Functional outcomes of intersphincteric resection in low rectal tumors.

Objectives: Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection. Material and Methods: This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed. Results: Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis. Conclusion: In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.

Effect of interval between neoadjuvant chemoradiotherapy and surgery on disease recurrence and survival in rectal cancer: long-term results of a randomized clinical trial.

BACKGROUND: The optimal timing of surgery following chemoradiotherapy (CRT) is controversial. This trial aimed to assess disease recurrence and survival rates between patients with locally advanced rectal adenocarcinoma (LARC) who underwent total mesorectal excision (TME) after a waiting interval of 8 weeks or less (classic interval; CI) versus more than 8 weeks (long interval; LI) following preoperative CRT. METHODS: This was a phase III, single-centre, randomized clinical trial. Patients with LARC situated within 12 cm of the anal verge (T3-T4 or N+ disease) were randomized to undergo TME within or after 8 weeks after CRT. RESULTS: Between January 2006 and January 2017, 350 patients were randomized, 175 to each group. As of February 2022, the median follow-up time was 80 (6-174) months. Among the 322 included patients (CI, 159; LI, 163) the cumulative incidence of locoregional recurrence at 5 years was 10.1 per cent in the CI group and 6.9 per cent in the LI group (P = 0.143). The cumulative incidence of distant metastasis at 5 years was 30.8 per cent in the CI group and 18.6 per cent in the LI group (sub-HR = 1.78; 95 per cent c.i. 1.14 to 2.78, P = 0.010). The disease-free survival (DFS) in each group was 59.7 and 69.9 per cent respectively (P = 0.157), and overall survival (OS) rates at 5 years were 73.6 versus 77.9 per cent (P = 0.476). CONCLUSION: Incidence of distant metastasis decreased with an interval between CRT and surgery exceeding 8 weeks, but this did not impact on DFS or OS. REGISTRATION NUMBER: NCT03287843 (http://www.clinicaltrials.gov).

The effects of chemoradiotherapy on recurrence and survival in locally advanced rectal cancers with curative total mesorectal excision: a prospective, nonrandomized study.

BACKGROUND: There are only two prospective, randomized studies comparing preoperative long-term chemoradiotherapy and postoperative chemoradiotherapy in locally advanced rectal cancer (LARC); however, conflicting results in terms of locoregional recurrence (LR) and survival rates have been reported. This prospective study aims to compare the effects of preoperative versus postoperative chemoradiotherapy on recurrence and survival rates in LARC patients. METHODS: From January 2003 to January 2016, a total of 336 eligible patients who were clinically diagnosed with LARC (T3-T4 tm or node-positive disease) were prospectively assigned into preoperative chemoradiotherapy (n = 177) and postoperative chemoradiotherapy (n = 159) groups. The preoperative treatment consisted of 50.4 Gy total dose of radiotherapy (delivered in fractions of 1.8 Gy) and concomitant two cycles chemotherapy of 5-fluorouracil and leucovorin. The patients in the preoperative group underwent curative total mesorectal excision (TME) following long-term chemoradiotherapy. Surgery was performed 8 (range 4-12) median weeks after the completion of the chemoradiotherapy. Similar protocol was administered to the postoperative group 4 weeks after the operation. Four cycles of adjuvant chemotherapy were added to the groups. The primary end points were locoregional recurrences and 5-year cancer-specific, overall, and disease-free survivals. RESULTS: The mean follow-up period was 60.4 (range 12 to 168) months. Five-year cumulative incidence of locoregional recurrence (LR) was 7.4% in the preoperative group and 13.4% in the postoperative group (p = 0.021). Five-year cancer-specific survival (CSS) was 87.5% in the preoperative group and 80% in the postoperative group (p = 0.022). Overall survival (OS) was 79.8 versus 74.7% (p = 0.064), disease-free survival (DFS) was 75.2 versus 64.8% (p = 0.062), and severe late toxicity was 7.4 versus 13.2% (p = 0.002), respectively. The rate of patient compliance was higher in the preoperative group (p < 0.001). CONCLUSIONS: Preoperative chemoradiotherapy, as compared with postoperative chemoradiotherapy, significantly improved local control, patient compliance, CSS, and late toxicity and suggested a trend toward improved overall and disease-free survival.

Unexpected Benefit of the Positron Emission Tomography/Computed Tomography Using 18F-Fluorodeoxyglucose: Report of a Case.

The positron emission tomography/computed tomography (PET/CT) has been a new tool utilized in the diagnosis and staging of various cancers. However, common worldwide utilization of the PET/CT includes some economic, legal, and ethic controversies. Although PET/CT scanning can detect colorectal premalignant lesions in an early treatable stage, most governments' health care system does not pay for it as a screening test because of its economic burden. Thus, people are forced to make vital decisions about their health because of health policies of their governments. Here, we present an unusual case and discuss the utilization of PET/CT for detection of incidental neoplasms.

Recurrent pilonidal sinus: lay open or flap closure, does it differ?

