Cancer in an unexpected site post pouch surgery for familial adenomatous polyposis (FAP).

INTRODUCTION: Familial Adenomatous Polyposis (FAP) is a hereditary condition characterized by multiple colorectal adenomatous polyps. FAP is the most common adenomatous polyposis syndrome. Restorative proctocolectomy is the most commonly performed surgical procedure performed for patients suffering from FAP with different options for anastomosis, namely ileorectal anastomosis (IRA) or ileal pouch anal anastomosis (IPAA). The occurrence of adenomas is a common finding during follow up and surveillance post surgery for these patients. Although there are a few cases of carcinoma that were namely at the anal transitional zone (ATZ), there are only a few cases of ileal pouch related adenocarcinoma reported. This work has been reported in line with the SCARE criteria (Agha et al., 2016) [1]. PRESENTATION OF CASE: We report a case of a 34-year-old man diagnosed with FAP who underwent proctocolectomy with IPAA, and subsequently referred to our center, who, despite appropriate measures and surveillance, developed adenocarcinoma in the ileal pouch. DISCUSSION: Restorative proctocolectomy for Familial Adenomatous Polyposis (FAP) is the mainstay of treatment. There are different surgical options, each with its own set of advantages and disadvantages. The most favored option is proctocolectomy with ileal pouch anal anastomosis (IPAA) due to because it involves resection of the rectum. Despite these interventions, adenomas and/or carcinomas have been reported on follow up post surgery. CONCLUSION: Although the risk of developing adenomas or carcinomas in the ileal pouch post proctocolectomy with IPAA is low it should not be neglected as cancer occurrence or recurrence is unpredictable even with appropriate measures.

Colorectal cancer in Saudi Arabia: incidence, survival, demographics and implications for national policies.

BACKGROUND AND OBJECTIVES: The national data on colorectal cancer in Saudi Arabia has not been analyzed. The objective of this study is to describe the demographics, incidence and survival rates for colorectal cancer in Saudi Arabia for the period 1994-2010. DESIGN: Retrospective analysis of the Saudi Cancer Registry data for the period 1994-2010. SETTING: Data from the Saudi Cancer Registry was analyzed by stage at presentation (local, regional, distal, unknown) and survival rates were calculated using the Kaplan-Meier method. PATIENTS: From 9889 colorectal cancer cases, a sample of 549 (5.6%) patients was selected and their living status ascertained to assess survival. RESULTS: Colorectal cancer has been the most common cancer among men and the third commonest among women since 2002 in Saudi Arabia. There has been a slight predominance among men with an average ratio of 116:100 over the years (range: 99:100-132:100). The overall age-standardized rate (ASR) approached a plateau of 9.6/100000 in 2010. The incidence of the disease has been highest in the capital, Riyadh, where it reached 14.5/100000 in 2010. Median age at presentation has been stable at around 60 years (95% confidence Interval (CI): 57-61 years) for men and 55 years (95% CI: 53-58 years) for women. Distant metastasis was diagnosed in 28.4% of patients at the time of presentation and rectal cancer represented 41% of all colorectal cancers diagnosed in 2010. The overall 5-year survival was 44.6% for the period 1994-2004. The ASR for all age groups below 45 years of age was lower than that for the United States. LIMITATIONS: The study was retrospective with a possibility of bias from inaccurate staging of patients, and inaccurate survival information and patient demographics due to the underdeveloped census system prior to 2001. Survival data for the period 2005-2010 are lacking. CONCLUSION: Colorectal cancer presents at a younger age in Saudis, especially in women. This has a major implication for decisions about the threshold age for screening. The ASR has increased, but is still much lower than in developed countries. The lower overall 5-year survival compared with developed countries is due to lack of screening, a higher proportion of advanced stage cancer at presentation, lack of specialized care outside the major cities and a higher proportion of rectal cancer cases.

National Guidelines for Colorectal Cancer Screening in Saudi Arabia with strength of recommendations and quality of evidence.

