Incarcerated Prolapsed Sigmoid Intussusception Presenting as Rectal Prolapse Without a Lead Point.

This case series presents two patients with symptoms consistent with acute rectal prolapse. The prolapses were subsequently found to be sigmoid intussusception that had prolapsed through the anus without rectal prolapse and without any intraluminal pathology or lead point. Both were recognised on examination and underwent colonic resection rather than proctectomy.

Comparison of robotic versus laparoscopic right colectomy node retrieval in the obese population.

Data are scarce comparing robotic and laparoscopic colectomy node retrieval based on body mass index or age. With differences in anastomosis, mobilization, and ligation between these approaches, obese and/or elderly patients undergoing robotic surgery may have differences in node yield compared to laparoscopy. A retrospective review was conducted between four institutions from February 1, 2019 through August 1, 2021, during which 144 right colectomies were performed. Benign pathology, open colectomies, and conversions to open were excluded. All included surgeons had at least five patients to ensure experience. The population was categorized by a robotic or laparoscopic approach. Records were reviewed focusing on age, body mass index, surgical approach, anastomosis, pathology, and node count. The node count was then compared by body mass index and age between the robotic or laparoscopic approach to identify differences. After applied exclusions and outlier analysis, our final sample consisted of 80 patients. Both body mass index and age were significant, (p = 0.002 and p = 0.005, respectively). Body mass index ≤ 25.0 and age < 60 years old had higher average node counts. These variables interacted, (p = 0.003); those with both < 60 years old and body mass index ≤ 25 showed the greatest number of nodes (36.9). Laparoscopy yielded more nodes in ≥ 60 years old than robotics (27.4 verses 20.9), though this was not significant (p = 0.68). Node retrieval in overweight and obese patients did not differ between approaches (p = 0.48). Both body mass index and age influence the number of nodes that can be extracted in right hemicolectomies by experienced surgeons.

Microsatellite instability and mutations in BRAF and KRAS are significant predictors of disseminated disease in colon cancer.

BACKGROUND: Molecular alterations are well studied in colon cancer, however there is still need for an improved understanding of their prognostic impact. This study aims to characterize colon cancer with regard to KRAS, BRAF, and PIK3CA mutations, microsatellite instability (MSI), and average DNA copy number, in connection with tumour dissemination and recurrence in patients with colon cancer. METHODS: Disease stage II-IV colon cancer patients (n = 121) were selected. KRAS, BRAF, and PIK3CA mutation status was assessed by pyrosequencing and MSI was determined by analysis of mononucleotide repeat markers. Genome-wide average DNA copy number and allelic imbalance was evaluated by SNP array analysis. RESULTS: Patients with mutated KRAS were more likely to experience disease dissemination (OR 2.75; 95% CI 1.28-6.04), whereas the opposite was observed for patients with BRAF mutation (OR 0.34; 95% 0.14-0.81) or MSI (OR 0.24; 95% 0.09-0.64). Also in the subset of patients with stage II-III disease, both MSI (OR 0.29; 95% 0.10-0.86) and BRAF mutation (OR 0.32; 95% 0.16-0.91) were related to lower risk of distant recurrence. However, average DNA copy number and PIK3CA mutations were not associated with disease dissemination. CONCLUSIONS: The present study revealed that tumour dissemination is less likely to occur in colon cancer patients with MSI and BRAF mutation, whereas the presence of a KRAS mutation increases the likelihood of disseminated disease.

CEA - a predictor for pathologic complete response after neoadjuvant therapy for rectal cancer.

BACKGROUND: Preoperative chemoradiation therapy in patients with rectal cancer results in pathologic complete response in approximately 10% to 30% of patients. Accurate predictive factors for obtaining pathologic complete response would likely influence the selection of patients best treated by chemoradiation therapy as the primary treatment without radical surgery. OBJECTIVE: The aim of this study was to evaluate the impact of tumor size, stage, location, circumferential extent, patient characteristics, and pretreatment CEA levels on the development of pathologic complete response after chemoradiation therapy. DESIGN: This study is a retrospective review. SETTINGS AND PATIENTS: Five hundred thirty patients treated with preoperative chemoradiation therapy and radical surgery for rectal adenocarcinoma between 1998 and 2011 were identified. A total of 469 patients remained after excluding patients with a history of pelvic radiation (n = 2), previous transanal endoscopic microsurgery or polypectomy of the primary lesion (n = 15), concurrent malignant tumor (n = 14), and no information about pre- or posttreatment T stage in the chart (n = 30). Preoperative CEA levels were available for 267 patients (57%). INTERVENTIONS: Preoperative chemoradiation therapy and total mesorectal excision were performed in patients with rectal cancer. MAIN OUTCOME: The primary outcome measured was pathologic complete response. RESULTS: : Ninety-six patients (20%) were found to have a pathologic complete response in the operative specimen. Low pretreatment CEA (3.4 vs 9.6 ng/mL; p = 0.008) and smaller mean tumor size (4.2 vs 4.7 cm; p = 0.02) were significantly associated with pathologic complete response. Low CEA levels and interruption in chemoradiation therapy were significant predictors of pathologic complete response in the multivariate analysis. When stratifying for smoking status, low CEA level was significantly associated with pathologic complete response only in the group of nonsmokers (p = 0.02). LIMITATIONS: This study was limited by its retrospective design, missing CEA values, and lack of tumor regression grade assessment. CONCLUSIONS: We demonstrated an association between low pretreatment CEA levels, interruption in chemoradiation therapy, and pathologic complete response in patients treated with neoadjuvant chemoradiation therapy for locally advanced rectal cancer. The predictive value of CEA in smokers can be limited, and further studies are needed to evaluate the impact of smoking on the predictive value of CEA levels for pathologic complete response in rectal cancer.

Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery?

BACKGROUND: The ligation of the intersphincteric fistula tract procedure has been reported to have high cure rates, with minimal impairment of continence. OBJECTIVE: The aim of this study was to evaluate the success rates and functional outcome after the ligation of the intersphincteric fistula tract procedure. DESIGN: This study was performed as a retrospective review. SETTINGS: The study was conducted at the Division of Colon and Rectal Surgery, University of Minnesota and at affiliated hospitals in Minneapolis and St. Paul, Minnesota, between March 2007 and September 2011. PATIENTS: Ninety-three patients with transsphincteric cryptoglandular anal fistula were included. INTERVENTIONS: Ligation of the intersphincteric fistula tract procedure was performed. MAIN OUTCOME MEASURES: Failure was defined as persistent or recurrent drainage, air leakage from a patent external opening, or intersphincteric incision or reoperation for recurrent fistula. Success was defined as healing of the external fistula opening and intersphincteric incision. Patients were followed up with a questionnaire to assess the recurrence rate and the Wexner incontinence score. RESULTS: The median follow-up time for was 19 months (range, 4-55). Thirty patients (32%) had a history of previous surgery for their fistula. The success rate of fistula healing was 40% after the first ligation of the intersphincteric fistula tract procedure. When including patients with repeat ligation of the intersphincteric fistula tract and subsequent intersphincteric fistulotomy after ligation of the intersphincteric fistula tract repair, the success rates were 47% and 57%. Patients with successful fistula closure reported a mean Cleveland Clinic Florida Fecal Incontinence score of 1.0 (SD 2.3). No predictor for successful fistula closure was found. LIMITATIONS: Retrospective design, limited accuracy of diagnosing fistula failure, and lack of baseline continence were limitations of this study. CONCLUSION: The present study indicates that the ligation of the intersphincteric fistula tract procedure for transsphincteric fistulas has a significant risk for failure but good functional outcome in patients with no recurrence.

Survival endpoints in colorectal cancer and the effect of second primary other cancer on disease free survival.

BACKGROUND: In cancer research the selection and definitions of survival endpoints are important and yet they are not used consistently. The aim of this study was to compare different survival endpoints in patients with primary colorectal cancer (CRC) and to understand the effect of second primary other cancer on disease-free survival (DFS) calculations. METHODS: A population-based cohort of 415 patients with CRC, 332 of whom were treated with curative intention between the years 2000-2003, was analysed. Events such as locoregional recurrence, distant metastases, second primary cancers, death, cause of death and loss to follow-up were recorded. Different survival endpoints, including DFS, overall survival, cancer-specific survival, relapse-free survival, time to treatment failure and time to recurrence were compared and DFS was calculated with and without inclusion of second primary other cancers. RESULTS: The events that occurred most often in patients treated with curative intention were non-cancer-related death (n = 74), distant metastases (n = 66) and death from CRC (n = 59). DFS was the survival endpoint with most events (n = 170) followed by overall survival (n = 144) and relapse-free survival (n = 139). Fewer events were seen for time to treatment failure (n = 80), time to recurrence (n = 68) and cancer-specific survival (n = 59). Second primary other cancer occurred in 26 patients and its inclusion as an event in DFS calculations had a detrimental effect on the survival. The DFS for patients with stage I-III disease was 62% after 5 years if second primary other cancer was not included as an event, compared with 58% if it was. However, the difference was larger for stage II (68 vs 60%) than for stage III (49 vs 47%). CONCLUSIONS: The inclusion of second primary other cancer as an endpoint in DFS analyses significantly alters the DFS for patients with CRC. Researchers and journals must clearly define survival endpoints in all trial protocols and published manuscripts.

Can DNA sampling from the rectal mucosa be a novel tool for the detection of colorectal cancer?

INTRODUCTION: The objective was to evaluate a new method for DNA sampling from the rectal mucosa for the detection of colorectal cancer or any clinically significant pathology in the colon and rectum. METHODS: This prospective cohort study included patients scheduled for colonoscopy (group 1, n = 185) or colonic resection because of suspected colorectal cancer (group 2, n = 62). A test instrument with a balloon-holding end was introduced through a proctoscope into the rectum to collect exfoliated cells, from which DNA was isolated and quantified. RESULTS: The detection of colorectal cancer in group 1 showed a sensitivity for the DNA cut-off levels 1.5, 2, and 2.5 microg/ml of 100%, 80%, and 60%, and a specificity of 37%, 46%, and 56%, respectively. In group 2, for the same cut-off levels, the sensitivity was 73%, 61%, and 55%, and the specificity was 67%, 67%, and 67%, respectively. CONCLUSIONS: This novel technique is a safe and easy way of collecting DNA from the rectal mucosa. The sensitivity and specificity of the test were too low to be acceptable for a screening test. The low sensitivity and specificity in this study could be explained by the diversity within the study groups as many patients presented with long-term history of colorectal disease and surgical interventions in the past.