Increased Incidence of Liver Metastases in Colorectal Versus Appendiceal Adenocarcinoma Peritonectomy Patients Despite Equivocal Survival.

BACKGROUND/AIM: Colorectal adenocarcinoma (CRAdenoCa) and appendiceal adenocarcinoma (AAdenoCa) are diseases of the same histopathological type that metastasise to the liver and peritoneum. In selected subgroups, peritonectomy and heated intraperitoneal chemotherapy (HIPEC) may be indicated as part of the multimodal treatment plan. However, literature comparing the survival outcomes and preoperative tumour activity and burden of CRAdenoCa and AAdenoCa peritonectomy patients without synchronous liver metastases (sLM) is scarce. Little is also known about the comparative incidence of sLM and metachronous LM (mLM) between CRAdenoCa and AAdenoCa peritonectomy patients. This study aimed to clarify the above. PATIENTS AND METHODS: A retrospective cohort study of 684 CRAdenoCa and AAdenoCa primary peritonectomy patients between 2001-2021 was conducted at St George Hospital in Sydney, Australia. RESULTS: Median overall survival (years) was equivocal between CRAdenoCa and AAdenoCa peritonectomy patients (1.7 vs. 1.9, p=0.35). Peritoneal cancer index and preoperative carcinoembryonic antigen (CEA) were significantly elevated (25 vs. 9, p<0.0001 and 7.9 vs. 5, p=0.0080) in AAdenoCa versus CRAdenoCa peritonectomy patients without sLM. The incidence of sLM and mLM was increased in CRAdenoCa peritonectomy patients (24% vs. 3.1%, p<0.0001 and 26% vs. 10%, p=0.0001). CONCLUSION: This study demonstrates similar survival outcomes between CRAdenoCa and AAdenoCa peritonectomy patients. Despite elevated preoperative tumour burden and biological activity in AAdenoCa patients, CRAdenoCa patients had higher rates of sLM and mLM. Further studies are warranted to validate and identify cellular and molecular targets that increase CRAdenoCa's ability to metastasise to the liver.

The 'Starburst' Sign: A Novel Description of PET Images in Carcinoma of Unknown Primary.

BACKGROUND/AIM: Carcinoma of unknown primary (CUP) poses a formidable diagnostic challenge, characterised by high mortality rates and an elusive primary tumour site. While Positron emission tomography (PET) scans are routinely employed in the initial evaluation of CUP patients, identifying the primary tumour remains an ongoing struggle. In light of this, the aim of this case report is to introduce a novel radiological description, termed the 'Starburst' sign, derived from distinctive PET scan appearances associated with CUP. CASE REPORT: In this report, we present the case of a 47-year-old female patient who presented with abdominal symptoms. Upon investigation, extensive peritoneal disease was observed, yet the primary tumour source remained unidentified. Despite further diagnostic efforts, including a normal gastroscopy, a PET scan was able to confirm the presence of high-volume metastatic disease, without an identifiable primary tumour. Palliative treatment was initiated, but unfortunately, the patient's condition deteriorated rapidly, leading to her demise. CONCLUSION: The 'Starburst' sign, a unique radiological description of CUP in PET scans, has significant potential in advancing our understanding of the disease. It provides a visual analogy to a dying star, aiding comprehension of complex pathophysiology and implications of metastatic lesions. The introduction of the 'Starburst' sign benefits patients and healthcare professionals, enhancing education, assessment, and treatment of CUP. This novel description contributes to knowledge in the field and can impact clinical management.

Comparison of Proportion of Elevated Carcinoembryonic Antigen Levels in Patients With Appendiceal and Colorectal Adenocarcinoma: A Systematic Review and Meta-analysis.

