Retroperitoneal and iliopsoas abscess as Crohn's disease onset mimicking a common lumbosciatic pain.

Crohn's Disease (CD) refers to a chronic transmural bowel inflammation affecting a range between 5 and 15 per 100,000 person-years worldwide 1. In patients with stricturing CD, the transmural pattern of inflammation may trigger the development of sinus tracts able to connect to other tissues, leading to the formation of fistulas or abscesses 2. Intra-psoas abscesses are rare, affecting between 0.4-4.3% of patients with CD 3. We present the case of a 36-year-old male with no past medical history except for a two-week worsening lumbosciatalgia not responding to standard nonsteroidal anti-inflammatory drugs, who complained sudden abdominal pain, with right lower abdominal stiffness combined to a severe edema and erythema of the right lower limb, extended from the gluteus down to the knee, involving the anteromedial and posteromedial areas of his thigh. Patient was septic and CT scans revealed a large complex air-fluid collection within the right iliac region, involving terminal ileum, right retroperitoneum and right lateral abdominal wall towards the inner edge of his thigh. Diagnosis of CD was made on histopathology and the patient gained full recovery thanks to a prompt surgical intervention followed by high-dose antibiotic infusion and vacuum-assisted wound closure. Intra-psoas abscesses, albeit rare, are a known manifestation of CD and frequently lead to misdiagnosis because of their rarity and their unusual location easily mimicking other diseases. Therefore, clinician's awareness must be heightened for complicated CD in the setting of intra-psoas abscesses in order to avoid delayed treatment. KEY WORDS: Crohn disease, Psoas abscess, Sciatica, Late onset disorders, Negative pressure Wound therapy.

Rivaroxaban vs placebo for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer.

The clinical benefit of extended prophylaxis for venous thromboembolism (VTE) after laparoscopic surgery for cancer is unclear. The efficacy and safety of direct oral anticoagulants for this indication are unexplored. PROphylaxis of venous thromboembolism after LAParoscopic Surgery for colorectal cancer Study II (PROLAPS II) was a randomized, double-blind, placebo-controlled, investigator-initiated, superiority study aimed at assessing the efficacy and safety of extended prophylaxis with rivaroxaban after laparoscopic surgery for colorectal cancer. Consecutive patients who had laparoscopic surgery for colorectal cancer were randomized to receive rivaroxaban (10 mg once daily) or a placebo to be started at 7 ± 2 days after surgery and given for the subsequent 3 weeks. All patients received antithrombotic prophylaxis with low-molecular-weight heparin from surgery to randomization. The primary study outcome was the composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected deep vein thrombosis (DVT), or VTE-related death at 28 ± 2 days after surgery. The primary safety outcome was major bleeding. Patient recruitment was prematurely closed due to study drug expiry after the inclusion of 582 of the 646 planned patients. A primary study outcome event occurred in 11 of 282 patients in the placebo group compared with 3 of 287 in the rivaroxaban group (3.9 vs 1.0%; odds ratio, 0.26; 95% confidence interval [CI], 0.07-0.94; log-rank P = .032). Major bleeding occurred in none of the patients in the placebo group and 2 patients in the rivaroxaban group (incidence rate 0.7%; 95% CI, 0-1.0). Oral rivaroxaban was more effective than placebo for extended prevention of VTE after laparoscopic surgery for colorectal cancer without an increase in major bleeding. This trial was registered at www.clinicaltrials.gov as #NCT03055026.

An extremely rare finding of goblet cell carcinoid of the appendix. A case report.

Goblet cell carcinoid or carcinoma (GCC) refers to an extremely rare appendiceal tumor usually diagnosed on post-operative histology as an incidental finding. Primary cancers of the vermiform appendix are quite rare, representing less than 1% of all gastrointestinal malignancies. GCCs are considered as a distinct entity of appendiceal tumors, consisting of both epithelial (glandular) and neuroendocrine elements containing goblet cells. This entity tends to be more aggressive than typical carcinoid tumors as it often presents with metastatic disease. Therefore, an early recognition and an appropriate grading is essential. The 5-year overall survival is 14-22% in stage III-IV disease. As a matter of fact, GCC warrants more aggressive surgical and medical (chemotherapy) treatments than typical carcinoid tumors. We, hereby, report a case of a 67-year old male presenting with an acute abdominal obstruction and a severe tenderness predominant in his right lower quadrant, together with an endoscopic and radiological suspect of left colonic malignancy and acute appendicitis. Left hemicolectomy and appendicectomy were performed and pathological specimens revealed a lowgrade adenocarcinoma of the descending colon and a high-grade appendiceal goblet cell carcinoid. Subsequent right hemicolectomy was performed according to the current guidelines. GCCs are more aggressive compared with conventional appendiceal tumors but less aggressive compared with adenocarcinomas and they often present with serosal and mesoappendiceal involvement. The lack of a standardized classification system for GCC and the discrepancies in specific reliable markers are responsible for an insufficient prognostic and predictive value at diagnosis. KEY WORDS: Appendiceal neoplasms, Carcinoid tumor, Colectomy, Goblet cells, Immunochemistry.

