Colonic duplication in an adult with chronic constipation: a case report and review of its surgical management.

One of the possible causes of chronic constipation is colonic duplication. Although seldom asymptomatic, its diagnosis is important due to the risk of malignancy that it carries. We present a case of a young female patient with long-standing constipation who was referred to Kolorektal Cerrahi Clinic (Izmir, Turkey) after scans revealed tubular type of colonic duplication. We successfully performed a laparoscopic total colectomy, and she recovered well. Identifying the type of duplication is important to ensure adequate resection and treatment. A proper workup, including carcinoembryonic antigen levels, must be done as well. Multiple surgical techniques and procedures have been introduced for this condition, but resection of the duplicated colon with its native lumen should be the management of choice, especially in tubular type of duplications such as in our case. In centers where laparoscopic services are available, laparoscopy could be a better option, as it provides multiple benefits of minimally invasive surgery. Attention should also be paid to anatomical details during surgery to ensure better results and outcomes.

In vitro 3D microfluidic peritoneal metastatic colorectal cancer model for testing different oxaliplatin-based HIPEC regimens.

Objectives: Treatment of colorectal peritoneal metastases with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is still evolving. Conducting a randomized trial is challenging due to the high heterogeneity in the presentation of peritoneal disease and various surgical approaches. Biological research may facilitate more rapid translation of information into clinical practice. There is an emerging need for a preclinical model to improve HIPEC treatment protocols in terms of drug doses and treatment durations. The aim of the study is to design a tool that serves as an in vitro three-dimensional (3D) microfluidic peritoneal metastatic colorectal cancer model to test the efficacy of different HIPEC treatments. Methods: We determined the effects of current therapy options using a 3D static disease model on human colon carcinoma cell lines (HCT 116) and transforming growth factor-ß1 induced epithelial-to-mesenchymal transition (EMT) HCT 116 lines at 37 °C and 42 °C for 30, 60, and 120 min. We determined oxaliplatin's half maximal inhibitory concentrations in a 3D static culture by using viability assay. Clinical practices of HIPEC were applied in the developed model. Results: EMT-induced HCT 116 cells were less sensitive to oxaliplatin treatment compared to non-induced cells. We observed increased cytotoxicity when increasing the temperature from 37 °C to 42 °C and extending the treatment duration from 30 to 120 min. We found that 200 mg/m2 oxaliplatin administered for 120 min is the most effective HIPEC treatment option within the framework of clinic applications. Conclusions: The tool map provide insights into creating more realistic pre-clinical tools that could be used for a patient-based drug screening.

Management and Morbidity of Major Pelvic Hemorrhage in Complex Abdominopelvic Surgery.

INTRODUCTION: Hemorrhage is a challenging complication of pelvic surgery. This study aimed to analyze the causes, management, and factors associated with morbidity in patients experiencing major pelvic hemorrhage during complex abdominopelvic surgery. METHODS: Patients who had major intraoperative pelvic hemorrhage during complex abdominopelvic surgery at 11 tertiary referral centers between 1997 and 2017 were included. Patient characteristics, management strategies to control bleeding, short- and long-term postoperative outcomes were evaluated retrospectively. RESULTS: There were 120 patients with a mean age of 56.6 ± 2.4 years and a mean BMI of 28.3 ± 1 kg/m2. While 104 (95%) of the patients were operated for malignancy, 16 (5%) of the patients had surgery for a benign disease. The most common bleeding site was the presacral venous plexus 90 (75%). Major pelvic hemorrhage was managed simultaneously in 114 (95%) patients. Electrocauterization 27 (23%), pelvic packing 26 (22%), suturing 7 (6%), thumbtacks application 7 (6%), muscle welding 4 (4%), use of energy devices 2 (2%), and topical hemostatic agents 2 (2%) were the management tools. Combined techniques were used in 43 (36%) patients. Short-term morbidity and mortality rates were 48 (40%) and 2 (2%), respectively. High preoperative CRP levels (p = 0.04), history of preoperative radiotherapy (p = 0.04), longer bleeding time (p = 0.006), and increased blood transfusion (p = 0.005) were the factors associated with postoperative morbidity. CONCLUSION: Postoperative morbidity related to major pelvic hemorrhage can be reduced by optimizing the risk factors. Prehabilitation prior to surgery to moderate inflammatory status and prompt action with proper technique to control major pelvic hemorrhage can prevent excessive blood loss in complex abdominopelvic surgery.

