Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes.

Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.

Acid Reflux Is Common in Patients With Gastroesophageal Reflux Disease After One-Anastomosis Gastric Bypass.

INTRODUCTION: Patients with one-anastomosis gastric bypass (OAGB) can develop gastroesophageal reflux disease (GERD). The nature of this GERD (acid or biliary) remains unclear. OBJECTIVE: To assess the nature of GERD via impedance pH testing in patients presenting with reflux post OAGB. METHODS: Retrospective analysis of a prospectively collected database of 43 patients with OAGB backgrounds who developed postoperative GERD and were investigated with impedance pH monitoring between 2006 and 2019. RESULTS: Mean age was 52.48 ± 9 years. Mean body mass index (BMI) prior to OAGB was 46.82 kg/m2. None of these patients had clinical GERD before surgery. The median time interval between surgery and investigation with 24-h impedance pH monitoring was 64 (56) months. The mean BMI at the time of investigations was 32.67 ± 6.9 kg/m2. The type of reflux was acid in 13 (30.2%), non-acid (biliary) in 12 (27.9%), and mixed (acid and biliary) in 5 (11.6%) patients. However, it remained not confirmed in 13 (30.2%). Median DeMeester score was 48.95 (27.67) in patients with acid, 2.8 (7.4) in patients with biliary, and 28.7 (5.6) in patients with mixed reflux. Median percent of time spent with pH < 4 was 9.65 (8) in patients with acid, 0.6 (1.75) in patients with biliary, and 7.7 (3.9) in patients with mixed reflux. CONCLUSION: Acid reflux seems to be as common as bile reflux in patients presenting with GERD after OAGB. In case of revisional surgery for severe GERD post OAGB, 24-h impedance pH monitoring could be essential to determine the surgical procedure of choice.

A 58-Year-Old Woman with Acute Gastric Perforation Due to Metastatic Ductal Carcinoma 18 Years Following Bilateral Mastectomy for Invasive Ductal Carcinoma of the Breast.

BACKGROUND Invasive lobular carcinoma and ductal carcinoma of the breast can metastasize to all sites in the body, including the gastrointestinal tract. Late presentation of metastases of lobular carcinoma of the breast to the gastrointestinal tract have previously been reported, but late metastasis of ductal carcinoma of the breast to the gastric mucosa is rare. This report is of a 58-year-old Lebanese woman who presented with acute gastric perforation due to metastatic ductal carcinoma,18 years following bilateral mastectomy for invasive ductal carcinoma of the breast. CASE REPORT We present the case of a 58-year-old woman who underwent a right modified mastectomy for an invasive ductal carcinoma in 2002 combined with a contralateral prophylactic mastectomy for cosmetic purposes. She presented a secondary gastric lesion 18 years later. The clinical presentation resembled perforated ulcer. The choice of gastrectomy was denied due to retrogastric and pancreatic invasion by the tumor. A laparoscopic gastric closure failed to heal the perforation. A supraumbilical laparotomy incision was performed for the placement of a Pezzer tube in the gastric perforation and the installation of a feeding jejunostomy. CONCLUSIONS This report is of a rare presentation of metastatic ductal carcinoma of the breast to the gastric mucosa associated with gastric perforation that presented 18 years after bilateral mastectomy. This case highlights the importance of obtaining a full past medical history to identify previous primary malignancy, and also is a reminder that ductal carcinoma of the breast can present with metastatic involvement in the gastrointestinal tract several months, or even years, following mastectomy.

A Case Report Presenting an Undifferentiated Pancreatic Carcinoma with Osteoclastic-Like Giant Cells with an Unusual Indolent Course.