BACKGROUND/AIM: The proportion of patients with liver metastases in patients with appendiceal versus colorectal adenocarcinomas was 3.1 percent and 24 percent, respectively, in our peritonectomy centre. From our internal analyses, carcinoembryonic antigen (CEA) was potentially involved. A hypothesis was proposed regarding the natural progression of appendiceal adenocarcinoma. To support this, a systematic review and meta-analysis were performed to examine whether there was a difference in the proportion of patients with an elevated CEA in appendiceal versus colorectal adenocarcinoma patients in the current literature. MATERIALS AND METHODS: Medline (PubMed), EMBASE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature, Clinicaltrials.gov, Web of Science, and Google Scholar were searched. All studies involving patients with appendiceal and/or colorectal adenocarcinoma were eligible. Data were analysed by grouping appendiceal and colorectal adenocarcinoma in separate meta-analyses, and then comparing their weighted proportions of elevated CEA. Principal summary measures were weighted proportions of patients with elevated CEA. RESULTS: From the initial identification of 1,928 articles, 136 articles were included in the final synthesis. Ninety-two articles were included in the meta-analysis. Proportions of appendiceal and colorectal adenocarcinoma with elevated CEA were 56% (95%CI=47-65%) and 42% (95%CI=38-46%), respectively (p=0.0001). CONCLUSION: Patients with appendiceal adenocarcinoma had a higher proportion of CEA than those with colorectal adenocarcinoma. Future studies should focus on the several aspects of CEA presented in patients with appendiceal adenocarcinoma. This could provide treatments for patients with colorectal adenocarcinoma by preventing the development of liver metastases.

Development and validation of a multivariable prediction model in open abdomen patients for entero-atmospheric fistula.

BACKGROUND: Laparostomy or Open Abdomen (OA) has matured into an effective strategy in the management of abdominal catastrophe. Single prognostic factors have been identified in a previous systematic review regarding entero-atmospheric fistula (EAF). Unfortunately, no prognostic multivariable model for EAF exist. The aim was to develop and validate a multivariable prediction model from a retrospective cohort study involving three hospital's databases. METHODS: Fifty-seven variables were evaluated to develop a multivariable model. Univariate and multivariable logistic regression analyses were performed for on a developmental data set from two hospitals. Receiver operator characteristics analysis with area under the curve (AUC) and 95% confidence intervals (CI) were performed on the developmental data set (internal validation) as well as on an additional validation data set from another hospital (external validation). RESULTS: Five-hundred and forty-eight patients managed with an OA. Two variables remained in the multivariable prediction model for EAF. The AUC for EAF on internal validation were 0.74 (95% CI: 0.58-0.86) and 0.79 (95% CI: 0.67-0.92) on external validation. CONCLUSIONS: A multivariable prediction model for EAF was externally validated and an easy-to-use probability nomogram was constructed using the two predictor variables. LEVEL OF EVIDENCE: III; prognostic.

Dilemma of mucosal appendicitis: a clinico-pathological entity? A retrospective cohort study.

BACKGROUND: The presence of mucosal inflammation within appendicectomy specimens is poorly described in the literature, and there is debate regarding the clinical significance of this histological finding. The aim of this study is to correlate clinical and radiological data with histologically confirmed acute mucosal appendicitis (MA). METHODS: A retrospective cohort study was performed to identify all patients who underwent appendicectomy over 5 years at Caboolture Hospital. Data were collected in regards to clinical Alvarado score, pathological specimen findings, radiological findings and coincidental conditions, and comparison made between MA and negative appendicectomy groups. RESULTS: A total of 1347 appendicectomy specimens and data were reviewed. Of these, 219 (16%) specimens were microscopically confirmed to have acute mucosal inflammation, 150 (68%) were females. Median age was 19 ± 14 years. A total of 243 (18%) were histologically negative. There was a statistically significant difference in mean Alvarado score in the MA group (5.0 ± 1.9 versus 4.3 ± 1.8, P = 0.0002). Patients with MA are more likely to report migratory pain (48.4 versus 31.4%, P = 0.0001) and rebound tenderness (24.9 versus 14.6%, P = 0.002). Computed tomography and ultrasound scans were negative in 74.1 and 72.6%, respectively, in patients with MA. More MA patients benefited from appendicectomy compared with the negative appendicectomy group (82 versus 63%, P = <0.0001). CONCLUSION: There is a subgroup of patients with MA who are young females with have low Alvarado scores, have non-diagnostic imaging, and may represent almost one-fifth of appendicectomy specimens. This study supports the probability that MA is a pathological entity.

