Colorectal cancer is increasing in rural Kenya: challenges and perspectives

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Biomarkers of Chronic Pancreatitis: A systematic literature review

BackgroundChronic pancreatitis (CP) does not have diagnostic or prognostic biomarkers. CP is the end stage of a progressive inflammatory syndrome that is diagnosed at late stages by morphologic features. To diagnose earlier stages of the disease, a new mechanistic definition was established based on identifying underlying pathogenic processes and biomarker evidence of disease activity and stage. Although multiple risk factors are known, the corresponding biomarkers needed to make a highly accurate diagnosis of earlier disease stages have not been established. The goal of this study is to systematically analyze the literature to identify the most likely candidates for development into biomarkers of CP.MethodsWe conducted a systematic review of candidate analytes from easily accessible biological fluids and identified 67 studies that compared CP to nonpancreatic-disease controls. We then ranked candidate biomarkers for sensitivity and specificity by area under the receiver operator curves (AUROCs).ResultsFive biomarkers had a large effect size (an AUROC > 0.96), whereas 30 biomarkers had a moderate effect size (an AUROC between 0.96 and 0.83) for distinguishing CP cases from controls or other diseases. However, the studies reviewed had marked variability in design, enrollment criteria, and biospecimen sample handling and collection.ConclusionsSeveral biomarkers have the potential for evaluation in prospective cohort studies and should be correlated with risk factors, clinical features, imaging studies and outcomes. The Consortium for the Study of Chronic Pancreatitis, Diabetes and Pancreas Cancer provides recommendations for avoiding design biases and heterogeneity in sample collection and handling in future studies.     

EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma

BACKGROUND: The clinical impact of EUS-guided FNA (EUS-FNA) in regional lymph-node staging in patients with unresectable hilar cholangiocarcinoma before liver transplantation has yet to be determined. OBJECTIVES: To determine the frequency of regional lymph-node detection, identify EUS features predictive of benign or malignant lymph nodes, compare EUS lymph-node detection rates to CT/magnetic resonance imaging and exploratory laparotomy, and evaluate the impact of EUS-FNA on patient selection for liver transplantation. DESIGN: Retrospective case series. SETTING: Tertiary referral EUS unit. PATIENTS: Clinical, radiographic, EUS, cytologic, and surgical data of 47 patients with unresectable hilar cholangiocarcinoma before liver transplantation were evaluated. INTERVENTIONS: EUS-FNA. MAIN OUTCOME MEASUREMENTS: Lymph-node morphology and echo features. RESULTS: EUS identified lymph nodes in all patients. FNA of 70 lymph nodes identified metastases in 9 nodes of 8 patients (17%), who were then precluded from transplantation before a staging laparotomy. Identified lymph nodes, irrespective of malignant involvement, were typically oval and geographic in shape, of mixed echogenicity, with a hypoechoic border. There were no morphologic criteria or echo features to correlate with nodal malignancy. The EUS finding of absent regional lymph-node metastases was confirmed in 20 of 22 by a subsequent exploratory staging laparotomy. LIMITATIONS: Single institution, retrospective analysis. CONCLUSIONS: EUS identified lymph nodes in all patients, and confirmation of malignant lymph nodes detected by FNA precluded 17% of patients from transplantation. EUS-FNA of visualized lymph nodes irrespective of appearance is advised because morphology and echo features do not predict malignant involvement.     

Effect of maxillary osteotomy on subsequent craniofacial growth in adolescent monkeys

LeFort I osteotomy was performed on seven adolescent Macaca fascicularis monkeys to study its effect on the subsequent dentocraniofacial growth. Eight adolescent monkeys were used as controls. Tantalum implants were inserted at predetermined areas in certain craniofacial bones of all monkeys. For stereometric cephalometry, implants were placed in both the left and right sides of the facial bones. Lateral cephalometric radiographs of all monkeys were taken prior to and immediately after metallic implant placement, immediately after maxillary osteotomy, and thereafter every 4 weeks during the postsurgical period. At least two cephalograms were taken on each occasion, one with the teeth in occlusion and the other with mouth wide open. The latter was used to view the mandibular condyle adequately. These findings suggest that the maxillary osteotomy did disturb the vertical growth of the maxilla at the PNS and retarded the horizontal growth at the premaxilla. The anterior growth of the maxilla and mandible and the vertical growth of the face were substantially reduced. The most interesting finding was also a reduction of the mandibular growth in all of its dimensions. The rate and the amount of reduced anterior mandibular growth were found to be coordinated with the anterior maxillary growth which resulted in all animals showing a normal overjet, overbite, and occlusion throughout the postsurgical observation period.     

