Rollins Alumni Record, October 1959

Committee Studies Field House Plan

Electron microscopic study of esophageal epithelium in non-erosive reflux disease

Introduction: Non-erosive reflux disease (NERD) is the most common phenotype of gastro esophageal reflux disease (GERD). Dilated intercellular spaces (DIS) in prickle cell layers are considered as early signs of acid damage to the esophageal epithelium. Objectives: The objective of this study was to explore DIS in both superficial and prickle cell layer of the esophageal epithelium of NERD patients and normal controls by using scanning electron microscopy (SEM) and transmission electron microscopy (TEM). Material and methods: The study group included 5 normal controls and 8 NERD patients with reflux symptoms, normal mucosa on endoscopy and positive 24-hour pH monitoring. Specimens were taken 5 cm above the Z line during gastroduodenoscopy and then routinely processed for both SEM & TEM studies. The nature of intercellular spaces between superficial cells and prickle cell layers were viewed by TEM and SEM respectively. Results: We found out that cellular attachments in the superficial cells differ significantly between the normal controls and patients with NERD (p value 0.007). Morphometric analysis of TEM microphotographs showed that the mean intercellular space diameter values of NERD patients were significantly ( two times) higher than that in normal controls (p<0.001). Conclusions: We can conclude that SEM study on DIS in esophageal surface cells is not a useful diagnostic test for differentiating between normal and NERD patients but TEM study in prickle cell layer is a promising diagnostic finding of early damage of esophageal epithelium

The ACT-ONE trial, a multicentre, randomised, double-blind, placebo-controlled, dose-finding study of the anabolic/catabolic transforming agent, MT-102 in subjects with cachexia related to stage III and IV non-small cell lung cancer and colorectal cancer: study design

Aims Cachexia, the wasting disorder associated with a wide range of serious illnesses including cancer, is a major cause of morbidity and mortality. There is currently no widely approved therapeutic agent for treating or preventing cancer-associated cachexia. Colorectal cancer and nonsmall cell lung cancer have relatively high incidences of cachexia, approximately 28% and 34%, respectively. Neurohormonal overactivity has been implicated in the genesis and progression of cachexia and beta receptor antagonism has been proposed as a potential therapy. MT-102, a novel anabolic/catabolic transforming agent, has a multi-functional effect upon three potential pharmacological targets in cancer cachexia, namely reduced catabolism through non-selective β-blockade, reduced fatigue, and thermogenesis through central 5-HT1a antagonism and increased anabolism through partial β-2 receptor agonism. Methods At least 132 male and female patients, aged between 25 and 80 years with a confirmed diagnosis of late-stage non-small cell lung cancer or colorectal cancer, with cachexia will be randomised to either one of the two MT-102 doses or placebo in a 3:1:2 ratio (MT-102 10 mg BD−1/MT-102 2.5 mg BD/placebo). Patients will continue on study treatment for maximally 16 weeks. The primary endpoint, to be analysed by assigned treatment group, will be body weight change over 16 weeks. For this endpoint, the study has 85% power (0.05% significance level) to detect per 4-week period a mean change of −0.8 kg in the placebo group and 0 kg in the high-dose MT-102 arm. The first patient was randomised in February 2011 and patient recruitment is expected to continue until mid-2012. Perspective The ACT-ONE trial is designed to test whether the anabolic/catabolic transforming agent MT-102 will positively impact on the rate of change of body weight in cancer cachexia, thereby evaluating a novel therapeutic strategy in this hitherto poorly treatable condition. A separate ACT-TWO trial will recruit patients who complete the ACT-ONE trial and remain on randomised double-blind medication. Participants in ACT-TWO will be followed for an additional period with a separate primary endpoint

Gracilis muscle as neoanal sphincter for faecal incontinence

Faecal incontinence is a debilitating chronic clinical condition which may affect the patient and care givers. Modality of treatment is based on severity of the symptoms as well as the anatomical defect itself, availability of resources and expertise. We describe a modified technique of dynamic graciloplasty as neoanal sphincter for the treatment severe faecal incontinence who has failed previous over lapping sphincteroplasty. In our modified version, instead of using implanted intramuscular electrodes and subcutaneous neurostimulator to provide continuous stimulation, the patient will undergo an external stimulation on the nerve of transplanted gracilis periodically and concurrent biofeedback therapy. We believe the technique is relatively easy to learn and very cost effective without any electrodes or neurostimulator related complications

Modified dynamic gracilis neosphincter for fecal incontinence: an analysis of functional outcome at a single institution

