Factors affecting operative morbidity and long-term outcomes in patients undergoing surgery for presacral tumours: a multicentric cohort study from the Turkish Collaborative Group for Quality Improvement in Colorectal and Pelvic Surgery.

AIM: Data regarding the operative management of presacral tumours present various dilemmas due to their rarity and heterogeneous nature. The aim of this study was to evaluate the management strategy, factors associated with operative morbidity and long-term postoperative outcomes in a large group of patients undergoing surgery for presacral tumours. METHOD: This study was designed as a multicentre retrospective cohort study. Records of patients who underwent surgery for presacral tumours at 10 tertiary colorectal centres between 1996 and 2017 were evaluated. RESULTS: One hundred and twenty seven patients (44 men) with a mean age of 46 years and body mass index of 27 kg/m2 were included. Fifty eight per cent of the patients had low sacral lesions (below S3). The operative approaches were transabdominal (17%), transsacral (65%) and abdominosacral (17%). The postoperative morbidity was 19%. Thirty per cent of the patients had a malignant tumour. Longer duration of symptoms (p = 0.001), higher American Society of Anesthesiologists score (p = 0.01), abdominosacral operations (p = 0.0001) and presacral tumours located above S3 (p = 0.004) were associated with an increased risk of postoperative morbidity. Overall long-term postoperative recurrence and mortality were 6% and 5%, respectively, within a 3-year mean follow-up period in patients with presacral malignant tumours. CONCLUSION: Reduced physical condition, omission of symptoms prior to surgery, combined resections and high sacral tumours are the risk factors associated with postoperative complications in patients undergoing surgery for presacral tumours. Meticulous planning of the operation and intensified perioperative care may improve the outcomes in high-risk patients.

Morbidity and mortality after the closure of a protective loop ileostomy: analysis of possible predictors.

BACKGROUND/AIMS: A diverting loop ileostomy is often created to protect distal colorectal, coloanal and ileoanal anastomoses. Ileostomy closure is associated with somewhat morbidity and mortality. The aim of this study was to determine the morbidity and morbidity related factors of ileostomy closure. METHODOLOGY: Prospectively recorded data of 255 patients who underwent diverting loop ileostomy between October 2000 and May 2011 were analyzed retrospectively. RESULTS: The study consisted of 139 male and 116 female patients with a median age of 54 years (range 17-79) who underwent ileostomy closure. The morbidity rate of ileostomy closure was 18.4% (47 patients) and the mortality rate was 1.2% (3 patients). When patients with morbidity and without morbidity were compared in terms of gender; age, American Society of Anesthesiology Score, primary pathology, surgeon factor; setting of ileostomy creation and time to stoma closure, only American Society of Anesthesiology Score was found as a predictor for morbidities. CONCLUSIONS: Closure of loop ileostomy is a simple procedure with low morbidity and a small but significant risk of mortality. Surgeons must consider the known risks in conjunction with the overall benefit/risk analysis before deciding between a temporary fecal diversion and a discontinuous colonic resection.

Intussusception in adult and pediatric patients: two different entities.

PURPOSE: Intussusception is one of the most common abdominal emergencies in pediatrics, but adult intussusception is an uncommon entity and most surgeons have only limited experience in treating this disease. The purpose of this study was to highlight the differences between pediatric and adult intussusception. METHODS: The records of 40 patients during 14 years were reviewed retrospectively. The symptoms, diagnosis, sites of intussusception, associated pathologies, and treatment methods of each patient were analyzed. RESULTS: A total of 31 pediatric and 9 adult patients were included in the study. In the pediatric group, bloody stool and vomiting were the most common symptoms whereas adult patients commonly presented with abdominal pain. The physical examination was diagnostic in a remarkable proportion of the pediatric patients but the diagnosis was suggested based on imaging techniques in the adults, and preoperative diagnosis was more successful in the pediatric group. Intussusception was more often associated with an underlying pathology in adults and no adult patient underwent nonoperative reduction, whereas pediatric patients were managed either with hydrostatic reduction or surgery. CONCLUSIONS: Although intussusceptions occur at all ages, there are major differences in the clinical presentation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective.

Surgical interventions in patients with chronic constipation refractory to intensive medical treatment.

INTRODUCTION: Management of patients with chronic constipation (CC), irresponsive to medical treatment, is very difficult. There are some surgical approaches reported for the treatment. In this study we aimed to assess the results of different surgical procedures in patients with severe CC who were refractory to intensive medical treatments. METHODS: Fifteen patients with refractory chronic constipation underwent surgical management between 1998 and 2003 in Ankara University School of Medicine Department of General Surgery. RESULTS: Median age of the patients was 40 years (range, 24-77), female/male ratio was 11/4, median duration of symptoms was 13 years (range, 4-35 years) and median interval of two subsequent bowel movements was 15 (range, 5-30) days. Preoperative evaluation including barium enema, colonoscopy, colonic transit time, and cinedefecography and balloon expulsion test were done in all patients. Clinical analysis of constipation with these tests indicated a simple slow transit colon in three patients but more complicated variations of combined anatomical functional disorders in the rest of the cases. Surgical procedures consisted of total colectomy, Frykman-Goldberg procedure, Wells procedure and appendisostomy, laparoscopically in 8 of them. Deep vein thrombosis developed in the postoperative period after rectopexy and pelvic floor repair in one case. The median follow-up time was 5.5 years. Fourteen (93.3%) patients had an excellent bowel movement and were highly satisfied with the surgical management. CONCLUSION: Surgical interventions may be beneficial in selected patients with refractory chronic constipation (Tab. 2, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

Rectal cancer confined to the bowel wall: the role of 3 Tesla phased-array MR imaging in T categorization.

