Colocutaneous fistula following Clostridioides difficile infection managed as an 'autocolostomy': a novel approach to a recognised complication.

Colocutaneous fistula is a rare entity in colorectal disease. We present a case of colocutaneous fistula in a patient whose postoperative course following a laparoscopic anterior resection for sigmoid cancer was complicated by Clostridioides difficile colitis. During the follow-up period, it was found that his bowel contents were preferentially discharging through this fistula which had taken up the role of an 'autocolostomy'. Given the physiological impact of an additional surgical procedure, a definitive repair of the fistula was deferred and instead the patient was taught to manage it in keeping with general principles of stoma care. Over the subsequent follow-up period, he has now developed a large parastomal hernia and is being considered for definitive repair.

Prognostic potential of hepatocyte volume and cytokine expression in cirrhotic portal hypertension.

BACKGROUND: Differentiating the prognosis of Child-Pugh A and B patients is difficult, particularly following an acute variceal hemorrhage. We have examined the prognostic significance of hepatocyte volume (HV) and the expression of selected cytokines controlling liver repair and regeneration. METHODS: Forty Child-Pugh A and B cirrhotic patients surviving a first acute variceal hemorrhage were recruited prospectively. Hematological, biochemical, neurological, hemodynamic, radio-nuclear and histological assessments were carried out following recovery (at 3 weeks). Fibrosis (%) and HV were calculated using histological morphometry and radio-nuclear liver volume assessment. Immunohistochemistry was used in liver biopsy specimens to assess markers of proliferation (PCNA) and the expression of mitogens (TGF-alpha, TGF-beta(1)) or their receptors (C-met and EGFR). RESULTS: In total, 27 patients died during the follow-up period. HV was predictive of survival in Child-Pugh grade A patients (chi(2) = 10.5, P = 0.0012), but percentage fibrosis and regeneration factor expression were not predictive in either Child-Pugh A or B patients. Cox regression modeling with Child-Pugh grade demonstrated HV to be an independent predictor of survival (chi(2) = 7.1, P = 0.02). CONCLUSIONS: HV predicts survival independently in cirrhotic portal hypertension, and may help to differentiate prognosis in those at the more favorable end of the disease spectrum. Liver cytokine expression 3 weeks following an acute variceal bleed did not appear useful in determining prognosis.

Molecular prognostic markers in pancreatic cancer.

Pancreatic cancer has a very poor prognosis and is a common cause of cancer death in the Western world. Certain genetic alterations may be important in the prognosis of pancreatic cancer. Activation mutations in the K- ras oncogene occur in around 90% of pancreatic cancers, and the overexpression of growth factors epidermal growth factor (EGF), transforming growth factor (TGF)alpha, TGFbetas 1-3, acidic fibroblast growth factor (aFGF), basic FGF (bFGF), and growth factor receptors c-erbB-2 and -3 and TGFRbetas 1-3 is common. High mutation levels of cell cycle control genes such as p53, p16, p21, SMAD4, and cyclin D1 are found, and there is abnormal expression of apoptotic genes, such as bcl-2, bcl-XL, and bax. The expression of several of these growth factors and their receptors has been found to be associated with poorly differentiated tumors of an advanced stage and decreased survival. However, the inactivation and loss of expression of p16, p53, and p21, and the expression of several apoptotic genes, such as bax and bcl-2, have not been found to be of any prognostic significance. The expression of wild type p53, however, may predict responsiveness to chemotherapy. TGFbeta1 expression has been shown to be associated with longer survival in patients with pancreatic cancer. Two studies (including our own) have found bcl-XL expression to be significantly associated with poor survival. These and newer molecular markers may prove to be important in the choice of future therapies for pancreatic cancer.