A Case Report of Female Hydrocele of the Canal of Nuck (Type I): A Diagnostic Challenge and Surgical Solution.

The canal of Nuck is an anomaly of the female inguinal canal that can lead to the development of hernias or hydroceles. It is a result of incomplete obliteration of a pouch of the parietal peritoneum that accompanies the round ligament throughout the inguinal canal. This is a case report of a 27-year-old female with hydrocele of the canal of Nuck which was initially misdiagnosed as a reducible right inguinal hernia. Physical examination and ultrasound revealed a right groin 64 × 15 × 36 mm cystic mass extending from the right inguinal region to the labia majora. Right inguinal exploration was performed with an oblique inguinal incision. A cystic lesion measuring 65 × 15 mm was carefully dissected from the round ligament and excised. Histopathological examination confirmed the diagnosis of hydrocele of the canal of Nuck. The patient is doing well after six months with no signs of recurrence on the operated side. The hydrocele of the canal of Nuck, though a rare condition, should always be considered in the differential diagnosis when evaluating inguinolabial swellings in female patients.

Adipose tissue imaging as nutritional predictors in patients undergoing enterocutaneous fistula repair.

OBJECTIVES: The management of enterocutaneous fistulae (ECF) is complex, challenging, and often associated with metabolic, septic, and nutritional complications. Radiographic quantification of body composition such as fat or lean body mass distribution is a potentially valuable preoperative assessment tool to optimize nutritional status. The aim of this study was to investigate the correlation between total adipose tissue (fat) area (TFA), assessed by computed tomography and magnetic resonance imaging radiology tests, with body weight, body mass index (BMI), various biochemical parameters, need for nutritional support, and survival in patients undergoing ECF repair. METHODS: Biochemical and anthropometric parameters at the time of ECF surgery were retrospectively collected for adult patients undergoing ECF repair at University College London Hospital, UK. Visceral and subcutaneous adiposity was measured at the level of the third lumbar vertebra (Image J) at computed tomography or magnetic resonance imaging. Statistical analysis included descriptives, univariate and multivariate analysis between TFA and various parameters, and their influence on postoperative survival. RESULTS: A complete set of data was available for 85 patients (51 women, 56.9 ± 14.5 y of age) who underwent ECF repair. ECF originated mainly as a surgical complication (86%) while 14% were undergoing a second ECF repair. Median BMI was 22.8 kg/m2 and mean TFA was 361 ± 174.9 cm2, with a higher visceral fat content in men than in women (183.8 ± 99.2 versus 99 ± 59.7 cm2, P < 0.001). BMI, body weight, and creatinine were significantly positively correlated with TFA (ρ = 0.77, 0.73, and 0.50, respectively, P < 0.001); no correlation was noted between TFA and preoperative albumin levels. Patients in the low TFA group had a higher use of parenteral nutrition (P = 0.049). Hospital length of stay was longer in patients receiving artificial nutrition support (70 versus 22 d, P < 0.001). A TFA cutoff point of 290 cm2 discriminated patients who required artificial nutrition versus no nutritional support with moderate sensitivity (75%) but poor specificity (45%). At multivariate analysis, only >60 y of age (hazard ratio [HR], 2.69, P < 0.02) and use of parenteral nutrition (HR, 3.90, P < 0.02) were associated with worse overall survival. CONCLUSION: Abdominal adiposity was strongly correlated with anthropometric parameters at the time of surgery. Earlier identification of patients requiring artificial nutrition at standard preoperative imaging might allow integration of nutritional optimization into initial clinical management plans reducing length of stay and improving clinical outcomes.

Follow up colonoscopy may be omissible in uncomplicated left-sided acute diverticulitis diagnosed with CT- a retrospective cohort study.

