Comparative study of magnetic resonance defaecography and evacuation proctography in the evaluation of obstructed defaecation.

AIM: Obstructed defaecation syndrome is a common condition of multifactorial aetiology and requires specialized evaluation. Accurate and reproducible pelvic floor imaging is imperative for multidisciplinary decision-making. Evacuation proctography (EP) and magnetic resonance defaecography (MRD) are the main imaging modalities used to assess dynamic pelvic floor function. The aim of this prospective study was to compare the findings and acceptability of MRD and EP in the same cohort of patients. METHOD: This was a prospective comparative study of MRD vs EP in 55 patients with obstructed defaecation syndrome in a single National Health Service Foundation Trust. RESULTS: Fifty-five patients were recruited and underwent both EP and MRD. Detection rates for rectocoele were similar (82% vs 73%, P = 0.227), but EP revealed a significantly higher number of trapping rectocoeles compared to MRD (75% vs 31%, P < 0.001). EP detected more rectal intussusceptions than MRD (56% vs 35%, P = 0.023). MRD appeared to underestimate the size of the identified rectocoele, although it detected a significant number of anatomical abnormalities in the middle and anterior pelvic compartment not seen on EP (1.8% enterocoele, 9% peritoneocoele and 20% cystocoele). Patients achieved higher rates of expulsion of rectal contrast during EP compared to MRD, but this difference was not significant (76% vs 64% in MRD, P = 0.092). Of the two studies, patients preferred MRD. CONCLUSIONS: MRD provides a global assessment of pelvic floor function and anatomical abnormality. MRD is better tolerated by patients but it is not as sensitive as EP in detecting trapping rectocoeles and intussusceptions.

Role of lymphatic vessel density in colorectal cancer: prognostic significance and clinicopathologic correlations.

BACKGROUNDS AND AIMS: Over the past decades the identification of several molecules that are expressed specifically in the lymphatic endothelial cells has resulted in marked advances in the field of lymphangiogenesis. We aimed to measure LVD in colorectal cancer patients and to compare it with microvascular density (MVD) - a marker of angiogenesis - and patients' clinicopathological parameters and survival, as the measurement of lymphatic vessel density (LVD) has been documented in various tumor types, including colorectal cancer. PATIENTS AND METHODS: Fifty one patients who had undergone surgical resection for stage I-III colorectal cancer entered this study. LVD and MVD were determined immunohistochemically with the use of D2-40 and CD34 antibody respectively. The evaluation of LVD was performed by both visual and computer-aided image analysis. RESULTS: The majority of lymphatic vessels were located in the peritumoral areas rather than within the tumor. The results obtained from the image analyzer correlated significantly with the data obtained using visual counting with light microscopy. Both visual and image analysis LVD failed to correlate with patients' age and gender and tumor location, stage, grade, MVD count and survival. CONCLUSIONS: The biologic role of the lymphatic vasculature in tumor progression remains controversial. The present study failed to associate LVD with outcome markers and prognosis and further studies would be required to verify our results.

The most frequent cause of 90-day unplanned hospital readmission following colorectal cancer resection is chemotherapy complications.

AIM: NHS England deems 90-day readmission rates as a marker of quality of care. The causes of readmission have not been previously reported in the UK. The aim of this study was to examine the factors associated with 90-day readmission following colorectal cancer surgery at a hospital trust with a catchment population 1.2 million. METHOD: A retrospective review was performed of all patients undergoing resection for colorectal cancer between January 2012 and December 2013. Unplanned readmission was defined as an emergency admission to the trust for any cause within 90 days of surgery. Readmission analyses were restricted to patients discharged from hospital within 28 days of resection. RESULTS: A total of 570 patients underwent surgery, of whom 522 were discharged within 28 days and are included for readmission analysis. The readmission rate was 24.3% (127 patients with a total of 163 episodes of hospital readmissions) within 90 days following surgery. The most frequent cause for readmission was complications related to adjuvant chemotherapy (18.4%) followed by wound-related complications (14.1%). Most patients presenting with wound-related complications were admitted within 60 days and patients with chemotherapy-related complications after 61 days; 13/127 (10.2%) patients who were readmitted underwent emergency surgery, and one patient died following readmission. Multivariate analysis demonstrated that comorbidity was the only independent risk factor. CONCLUSION: Ninety-day readmissions include a high number of readmissions secondary to chemotherapy-related complications, whereas most surgical-related readmission present within 60 days.