Mandibular growth following Le Fort I osteotomy in adolescent monkeys

Le Fort I osteotomy with anterior and superior repositioning of the maxilla was performed on adolescent Macaca fascicularis monkeys to study its effect on the subsequent growth and remodeling changes of the mandible. Six adolescent Macaca fascicularis monkeys were randomly divided into two surgical groups and eight others served as controls. Group I animals underwent a Le Fort I advancement and Group II animals experienced a Le Fort I advancement and impaction. All monkeys received tantalum implants in the anterior part of the cranial base, on opposite sides of craniofacial sutures and in multiple sites of the maxilla and mandible. The immediate postsurgical occlusion of all experimental animals was a Class II molar relationship. The animals were followed for up to 12 months postoperatively. Analysis of cephalometric head films taken at monthly intervals showed that both the maxilla and the mandible of all experimental monkeys grew in a coordinated fashion, although the amount, rate, and direction of growth varied between control and experimental animals as well as between Group I and Group II animals. The largest increments and rates of growth were observed in the control animals, Group I animals, and Group II animals, respectively. This study indicates that the growth changes in both maxilla and mandible are related to the extent of injury caused by maxillary surgery. The results also showed that although the surgical procedures were performed in the maxilla, mandibular growth was significantly modulated by the surgically changed maxillary environment.     

Endoscopic Ultrasound-Guided Gastric Botulinum Toxin Injections in Obese Subjects: A Pilot Study

Background Gastric injections of botulinum toxin A (BTA) may induce changes in gastric emptying and body weight, but results vary. BTA dose and depth of injection may affect efficacy. This study assessed changes in gastric emptying, satiation, symptoms, and body weight after endoscopic ultrasound (EUS)-guided injection of 100 or 300 U BTA into gastric antral muscularis propria of obese subjects. Methods Open label study of ten healthy, obese adults (age = 29–49 years, body mass index = 31–54 kg/m²) who received 100 U (n = 4) or 300 U (n = 6) BTA and were followed for 16 weeks. Measures included gastric emptying of solids (by scintigraphy), satiation (by maximum tolerated volume [MTV] during nutrient drink test), gastrointestinal symptoms (by the Gastrointestinal Symptom Rating Scale), caloric intake (by food frequency questionnaire), and body weight. Results For the entire cohort, MTV decreased from 1,380 cc (range: 474–2,014) at baseline to 620 cc (range: 256–1,180) 2 weeks after BTA injection; decreases were statistically significant in the subjects receiving 300 U BTA (p = 0.03). Average body weight loss was 4.9 (±6.3) kg after 16 weeks. Gastric emptying T_1/2 was prolonged in the 300 U BTA group, but not significantly different from baseline (p = 0.17). BTA injections were well tolerated without significant adverse effects. Conclusion EUS-guided injection of BTA into gastric muscularis propria can be performed safely with minimal adverse effects. A dose of 300 U BTA significantly enhances satiation, is associated with weight loss, and may slow gastric emptying. Further study of higher dose BTA in obese subjects is warranted.     

Facial fractures occurring in a medium-sized metropolitan area: recent trends

A retrospective 3-year survey of 311 patients sustaining 564 facial fractures in a medium-sized metropolitan area is presented. Etiology, distribution and treatment of these facial fractures are reported and compared with earlier studies, where changing patterns of etiology and treatment were noted. Contemporary knowledge of facial injuries is important if diagnosis and treatment are to be accurate and treatment optimal.     

Expandable stents for iatrogenic perforation of esophageal malignancies

The management of patients with iatrogenic perforation of esophageal cancers is controversial. We reviewed the management of perforated esophageal malignancies at a single institution with a large volume of patients with esophageal cancer. Cases of iatrogenic perforation of the esophagus occurring during a 3-year period were identified from the hospital endoscopy database. Inpatient and outpatient records were reviewed, and subjects were visited to obtain follow-up information. Perforation was suspected after 10 of 492 endoscopic dilatation procedures done in patients with obstructing esophageal malignancies. All patients were diagnosed immediately. One patient with pneumomediastinum and pneumoperitoneum died 7 days after laparotomy. Nine patients with pneumomediastinum were managed endoscopically with delayed (n=1) or immediate (n=8) placement of a self-expanding metal stent. Patients were treated in the hospital for an average of 5.4 days. No patients developed clinical signs of sepsis, and all were discharged tolerating a soft diet. Follow-up data were obtained for seven of nine discharged patients (range 152 to 263 days). None developed signs or symptoms of infection or recurrent dysphagia. Immediate placement of a coated self-expanding metal stent is an effective treatment for iatrogenic perforation of an obstructing esophageal malignancy. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002.