International guidelines recommend colonoscopy following hospitalisation for acute diverticulitis. There is a paucity of evidence supporting the efficacy of colonoscopy in this context, particularly for patients with CT-diagnosed uncomplicated left-sided diverticulitis. This study aims to investigate the frequency that colorectal cancer (CRC) and advanced adenomas (AA) are identified during follow-up colonoscopy after hospitalisation with CT-proven left-sided diverticulitis for the first time in a UK population. In this single-centre retrospective-cohort study all patients presenting with CT-diagnosed uncomplicated left-sided diverticulitis between 2014 and 2017 were identified. The incidence of histologically confirmed CRC and AA identified at follow-up colonoscopy 4-6 weeks following discharge was assessed. 204 patients with CT proven uncomplicated left-sided diverticulitis underwent follow-up colonoscopy. 72% were female and the median age was 63 years. There were no major complications. 22% of patients were found to have incidental hyperplastic polyps or adenomas with low-grade dysplasia. No CRC or AA were found. Routine colonoscopy following acute diverticulitis in this cohort did not identify a single CRC or AA and could arguably have been omitted. This would significantly reduce cost and pressure on endoscopy departments, in addition to the pain and discomfort that is commonly associated with colonoscopy.

Multifunctional imaging signature for V-KI-RAS2 Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations in colorectal cancer.

UNLABELLED: This study explores the potential for multifunctional imaging to provide a signature for V-KI-RAS2 Kirsten rat sarcoma viral oncogene homolog (KRAS) gene mutations in colorectal cancer. METHODS: This prospective study approved by the institutional review board comprised 33 patients undergoing PET/CT before surgery for proven primary colorectal cancer. Tumor tissue was examined histologically for presence of the KRAS mutations and for expression of hypoxia-inducible factor-1 (HIF-1) and minichromosome maintenance protein 2 (mcm2). The following imaging parameters were derived for each tumor: (18)F-FDG uptake ((18)F-FDG maximum standardized uptake value [SUVmax]), CT texture (expressed as mean of positive pixels [MPP]), and blood flow measured by dynamic contrast-enhanced CT. A recursive decision tree was developed in which the imaging investigations were applied sequentially to identify tumors with KRAS mutations. Monte Carlo analysis provided mean values and 95% confidence intervals for sensitivity, specificity, and accuracy. RESULTS: The final decision tree comprised 4 decision nodes and 5 terminal nodes, 2 of which identified KRAS mutants. The true-positive rate, false-positive rate, and accuracy (95% confidence intervals) of the decision tree were 82.4% (63.9%-93.9%), 0% (0%-10.4%), and 90.1% (79.2%-96.0%), respectively. KRAS mutants with high (18)F-FDG SUVmax and low MPP showed greater frequency of HIF-1 expression (P = 0.032). KRAS mutants with low (18)F-FDG SUV(max), high MPP, and high blood flow expressed mcm2 (P = 0.036). CONCLUSION: Multifunctional imaging with PET/CT and recursive decision-tree analysis to combine measurements of tumor (18)F-FDG uptake, CT texture, and perfusion has the potential to identify imaging signatures for colorectal cancers with KRAS mutations exhibiting hypoxic or proliferative phenotypes.

Integrated (18)F-FDG PET/CT and perfusion CT of primary colorectal cancer: effect of inter- and intraobserver agreement on metabolic-vascular parameters.

OBJECTIVE: The purpose of this article is to assess the effect of observers on combined metabolic-vascular parameters in colorectal cancer. SUBJECTS AND METHODS: Twenty-five prospective patients (12 men and 13 women; mean age, 66.9 years) with proven primary colorectal adenocarcinoma underwent integrated (18)F-FDG PET/perfusion CT to assess tumor metabolism (mean and maximum standardized uptake value [SUV(mean) and SUV(max), respectively]) and vascularization (blood flow [BF], blood volume [BV], permeability surface-area product, and standardized perfusion value). Intra- and interobserver agreement for PET, perfusion CT, and combined metabolic-flow parameters were determined by Bland-Altman statistics and intraclass correlation coefficients (ICCs). RESULTS: The mean tumor size was 3.8 ± 1.6 cm; there were five stage IA/B, six stage IIA/B, eight stage IIIA/B, and six stage IV tumors. Intra- and interobserver agreement for individual parameters was fair to good, with mean differences between observers of -0.74 for SUV(max), -0.16 for SUV(mean), 9.72 for BF, 0.15 for BV, -0.76 for permeability surface-area product, and 0.09 for standardized perfusion value. ICCs were 0.44-0.99 and 0.38-0.89 for intra- and interobserver agreement, respectively. Interobserver agreement was variable for combined metabolic-flow parameters but better for metabolic-flow difference than for metabolic-flow ratio: ICCs were 0.69-0.88 for the metabolic-flow difference and 0.44-0.94 for the metabolic-flow ratio. CONCLUSION: Combined parameters to assess the metabolic-flow relationship are influenced by observer variation. Intra- and interobserver agreement are better for the metabolic-flow differences than for the ratios, suggesting that metabolic-flow differences may be a more robust parameter for clinical practice.