Treatment options of pilonidal sinus, which has high recurrence rates, is still controversial. In this study, we aimed to analyze for possible factors affecting recurrence. Forty-one patients with recurrent pilonidal sinus were included in this study. Of them, 33 were male and 9 were female (mean age, 24.9 years; age range, 16-42). Factors (i.e., risk factors) were detected in 32 patients. Excision-secondary healing and lay open was performed on 30 of the patients admitted with recurrence. Excision and flap closure was applied on 11 patients. Our recurrence rate was 9.7%. The recurrence rate of our study is compatible with the literature. Comparative studies are needed to determine the appropriate method to decrease recurrence rate.

Complicated Meckel's diverticulum and therapeutic management.

OBJECTIVE: This study aimed to investigate the treatment options and compare patient management with the literature for patients operated on for an acute abdomen who had complications due to inflammation of the Meckel's diverticulum at our clinics. MATERIAL AND METHODS: This study retrospectively evaluated 14 patients who had been operated on for acute abdomen and had been diagnosed with Meckel's diverticulitis (MD) in Ege University Medical Faculty Department of General Surgery, between October 2007 and October 2012. RESULTS: Fourteen patients with a diagnosis of Meckel's diverticulitis (MD) were retrospectively analyzed. Radiologically, the abdominal computer tomography showed pathologies compatible with mechanical intestinal obstruction, Meckel's diverticulitis and peridiverticular abscess, as well as detection of free air within the abdomen on direct abdominal X-ray. Among patients diagnosed with complicated Meckel's diverticuli (obstruction, diverticulitis, perforation) 10 patients had partial small bowel resection and end-to-end anastomosis (71.5%), three patients underwent diverticulum excision (21.4%), and one patient underwent right hemicolectomy+ileotransversostomy (7.1%). CONCLUSION: Meckel's diverticulum is a vestigial remnant of an omphalomesenteric channel in the small bowel. It is a real congenital diverticular abnormality that contains all three layers of the small bowel. Surgical excision should be performed if Meckel's diverticulum is detected in order to avoid incidental complications such as ulceration, bleeding, bowel obstruction, diverticulitis or perforation. Meckel's diverticulitis does not have specific clinical and radiological findings. Delayed diagnosis can lead to lethal septic complications. Complications associated with Meckel's diverticulitis, especially if a definite diagnosis is not made during the preoperative period, should be considered in the differential diagnosis. In the presence of a complicated diverticulum the appropriate treatment should be emergent surgical intervention.

Spontaneous intestinal intramural hematoma: What to do and not to do.

OBJECTIVE: Spontaneous intestinal intramural hematoma is a rare complication of anticoagulant treatment. In this study, we retrospectively evaluated 14 patients with the diagnosis of intramural hematoma of the small intestine who were followed-up and treated in our clinic, and we aimed to determine current approaches in the diagnosis and treatment of intramural hematoma. MATERIAL AND METHODS: Between February 2010-October 2012, 14 patients diagnosed with small intestinal intramural hematoma were retrospectively analyzed. Nine patients were followed due to clinical findings and 5 patients underwent operation with a histopathological diagnosis of intramural hematoma. RESULTS: Abdominal computed tomography demonstrated ileal and jejunal wall thickening in 10 patients, while findings were consistent with mesenteric vascular disease in four. Five patients were operated due to mechanical bowel obstruction and acute abdomen. The other 9 patients were followed up with medical treatment and 8 of these patients were already using warfarin due to cardiac bypass and valve replacement. CONCLUSION: Spontaneous intestinal intramural hematoma is a rare cause of small bowel obstruction due to intramural hematoma, which is encountered even more rarely. An intramural hematoma should be considered among differential diagnosis of patients who present with abdominal pain and symptoms of obstruction with a history of anticoagulant drug use and elevated International Normalized Ratio (INR) levels. Early diagnosis and medical follow-up can provide a good response to treatment in the majority of patients without requiring surgery.

Foreign bodies in the rectum: an analysis of 30 patients.

PURPOSE: A foreign body in the rectum is a rare clinical entity. These foreign bodies can be classified under two major groups: the ones that are inserted from the anus and the ones that are swallowed and thereafter become stuck in the rectum. METHODS: Data of patients admitted with a foreign body in the rectum between 1988 and 2008 were retrospectively analyzed. A total of 30 patients were reviewed. RESULTS: The most common reason for a foreign body in the rectum was insertion for erotic purposes, which was seen in 19 of the 30 patients. All these patients were male. The remaining 11 patients reported nonerotic causes. The most efficient and implemented therapeutic method was simple extraction during the first examination. CONCLUSIONS: The most common reason for a foreign body in the rectum is insertion for erotic purposes. The first target of therapy should be extraction of the foreign body using the simplest method possible. Meanwhile, protecting the integrity of the intestine is of the utmost importance. The care for maintaining the integrity of the rectum should include an evaluation of the patient's psychological status.

Abdominal cocoon syndrome as a rare cause of mechanical bowel obstruction: report of two cases.

An abdominal cocoon is an extremely rare condition, and has been reported mainly in young adolescent women as a cause of small bowel obstruction. In these patients, the small bowel is encased in a fibrous sac called an abdominal cocoon. We hereby present two cases who were diagnosed only by laparotomy and their correlation with the literature. They both received early intervention, thus preventing the need for bowel resection. The pathology of both membranes showed inflammation.