Diagnostic performance of magnetic resonance imaging in preoperative local staging of rectal cancer after neoadjuvant chemoradiotherapy

PURPOSE: This paper aims to investigate the diagnostic performance of magnetic resonance imaging (MRI) in predicting the pathologic stage of locally advanced rectal cancer (LARC) after neoadjuvant chemoradiotherapy (CRT) and the role of MRI in selecting patients with a pathologic complete response (ypCR). METHODS: Restaging MRI (yMRI) examinations of 136 patients with LARC treated with neoadjuvant CRT followed by surgery were retrospectively analyzed by two radiologists. All examinations were performed on a 1.5 Tesla MRI machine with a pelvic phased-array coil. T2-weighted turbo spin-echo images and diffusion-weighted imaging were obtained. Histopathologic reports of the surgical specimens were the reference standard. The accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) of yMRI in predicting the pathologic T-stage (ypT), N-stage, and ypCR were calculated. The inter-observer agreement was evaluated using kappa statistics. RESULTS: The yMRI results showed 67% accuracy, 59% sensitivity, 80% specificity, 81% PPV, and 56% NPV in identifying ypT (ypT0-2 versus ypT3-4). In predicting the nodal status, the yMRI results revealed 63% accuracy, 60% sensitivity, 65% specificity, 47% PPV, and 75% NPV. In predicting ypCR, the yMRI results showed 84% accuracy, 20% sensitivity, 92% specificity, 23% PPV, and 90% NPV. The kappa statistics revealed substantial agreement between the two radiologists. CONCLUSION: Utilization of yMRI showed high specificity and PPV in predicting the tumor stage and high NPV in predicting the nodal stage; in addition, yMRI revealed moderate accuracy in the T and N classifications, mainly due to underestimating the tumor stage and overestimating the nodal status. Finally, yMRI revealed high specificity and NPV but low sensitivity in predicting the complete response.

Psychometric Properties of the Turkish version of The Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ-TR).

PURPOSE: Preparing a patient cognitively, psychosocially and emotionally for an operation is important for the healing process. The purpose of this study is to investigate the psycholinguistic and psychometric properties of the Turkish version of The Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ-TR). DESIGN: Methodological study. METHODS: The sample consisted of 220 patients. Patients who underwent operation or reoperation for colorectal cancer were included. The language validity, content validity, discriminant validity and construct validity (confirmatory factor analysis) analyses were performed. The item analysis and internal consistency were examined. FINDINGS: Item total score correlations were between 0.38 and 0.85. The Cronbach's alpha was 0.97 for the overall PCSQ-TR and ranged between 0.85 and 0.91 for its domains. Discriminant validity revealed a statistically significant moderate positive correlation between the patients' mean score for the overall PCSQ-TR and their subjective preparedness for surgery score (r = 0.64, P = .000). In the confirmatory factor analysis, the fit indexes were χ2/df = 2.5; P = .00, RMSEA = 0.08, CFI = 0.92, IFI = 0.92, RMR = 0.18, GFI = 0.79. CONCLUSIONS: PCSQ-TR is a valid and reliable scale that can be used to determine colorectal cancer patients' preparedness for surgery and recovery. PCSQ-TR can be administered in writing or online and can help identify patients who do not feel ready for the surgical recovery process and need advanced nursing care support.

Cross-sectional areas of rectus abdominis and psoas muscles reduces following surgery in rectal cancer patients.

