Drain-site recurrence of an ileocaecal valve adenocarcinoma.

Drain-site recurrence following colorectal cancer resection is a rare event and is described in few case reports. The majority of these reports are following minimally invasive surgery. This report describes a case of an isolated drain-site recurrence of primary colorectal cancer in a male patient in his 50s. He previously underwent an open right hemicolectomy and segmental small bowel resection for an obstructing ileocaecal valve adenocarcinoma. This was followed by adjuvant chemotherapy. Two years into surveillance, a redo ileocolic resection was performed for an anastomotic recurrence. While undergoing surveillance imaging, a new deposit was detected at a right-sided surgical drain site. Subsequently, a full thickness en bloc resection was performed. To date, the postoperative course has been uneventful. This case describes a drain-site recurrence from a colorectal primary.

The impact of the acute surgical assessment unit on the management of acute appendicitis: a single-centre review.

BACKGROUND: Acute surgical assessment units (ASAUs) aim to optimise management of surgical patients compared to the traditional 'on-call' emergency department (ED) system. Acute appendicitis (AA) is the most common acute surgical condition requiring emergency surgery. AIM: We set out to assess if the ASAU improved care provided to patients with AA compared to those managed through the ED. METHODS: Patients admitted via the ED with AA in the 6 months prior to opening the ASAU were compared to those admitted via the ASAU in the first six months following its implementation. Relevant data was collected on key performance indicators from their charts. RESULTS: In the ASAU cohort, the mean time to be seen was one hour less than the ED cohort (21 min vs 74 min). The mean time to surgery was also 8.8 h shorter. Most patients in the ASAU group (78.6%) underwent surgery during the day, compared to 40.3% of ED patients. The ASAU patients also had a lower postoperative complication rate (0.9% vs 3.9%), as well as a lower negative appendicectomy rate (14.2% vs 18.6%) and lower conversion-to-open surgery rate. Greater consultant supervision and presence was observed. CONCLUSIONS: The ASAU has resulted in better outcomes for patients with AA than those admitted via ED. More operations were performed in safer daytime hours with greater consultant presence, allowing for improved senior support for trainee surgeons. Our study supports the role of the ASAU in improving the quality and efficiency of emergency general surgery.

Specimen retrieval during elective laparoscopic cholecystectomy: is it safe not to use a retrieval bag?

BACKGROUND: Since the introduction of laparoscopic surgery for gallbladder disease different types of retrieval devices have been used to extract the gallbladder from the peritoneal cavity. These devises infer additional costs and may lead to associated risks and complications. We aimed to evaluate the safety of gallbladder retrieval without the use of a retrieval device. METHODS: A prospective study was conducted across two teaching hospitals in the Republic of Ireland from July 2010-2013. Patients undergoing planed elective day case laparoscopic cholecystectomy in the two institutions were included in the study. Data were collected on patient demographics, the use of a bag, any need for extension of fascial incision, any unexpected over night stay, any 30-day post operative complications and presence of port site hernia within 1 year surgery. RESULTS: There were 373 planned elective day case laparoscopic cholecystectomy performed during the study period. A bag was not used to retrieve the gallbladder in 41 % (n = 152) patients. A retrieval bag was used in the majority of patients (71 %) who required over night stay due to pain. Overall wound infection rate was low (2.4 %), with 57 % of those being in patients where no retrieval bag was used. An increase incision in the fascia was required in 9.7 % of patients. The majority of these were in patients in whom a retrieval bag was used (75 %). At 1 year follow up, there were no recorded cases of port site hernia for the no retrieval bag group and two (0.9 %) cases of umbilical port site hernias in the group where retrieval bag was used. CONCLUSION: In cases of elective uncomplicated laparoscopic cholecystectomy for radiologically confirmed benign disease there was no benefit in using a retrieval bag. Furthermore, not using a bag was associated with less need for increasing the size of the fascial incision thereby reducing post operative pain and risk of port site hernia.

Epidural abscess secondary to acute appendicitis.