A new extraction technique for rectal foreign bodies with a rubber band ligation device.

Foreign bodies in the rectum are a rare clinical condition that should be noted. The most frequently encountered cause is erotic activity. The first goal of the therapy is extraction of the foreign body using the simplest method possible while protecting the integrity of the intestine. Many instruments and methods have been suggested for this purpose. This report discusses a new management strategy for these patients along with a review of the literature.

Steroid utilization in eosinophilic jejunitis: beneficial or harmful?

PURPOSE: Eosinophilic jejunitis is a rare disorder of undetermined origin, which is characterized by infiltration of eosinophils in the intestine. The aim of this study is to evaluate steroid therapy effect in patient treated for eosinophilic jejunitis to share our experience with other colleagues. METHODS: We report a patient with symptoms of small bowel obstruction whose diagnosis was confirmed by previous operation owing to a well-known pathology due to an unusual reason, perforation, which was masqueraded by therapeutic drugs. RESULT: This clinical entity is usually encountered between the third and fifth decades. Stomach and small intestine are the most affected organs; however, it can affect any part of the gastrointestinal system. Abdominal pain and obstructive symptoms concomitant with weight loss are the common presenting complaints. According to current knowledge, avoiding unnecessary resection unless it is inevitable is an acceptable option for the management of eosinophilic jejunitis disease. CONCLUSION: Recent data suggest that eosinophils may directly damage the gastrointestinal tract wall in eosinophilic gastroenteritis. A few limited literatures about this disease strongly recommends steroid therapy for treatment. Furthermore, beneficial or harmful effects of steroids in eosinophilic jejunitis and its treatment details are discussed and reviewed.

The comparative effects of calcium channel blockers in an experimental colitis model in rats.

BACKGROUND/AIMS: In this study two calcium channel blockers (CCB), diltiazem and verapamil, which demonstrate their effects on two different receptor blockage mechanisms, were assessed comparatively in an experimental colitis model regarding the local and systemic effect spectrum. METHODS: Eighty male Swiss albino rats were divided into eight groups (n:10 each): Group I) colitis was induced with 1 ml 4% acetic acid without any medication. Group II) Sham group. Group III) Intra-muscular (IM) diltiazem was administered daily for five days before inducing colitis. Group IV) IM verapamil was administered daily for five days before inducing colitis. Group V) Transrectal (TR) diltiazem was administered with enema daily for two days before inducing colitis. Group VI) TR saline was administered four hours before inducing colitis. Group VII) TR diltiazem was administered with enema four hours before inducing colitis. Group VIII) TR verapamil was administered with enema four hours before inducing colitis. All subjects were sacrificed 48 hours after the colitis induction. The distal colon segment was assessed macroscopically and microscopically for the grade of damage, and myeloperoxidase (MPO) activity was measured. RESULTS: All the data of the control colitis group (group I), including the microscopic, macroscopic and MPO activity measurements, were significantly higher than in the groups in which verapamil and diltiazem were administered over seven days (3.100+/-0.7379 to 1.300+/-0.9487 and 1.600+/-0.9661) (p<0.05). The data of the Sham group, group II, were less than the other groups in which colitis was induced (p<0.05). For the local effect spectrum, after the assessment of groups V-VIII, the control colitis group (group I) and group VI had significantly higher values than the others (3.300+/-0.4830 to 1.800+/-0.6325 and 1.700+/-0.8233 (p<0.05). CONCLUSIONS: Calcium channel blockage has systemic and local effects on the colitis model.

Outcome analysis in patients with Fournier's gangrene: report of 45 cases.

INTRODUCTION: Despite antibiotics and aggressive debridement, the mortality rate of Fournier's gangrene remains high. Attempts have been made to study factors that may affect prognosis; however, reliable criteria are still lacking. METHODS: The medical records of 45 patients with Fournier's gangrene who presented at the Ege University Medical Faculty Hospital from January 1990 to May 2001 were reviewed retrospectively to analyze the outcome and identify the risk factors and prognostic indicators of mortality. Univariate analysis was performed using the chi-squared test and Fisher's exact probability test, then multivariate analysis of statistically significant variables was performed using logistic regression. RESULTS: The most prominent associated disease was diabetes, affecting 55.6 percent of the patients. The overall mortality rate was 20 percent. However, the mortality rate among diabetics was 36 percent (P = 0.002). The other statistically significant predictors of outcome were the interval from the onset of symptoms to the initial surgical intervention (P = 0.001) and the need of fecal diversion (P = 0.009). Multivariate regression analysis disclosed that the interval from the onset of symptoms to the initial surgical intervention and diabetes were independent predictors of mortality (P = 0.001 and P = 0.003, respectively). CONCLUSION: The interval from the onset of clinical symptoms to the initial surgical intervention seems to be the most important prognostic factor with a significant impact on outcome. Given the significantly high mortality rate among diabetics, diabetes is also an independent prognostic factor. Despite the decreased number of idiopathic cases and extensive therapeutic efforts, Fournier's gangrene remains a surgical emergency, and early recognition with prompt radical debridement is the mainstays of management.