PURPOSE: To evaluate the trophic changes in rectus abdominis and psoas muscles in patients who underwent open or laparoscopic rectum resection for rectal cancer. METHODS: We retrospectively analyzed preoperative staging computerized tomographies (CT) and postoperative first oncological follow-up CTs of the patients who underwent low anterior resection (LAR) for rectal cancer from 2010 through 2015. We measured cross-sectional area of left and right rectus abdominis muscles from two levels (above and below umbilicus) where they are widest and psoas muscle at mid-level of the fourth lumbar vertebral body in axial CT images and compared preoperative and postoperative measurements. We investigated the effects of age, sex, administration of preoperative chemoradiotherapy (CRT), type of surgery (open or laparoscopic), or construction of a diverting ileostomy on cross-sectional muscle area changes. RESULTS: After applying inclusion and exclusion criteria 60 patients found to be eligible for the study. Muscle areas of all measurement sites were reduced postoperatively compared to paired preoperative values. There was no significant effect of age, sex, administration of preoperative CRT, type of surgery (open or laparoscopic), or construction of a diverting ileostomy to muscle cross-sectional area reductions. CONCLUSION: Cross-sectional areas of the rectus abdominis and the psoas muscles of rectal cancer patients reduces following rectum resection which indicates atrophy of these muscles. Clinicians should be aware of this problem and focus on prevention of muscle atrophy during the treatment of rectal cancer patients.

The Effects of Patient Care Results of Applied Nursing Intervention to Individuals With Stoma According to the Health Belief Model.

BACKGROUND: Individuals who have undergone stoma surgery take time to adjust to the stoma, and their quality of life is decreasing. OBJECTIVE: The aim of this study was to examine the effects of home-based nursing interventions informed by the Health Belief Model on patient care outcomes for individuals having a stoma. METHODS: This pretest, posttest, and semiexperimental design with a control group included adults who underwent a stoma operation in the previous 3 months. In total, 30 were assigned to the experimental group and 31 to the control group. Study forms included a sociodemographic questionnaire, the Stoma Quality of Life Scale, the Ostomy Adjustment Inventory, and the Pittman Complication Severity Index. RESULTS: After home nursing interventions, there was a significant difference between the compliance rates of the individuals in the experimental group and the complication rates and cost averages (P < .05) with individuals in the control group; no significant difference in quality-of-life scores was found between the 2 groups. CONCLUSION: In order to effectively support postoperative individuals following stoma surgery when they are released from the hospital, postdischarge follow-up care informed by the Health Belief Model components should be offered. IMPLICATIONS FOR PRACTICE: We recommend creating hospital-based, home care teams that follow individuals with a stoma for at least 6 months after discharge.

Fall of another myth for colon cancer: Duration of symptoms does not differ between right- or left-sided colon cancers.

BACKGROUND/AIMS: Patients with colorectal cancer continue to present with relatively advanced tumors that are associated with poor oncological outcomes. The aim of the present study was to assess the association between localization, symptom duration, and tumor stage. MATERIALS AND METHODS: A prospective, multicenter cohort study was conducted on patients newly diagnosed with a histologically proven colorectal adenocarcinoma. Standardized questionnaire-interviews were performed. Data were collected on principal presenting symptoms, duration of symptoms (time to first presentation to a doctor and time to diagnosis) and treatment, diagnostic procedures, tumor site, and stage of the tumor (tumor, node, and metastasis (TNM)). RESULTS: A total of 1795 patients with colorectal cancer were interviewed (mean age: 60.76±13.50 years, male patients: 1057, patients aged >50 years: 1444, colon/rectal cancer: 899/850, right side/left side: 383/1250, stage 0-1-2/stage 3-4: 746/923). No statistically significant correlations were found between duration of symptoms and either tumor site or stage. Principal presenting symptoms were significantly associated with left colon cancer. Patients who had "anemia," "change in bowel habits," "anal pruritus or discharge," "weight loss," and "tumor in right colon" had a significantly longer symptom time. CONCLUSION: Symptom duration is not associated with localization, nor is the tumor stage. Diagnosis of colorectal cancer at an earlier stage may be best achieved by screening of the population.

The Prognostic Implications of FIX and FLO Patterns in Mucinous Colon Carcinomas.