Assessment of the metabolic flow phenotype of primary colorectal cancer: correlations with microvessel density are influenced by the histological scoring method.

OBJECTIVES: To investigate how the histological scoring of microvessel density affects correlations between integrated (18)F-FDG-PET/perfusion CT parameters and CD105 microvessel density. METHODS: A total of 53 patients were enrolled from 2007 to 2010. Integrated (18)F-FDG-PET/perfusion CT was successful in 45 patients, 35 of whom underwent surgery without intervening treatment. Tumour SUV(max), SUV(mean) and regional blood flow (BF) were derived. Immunohistochemical staining for CD105 expression and analysis were performed for two hot spots, four hot spots and the Chalkley method. Correlations between metabolic flow parameters and CD105 expression were assessed using Spearman's rank correlation. RESULTS: Mean (SD) for tumour size was 38.5 (20.5) mm, for SUV(max), SUV(mean) and BF it was 19.1 (4.5), 11.6 (2.5) and 85.4 (40.3) mL/min/100 g tissue, and for CD105 microvessel density it was 71.4 (23.6), 66.8 (22.9) and 6.18 (2.07) for two hot spots, four hot spots and the Chalkley method, respectively. Positive correlation between BF and CD105 expression was modest but higher for Chalkley than for four hot spots analysis (r = 0.38, P = 0.03; r = 0.33, P = 0.05, respectively). There were no significant correlations between metabolic parameters (SUV(max) or SUV(mean)) and CD105 expression (r = 0.08-0.22, P = 0.21-0.63). CONCLUSIONS: The histological analysis method affects correlations between tumour CD105 expression and BF but not SUV(max) or SUV(mean). KEY POINTS: • FDG-PET/perfusion CT offers new surrogate biomarkers of angiogenesis. • Microvessel density scoring influences histopathological correlations with CT blood flow. • Highest correlations were found with the Chalkley analysis method. • Correlations between SUV and CD105 are not affected by the scoring method.

The flow-metabolic phenotype of primary colorectal cancer: assessment by integrated 18F-FDG PET/perfusion CT with histopathologic correlation.

UNLABELLED: The aim of this study was to assess the in vivo flow-metabolic phenotype in primary colorectal cancer with integrated (18)F-FDG PET/perfusion CT and its relationship to gold standard histopathologic assessment of angiogenesis and hypoxia. METHODS: 45 patients (26 male and 19 female; mean age, 67.6 y) with primary colorectal cancer underwent integrated (18)F-FDG PET/perfusion CT, deriving tumor glucose metabolism (maximum standardized uptake value) and regional blood flow. From this cohort, 35 underwent surgery subsequently, without intervening neoadjuvant treatment, allowing histopathologic correlation with tumor stage, CD105 microvessel density, vascular endothelial growth factor (VEGF), glucose transporter protein 1 (Glut-1), and hypoxia-inducible factor 1 expression. RESULTS: The flow-metabolic ratio was significantly lower for tumors with higher VEGF (3.65 vs. 5.98; P = 0.01) or hypoxia-inducible factor 1 expression (3.63 vs. 5.48; P = 0.04) versus tumors with lower expression. There were significant negative correlations between the tumor flow-metabolic ratio and VEGF expression (r = -0.55, P = 0.0008), indicating that tumors with low blood flow but higher metabolism were associated with higher VEGF expression. Flow and metabolism were coupled in higher-stage (stage III/IV) tumors but not lower-stage tumors (stage I/II) (r = 0.47, P = 0.03, vs. r = 0.09, P = 0.65, respectively. CONCLUSION: Tumors with a low-flow-high-metabolism phenotype demonstrated higher VEGF expression and may reflect a more angiogenic phenotype.

