Laparoscopic versus open surgery for T4 colon cancer: evaluation of margin status.

BACKGROUND: Laparoscopic resection has been considered a relative contraindication for T4 colonic and rectal lesions due to concern over inadequate margins. The objective of this study was to compare planned laparoscopic and open resections of T4 lesions with respect to the positive margin rate. METHODS: Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program participant use file to perform a retrospective cohort analysis. The study population consisted of patients that underwent a colorectal resection for a primary T4 lesion during 2011 and 2012. A multiple logistic regression analysis was conducted to determine the adjusted odds ratio (OR) of positive margins based on surgical approach. An inverse probability of treatment weighting (IPTW) analysis was used to account for confounding by indication. A sensitivity analysis including only "as-treated" cases was also performed. RESULTS: The sub-selected population consisted of 455 and 406 patients in the laparoscopic and open group, respectively. In the original cohort, demographic variables were similar. The open group had a higher incidence of comorbidities, metastatic disease, and emergency cases. Laparoscopic surgery was found to be no different than open surgery with respect to positive margin status (OR 1.10, p = 0.54). After IPTW adjustment, surgical approach remained a nonsignificant predictor of positive margins (OR 1.18, p = 0.31). The "as-treated" analysis also showed that surgical approach had no significant effect on the positive margin rate (OR 1.24, p = 0.24). CONCLUSIONS: Using this large national surgical database, select patients with T4 lesions who underwent planned laparoscopic colorectal resections did not have a significantly higher positive margin rate compared with patients with open operations. Further research is needed to identify the role of laparoscopy in managing T4b lesions before any consensus can be reached regarding its application in locally advanced colon cancer.

Molecular population genetics and phenotypic sensitivity to ethanol for a globally diverse sample of the nematode Caenorhabditis briggsae.

New genomic resources and genetic tools of the past few years have advanced the nematode genus Caenorhabditis as a model for comparative biology. However, understanding of natural genetic variation at molecular and phenotypic levels remains rudimentary for most species in this genus, and for C. briggsae in particular. Here we characterize phenotypic variation in C. briggsae's sensitivity to the potentially important and variable environmental toxin, ethanol, for globally diverse strains. We also quantify nucleotide variation in a new sample of 32 strains from four continents, including small islands, and for the closest-known relative of this species (C. sp. 9). We demonstrate that C. briggsae exhibits little heritable variation for the effects of ethanol on the norm of reaction for survival and reproduction. Moreover, C. briggsae does not differ significantly from C. elegans in our assays of its response to this substance that both species likely encounter regularly in habitats of rotting fruit and vegetation. However, we uncover drastically more molecular genetic variation than was known previously for this species, despite most strains, including all island strains, conforming to the broad biogeographic patterns described previously. Using patterns of sequence divergence between populations and between species, we estimate that the self-fertilizing mode of reproduction by hermaphrodites in C. briggsae likely evolved sometime between 0.9 and 10 million generations ago. These insights into C. briggsae's natural history and natural genetic variation greatly expand the potential of this organism as an emerging model for studies in molecular and quantitative genetics, the evolution of development, and ecological genetics.

Predictors of Vitamin Adherence After Bariatric Surgery.

BACKGROUND: Vitamin supplementation in bariatric aftercare is essential to prevent nutrient deficiencies; however, rates of vitamin adherence have been as low as 30 % 6 months post-surgery. Preliminary literature suggests non-adherence to prescribed treatments can be linked to demographic and psychological factors. We aimed to determine the relationship between these factors to vitamin adherence in post-bariatric surgery patients. METHODS: A total of 92 bariatric patients were assessed 6 months post-surgery. Patients were administered a questionnaire collecting demographic information, psychological scores, and self-reported adherence. Nutrient deficiencies were analyzed through serum vitamin levels measured 3 and 6 months after surgery. Wilcoxon rank-sum and chi-square tests were used for analysis. RESULTS: Non-adherence was associated with male sex and full-time employment (p = 0.027, p = 0.015). There were no differences with respect to living situation, education level, or relationship type. Non-adherent patients did not have significantly higher scores for generalized anxiety, depressive symptoms, or avoidant behaviors. However, non-adherent patients displayed greater attachment anxiety than their adherent counterparts (p = 0.0186). Non-adherence was also associated with lower vitamin B12 levels 6 months post-surgery (p = 0.001). CONCLUSIONS: Male gender and full-time work have previously been shown to be associated with non-adherence. This is the first study to demonstrate that attachment anxiety is associated with poor multivitamin adherence in the post-surgical bariatric population. This result is concordant with recent literature that has demonstrated attachment anxiety is associated with poor adherence to dietary recommendations in bariatric patients 6 months postoperatively. Presurgical screening for attachment anxiety could facilitate early interventions to promote better bariatric aftercare in this group.