PURPOSE: Colon mucinous carcinomas (MUCs) have two morphological patterns: (i) glands lined by mucinous epithelium with direct contact to the stroma (FIX) and (ii) carcinoma cells floating in mucin (FLO). In this study, we evaluated the prognostic value of these patterns. METHODS: Digital images were captured from the 38 MUC's tissue sections. A grid with 140 points was laid over the computer screen. Totally, 100 points, falling on tumor cells floating in mucin (FLO patterned cells) or on cells contacting stroma (FIX patterned cells), were counted. Tumors were grouped according to the median value of the FIX patterned cells. Cases with more than this value were grouped as FIX and less were grouped as FLO cases. The prognostic value of FIX and FLO pattern was evaluated. RESULTS: The median for FIX patterned cells was 66%, and the cases with lower values than this were grouped as FLO (N = 18; 47.37%), while the rest were grouped as FIX cases. There was no significant difference between FIX and FLO cases for overall survival cases (p = 0.167). For FIX cases, 62.7 and 51.3% of the patients were alive at second and third years, while this was 78.9 and 72.4% for the FLO group, respectively. CONCLUSIONS: This is the first study using a quantitative methodology depending on count pointing to evaluate FIX/FLO feature of MUCs to the best of our knowledge, although we could not observed any prognostic and clinicopathologic relationship statistically. This distinctive feature should be studied in larger cohorts with prognostic information, with a quantitative method, like the one that was applied in this study, in order to achieve strict conclusions.

Does Wound Irrigation with Clorhexidine Gluconate Reduce the Surgical Site Infection Rate in Closure of Temporary Loop Ileostomy? A Prospective Clinical Study.

BACKGROUND: The aim of this study was to investigate the effect of irrigating the surgical site with 0.05% chlorhexidine gluconate (CHG) on surgical site infection (SSI) in temporary loop ileostomy closure. METHODS: In this observational cohort, patients who underwent diverting loop ileostomy and elective ileostomy closure for any reason between September 2014 and July 2016 were enrolled. Irrigation of the surgical site with 0.05% CHG or saline were compared regarding post-operative incision complications. Infection risk was estimated by the National Nosocomial Infection Surveillance System (NNIS) and Study of the Effect of Nosocomial Infection Control (SENIC) scores. Post-operative follow-up was performed by a surgeon blinded to the treatment. Diagnosis of SSI was recorded according to the Guidelines for Prevention of Surgical Site Infection. Wound healing was evaluated by the Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria, and the duration of inpatient Stay (ASEPSIS) score. RESULTS: There were 122 patients meeting the inclusion criteria: 60 in the saline (control) and 62 in the CHG (study) group. The mean age was 56.5 ± 13.5 (standard deviation [SD]); 74 patients were male. The groups were similar regarding age, sex, indication for ileostomy, neoadjuvant therapies, and SENIC and ASEPSIS scores. The overall SSI rate was 18%: 19 patients (31.6%) in the control group and 3 (4.8%) patients in the study group (p < 0.001). The mean ASEPSIS score was higher in the control group (12.8 ± 17.7) than in the study group (3.7 ± 7.8) (p < 0.001). Patients in the control group had significantly higher rates of seroma (13.3% vs 1.6%; p = 0.014) and incision dehiscence (31.6% and 4.8%; p = 0.001). Time to healing was 9.9 ± 5.1 days in the control group and 7.3 ± 5.3 days in the study group (p = 0.007). CONCLUSIONS: Irrigation of the incision with 0.05% CHG reduces the SSI rate compared with saline irrigation. There is a need for randomized and wider trials to clarify the effect and standards of incision irrigation.

Treatment of intraoperatively detected peritoneal carcinomatosis of colorectal origin with cytoreductive surgery and intraperitoneal chemotherapy.

BACKGROUND: Diagnosis of peritoneal carcinomatosis (PC) may be missed by preoperative imaging. We are presenting our experience with incidentally detected PC of colorectal origin treated with cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) at the same operation. METHODS: Between January 2010 and September 2016, 19 patients underwent CRS and IPC due to incidentally detected PC of colorectal origin. Data were analyzed from a prospectively collected database. RESULTS: The median age was 59 (29-78). In three patients, PC was diagnosed during emergency surgery. The primary tumor was located in the rectum (three patients; one with recurrent disease), left colon (9 patients), and right colon (7 patients). All patients underwent CRS and IPC, and one patient operated laparoscopically. Median peritoneal cancer index (PCI) was 5 (range, 3-14), and complete cytoreduction (CC-0) was achieved in 14 patients. After CRS, 8 patients received early postoperative intraperitoneal chemotherapy (EPIC), 7 patients received hyperthermic intraperitoneal chemotherapy (HIPEC), and 4 patients received both HIPEC and EPIC. The median hospital stay was 9 (6-29) days. Postoperative complications occurred in 6 patients. There was no postoperative mortality. Median follow-up was 40.2 (12-94) months. Five-year overall survival was 63.2%. Estimated mean survival time is longer in patients who underwent complete cytoreduction compared to patients having CC-1 or CC-2 cytoreduction (87.7 vs. 20.3 months; p < 0.001). CONCLUSION: Cytoreductive surgery and IPC can be performed safely in patients with intraoperatively detected incidental PC of colorectal origin.