The role of 18FDG PET/CT in the management of colorectal liver metastases.

INTRODUCTION: Surgical resection remains the only potentially curative treatment for colorectal liver metastases (CLM). However, involvement of both the hepatic lobes or extrahepatic disease (EHD) can be a contra-indication for resection. The aim of the present study was to examine the addition of combined positron emission and computed tomography (PET/CT) to CLM staging to assess the effects upon staging and management. METHODS: All CLM patients referred to a single centre between January 2005 and January 2009 were prospectively included. All underwent routine staging (clinical examination and computed tomography), followed by a whole body (18) fluoro-deoxy-glucose ((18)FDG)-PET/CT scan and Fong clinical risk score calculation. RESULTS: Sixty-four patients were included [63% male with a median age of 63 years (age range 32-79 years)]. The addition of PET/CT led to disease upstaging in 20 patients (31%) and downstaging in two patients (3%). EHD was found in 24% of low-risk patients (Fong score 0-2) as compared with 44% of high-risk patients (Fong score 3-5) (P= 0.133). There was a trend towards a greater influence upon management in patients with a low score (44% vs. 17%; P= 0.080). CONCLUSION: The addition of PET/CT led to management changes in over one-third of patients but there was no correlation between alterations in staging or management and the Fong clinical risk score; suggesting that PET/CT should be utilized, where available, in the pre-operative staging of CLM patients.

Temporary sacral nerve stimulation alters rectal sensory function: a physiological study.

BACKGROUND: The indications for sacral nerve stimulation are increasing, but the mechanism remains poorly understood. OBJECTIVE: This study aimed to examine the effect of sacral nerve stimulation on rectal compliance and rectal sensory function. DESIGN: This was a prospective study. SETTINGS: This study took place at a university teaching hospital. PATIENTS: Twenty-three consecutive consenting patients (22 female; median age, 49 y) undergoing temporary sacral nerve stimulation for fecal incontinence were prospectively studied. Clinical response was assessed by the use of bowel diaries and Wexner scores. MAIN OUTCOME MEASURES: Anal manometry, rectal compliance, volume and pressure thresholds to rectal distension (barostat), and rectal Doppler mucosal blood flow were measured before and at the end of stimulation. RESULTS: Sixteen patients (70%) had a favorable clinical response. Median anal squeeze pressures increased with stimulation from 40 (range, 6-156) cmH2O to 64 (range, 16-243) cmH2O. Median rectal compliance did not significantly change with stimulation (prestimulation: 11.5 (range, 7.9-21.8) mL/mmHg, poststimulation: 12.4 (range, 6.2-22) mL/mmHg, P = .941). Rectal wall pressures associated with urge (baseline: 15.4 (range, 11-26.7) mmHg, poststimulation: 19 (range, 11.1-42.7) mmHg, P = .054) and maximal tolerated thresholds (baseline: 21.6 (8.5-31.9) mmHg, poststimulation: 27.1 (14.3-43.3) mmHg, P = .023) significantly increased after stimulation. Rectal Doppler mucosal blood flow did not significantly change with stimulation (baseline: 125.8 (69.9-346.8), poststimulation: 112.4 (50.2-404.1), P = .735). Changes in anal resting pressure and rectal wall pressures with stimulation were evident only in responders; however, changes in anal squeeze pressures were evident in both responders and nonresponders. LIMITATIONS: The study reports results following short-term stimulation in a small but homogenous group of patients. A larger long-term study will follow. CONCLUSION: Temporary sacral nerve stimulation does not change rectal compliance, but is associated with significant changes to the pressure thresholds of rectal distension. This, together with the observation that outcome is not related to sphincter integrity, supports the hypothesis of an afferent-mediated mechanism of action.

Results of laparoscopic repair of primary and recurrent incisional hernias at a single UK institution.