Robotic simultaneous resection of rectal cancer and liver metastases.

Surgical resection is the only potential cure for colorectal cancer with synchronous liver metastases (SLM). Simultaneous resection of colorectal cancer and SLM using robotic-assistance has been rarely reported. We demonstrate that robotic-assisted simultaneous resection of colorectal cancer and SLMs is feasible, safe, and has potential to demonstrate good oncologic outcomes.

Multivisceral resections for gastrointestinal stromal tumors: are the risks justifiable?

BACKGROUND: Surgical resection is the cornerstone of treatment for non-metastatic gastrointestinal stromal tumors (GISTs). Multivisceral resection (MVR) for locally advanced tumors is often required to achieve negative margins. The purpose of this study was to review the peri-operative and long-term oncologic outcomes for patients who required MVR versus single-organ resection (SOR) for GISTs. METHODS: All patients who underwent treatment for GISTs at a tertiary cancer center between 2001 and 2011 were identified. Patient characteristics and clinical outcomes were compared using the chi-squared/Fisher's exact test and Student's t-test. Disease-free (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier product-limit method. RESULTS: 33 patients underwent MVR and 77 underwent SOR. Tumors in the MVR group were larger and had a higher mitotic index. MVR patients had longer operative times, greater operative blood loss and more peri-operative complications. There was no significant difference in the final margin status between the two groups (R0 resection: SOR 92.2%, MVR 81.8%, p = 0.1303). 5-year DFS was significantly lower in the MVR cohort (44.4% vs. 78.9%, p = 0.0090), but there was no difference in 5-year OS (80.2% vs. 90.5%, p = 0.2547). CONCLUSIONS: MVR patients had more aggressive tumors and more complications; however, there was no difference in 5-year OS between the MVR and SOR cohorts. These findings support the use of MVR in the appropriately selected patient. Further studies are necessary to fully define its clinical application.

Relapse of acute myeloid leukemia manifested by cholecystitis: A case report and review of the literature.

INTRODUCTION: AML is the most common form of leukemia in adults. In rare circumstances AML may present in the form of extra-medullary disease. Gallbladder infiltration with myeloblasts is rare and only a few cases exist in the literature describing this entity. PRESENTATION OF CASE: We present a rare case of AML relapse in the form of extramedullary infiltration of the gallbladder in a 50-year-old male patient. The leukemic infiltration presented as symptomatic cholecystitis and sepsis. A laparoscopic cholecystectomy was performed and the gallbladder was pathologically examined. Histopathologic examination demonstrated multiple scattered, highly atypical single cells admixed with some plasma cells, small lymphocytes and macrophages consistent with leukemic infiltration. The abnormal cells demonstrated immunohistochemical staining for CD68, CD33 and CD117. The patient did well post-operatively but the relapse precluded him from bone marrow transplantation. DISCUSSION: Although AML is relatively common, 3 cases per 100,000 population, extramedullary disease in the form of gallbladder infiltration is exceedingly rare. An extensive review of the literature revealed only four cases of myeloid infiltration of the gallbladder. To our knowledge this is the only case of relapsing disease in the form of gallbladder infiltration presenting as symptomatic cholecystitis in a pre-bone marrow transplantation patient. CONCLUSION: This case highlights the importance of maintaining a high index of suspicion of atypical manifestations of AML when managing refractory sepsis. Extramedullary manifestations of AML in the form of gallbladder infiltration must be considered in the differential diagnosis of patients with a history of myeloid malignancies and for patients whom fail conventional non-operative management.