Closing Perianal Fistulas Using a Laser: Long-Term Results in 103 Patients.

BACKGROUND: Primary closure of the fistula tract using energy emitted by a radial fiber connected to a diode laser is a novel procedure for treating perianal fistulas. OBJECTIVE: The aim of this study was to determine the long-term effectiveness of this new technique. DESIGN: The surgical objective was to seal the fistula tract using laser energy. SETTINGS: The study was conducted at a single day-case surgery center. PATIENTS: Between April 2012 and June 2016, 103 consecutive patients with primary or recurrent perianal fistula underwent a laser closure procedure using a 12-watt laser emitting at a wavelength of 1470 nm. MAIN OUTCOME MEASURES: Patients were classified according to the Park classification, and healing was evaluated based on the perianal fistula disease severity score. RESULTS: Among the 103 patients treated using the laser closure procedure, 82 (80%) were men and 21 (20%) were women. The median age of the patients was 43 years (range, 18-78 y). Fifty-three patients (52%) had previous perianal fistula repair surgery. Based on the Park classification, 56 patients (54%) had intersphincteric fistula, 29 (28%) had transsphincteric fistula, 11 (11%) had suprasphincteric or extrasphincteric fistula, and 7 (7%) had superficial perianal fistula. Based on the perianal disease severity score, 41 patients (40%) obtained overall complete healing, 38 (37%) had persistent symptomatic drainage, 20 (19%) had slight drainage with minimal symptoms, and 4 (4%) had painful symptomatic drainage. LIMITATIONS: This was a retrospective analysis of noncomparative data with a lack of formal prospective continence assessment. CONCLUSIONS: Closure of perianal fistulas using a laser should be considered as a treatment option but with modest expectations. Although our complete healing rate was not as high as in earlier studies, this technique is a reasonable option with nearly no risk of sphincter damage when treating perianal fistulas. See Video Abstract at http://links.lww.com/DCR/A545.

Is advanced age a hesitation for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in colorectal cancer?

PURPOSE: The purpose of this study was to assess the feasibility and safety of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in elderly patients with peritoneal carcinomatosis of colorectal cancer. METHODS: Patients who underwent curative complete CRS and HIPEC for peritoneal carcinomatosis of colorectal cancer with minimum follow-up of 24 months were included in the analysis. Charlson comorbidity index and ECOG performance status were used to evaluate preoperative condition. Patients were tiered into two groups according to age (<65 and ≥65 years). Postoperative morbidity, mortality, recurrence, and overall survival were compared between groups. RESULTS: One-hundred patients were meeting the inclusion criteria. Median age was 56 years (ranging, 20-86). The origin of peritoneal carcinomatosis (PC) was colon in 77 and rectum in 23 patients. There were 31 patients in the elderly group. Mean hospital stay was 1711.8 and 16.814.3 days in young and elderly groups (p=0.937). In young patients, postoperative morbidity was seen in 26 (37.6%) patients versus 9 (29%) patients in elderly group (p=0.272). Mortality was higher in elderly group (n=4, 12.9%) than in the younger group (n=5, 7.2%), but the difference was not statistically significant (p=0.287). Median follow-up was 25 months (ranging, 2-112). Local and/or distant recurrence occurred in 30 (43.4%) patients in the young group and 9 (29%) patients in elderly group (p=0.169). Two-years disease-free survival was similar: 67.1% in the young and 74% in the elderly groups (p=0.713). CONCLUSIONS: CRS and HIPEC offer comparable oncologic outcome in meticulously selected medically-fit elderly patients without increased postoperative morbidity and mortality.