A rare finding of Actinomyces odontolyticus abdominal actinomycosis presenting as abdominal wall and pericolic pseudotumoral mass.

Abdominal actinomycosis refers to a rare chronic suppurative infectious occurrence, caused by filamentous Gram-positive microaerophilic and anaerobic bacteria Actinomyces, that may appear as an abdominal mass and/or abscess, feasibly mimicking a malignancy 1,2. Due to its rarity and unspecific clinical evidence, the majority of cases are diagnosed after tissue specimen. We hereby report a case of a 69-year-old patient with a one week worsening abdominal pain and swelling. A large tender palpable mass in the epigastric region was noted on physical exam. An ultrasound-guided drainage followed by a surgical excision approach became both a way to confirm the diagnosis and a therapeutic tool. Diagnosis of actinomycosis was made on histopathology and microbiology. Even though the incidence of actinomycosis has decreased, the abdominal presentation has been observed with increasing frequency 3. KEY WORDS: Actinomycosis, Abdominal wall, Abdominal abscess, foreign-body reaction, Colonic neoplasms.

Rivaroxaban for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer. Design of the PRO-LAPS II STUDY.

BACKGROUND: The clinical benefit of extending prophylaxis for venous thromboembolism (VTE) beyond hospital discharge after laparoscopic surgery for cancer is undefined. Extended prophylaxis with rivaroxaban is effective in reducing post-operative VTE after major orthopedic surgery without safety concern. METHODS: PROLAPS II is an investigator-initiated, randomized, double-blind study aimed at assessing the efficacy and safety of extended antithrombotic prophylaxis with rivaroxaban compared with placebo after laparoscopic surgery for colorectal cancer in patients who had received antithrombotic prophylaxis with low molecular-weight heparin for 7 ± 2 days (NCT03055026). Patients are randomized to receive rivaroxaban (10 mg once daily) or placebo for 3 weeks (up to day 28 ± 2 from surgery). The primary study outcome is a composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT or VTE-related death at 28 ± 2 days from laparoscopic surgery. The primary safety outcome is major bleeding defined according to the International Society of Thrombosis and Haemostasis. Symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT, major bleeding or death by day 28 ± 2 and by day 90 from surgery are secondary outcomes. Assuming an 8% event rate with placebo and 60% reduction in the primary study outcome with rivaroxaban, 323 patients per group are necessary to show a statistically significant difference between the study groups. DISCUSSION: The PROLAPS II is the first study with an oral anti-Xa agent in cancer surgery. The study has the potential to improve clinical practice by answering the question on the clinical benefit of extending prophylaxis after laparoscopic surgery for colorectal cancer.

A randomized study on 1-week versus 4-week prophylaxis for venous thromboembolism after laparoscopic surgery for colorectal cancer.

OBJECTIVE: To compare the efficacy and safety of antithrombotic prophylaxis given for 1 week or 4 weeks in patients undergoing laparoscopic surgery for colorectal cancer. BACKGROUND: Extending antithrombotic prophylaxis beyond 1 week reduces the incidence of venous thromboembolism (VTE) after open abdominal surgery for cancer. METHODS: In consecutive patients who underwent laparoscopic surgery for colorectal cancer, complete compression ultrasonography of the lower limbs was performed after 8 ± 2 days of antithrombotic prophylaxis. Patients with no evidence of VTE were randomized to short (heparin withdrawal) or to extended (heparin continued for 3 additional weeks) prophylaxis. Complete compression ultrasonography was repeated at day 28 ± 2 after surgery by investigators blinded to treatment allocation. The primary outcome of the study was the composite of symptomatic and ultrasonography-detected VTE at day 28 ± 2 after surgery. RESULTS: Overall, 301 patients were evaluated for inclusion in the study and 225 were randomized. VTE occurred in 11 of 113 patients randomized to short (9.7%) and in none of the 112 patients randomized to extended heparin prophylaxis (P = 0.001). The incidence of VTE at 3 months was 9.7% and 0.9% in patients randomized to short or to extended heparin prophylaxis, respectively (relative risk reduction: 91%, 95% confidence interval: 30%-99%; P = 0.005). The rate of bleeding was similar in the 2 treatment groups. Two patients died during the study period, 1 in each treatment group. CONCLUSIONS: After laparoscopic surgery for colorectal cancer, extended antithrombotic prophylaxis is safe and reduces the risk for VTE as compared with 1-week prophylaxis (NCT01589146).