Quality of life after cytoreductive surgery and intraoperative hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies: a systematic review.

BACKGROUND: Cytoreductive Surgery (CRS) accompanied by Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a promising technique in the treatment of peritoneal metastatic disease. The complexity and the potential adverse effects of the procedure can significantly affect patients' Quality of Life (QoL). Few studies have assessed the impact of CRS + HIPEC in patients' QoL using structured and validated tools. This is a systematic review of the currently available published data, investigating the QoL after performing CRS + HIPEC for tumours of varying primary origin. METHODS: We performed a systematic review of the studies indexed in PubMed database until July 2014, using as key phrase "quality of life" and "intraperitoneal chemotherapy", including studies using only validated questionnaires for assessing quality of life parameters. RESULTS: 20 studies were identified that matched the criteria set. The results of these studies, although of significant heterogeneity, clearly demonstrate that although overall QoL scores drop in the immediate postoperative period, at an average of 3 months post procedure they recover to 80%-100% or even exceed baseline values. Furthermore, between 6 and 12 months postoperatively, overall QoL is improved in survivors compared to pre-operative status. CONCLUSIONS: CRS and HIPEC is feasible as a treatment modality in selected patients with peritoneal metastatic disease and can preserve or even improve patients' overall quality of life.

HELLP syndrome: understanding and management of a pregnancy-specific disease.

HELLP, a syndrome characterised by haemolysis, elevated liver enzymes and low platelets, a variant of pre-eclampsia/eclampsia, is a multisystemic disorder with an incidence of up to 0.9% in all pregnancies and occurs in about one-quarter of pre-eclamptic patients. Most obstetricians presume that HELLP derives from an autoimmune reaction, leading to a materno- fetal imbalance, with accompanying aggregation of platelets, endothelial malfunction along with inborn errors of fatty acid oxidative metabolism. HELLP is characterised by high mortality and morbidity rates, leading to possibly life-threatening complications regarding both the mother and the fetus. Delivery is indicated if HELLP syndrome occurs after 34 gestational weeks or the fetal and/or maternal conditions deteriorate. Vaginal delivery is preferable. Standard corticosteroid treatment is of uncertain clinical value in maternal HELLP syndrome. Future observations and research results may shed more light on improving our understanding of the aspects of HELLP syndrome.

Clinical role of HER-2/neu expression in colorectal cancer.

PURPOSE: To evaluate the HER-2/neu expression and its relationship with clinicopathological parameters and prognosis in colorectal cancer patients. METHODS: A total of 51 colorectal cancer patients who underwent resection with curative intent from January 2005 to March 2006 were included in this study. Patients were regularly followed up and survival data were obtained as of as April 2011. HER-2/neu protein expression was evaluated from tissue samples from the primary tumor using a semiquantitative standardized immunohistochemical staining kit. Staining intensity was scored as faint (1+), weak to moderate (2+) and moderate to strong (3+). RESULTS: Forty-nine (96.1%) patients showed 1+ staining, 2 (3.9%) 2+, while no case was strongly positive (3+) for HER-2/neu. No apparent association was noted between HER-2/neu expression and patients' age, gender, tumor location, tumor grade, stage and survival. CONCLUSION: Moderate (2+) overexpression of HER-2/neu was detected in a small proportion of colorectal cancer patients. Considering the low rate of HER-2/neu overexpression in colorectal cancer, studies with larger sample sizes using standardized tests are essential to understanding the biologic role of HER-2/neu in this disease.

Constipation-predominant irritable bowel syndrome associated to hyperprolactinemia.

Irritable bowel syndrome (IBS) is considered to be a physical disorder that mainly affects the bowel and is clinically characterized by lower abdominal pain or discomfort, diarrhea, constipation (or alternating diarrhea/constipation), gas, bloating, and nausea. According to recent studies, it appears that there is an association with increased prolactin levels in patients suffering from IBS. We report a rare case of regression of IBS symptoms (constipation type) in a 16-year-old female adolescent after receiving cabergoline for treating hyperprolactinemia due to pituitary macroadenoma. Our hypothesis is that increased prolactin levels, for instance due to a pituitary adenoma, may suppress prolactin-releasing peptide release and lead to a reverse feedback interaction, consequently resulting in oversecretion of cholecystokinin, inducing the development of IBS.