In this study incisional hernia repairs at a single UK institution between 1994 and 2008 were analyzed with respect to short-term and long-term results. Prospectively collected data were analyzed retrospectively to ascertain outcomes, complications, and recurrences. Two hundred and twenty-seven operations were performed with 35% of the operations being for recurrent hernias. A self-centering suture technique was used. Median operating time was 55 minutes. There were 8 conversions and median hospital stay was 1 night. There were 52 complications (23%) including 3 postoperative bleeds, 3 mesh infections, and 4 small bowel obstructions. Median postoperative follow-up was 53 months. There were 25 recurrences (11%) being detected, a median of 17 months after initial operation. In this large series, laparoscopic incisional hernia repair is safe and is associated with a short hospital stay. Recurrences after repair remain a concern prompting the development of strategies to try and minimize the likelihood of this occurring.

Laparoscopic nonresectional suture rectopexy in the management of full-thickness rectal prolapse: substantive retrospective series.

BACKGROUND: Numerous surgical options exist for the correction of rectal prolapse, with the optimal choice remaining controversial. The laparoscopic approach has proved to be popular and effective. Concern exists about nonresectional rectopexy in the form of intractable postoperative constipation. The authors present their experience with nonresectional laparoscopic suture rectopexy. METHODS: All patients presenting with a full-thickness rectal prolapse between August 1994 and August 2009 who proved to be fit for a general anesthesia were offered a laparoscopic repair. Data were entered into a database, then prospectively and retrospectively analyzed. The data recorded included patient demographics, preoperative symptoms, conversion to open procedure, length of hospital stay, and postoperative complications. Preoperative Cleveland Clinic Incontinence Scores (CCIS) were calculated. Follow-up evaluation was by telephone questionnaire. Postoperative constipation, recurrence, and CCIS were noted. RESULTS: The series included 72 patients (71 women, 98%) with a median age of 72 years (range, 24-88 years). The median follow-up period was 48 months (range, 5-144 months). A total of 13 patients were lost to follow-up evaluation. The median operating time was 98 min (range, 35-200 min), and the median hospital stay was 2 days (range, 1-29 days). Three conversions to open procedure (5%) were performed. The median preoperative CCIS was 9.54 compared with 4.44 postoperatively (p = 0.024). The complications included one postoperative bleed requiring transfusion, one port-site abscess requiring incision and drainage, one postoperative retention of urine, and one chest infection. Postoperatively, 10 patients (17%) reported occasional constipation not requiring intervention, and an additional 10 patients (17%) reported more severe constipation, all managed successfully with regular laxatives. The patients followed up experienced six recurrences (9%). No postoperative deaths occurred. CONCLUSION: Laparoscopic abdominal suture rectopexy without resection is safe and effective for the treatment of full-thickness rectal prolapse.

Commercial software upgrades may significantly alter Perfusion CT parameter values in colorectal cancer.

OBJECTIVE: To determine how commercial software platform upgrades impact on derived parameters for colorectal cancer. MATERIALS AND METHODS: Following ethical approval, 30 patients with suspected colorectal cancer underwent Perfusion CT using integrated 64 detector PET/CT before surgery. Analysis was performed using software based on modified distributed parameter analysis (Perfusion software version 4; Perfusion 4.0), then repeated using the previous version (Perfusion software version 3; Perfusion 3.0). Tumour blood flow (BF), blood volume (BV), mean transit time (MTT) and permeability surface area product (PS) were determined for identical regions-of-interest. Slice-by-slice and 'whole tumour' variance was assessed by Bland-Altman analysis. RESULTS: Mean BF, BV and PS was 20.4%, 59.5%, and 106% higher, and MTT 14.3% shorter for Perfusion 4.0 than Perfusion 3.0. The mean difference (95% limits of agreement) were +13.5 (-44.9 to 72.0), +2.61 (-0.06 to 5.28), -1.23 (-6.83 to 4.36), and +14.2 (-4.43 to 32.8) for BF, BV, MTT and PS respectively. Within subject coefficient of variation was 36.6%, 38.0%, 27.4% and 60.6% for BF, BV, MTT and PS respectively indicating moderate to poor agreement. CONCLUSION: Software version upgrades of the same software platform may result in significantly different parameter values, requiring adjustments for cross-version comparison.