OBJECTIVE: To determine the diagnostic value of 3 Tesla MR imaging in detection of mucosal (Tis), submucosal (T1) and muscularis propria (T2) invasion in patients with early rectal cancer. METHODS: A total of 50 consecutive patients who underwent 3 Tesla MR imaging and curative-intent intervention for MRI-staged Tis/T1/T2 rectal cancer from March 2012 to December 2016 were included. The radiological T category of each rectal tumour was compared retrospectively with histopathological results assessed according to the tumor, node, metastasis (TNM) classification. The sensitivities, specificities, and overall accuracy rates of 3 Tesla MR imaging for Tis, T1, and T2 cases were calculated using MedCalc statistical software v. 16. RESULTS: The sensitivity, specificity, PPV, NPV of 3 Tesla MR imaging in T categorization for T2 were: 93.7% [95% CI (0.79-0.99)], 77.7% [95% CI (0.52-0.93)], 88.2% [95% CI (0.75-0.94)] and 87.5% [95% CI (0.64-0.96)]; for T1 were 92% [95% CI (0.63-0.99)], 91.8% [95% CI (0.78-0.98)], 80% [95% CI (0.57-0.92)] and 97.1% [95% CI (0.83-0.99)]; for Tis were: 20% [95% CI (0.51-0.71)], 100% [95% CI (0.92-1)], 100%, 91.8% [95% CI (0.87-0.94)], respectively. MR categorization accuracy rates for T2, T1 and Tis were calculated as 88, 92 and 92%, respectively. CONCLUSION: 3 Tesla MR imaging seems to be useful for accurate categorization of T-stage in early rectal cancer, especially for T1 cancers. The method is not a reliable tool to detect Tis cases. The potential for overstaging and understaging of the technique should be realized and taken into consideration when tailoring the treatment protocol for each patient. Advances in knowledge: High-resolution MR with phased-array coil is being increasingly used in the pre-operative assessment of rectal cancer. 3 Tesla high-resolution MR imaging allows improved definition of bowel wall and tumour infiltration.

Prognostic Importance of the Presence of Early Metabolic Response and Absence of Extrahepatic Metastasis After Selective Internal Radiation Therapy in Colorectal Cancer Liver Metastasis.

AIMS: In this study, the authors aimed to identify prognostic factors after selective internal radiation therapy (SIRT) for colorectal cancer (CRC) liver metastasis. METHODS: Forty-nine (28 male, 21 female; mean age: 64.6 ± 10.8) patients who received SIRT for CRC liver metastasis were studied. Effects of number (<5 vs. ≥5), maximum dimension, and standardized uptake value (SUV) of liver metastases, liver tumor load (<25% vs. 26%-50% vs. 51%-75%), presence of extrahepatic disease, and metabolic early response on overall survival were analyzed. RESULTS: Mean follow-up time was 44.1 ± 27.5 months. Overall survival time was calculated as 10.03 ± 1.61 (95% CI; 6.86-13.20) months. SUV (0.004) of liver metastases, early metabolic response (p = 0.015), and presence of extrahepatic metastasis (p = 0.001) were identified as significant factors influencing overall survival. The hazard ratio was 1:2.3 for the presence of extrahepatic metastasis and 1:2.7 for the absence of early metabolic response. CONCLUSION: These findings suggest that patients with CRC liver metastasis who have lower SUV at presentation and early metabolic response have better outcomes after SIRT.

Correlation of minimum apparent diffusion coefficient with maximum standardized uptake on fluorodeoxyglucose PET-CT in patients with rectal adenocarcinoma.

PURPOSE: The aim of this study was to retrospectively assess the correlation between minimum apparent diffusion coefficient (ADCmin) values obtained from diffusion-weighted magnetic resonance imaging (MRI) and maximum standardized uptake values (SUVmax) obtained from positron emission tomography-computed tomography (PET-CT) in rectal cancer. MATERIALS AND METHODS: Forty-one patients with pathologically confirmed rectal adenocarcinoma were included in this study. For preoperative staging, PET-CT and pelvic MRI with diffusion-weighted imaging were performed within one week (mean time interval, 3±1 day). For ADC measurements, the region of interest (ROI) was manually drawn along the border of each hyperintense tumor on b=1000 s/mm2 images. After repeating this procedure on each consecutive tumor-containing slice to cover the entire tumoral area, ROIs were copied to ADC maps. ADCmin was determined as the lowest ADC value among all ROIs in each tumor. For SUVmax measurements, whole-body images were assessed visually on transaxial, sagittal, and coronal images. ROIs were determined from the lesions observed on each slice, and SUVmax values were calculated automatically. The mean values of ADCmin and SUVmax were compared using Spearman's test. RESULTS: The mean ADCmin was 0.62±0.19×10-3 mm2/s (range, 0.368-1.227×10-3 mm2/s), the mean SUVmax was 20.07±9.3 (range, 4.3-49.5). A significant negative correlation was found between ADCmin and SUVmax (r=-0.347; P = 0.026). CONCLUSION: There was a significant negative correlation between the ADCmin and SUVmax values in rectal adenocarcinomas.

