Risk of complications and long-term functional alterations after local excision of rectal tumors with transanal endoscopic microsurgery (TEM).

INTRODUCTION: Transanal endoscopic microsurgery (TEM) is a consolidated technique for the excision of rectal tumors. However, many aspects relating to its morbidity, risk of functional alterations, and therapeutic outcomes are still unclear. The aim of this study was to assess the rate of morbidity and fecal incontinence after TEM, and to identify associated risk factors. METHODS: We prospectively recorded the clinical data of 157 patients who underwent TEM from 1996 to 2013. Among these, 89 patients answered a questionnaire for the assessment of fecal continence at a median follow-up time of 40 months. RESULTS: Intraoperative and postoperative TEM complication rates were 3.8 and 20.4%. The mortality rate was 0.6%. A distance from the anal verge of more than 6 cm correlated with a higher risk of perforation, while patients with cancer were more likely to have postoperative bleeding. Incontinence was reported by 32 (36%) patients, of which 7 (8%) experienced transitory symptoms only, while 25 (28%) reported persistent symptoms. We found a correlation between patients receiving preoperative radiotherapy (RT) and the development of fecal incontinence. The recurrence rate was 3% (1/32) in pT1, 80% (4/5) in pT2, and 100% (1/1) in pT3. After radiotherapy, 7% (1/9) showed a good response (pT0-1), and 18% (2/7) showed no response (pT2-3). CONCLUSIONS: TEM is associated with low morbidity but the risk of developing functional alterations is not negligible and should be discussed with the patient before the operation. Good oncological outcomes are possible for early invasive cancers and for selected advanced cancers following a good response to preoperative RT.

Aspirin as a neoadjuvant agent during preoperative chemoradiation for rectal cancer.

BACKGROUND: Recently, many studies have suggested a possible adjuvant role of aspirin in colorectal cancer, reporting a positive prognostic effect with its use in patients with established disease. The aim of this study was to investigate the anticancer effect of aspirin use during preoperative chemoradiation for rectal cancer. METHODS: Two hundred and forty-one patients with stage II-III rectal cancer and candidates for chemoradiation (CRT) were selected and assigned to two groups: group 1, patients taking aspirin at the time of diagnosis, and group 2, all others. Treatment and oncological outcomes were explored. RESULTS: Aspirin use was associated with a higher rate of tumour downstaging (67.6% vs 43.6%, P=0.01), good pathological response (46% vs 19%; P<0.001), and a slightly, although not significant, higher rate of complete pathological response (22% vs 13%; P=0.196). Aspirin use was also associated with a better 5-year progression-free survival (86.6% vs 67.1%; hazard rate (HR)=0.20; 95% CI=0.07-0.60) and overall survival (90.6% vs 73.2%; HR=0.21; 95% CI=0.05-0.89). Although chance of local relapse was similar (HR=0.6; 95% CI=0.06-4.5), aspirin use was associated with a lower risk of developing metastasis (HR=0.30; 95% CI=0.10-0.86). CONCLUSIONS: Aspirin might have anticancer activity against rectal cancer during preoperative CRT. This finding could be clinically relevant and should be further investigated with randomised trials.

Limits of endorectal ultrasound in tailoring treatment of patients with rectal cancer.

BACKGROUND: Endorectal ultrasound (ERUS) is considered reliable in staging rectal cancer, but recently some critics have questioned its accuracy. The aim of this study was to evaluate how often an ERUS-based decision leads to an appropriate treatment. METHODS: Two hundred and twenty patients with rectal cancer staged with ERUS who underwent a surgical resection or a local excision without neoadjuvant therapy from 1997 to 2012 were included. According to ERUS, patients were divided into three groups of indication: (a) local excision (Tis-1 N0), (b) direct surgery (T2 N0), (c) preoperative chemoradiation (T3-4 or N+). Accuracy was explored by the correlation established with the final pathology. RESULTS: Accuracy for T and N staging was 65 and 64%, respectively. Indication to local excision and to chemoradiation was correct in 97 and 88% of patients staged by ERUS. Accuracy of indication to direct surgery was poor (37%), and 21% of patients were overtreated in this group. CONCLUSIONS: ERUS seems not able to fulfill all the needs of ideal tailored therapeutic strategies. T2 diagnosis needs to be confirmed by an excisional biopsy before a final decision is made because overstaging of early tumors may occur in a not-so-negligible proportion of patients.

The Role of Aspirin as Antitumoral Agent for Heavily Pretreated Patients With Metastatic Colorectal Cancer Receiving Capecitabine Monotherapy.

BACKGROUND: The potential clinical impact of aspirin use beyond its canonical indications is a novel matter of scientific debate. In patients with metastatic colorectal cancer failing all available options, regorafenib and TAS 102 represent the only chance of treatment. Although effective, these therapeutic options bring along a not-negligible burden in terms of economic costs and toxicity. In this setting, the indication to use aspirin in combination with chemotherapy would potentially represent a medical revolution under the economic and toxicity profile. PATIENTS AND METHODS: We assessed the role of aspirin in patients with metastatic colorectal cancer who failed all previous treatments and were receiving capecitabine as a salvage option before the introduction of regorafenib and TAS-102. RESULTS: Sixty-six patients were eligible. Twenty patients (30%) were on incidental treatment with aspirin for cardiovascular diseases. Twelve (60%) partial responses were seen in patients on treatment with aspirin, compared with 3 (6%) partial responses in the remaining patients (P = .00007). Sixteen patients on aspirin (80%) obtained disease control versus 14 (30%) patients who were not on aspirin (P = .000377). The median progression-free survival for patients receiving treatment with aspirin was 6.5 months versus 3.3 months for patients who were not on aspirin (hazard ratio, 0.48; 95% confidence interval, 0.30-0.79; P = .0042). A significantly improved overall survival was also evident in aspirin users (median overall survival, 14.7 vs. 8.7 months, respectively; hazard ratio, 0.43; 95% confidence interval, 0.26-0.72; P = .0023). CONCLUSION: Aspirin may improve the clinical outcome of heavily pre-treated patients with metastatic colorectal cancer receiving chemotherapy. Further studies are necessary before application in the clinical practice.