A case report of small bowel obstruction from previously undiagnosed lobular breast carcinoma: First in Australian literature.

INTRODUCTION: This case report is the first in the Australian literature of a patient, without prior diagnosis, presenting with a bowel obstruction secondary to lobular breast cancer. This highlights a relatively rare cause of bowel obstruction, but also the importance of breast self-examination as a compliment to the current BreastScreen Australia program. PRESENTATION OF CASE: A 67-year-old female presented to the Emergency Department with a 48-h history of sharp, constant epigastric pain, vomiting and constipation. The patient proceeded to emergency laparotomy for presumed large bowel obstruction, which revealed a stricture in the distal terminal ileum causing a distal small bowel obstruction. A right hemicolectomy was performed. Histopathology revealed the terminal ileum stricture to be metastatic lobular breast carcinoma. Clinical examination of the patient's right breast revealed a lesion suggestive of the primary malignancy despite a normal ultrasound and mammogram in 2014. After failing to progress, a CT scan was performed which revealed progressive small and large bowel distension. A repeat laparotomy was performed revealing dilated large bowel without obstructing pathology and an intact anastomosis. A loop ileostomy was performed. Following a further febrile episode, the patient decided to withdraw care and the patient passed away three weeks into her admission from suspected intra-abdominal sepsis. DISCUSSION: Breast cancer is becoming the third most common cancer amongst Australian women with a significant burden of disease and mortality. CONCLUSION: Despite the rare presentation, this case reminds the medical community and general population of the importance of breast self-examination and the BreastScreen Australia program.

Treatments and other prognostic factors in the management of the open abdomen: A systematic review.

BACKGROUND: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications. METHODS: An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality. RESULTS: Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level. LIMITATIONS: Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed. CONCLUSION: Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model. LEVEL OF EVIDENCE: Systematic review, level III.

The impact of temporal artery biopsy on surgical practice.

BACKGROUND: Giant cell arteritis (GCA) has the potential to cause irreversible blindness and stroke in affected patients [1-4]. Temporal artery biopsy (TAB) remains the gold standard test for GCA [6-8]. Recent literature suggests that TAB does not change management of patients with suspected GCA and that ultrasound scan (USS) may be sufficient enough alone to confirm the diagnosis [9-11,13]. The aim of this study is to therefore determine the impact of TAB on current surgical practice and emergency theatre services. MATERIALS AND METHODS: A retrospective clinical study was performed of patients who had undergone TAB at the Caboolture Hospital from January 2010 to September 2015. Demographic and clinical data was collected from patient's medical records in regards to GCA. RESULTS: A total of 55 TAB were performed on 50 patients. Only two TAB were positive for GCA. Thirty-eight (76%) patients had a pre-TAB ACR criteria score of ≥3. Pre-operative corticosteroids were administered in forty-five (90%) patients, on average 4 ± 10 days pre-TAB. Mean time to TAB was 1.6 ± 1.6 days following their booking. Ninety-one percent of TAB were performed by surgical registrars. All TAB were performed using local anaesthesia alone. CONCLUSIONS: TAB is an expensive procedure with a low positive yield. Recent evidence suggests promising results with USS in diagnosing GCA. With the exceedingly low positive TAB results found in this study, patients with suspected GCA should be investigated in accordance with the above algorithm. The routine use of USS will reduce the number of negative TAB performed.

A surgeon-led model to improve operating theatre change-over time and overall efficiency: A randomised controlled trial.