A 62-year-old man presented via the emergency department with a 1-week history of back pain, on a background of non-insulin-dependent diabetes mellitus and rectal carcinoma for which he had undergone abdominoperineal resection, chemotherapy and radiotherapy. He exhibited signs of sepsis, midline lumbar spine tenderness and reduced hip flexion. CT of the abdomen and pelvis showed a presacral collection contiguous with the tip of the appendix, and MRI lumbar spine revealed abscess invation into the epidural space extending to T9. He underwent a laparotomy with washout of the presacral abscess and appendicectomy and prolonged course intravenous antibiotic therapy. At 3 months after initial presentation he had made a full clinical recovery with progressive radiological resolution of the epidural abscess. The objective of the case report is to highlight a unique and clinically significant complication of a very common pathology (appendicitis) and to briefly discuss other intra-abdominal sources of epidural abscess.

The frequencies and clinical implications of mutations in 33 kinase-related genes in locally advanced rectal cancer: a pilot study.

BACKGROUND: Locally advanced rectal cancer (LARC: T3/4 and/or node-positive) is treated with preoperative/neoadjuvant chemoradiotherapy (CRT), but responses are not uniform. The phosphatidylinositol 3-kinase (PI3K), MAP kinase (MAPK), and related pathways are implicated in rectal cancer tumorigenesis. Here, we investigated the association between genetic mutations in these pathways and LARC clinical outcomes. METHODS: We genotyped 234 potentially clinically relevant nonsynonymous mutations in 33 PI3K and MAPK pathway-related genes, including PIK3CA, PIK3R1, AKT, STK11, KRAS, BRAF, MEK, CTNNB1, EGFR, MET, and NRAS, using the Sequenom platform. DNA samples were extracted from pretreatment LARC biopsy samples taken from 201 patients who were then treated with long-course neoadjuvant CRT followed by surgical resection. RESULTS: Sixty-two mutations were detected in 15 genes, with the highest frequencies occurring in KRAS (47 %), PIK3CA (14 %), STK11 (6.5 %), and CTNNB1 (6 %). Mutations were detected in BRAF, NRAS, AKT1, PIK3R1, EGFR, GNAS, MEK1, PDGFRA, ALK, and TNK2, but at frequencies of <5 %. As expected, a pathologic complete response (pCR) was associated with improved 5-year recurrence-free survival (RFS; hazard ratio, 0.074; 95 % CI 0.01-0.54; p = 0.001). Mutations in PI3K pathway-related genes (odds ratio, 5.146; 95 % CI 1.17-22.58; p = 0.030), but not MAPK pathway-related genes (p = 0.911), were associated with absence of pCR after neoadjuvant CRT. In contrast, in patients who did not achieve pCR, mutations in PI3K pathway-related genes were not associated with recurrence-free survival (p = 0.987). However, in these patients, codon 12 (G12D/G12 V/G12S) and 13 mutations in KRAS were associated with poor recurrence-free survival (hazard ratio, 1.579; 95 % confidence ratio, 1.00-2.48; p = 0.048). CONCLUSIONS: Mutations in kinase signaling pathways modulate treatment responsiveness and clinical outcomes in LARC and may constitute rational targets for novel therapies.

Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis.

PURPOSE: Use of thoracic epidural analgesia (TEA) with local anesthetic and adjuncts, such as opioids, are cornerstones of ERAS (Enhanced Recovery After Surgery) and are considered to play a key role in recovery after colorectal surgery. However, its effect on bowel function may lead to prolong hospital stay and is still a matter of debate. The purpose of this systemic review was to assess whether epidural analgesia could have a detrimental effect on bowel function in laparoscopic colorectal surgery with a subsequent effect on hospital stay duration, leading to failure of ERAS in colorectal surgery. METHODS: A systematic review of randomized, controlled trials for the effect of epidural analgesia on laparoscopic colorectal surgery was performed. The effect on postoperative recovery was evaluated in terms of return of bowel function as the primary outcome, whereas length of stay (LOS), pain score on visual analogue scale, operative time, and incidence of postoperative complications and side-effects of analgesia were recorded as secondary outcomes. RESULTS: Six trials published between 1999 and 2011 were included in the final analysis. TEA significantly improves return of bowel function assessed by time to first bowel motion [WMD -0.62 (-1.11, -0.12) with Z = 2.43; P = 0.02, 95 % confidence interval (CI)], and pain scores [WMD -1.23 (-2.4, -0.07)] with Z = 2.07; P = 0.04, 95 % CI]. TEA did not influence duration of hospital stay [WMD -0.47 (-1.55, 0.61)] with Z = 0.85 (P = 0.39, 95 % CI). No significant increase in operative time or side effects was associated with TEA. CONCLUSIONS: Despite of some beneficial effect of epidural analgesia on return of bowel function and pain in laparoscopic surgery, it does not affect LOS, which is multifactorial.