Pneumatosis cystoides of the right colon: a possible source of misdiagnosis. Report of a case.

Pneumatosis cystoides intestinalis is a rare condition that can be located in any part of the gastrointestinal tract. It is usually associated with a wide variety of gastrointestinal or pulmonary diseases. The primitive form is much less frequent and usually involves the left colon. The pathogenesis of pneumatosis cystoides intestinalis is still unclear. The mechanical theory, which is the most accepted explanation, postulates that gas is forced into the bowel wall by breaks in the mucosa; this is more likely to occur when the intraluminal pressure is higher, as happens in obstructive conditions, during endoscopies, or during infections from gas-forming bacteria. Pneumatosis cystoides is often asymptomatic, representing an occasional finding during investigations for other abdominal conditions. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation. When presenting acutely or in association with other abdominal conditions the differential diagnosis is rarely a problem. More important is to diagnose asymptomatic primitive submucosal pneumatosis of the colon, in order to avoid unnecessary intestinal resections. The Authors present the case of a patient with pneumatosis coli who underwent laparotomy for a suspected colonic lipomatosis of the right colon.

Primary hydatid cysts of psoas muscle.

BACKGROUND: Hydatid cysts may occur in any area of the body, but they usually localize to the liver and the lungs. Primary localization in muscle is not common, accounting for 2-3% of all sites; even rarer is the development of multiple cysts. METHODS: The patient presented with a painless abdominal mass which gradually increased in size to a diameter of approximately 16 cm. Organ imaging scan revealed multiple hydatid cysts within the right psoas muscle. Because of the proximity of the lesions to the iliac vessels, ureter and nerves to the lower limb, percutaneous drainage and alcoholization under local anaesthesia were -performed with the aim of reducing the size of the cysts and sterilizing them prior to definitive surgery. This procedure was not effective. Two weeks after percutaneous treatment the patient underwent surgery. RESULTS: At operation the cysts were localized and successfully removed under ultrasound guidance. Postoperative stay was -uneventful. Two years after surgery the patient has no evidence of recurrent hydatid disease. CONCLUSIONS: Ultrasonography is the preferred method for detecting muscular hydatid cyst and for guiding the surgeon during resection.

Synchronous colorectal and renal carcinomas. Is it a definite clinical entity?

The aim of the study was to assess the frequency of synchronous colorectal and renal cancers among our patients. To this end we reviewed 781 consecutive patients operated on for colorectal carcinoma in our institution. Three patients (0.4%) had diagnosis of synchronous renal-cell cancer during the work-up for their colorectal primary tumours. The colon and rectum are frequently affected by multiple malignant tumours. Second primaries are not frequently associated with colorectal cancer. On the other hand, renal cell carcinoma has been described as being associated with other synchronous malignancies in up to 27.4% of cases. A recent report has described a 4.8% incidence of synchronous colorectal and renal carcinomas, which is much higher than that previously reported in the literature (0.03-0.5%). We found a 0.4% incidence of simultaneous colorectal cancer and renal cell carcinoma. The latter was invariably asymptomatic and diagnosed during the work-up for the colorectal cancer. We are unable to confirm the observation of a higher than expected incidence of synchronous colorectal and renal neoplasms. Nevertheless, the surgeon should be conscious of this association, when considering renal lesions detected during the work-up for colorectal cancer.

Metformin-associated lactic acidosis and temporary ileostomy: a case report.

INTRODUCTION: Lactic acidosis is a well-known complication of the anti-hyperglycemic biguanide agent metformin, especially in peculiar but not rare clinical conditions. Attempts to reduce the incidence of this adverse reaction have been enforced by national agencies over the years. The Italian Medicines Agency recently released a safety recommendation on prescribing the drug and with regard to the existence of several conditions that contraindicate drug continuation, such as dehydration, infection, hypotension, surgery or hyperosmolar contrast agent infusion, but the recommendation does not mention the increased risk related to stoma. The present case report is, to our knowledge, the first in the literature of metformin-associated lactic acidosis in a patient with a recently created ileostomy and low anterior resection for rectal cancer. CASE PRESENTATION: A 70-year-old Caucasian man who had undergone low anterior resection with total mesorectal excision and temporary loop ileostomy creation at our institution returned to our department 30 days later because of nausea, vomiting, diffuse abdominal pain and anuria of about 24 hours' duration. During his physical examination, the patient appeared dehydrated and had tachypnea and a reduced level of consciousness. His laboratory tests showed that he had acute kidney injury and severe lactic acidosis. CONCLUSION: An ileostomy puts patients at high risk for output losses that can lead to dehydration and electrolyte abnormalities. The assessment of the losses through the stoma, especially the ileostomy, should be added to the recommendations issued by pharmacovigilance societies. The present clinical case illustrates the need for clinicians on surgical wards to carefully evaluate patients before resuming metformin therapy and to provide appropriate information at discharge to patients with type 2 diabetes mellitus who have undergone ileostomy. Furthermore, this case report highlights the increasing need for more training of general physicians regarding both surgical and internal medicine problems that may arise in the post-operative course after major surgery in patients with co-morbidities.