernia appears to occur more frequently following transhiatal esophagectomy (THE) than after transthoracic procedures, likely because of the enlargement of the diaphragmatic hiatus required to perform THE.
Methods
After 199 consecutive esophagectomies were performed at Rutgers Robert Wood Johnson University Hospital between January 2000 and June 2013, ten patients were identified with DH; all underwent diaphragmatic hernia repair (DHR). All patients who underwent esophagectomy during this time period were cataloged in a prospectively maintained database that was then retrospectively reviewed. All DH were repaired using a novel biologic plug mesh technique.
Results
Ten esophagectomy patients developed DH; nine post-THE and one post-McKeown esophagectomy. One patient was excluded from analysis because of atypical presentation. Demographic data were similar between esophagectomy patients who developed DH and those who did not. Administration of neoadjuvant chemoradiation correlated with development of DH, but did not reach statistical significance. Complications directly related to DHR were few and mostly infectious, including empyema and pneumonia, and were more likely to occur in those who presented with acute obstruction. One patient presented with dysphagia post repair.
Conclusions
Diaphragmatic hernia development post esophagectomy is an uncommon complication, but can have devastating results when there is bowel compromise. Repair by plugging the diaphragmatic hiatus with a biologic mesh is a safe and effective method for closing the defect and results in few complications.
Hidradenocarcinoma (HC) is a rare malignant sweat gland tumor with metastatic potential primarily located in the head, neck, and trunk. We present an unusual case of a large lower extremity Clear ...Cell HC managed with surgical resection and adjuvant locoregional radiation after excluding lymph node involvement.
Unilateral crossed renal ectopia without fusion is an uncommon anatomic anomaly, which often goes undiagnosed. We report a case of this renal variant discovered incidentally during colostomy reversal ...after Hartmann’s procedure for diverticular stricture.
Controversy exists regarding the ability of neoadjuvant chemoradiation (nCR) to diminish lymph node yield (LNY) and how that relationship is influenced by tumor response in patients undergoing ...proctectomy for locally advanced rectal cancer.
The National Cancer Database was used to identify patients with rectal adenocarcinomas from 2004 to 2014. Patients that received nCR were compared with those that underwent surgery alone. LNY was stratified into <12 and ≥12 groups to determine their differences in stage specific overall survival.
Of 56,812 patients 46.5% underwent surgery alone and 53.5% were administered nCR. There were more patients with LNY<12 in the nCR group compared to surgery alone, across all stages (44.1% versus 36.5%, P < 0.001). nCR improved OS regardless of LNY (P < 0.001). Although patients with LNY≥12 had improved overall survival, patients who had a pathologic complete response (pCR) achieved the greatest survival. In patients that did not achieve a pCR, LNY≥12 was a marker of improved OS but LNY did not impact OS in patients that attained pCR (P < 0.001).
Although nCR diminished LNY, LNY≥12 improved OS demonstrating the importance of quality total mesorectal excision. However, LNY did not impact patients that achieved pCR. These patients, who achieved the best OS, demonstrated that tumors' biologic response to nCR had the greatest impact on patient outcomes.
Epithelioid angiosarcoma is a rare high-grade tumor with irregular vascular morphology. We report an unusual case of intra-abdominal epithelioid angiosarcoma affecting the omentum and peritoneal ...surfaces resulting in significant hemorrhagic and inflammatory changes. As in other cases of this tumor this patient had previously undergone radiation treatment for a history of cervical cancer.
We performed a large retrospective study of the National Cancer Database to investigate the possible underlying factors associated with the poorer survival seen in right-sided colon cancer compared ...with left-sided colon cancer. Right-sided colon cancer patients were older, had more biologically aggressive tumors, and a greater incidence of microsatellite instability and KRAS mutations, which more profoundly affected survival, especially in later disease stages.
Previous studies have shown that variability in molecular markers correlates with poorer survival outcomes in patients with right-sided colon cancer (RCC) compared with left-sided colon cancer (LCC). However, several studies have shown conflicting results when examined stage for stage. We examined RCC and LCC to assess for differences in histopathologic features and overall survival (OS).
The National Cancer Database was used to identify patients with RCC and LCC from 2004 to 2013. A propensity-adjusted analysis evaluating the association between the primary site and OS was performed.
Of the 422,443 patients identified, 54.7% had RCC and 45.3% had LCC. For all stages, the patients with RCC were older, had more poorly differentiated tumors, and had a greater degree of microsatellite instability compared with those with LCC. Patients with RCC also had more KRAS mutations than did those with LCC. RCC patients had poorer 3- and 5-year OS at all stages, especially stage 3 (62% vs. 73% and 50% vs. 62%, respectively; P < .001). The median OS was 77.5 months for LCC and 62.3 months for RCC (P < .001).
The present study is one of the largest studies demonstrating that RCC and LCC are different biologic entities. Patients with RCC had significantly greater rates of microsatellite instability for all stages, which has been previously shown to be prognostically advantageous. However, the results of the present study showed poorer OS at every disease stage for RCC compared with LCC. These factors have important implications for the further use of targeted therapies in the treatment of advanced colon cancer.