Training in laparoscopic colorectal surgery - experience of training in a specialist unit.

INTRODUCTION: Laparoscopic colorectal surgery, although technically demanding, is an increasingly desirable skill for coloproctologists. We believe that trainees with adequate supervision from an experienced trainer may perform these procedures safely with good outcome. PATIENTS AND METHODS: Surgical logbooks of two senior trainees were reviewed over a 2-year period. A case note analysis was then undertaken. Patient data were recorded with regards to age, sex, operation type, American Society of Anesthesia (ASA) grade, conversion, length of hospital stay and complications. Lymph node yield, resection margins and grade of total mesorectal excision were recorded in oncological procedures. RESULTS: Over the 2-year period, trainees were involved in 140 resections (age range, 23-88 years; ASA grades I-III). Seventy patients were male. Trainees were first assistant in at least 20 cases prior to undertaking the procedures themselves. Trainees performed a total of 71 operations. Median hospital stay was 7 days (range, 2-48 days). There were three conversions. Anastomotic leaks developed in two patients, one requiring a laparotomy. One patient developed small bowel obstruction secondary to a port site hernia, which was repaired laparoscopically. There was one postoperative death. All oncological resection margins were clear with adequate lymphadenectomies. All total mesorectal excisions were Quirke grade III. CONCLUSIONS: Adequately trained and supervised trainees may perform major colorectal resections without compromising outcome.

The management of enterocutaneous fistula in a regional unit in the United kingdom: a prospective study.

BACKGROUND: Enterocutaneous fistula associated with type 2 intestinal failure is a challenging condition that involves a multidisciplinary approach to management. It is suggested that complex cases should only be managed in select national centers in the United Kingdom. METHODS: Over an 18-month period, we prospectively studied all patients referred to us with established enterocutaneous fistulas. Patients followed standardized protocols. Eradication of sepsis, appropriate wound management, establishment of nutritional support, and restoration of normal physiology were attempted. Definitive surgical management was deferred for at least 6 months after the last abdominal surgical intervention. Follow-up was for a minimum of 6 months. RESULTS: Of 55 patients, 10 were internal referrals and 45 were from institutions elsewhere. The mean age was 50 years. Nine patients had colonic fistulas. Forty-six had small bowel fistulas; 19 of these (35%) were associated with inflammatory bowel disease. Patients had undergone a median of 3 previous operations. Four fistulas (7%) healed spontaneously. Thirty-five patients (63%) underwent definitive surgery. Recurrent fistula occurred in 4 patients (13%); 1 required further surgery, and 3 healed spontaneously. The overall mortality rate was 7% (4/55 patients), with 3 patients dying before definitive surgery and 1 patient dying postoperatively. CONCLUSIONS: Our results compare favorably with data from designated national centers (overall mortality, 9.5%-10.8%; operative mortality, 3%-3.5%), suggesting that these patients can be effectively managed in regional units that have sufficient expertise, interest, and volume of patients. Rationalization of funding and referral of patients with type 2 intestinal failure to regional centers may allow national centers to conserve their scarce resources.

Marathon-induced ischemic colitis: why running is not always good for you.

We present the case of a 31 year-old man who presented to the emergency department of University College Hospital London after collapsing upon finishing the London marathon. Contrast-enhanced multidetector computed tomography scanning revealed ischemic colitis of the cecum and ascending colon, which progressed to the development of clinical peritonism after 48 hours. This patient subsequently underwent a laparotomy and right hemicolectomy, with ileostomy formation, on the third day after admission. Operative and histologic findings confirmed ischemic colitis of the cecum and proximal colon. The postoperative recovery was uneventful, and he was discharged home well. Possible mechanisms of ischemia in marathon runners and those undergoing intense exercise include a combination of splanchnic vasoconstriction, dehydration, and hyperthermia, combined with mechanical forces. Most patients presenting with marathon-running-induced ischemic colitis respond to conservative treatment and the need for operative intervention is extremely rare.