Background: We undertook a prospective longitudinal study of patients with end-stage fecal incontinence who were undergoing transposition of the gracilis muscle as a neo-anal sphincter with external low-frequency electrical stimulation of the nerve to the gracilis combined with biofeedback. Methods: A total of 31 patients (21 male, 10 female: median age: 22 years; range: 4-77 years) underwent this procedure for treatment of traumatic disruption (11 patients, 35%), congenital atresia (11 patients, 35%), iatrogenic injury (6-20%), and perineal sepsis (3 patients, 10%). The gracilis muscle was transposed at operation in an alpha or gamma configuration. Low-frequency (7 Hz) transcutaneous electrical stimulation commenced 2 weeks after operation and was continued for up to 12 weeks. Biofeedback therapy, which consisted of supervised neosphincter squeeze exercises, commenced simultaneously and continued for up to 28 weeks. Outcome was assessed by clinical examination, anal manometry, the Cleveland Clinic Florida continence score (CCFS), and the Rockwood quality of life scale (FIQL). Successful outcome was defined by improvement in clinical outcome, patient satisfaction, a positive result on anal manometry, and/or CCFS < 9, or FIQL ≥ 4. Results: At median follow-up of 67 months, overall improvement was seen in 22 (71%). Maximum resting pressure (MRP) and maximum squeeze pressure (MSP) improved significantly after operation [MRP pre versus post, mean (SD), cm water-13.8 (9.6) versus 20.9 (11.3); P = 0.01; and MSP 36.6 (22.4) versus 95.4 (71.2), P = 0.001]. In a subset of 18 patients who showed improvement after operation, the CCFS score (mean, SD) improved from 19.2 (3.4) to 5.2 (5.6); P = 0.0001. FIQL (mean, SD) showed significant improvement in all four domains in 14 patients who reported improvement since the year 2000. Conclusions: A modified dynamic gracilis neoanal sphincter for end-stage fecal incontinence helps restore and sustain continence with improvement in quality of life in the majority of patients. The procedure was most effective as augmentation in those who had suffered a traumatic injury, when compared with patients with congenital atresia and sepsis that had resulted in loss of the native anal sphincter

Successful enhanced recovery program after colorectal surgery in the county hospital setting

In recent years, some enhanced recovery protocols after colorectal surgery have gained some acceptance as they have shown to improve patient recovery and decreased length of hospital stay.This study was designed to assess the feasibility of such a program in a large county hospital with a diverse patient population

Isolated metacarpal bone metastasis from advanced rectosigmoid carcinoma

Distant metastasis is a common sequelae of stage III colorectal adenocarcinoma. Liver and lungs are the most common sites for distant metastases, but, metastases to extremities are very rare. We report a case of rectosigmoid adenocarcinoma, which metastasizes to left first metacarpal bone, which is the first occurrence in our experience. The investigations and management of the patient are discussed

Perineal myxoid liposarcoma: report of a case and literature review

Liposarcomas are rare soft tissue tumour, with an incidence of 30 cases per million population. The myxoid liposarcoma (MLS) consists of 45 – 55% of these tumours, making it the most common subtype. MLS commonly involves the thigh and retroperitoneum but relatively rare in the perineum or pararectal spaces. MLS presents with unique radiological challenges and have the potential for overt malignant behaviour. The determination of clinical behaviour and pathological subtype is invaluable to the management of these patients, as there is no available consensus on the use of neoadjuvant and adjuvant therapies in the form of chemotherapy or radiotherapy for non-metastatic soft tissue sarcomas. Therefore, surgery remains the mainstay of treatment for MLS. We presents an unusual case of myxoid liposarcoma presenting as a large perineal swelling occupying the para-rectal and para-anal spaces. The diagnosis, management and prognosis of myxoid liposarcoma are discussed

Dilated Intercellular Spaces of Esophageal Epithelium among Malaysian With Nonerosive Reflux Disease: Transmission Electron Microscopic (Tem) study

Dilated intercellular space (DIS) is considered as early signs of acid damage to the esophageal epithelium. The diffusion of refluxed gastric acid into the intercellular space activates chemo sensitive nociceptors whose signals are transmitted via the spinal cord to the brain for symptom (heartburn) perception as well as initiated a short reflex arc to esophageal (longitudinal) smooth muscle as means of precipitating a sustained esophageal contraction. Objectives: This study aims to evaluate the intercellular space of oesophageal epithelium and to find out the association between clinical symptoms and DIS among Malaysian with NERD. Materials and methods: The study group included 8 NERD patients with reflux symptoms, normal mucosa on endoscopy and positive 24-hour pH monitoring and 5 normal controls. Specimens were routinely processed for transmission electron microscopy (TEM). The intercellular spaces between prickle cells were viewed and their widths were determined by TEM. Statistical analysis: Data were analyzed using the Statistical Package for Social Science (SPSS) version 16. The difference in mean DIS among NERD patients and controls was tested using independent t test. The association between categorical data and dilatation of intercellular space was tested using Chi-Square test. P-value of less than 0.05 was taken as significant. Results: Morphometric analysis performed on transmission electron microscopy microphotographs showed mean intercellular space diameter values of NERD patients were significantly ( two times) higher than that in normal controls (p 0.93 μm is considered as dilated (cut-off value). There was strong association between dilated intercellular space with heartburn (p 0.001) and not with acid regurgitation (p 0.075). Conclusions: We can conclude that DIS at prickle cell layer is a promising diagnostic finding of early damage of esophageal epithelium