The prognostic value of quantitative parameters of 18F-FDG PET/CT in the evaluation of response to internal radiation therapy with yttrium-90 in patients with liver metastases of colorectal cancer.

INTRODUCTION: The aim of this study was to evaluate tumor response using fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in patients who received yttrium-90 selective internal radiation therapy (SIRT) for colorectal liver metastases. The initial and sixth-week tumor lesion glycolysis values were calculated to evaluate the success of the treatment and compare it with patient survival. MATERIALS AND METHODS: Thirty-five patients (15 female, 20 male, mean age: 61.9 ± 9.0 years, range: 33-76 years) who received SIRT treatment for unresectable colorectal cancer liver metastases in our hospital between June 2008 and May 2011 were included in the study. All patients included in the study had liver-only or liver-dominant disease. The treatment response was evaluated by 18F-FDG PET/CT in the sixth week after treatment. Response was evaluated according to the change in total lesion glycolysis (ΔTLG). The ΔTLG was calculated using the following formula: ΔTLG=100 ×[standardized uptake value (SUV) mean1 × total functional tumor volumes (FTVs)1-SUV mean2 × FTV2]/SUV mean1 × FTV1. RESULTS: Mean FTV1 and FTV2 values were calculated to be 235.7 ± 203 and 107.3 ± 67 mm3, respectively (P=0.04). The mean ΔTLG was 43 ± 35 (range: 0-100). Mean overall survival time was 12.7 ± 8.0 months (range: 3-31 months). The cutoff value of ΔTLG was calculated to be 26.5 using receiver operating characteristic analysis (sensitivity 64%; specificity 85%; AUC=0.717 ± 0.087, P=0.034). Patients were allocated into those having values greater than the cutoff value (group 1) and those having values lower than the cutoff value (group 2) in order to calculate the effect of ΔTLG on survival. Survival was 11.32 ± 1.18 (95% CI 9.02-13.62) months in group 2 and 20.76 ± 2.71 (95% CI 15.46-26.06) months in group 1 (P=0.016). ΔTLG was found to be a significant factor in univariate analysis (P=0.01). CONCLUSION: An 18F-FDG PET/CT scan with calculation of ΔSUVmax3, ΔFTV, and ΔTLG before and at the sixth week after SIRT may play an important role in evaluating early tumor response and survival expectancy in these patients and help decide whether these patients should be referred to other treatment modalities or to follow-up.

Intestinal malignant melanoma presenting with small bowel invagination: a case report.

Gastrointestinal tract metastasis of any malignancy is rare. Cutaneous or ocular malignant melanomas are the most common tumors that metastasize to the gastrointestinal tract. Major symptoms of these metastatic lesions are bleeding and obstruction of the gastrointestinal tract. However, malignant melanoma arising in intestinal mucosa causing intestinal obstruction is a rare clinical entity. Herein, we present a case of primary gastrointestinal tract malignant melanoma who presented initially with iron deficiency anemia, which consequently triggered an invagination of jejunal and ileal segments causing obstruction symptoms, three months later.

Perianal infections: reader agreement and diagnostic performance of fat-suppressed contrast-enhanced MRI.

We aimed to determine the diagnostic performance of the contrast-enhanced fat-suppression technique in the detectability of perianal infections and to compare this technique with different MR sequences used for this purpose. Thirty consecutive patients with clinically suspected anorectal infections were examined with fast spin-echo (FSE) T2-weighted, short-inversion-time inversion recovery (STIR), and fat-suppressed and non-fat-suppressed T1-weighted spoiled gradient-echo (SGE) (in-phase) dynamic contrast-enhanced sequences. The results of MRI were correlated with the findings of surgery, which was considered as the standard of reference. Receiver-operating-characteristic curves were reconstructed to describe and compare the diagnostic value of each MR technique. The values of kappa were used as a measure of observer reliability. Diagnostic performances of STIR, FSE T2-weighted and fat-suppressed and non-fat-suppressed, contrast-enhanced SGE T1-weighted techniques showed statistically insignificant differences in detection of perianal infections. There was almost perfect interobserver agreement regarding the presence of lesions on each MR technique. Fat-suppressed, contrast-enhanced SGE T1-weighted MRI showed adequate diagnostic performance in the detection of perianal infections. However, its significance is not different from the other MR sequences used for the present study.