BACKGROUND: Colorectal cancer is the most common cancer among Saudi men and the third commonest among Saudi women. Given the predominance of colorectal cancer compared with other cancers in Saudi Arabia, context-specific guidelines are needed for screening. METHODS: Experts from the Saudi Society of Colon and Rectal Surgery, Saudi Gastroenterology Association, Saudi Oncology Society, Saudi Chapter of Enterostomal Therapy, Family Medicine and Department of Public Health at the Saudi Arabian Ministry of Health and a patient advocate was assembled by the Saudi Centre for Evidence-Based Healthcare, a subsidiary of the Saudi Arabian Ministry of Health. The panel collaborated with a methodological team from McMaster University, Canada to develop national guidelines for colorectal cancer screening. After identifying key questions, the panel conducted a systematic review of all reports on the utility of screening, the cost of screening for colorectal cancer in Saudi Arabia and on the values and preferences of Saudi patients. Meta- analyses, when appropriate, were performed to generate pooled estimates of effect. Using the GRADE approach, the panel used the evidence-to-decision (EtD) framework to assess all domains important in determining the strength and direction of the recommendations (benefits and harms, values and preferences, resource implications, equity, acceptability, and feasibility). Judgments related to the EtD domains were resolved through consensus or voting, if consensus was not reached. The final recommendations were developed during a two-day meeting held in Riyadh, Saudi Arabia in March 2015. Conflicts of interests among the panel members were handled according to the World Health Organization rules. LIMITATIONS: There is lack of national data on the incidence of adenomatous polyps or the age groups in which the incidence surges. There were no national clinical trials assessing the effectiveness of the different modalities of screening for colorectal cancer and their impact on mortality. CONCLUSION: The panel recommends screening for colorectal cancer in Saudi Arabia in asymptomatic Saudi patients at average risk of colorectal cancer. An infrastructure should be built to achieve that goal.

Risk Factors for Abdominal Incision Infection after Colorectal Surgery in a Saudi Arabian Population: The Method of Surveillance Matters.

BACKGROUND: Reported surgical site infection rates range from 2.1% to 40% after colorectal surgery and are believed to be underestimated depending on the method of surveillance. The study aims were to identify an accurate incidence and associated risk factors for abdominal incision surgical site infection after elective open colorectal surgery in a Saudi population. METHODS: This was a prospective observational longitudinal study of 300 consecutive adult patients, recruited upon admission to an 800-bed tertiary referral center. All consenting adults admitted for elective open colorectal surgery were included. Patients were followed for 36 d post-surgery by two certified and experienced wound care experts who diagnosed abdominal incision surgical site infections. The definition provided by the U.S. Centers for Disease Control and Prevention was used. Statistical analysis was performed using both univariate and multivariable logistic regression. RESULTS: Data were analyzed for 296 patients; the incidence of abdominal surgical site infection was 30%. Factors associated with surgical site infection by univariate analysis were pre-operative pre-albumin (p=0.04, odds ratio [OR] 0.81, 95% confidence interval [CI] 0.66-0.99); operative difficulty because of truncal obesity (p=0.006, OR 2.19, 95% CI 1.25-3.84) and obesity measured by body mass index (p=0.002, OR 4.00, 95% CI 1.95-8.20). Multivariable analysis identified only two significant risk factors: Pre-operative pre-albumin (p=0.02, OR 0.76, 95% CI 0.60-0.96), and obesity measured by body mass index (BMI; p=0.001, OR 4.71, 95% CI 2.20-10.10). CONCLUSION: Obesity and nutritional status correlated with post-operative abdominal surgical site infection. The method of surveillance and length of follow-up impact the rate reported.

Colorectal carcinomas from Middle East. Molecular and tissue microarray analysis of genomic instability pathways.

OBJECTIVE: To evaluate the overall incidence of microsatellite instability (MSI), hereditary non polyposis colorectal cancer, and tumor supressor gene (TP53) mutations in Saudi colorectal carcinomas. METHODS: We studied the MSI pathway in Saudi colorectal cancers (CRC) from 179 unselected patients using 2 methods: MSI by polymerase chain reaction, and immunohistochemistry detection of mutL homologs 1 and mutS homologs 2 proteins. The TP53 mutations were studied by sequencing exons 5, 6, 7, and 8. RESULTS: Of the 150 colorectal carcinomas analyzed for MSI, 16% of the tumors showed high level instability (MSI-H), 19.3% had low-level instability (MSI-L) and the remaining 64% tumors were stable. Survival of the MSI-H group was better as compared to the MSI-L or microsatellite stable group (p=0.0217). In the MSI-H group, 48% were familial MSI tumors, which could be attributable to the high incidence of consanguinity in the Saudi population. The TP53 mutations were found in 24% of the cases studied. CONCLUSION: A high proportion of familial MSI cases and a lower incidence of TP53 mutations are some of the hallmarks of the Saudi colorectal carcinomas, which need to be explored further.