BACKGROUND Undifferentiated pancreatic carcinoma with osteoclast-like giant cells represents less than 1% of pancreatic cancers. Histogenesis and prognosis are still debated. Three subtypes are defined by the World Health Organization: osteoclastic, pleomorphic, and mixed. The differential diagnosis of a pancreatic tumor with giant cells varies from a benign osteoclastoma to an undifferentiated pancreatic carcinoma with osteoclastic-like cells. The specimen should be carefully examined to rule out conventional pancreatic adenocarcinoma even in the presence of the giant cells. CASE REPORT A 77-year-old male was diagnosed with a pancreatic tail tumor with osteoclastic like cells revealed by a biopsy done by echo-endoscopy; the patient was lost to follow up for 24 months before he was admitted to our institute for severe abdominal pain. A computed tomography showed the same lesion without progression. He was operated on using laparoscopic distal pancreatectomy with splenectomy. Pathology analysis revealed the presence of osteoclast-like giant cells without pleomorphic cells. Mutated KRAS on molecular study confirmed the diagnosis of undifferentiated pancreatic carcinoma with osteoclast-like giant cells. The patient was in good performance status and disease-free 19 months after surgery without any sign of progression. CONCLUSIONS Undifferentiated pancreatic carcinoma with osteoclast-like cells has a challenging pathology diagnosis. Molecular and immunostaining are essential to diagnosis. The absence of pleomorphic cells in the present case has classified it into the osteoclastic subtype. Further cases and studies are needed to confirm the heterogeneity of the malignant course between subtypes.

Total or Subtotal Colectomy with Primary Anastomosis for Occlusive Left Colon Cancer: A Safe, Acceptable and Applicable Procedure.

INTRODUCTION: Occlusive left colon cancer is a major emergency setting in colon cancer with high morbidity and mortality rates. Different surgical treatment exist since there is no clear guidelines for the best treatment. We have conducted this retrospective study in order to evaluate the safety, morbidity, and bowel movement status of the operated patients. METHODS: One-hundred and one left occlusive colon cancer patients were operated of total or subtotal colon resection with primary anastomosis from March 2000 till March 2017 in Hotel Dieu de France hospital. We analyzed the sex ratio, age, caecum condition, tumor localization, number of synchronous adenoma and adenocarcinoma, Dukes stage, major complications and the number of stools per day at 3 and 12 months after surgery. RESULTS: Mean hospital stay was 7.8 days. Thirteen complications were observed in 11 (10.9%) patients, in which one (1%) patient had splenectomy for severe hemorrhage. Six synchronous adenocarcinoma and 40 adenoma with dysplasia were diagnosed on pathology specimens proximal to occlusion site. Caecum laceration was found in 33 (32.6%) of cases. No patient had anastomotic leak. After 12 months of surgery, the average bowel movement was 2 stools per day. CONCLUSION: Our study showed that treating occlusive left colon cancer with total or subtotal colectomy with primary anastomosis is a safe procedure, with a good bowel movement status and presents the advantage to resect an important number of synchronous tumors and adenomas proximal to the occlusion site.

Sporadic colon cancer in Lebanon: A clinicopathological study.

Colon cancer is a heavy public health burden. No data has been previously published on colon cancer epidemiology in Lebanon. The objective of this study was to report the clinical and pathological features of surgically operated colon cancer. From July 2005 to July 2012, 187 sporadic colonic tumors were operated in Hotel-Dieu de France Hospital (Beirut, Lebanon). Demographic, clinical, pathological and staging data was collected. The male: female sex ratio was 1.3 and the mean age at diagnosis was 66.0 years. Most tumors occurred at the right colon (54.0%). Histologically, conventional adenocarcinoma had the biggest proportion (88.2%), followed by mucinous adenocarcinoma (9.1%). Most cases operated belonged to stages II, III or IV, leaving only 8.0% of the cases in stage I. Some characteristics were similar to western countries like the predominance of right tumors while others were similar to developing countries like the sex ratio and the high proportion of stage IV tumors at diagnosis. This study reports for the first time in the middle-eastern populations a clinico-pathological analysis of surgically operated colon cancer.