Oncologic resections of the second and third portions of the duodenum (D2 and D3) via partial duodenectomy can pose a challenging clinical problem. The duodenum must be repaired primarily or ...reconstructed. We have adopted a method of reconstruction using a Roux-en-Y duodenojejunostomy (D-J) in patients with extensive duodenal wall loss. We report our results in the first series of these cases. A retrospective review of patients who underwent post partial duodenectomy with reconstruction between June 2004 and March 2014 was performed. Five patients underwent partial duodenectomy with reconstruction. Two had resection for extrinsic tumors (colonic adenocarcinoma). Three had intrinsic duodenal tumors (one tubular adenoma, one adenocarcinoma and one gastrointestinal stromal tumor). All patients were reconstructed via retrocolic Roux-en-Y D-J. Mean estimated blood loss was 470 mL with median length of stay of 11 days. Post-operative complications included three intra-abdominal abscesses, one superficial wound infection and one gastrointestinal bleed. There were no anastomotic leaks, injuries to the ampulla of Vater or mortalities. In conclusion, partial duodenectomy of lateral D2/D3 with Roux-en-Y D-J is a relatively safe and effective alternative to partial duodenectomy with primary repair or pancreaticoduodenectomy for certain tumors of the duodenum.
The corona virus disease of 2019 (COVID-19) imposed new public health constraints that deterred people from coming to the hospital. The outcome of patients who developed appendicitis during mandated ...COVID-19 quarantine has yet to be examined. The main objective was to establish whether there was an increased rate of perforated appendicitis seen during COVID-19 quarantine. Secondary objectives included observing the type of procedure performed, length of stay, and associated complications.
This retrospective analysis was designed to look at the rates of appendicitis and perforated appendicitis observed during mandatory "safer at home order" from March to May 2020. The same time period a year earlier was used for comparative analysis. The study utilized data gathered from a single health care system, which consisted of a large regional referral center with three emergency rooms (ERs). Patients were included in the study if they presented to any ER in our health care system with a chief complaint of acute appendicitis. Perforated appendicitis was determined either radiographically or intraoperatively. Interventions included surgery, percutaneous drainage, or medical management.
There were 107 patients who were included. During quarantine, a total of 48 patients presented with acute appendicitis, with 16 perforations, compared with the previous year where 59 patients presented with acute appendicitis, with 10 perforations (33% versus 17%
= .04). Most patients underwent laparoscopic appendectomy (91%,
= 98), six patients (6%) were managed with intravenous antibiotics and 3 patients (3%) with percutaneous drainage. Patients who perforated had a longer duration of symptoms (2 versus 1,
= .03), white blood cell count (13,190 versus 15,960 cells/mm
,
= .09), and longer operative time (72 versus 89 minutes,
= .01). Patients who perforated had an increased length of stay and rate of complication.
There was an overall increased rate of perforated appendicitis seen during quarantine compared with the previous year. Patients with perforated appendicitis had an increased length of stay, longer operative time, and increased rate of complications. Thus, although people were staying home due to public health safety orders, it negatively impacted those who developed appendicitis who may have presented to the hospital otherwise sooner.
Polo-like kinase 1 (
PLK1
), the most investigated member of the
PLK
family, plays a pivotal role both in the p53-mediated regulation of DNA damage repair and in mitosis, especially in the G2/M ...phase. However, the evidence on the clinical and prognostic relevance of
PLK1
is limited to triple negative subtype among breast cancer (BC). We hypothesized that high expression of
PLK1
is associated with TP53 inactivation, DNA repair deficiency, and worse prognosis in ER positive in BC in a large-scale cohort should clarify its clinical relevance for each BC subtype. Total of 3173 BC cases; 1025 from TCGA cohort, 1904 from METABRIC, and 244 from neoadjuvant chemotherapy (NAC) cohort from Gene Expression Omnibus dataset, GSE32603, were analyzed.
PLK1
expressions were significantly higher in high Nottingham Grade and triple negative BC. High expression of
PLK1
was significantly associated with
TP53
mutation, high expression of
TP53
mRNA as well as protein, and it significantly correlated with the homologous recombination deficiency score. High
PLK1
expression significantly enriched cell cycle related gene sets (G2/M check point, E2F targets), MTORC1 signaling, and MYC target gene sets in the Gene Set Enrichment Analysis. High expression of
PLK1
was significantly associated with tumor infiltrating lymphocytes and tumor associated macrophages (high levels of CD8+ T cells, M0 and M1 macrophage, and low levels of M2 macrophage), and high immune cytolytic activity. While high expression of
PLK1
did not associate with pathological complete response after NAC, it was associated with poor prognosis in the whole cohort and in the ER-positive/HER2-negative subtype of TCGA. High expression of
PLK1
is significantly associated with
TP53
mutations, DNA repair deficiency and worse prognosis in BC particularly in HR+HER2- subtype. Using bioinformatics methods with large cohorts.
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