En Bloc Pancreaticoduodenectomy for Locally Advanced Right Colon Cancers.

Locally advanced right colon cancer may invade adjacent tissue and organs. Direct invasion of the duodenum and pancreas necessitates an en bloc resection. Previously, this challenging procedure was associated with high morbidity and mortality; however, today, this procedure can be done more safely in experienced centers. The aim of this study is to report our experience on en bloc right colectomy with pancreaticoduodenectomy for locally advanced right colon cancers. Between 2000 and 2012, 5 patients underwent en bloc multivisceral resection. No major morbidities or perioperative mortalities were observed. Median disease-free survival time was 24.5 months and median overall survival time was 42.1 (range: 4.5-70.4) months in our series. One patient lived 70 months after multivisceral resection and underwent cytoreductive surgery and total pelvic exenteration during the follow-up period. In locally advanced right colon tumors, all adhesions should be considered as malign invasion and separation should not be done. The reasonable option for this patient is to perform en bloc pancreaticoduodenectomy and right colectomy. This procedure may result in long-term survival with acceptable morbidity and mortality rates. Multidisciplinary teamwork and multimodality treatment alternatives may improve the results.

Infectious Complications after Cytoreductive Surgery and Hyperthermic Intra-Peritoneal Chemotherapy.

BACKGROUND: The aim of this study was to review the post-operative and infectious complications and determine the risk factors associated with infections in cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC). PATIENTS AND METHODS: Between October 2007 and December 2013, patients who underwent CRS and HIPEC with a curative intent were included in the study. The Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System definitions were used to identify post-operative nosocomial infections. RESULTS: One hundred and sixty-nine CRS and HIPEC procedures were performed. Overall, 155 complications were observed in 82 (48.5%) patients. Grade 3-4 morbidity rate was 25.5% (n = 43). Seventy infections occurred in 47 patients. Surgical site infection was the most common infectious complication. The most common micro-organism isolated from the cultures was Escherichia coli. Age (odds ratio [OR]1.039, confidence interval [CI] 1.006-1.073), the mean total number of staff scrubbing in the operation(OR 2.241, CI 1.415-3.548), and intensive care unit stay (OR 1.325, CI 0.953-1.842) were independent risk factors for infectious complications. CONCLUSIONS: Infectious complications are the most important cause of peri-operative morbidity and death in CRS and HIPEC. As well as patient and tumor characteristics, surgeon/center-related factors play an important role in infectious morbidity. Patients with peritoneal carcinomatosis should be considered as a complex oncologic group at high risk of infectious complications.

A Case of a Gastrointestinal Stromal Tumor Diagnosed at the Postpartum Period.

Introduction. We discuss a rare gastrointestinal stromal tumor (GIST) case detected at the 10th postpartum week and we want to pay attention to the challenges and improvements in the diagnosis, surgery, chemotherapy, and follow-up of this rare tumor accompanied with the review of the current literature. Case Presentation. A 32-year-old multiparous woman presented with abdominal swelling 10 weeks after her second vaginal birth. Abdominal examination revealed a mass starting from the pelvic level and extending to the right upper quadrant. Radiological examinations showed a solid, multiloculated, and hypervascular mass starting from the pelvis and extending to the transverse colon. En bloc mass with a 20 cm jejunal segment resection and a left pelvic side wall peritonectomy with omentectomy was performed. The pathologic examination revealed a high-risk GIST which originated from the jejunum and disseminated to the peritoneum. The patient has been given imatinib 400 mg/day since then. She did not reveal any progression during the 15-month follow-up postoperatively. Conclusion. GIST tumors are rare and there is not sufficient information in the literature regarding its management. In this patient having high risk GIST and GIST sarcomatosis we successfully treated the patient by surgery and adjuvant imatinib chemotherapy.

The role of multidetector CT in local staging and evaluation of retroperitoneal surgical margin involvement in colon cancer.