BACKGROUND: The non-operative time during the process of patient change-over between operating theatre cases is a significant source of delay and overall theatre inefficiency. The aim of this study was to integrate and trial a working strategy to improve this change-over time. METHOD: This was a single-blinded, randomised controlled intervention study comparing a surgeon-led, team-based model of strategies versus routine patient change-over. This model was trialled by a single surgeon, and the primary outcome was the difference in change-over times compared with 4 other surgeons who were blinded and served as controls. Secondary outcome measures included overall differences in complications between the groups, and the number and differences in operative case cancellations due to inadequate theatre time. RESULTS: 1265 patients were randomised into 5 general surgical lists, and included all major and minor cases. Median number of operative cases were 214 per surgeon, with an overall median change over time of 17.9 ± 3.7 min. Surgeon A in the intervention group had a median change-over time of 12.1 ± 5.4 min (p < 0.001), with a median difference of 8.5 min ± 21.4 min (p < 0.0001), translating to a 58% reduction in median change-over time between the intervention and control groups. There were no differences in complication rates amongst the groups. The intervention group had no cancellations due to lack of time, compared with 37 cancellations in the control group. CONCLUSION: This study demonstrates a statistically significant improvement in median change-over times using this model. This re-design can be implemented without incurring extra costs, staff, or operating theatres.

A prospective randomised trial comparing mesh types and fixation in totally extraperitoneal inguinal hernia repairs.

The totally extraperitoneal (TEP) approach for surgical repair of inguinal hernias has emerged as a popular technique. We conducted a prospective randomised trial to compare patient comfort scores using different mesh types and fixation using this technique. Over a 14 month period, 146 patients underwent 232 TEP inguinal hernia repairs. We compared the comfort scores of patients who underwent these procedures using different types of mesh and fixation. A non-absorbable 15 × 10 cm anatomical mesh fixed with absorbable tacks (Control group) was compared with either a non-absorbable 15 × 10 cm folding slit mesh with absorbable tacks (Group 2), a partially-absorbable 15 × 10 cm mesh with absorbable tacks (Group 3) or a non-absorbable 15 × 10 cm anatomical mesh fixed with 2 ml fibrin sealant (Group 4). Outcomes were compared at 1, 2, 4 and 12 weeks using the Carolina Comfort Scale (CCS) scores. At 1, 2, 4 and 12 weeks, the median global CCS scores were low for all treatment groups. Statistically significant differences were seen only for median CCS scores and subscores with the use of partially-absorbable mesh with absorbable tacks (Group 3) at weeks 2 and 4. However, these were no longer significant at week 12. In this study, the TEP inguinal hernia repair with minimal fixation results in low CCS scores. There were no statistical differences in CCS scores when comparing types of mesh, configuration of the mesh or fixation methods.

Caecal diverticulitis: Presentation and management.

INTRODUCTION: While left sided colonic diverticular disease is common in Western countries, right sided colonic diverticular disease is rare. With increasing migration from Asia, many western countries including Australia, are now seeing more right sided diverticular disease, of which caecal diverticulitis is the commonest. This study aims to determine the incidence of caecal diverticulitis in patients presenting with colonic diverticulitis, as well as identify the symptoms and clinical features that may aid in making a pre-operative diagnosis. METHODS: Data was collected using the Queen Elizabeth II Hospital medical records database identifying patients diagnosed with colonic diverticulitis and, more specifically, those with caecal diverticulitis from January 2007 to December 2013. Only those patients who had confirmed caecal diverticulitis on imaging studies or at laparoscopy on their first admission were included in this study. RESULTS: A total of 632 patients with colonic diverticulitis were admitted to our institution over a seven-year period, of which 13 patients had caecal diverticulitis (2.06%). Of the 13 patients, twelve were of Asian background and ten were considered young (≤50 years of age). The main complaints were right sided abdominal pain (n = 11, 84.6%) and diarrhoea (n = 5, 38.5%). Nine were diagnosed using computed tomography (n = 9/10, 90%), three on laparoscopy and one using ultrasound (n = 1/2, 50%). Ten patients were treated successfully by conservative means. DISCUSSION: A high index of suspicion in Asian patients with atypical symptoms of appendicitis, especially diarrhoea, may provide the diagnosis of caecal diverticulitis.