The use of porcine small intestinal submucosa mesh (SURGISIS) as a pelvic sling in a man and a woman with previous pelvic surgery: two case reports.

INTRODUCTION: Closing the pelvic peritoneum to prevent the small bowel dropping into the pelvis after surgery for locally recurrent rectal cancer is important to prevent adhesions deep in the pelvis or complications of adjuvant radiotherapy. Achieving this could be difficult because sufficient native tissue is unavailable; we report on the use of small intestine submucosa extra-cellular matrix mesh in the obliteration of the pelvic brim. CASE PRESENTATION: We describe two cases in which submucosa extra-cellular matrix mesh was used to obliterate the pelvic brim following resection of a recurrent rectal tumour; the first patient, a 78-year-old Caucasian man, presented with small bowel obstruction caused by adhesions to a recurrent rectal tumour. The second patient, an 84-year-old Caucasian woman, presented with vaginal discharge caused by an entero-vaginal fistula due to a recurrent rectal tumour. CONCLUSION: We report on the use of submucosa extra-cellular matrix mesh as a pelvic sling in cases where primary closure of the pelvic peritoneum is unfeasible. Its use had no infective complications and added minimal morbidity to the postoperative period. This is an original case report that would be of interest to general and colorectal surgeons.

Referral patterns of patients with liver metastases due to colorectal cancer for resection.

INTRODUCTION: Colorectal carcinoma accounts for 10% of cancer deaths in the Western World, with the liver being the most common site of distant metastases. Resection of liver metastases is the treatment of choice, with a 5-year survival rate of 35%. However, only 5-10% of patients are suitable for resection at presentation. AIMS: To examine the referral pattern of patients with liver metastases to a specialist hepatic unit for resection. METHODOLOGY: Retrospective review of patient's charts diagnosed with colorectal liver metastases over a 10-year period. RESULTS: One hundred nine (38 women, 71 men) patients with liver metastases were included, mean age 61 years; 79 and 30 patients had synchronous and metachronus metastases, respectively. Ten criteria for referral were identified; the referral rate was 8.25%, with a resection rate of 0.9%. Forty two percent of the patients had palliative chemotherapy; 42% had symptomatic treatment. CONCLUSION: This study highlights the advanced stage of colorectal cancer at presentation; in light of modern evidence-based, centre-oriented therapy of liver metastasis, we conclude that criteria of referral for resection should be based on the availability of treatment modalities.

Early discharge policy of patients with acute colonic diverticulitis following initial CT scan.

INTRODUCTION: Diverticulitis develops in 15-20% of individuals with diverticulosis. Severity ranges from mild to severe. Mild diverticulitis is uncomplicated confined per colonic inflammation commonly treated conservatively. Recent literature suggests it could be managed in an outpatient setup. AIMS: To determine if patients with mild acute colonic diverticulitis (ACD) on early CT scan can be treated and discharged at an early time. METHODOLOGY: Retrospective review of patient's charts admitted during 2005 with ACD confirmed by CT scan performed within 24 h of admission. Severity of ACD was determined according to CT classification. RESULTS: Forty-two (31 women, 11 men) patients included, mean age 66 years, CT severity classification: 61.9% mild, 7.1% moderate, and 31.0% severe diverticulitis. Patients with mild ACD were discharged safely, had no recurrence of their symptoms, and needed no readmission within 6 months of follow-up. CONCLUSION: Patients with mild ACD on CT scan performed within 24 h could be safely discharged and treated according to protocols of outpatient management of diverticulitis.

Spontaneous gas gangrene associated with occult carcinoma of the colon: a case report and review of literature.

Clostridium septicum infection is a rare cause of spontaneous nontraumatic gas gangrene. The resultant myonecrosis is acutely painful and rapidly fatal. The infection occurs in the absence of trauma and is usually associated with an underlying malignancy. A case of spontaneous gas gangrene of the upper limb caused by C. septicum infection associated by carcinoma of the colon is presented, with a review of the literature.