PURPOSE: We aimed to evaluate preoperative T and N staging and retroperitoneal surgical margin (RSM) involvement in colon cancer using multidetector computed tomography (MDCT). METHODS: In this retrospective study, preoperative MDCTs of 141 patients with colon adenocarcinoma were evaluated in terms of T and N staging and retroperitoneal surgical margin involvement by two observers. Results were compared with histopathology. RESULTS: In determining extramural invasion, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MDCT were 81%, 50%, 95%, 26%, and 81% for observer 1 and 87%, 75%, 97%, 27%, and 84% for observer 2, respectively. Moderate interobserver agreement was observed (ĸ=0.425). In determining T stage of the tumor, accuracy of MDCT was 55% for observer 1 and 51% for observer 2. In the detection of lymph node metastasis, sensitivity, specificity, PPV, NPV, and accuracy of MDCT were 84%, 46%, 60%, 74% and 64% for observer 1 and 84%, 56%, 65%, 78%, and 70% for observer 2, respectively. Interobserver agreement was substantial (ĸ=0.650). RSM was involved in six cases (4.7%). When only retroperitoneal colon segments were considered, 1.6% of subjects demonstrated RSM involvement. Four of the six RSM-positive tumors were located on sigmoid colon and one tumor was on transverse colon and caecum. Considering all colon tumors, in the detection of RSM involvement, sensitivity and specificity of MDCT were 33% and 81% for observer 1 and 50% and 80% for observer 2. Interobserver agreement was moderate (ĸ=0.518). CONCLUSION: MDCT is a promising technique with moderate interobserver agreement in detection of extramural invasion, lymph node metastases, and RSM involvement in colon carcinomas.

Neutrophil-to-lymphocyte ratio: could it be used in the clinic as prognostic marker for gastrointestinal stromal tumor?

BACKGROUND/AIMS: The association between systemic inflammatory response and tumor biology has been well documented over the last decade. The aim of this study is to investigate the prognostic role of neutrophilto- lymphocyte ratio (NLR) in gastrointestinal stromal tumors (GISTs). METHODOLOGY: A prospectively recorded database of 67 patients who underwent surgical resection for GIST was reviewed. High and low NLR were defined with respect to the sample median, which was 1.92. Demographical, clinicopathological, and surgical characteristics were analyzed as well as disease free survival (DFS) rates according to NLR classification. RESULTS: We observed better disease free survival rates in patients with low NLR compared to patients with high NLR (85.7% and 69%, respectively; p=0.037). Estimated five-year overall and disease free survival rates were 95.1% and 78.7%, respectively. In univariate analysis synchronous sarcomatosis, tumor size, mitotic rate, presence of necrosis, lymph node metastasis, surgical margin status, risk category and NLR were associated with DFS. On multivariate analysis sarcomatosis (HR: 30.455), surgical margin status (HR: 4.228) and necrosis (HR: 4.415) were found as independent prognostic factors for DFS. CONCLUSIONS: NLR can give information about inflammatory status, tumor aggressivity and prognosis in GIST patients. It could be a new prognostic factor for GIST patients.

Peritoneal carcinomatosis of gastrointestinal tumors: where are we now?

The peritoneal stromal tissue which provides a rich source of growth factors and chemokines is a favorable environment for tumor proliferation. The pathophysiological mechanism of peritoneal carcinomatosis is an individual sequence consisting of genetic and environmental factors and remains controversial. The natural history of the disease reveals a poor median prognosis of approximately 6 mo; however aggressive surgery and multimodal treatment options can improve oncologic outcomes. Considering peritoneal carcinomatosis as though it is a locoregional disease but not a metastatic process, cytoreductive surgery and and intraperitoneal chemotherapy has been a curative option during recent years. Cytoreductive surgery implies a series of visceral resections and peritonectomy procedures. Although the aim of cytoreductive surgery is to eliminate all macroscopic disease, viable tumor cells may remain in the peritoneal cavity. At that point, intraperitoneal chemotherapy can extend the macroscopic disease elimination to microscopic disease elimination. The successful treatment of peritoneal carcinomatosis requires a comprehensive management plan including proper patient selection, complete resection of all visible disease, perioperative intraperitoneal chemotherapy and postoperative systemic chemotherapy. Surgical and oncologic outcomes are strictly associated with extent of the tumor, completeness of cytoreduction and patient-related factors as well as multidisciplinary management and experience of the surgical team. In this review, pathophysiology and current management of peritoneal carcinomatosis originating from gastrointestinal tumors are discussed according to the latest literature.