Oligometastatic colorectal adenocarcinoma to the spleen and ovaries.

In the context of colorectal cancer, splenic and ovarian metastases are rare outside of widely disseminated disease. Growing evidence suggests that 'oligometastatic' or limited metastatic disease can be treated surgically with good oncological outcomes. Splenic and ovarian metastases are not well represented in studies of oligometastatic colorectal cancer, resulting in uncertainty in the best management for these patients. We present the case of a 78-year-old woman diagnosed with oligometastatic colorectal cancer to bilateral ovaries and spleen, 5 years after resection of a primary colon cancer. The patient was treated with a bilateral salpingo-oopherectomy and subsequent open splenectomy. We discuss the role of surgery and peri-operative chemotherapy in the management of oligometastatic colorectal cancer involving atypical sites.

Referral pathways in colorectal cancer: an audit of surgeons's records.

PURPOSE: To explore the referral pathways of patients with newly diagnosed colorectal cancer to surgeons. METHOD: Australian surgeons from three states completed a questionnaire and their records were audited. RESULTS: Thirty-three surgeons provided data on 530 patients seen in the preceding 12 months. The median time between colonoscopy and first surgical consult was 10 days, with 19% of patients waiting more than 28 days. After adjustment for clustering, no surgeon factors were associated with the number of days between colonoscopy and surgery. A report back to the general practitioner (GP) was found in 78% of patients' records. This feedback varied between surgeons but none of the specific surgeon characteristics examined could explain this. CONCLUSION: Surgeons usually communicated with GP regardless of whether they were the referral source. However, communication with GP varied considerably among surgeons, with no evidence of a report to the GP in one-fifth of cases.

Effectiveness of an Oral Gastrografin Regimen for Complete Distal Intestinal Obstruction Syndrome.

Objectives: To assess the effectiveness of oral Gastrografin treatment and outcomes in adult patients with complete distal intestinal obstruction syndrome (cDIOS). Background: DIOS is an important gastrointestinal complication of cystic fibrosis (CF). Conservative treatment options for cDIOS are largely empirical, and the optimal management remains unclear. Surgery should be reserved for patients who have failed nonoperative treatment or have immediate indications for surgery. Methods: A retrospective single-institution cohort study was undertaken of adults with CF who had undergone lung transplantation and were admitted with an episode of cDIOS between 2004 and 2020. The outcomes of treatment in a high-volume CF transplant center with routine oral Gastrografin-based therapy were assessed. Results: Forty-seven episodes of cDIOS were recorded in 29 (23.3%) of 124 patients who had undergone lung transplantation for CF, and mean age at cDIOS was 30.3 years (SD ±11.2). Mean follow-up post cDIOS was 75.6 months (SD ±45.5). Twelve patients had >1 cDIOS episode. One episode occurred during recovery after transplantation, and 5 patients were readmitted within 30 days posttransplant with cDIOS. A history of previous abdominal surgery was associated with the development of cDIOS (P < 0.001). Oral Gastrografin therapy was used in 95.7% of the episodes, at varying doses. Three patients (7.0%) were resistant to oral Gastrografin treatment, requiring laparotomy. There were no deaths due to DIOS. Conclusions: Oral Gastrografin is effective and safe for the treatment of cDIOS, with low treatment failure rates. It should be considered as a first-line treatment option for patients with CF presenting with complete distal intestinal obstruction.

Anal cancer: a 20-year retrospective study from Australia.

BACKGROUNDS: Anal cancer is an uncommon condition, occurring at higher rates in specific subpopulations. Clinical experience is limited and substantial changes have recently occurred in our understanding of this condition. We, therefore, set out to characterize patients presenting with anal cancer and investigate whether there have been any changes over the past 20 years. METHODS: Retrospective audit of cases identified from pathology and clinical databases during the period 1 January 2000 to 31 December 2019. RESULTS: Two hundred and sixteen patients had anal squamous cell carcinomas, comprising 160 (74%) males and 56 (26%) females. Mean age at initial diagnosis was 55.1 ± 11.20 for males and 60.6 ± 15.18 for females (P = 0.02). At initial diagnosis, HIV-positive cases were significantly younger than HIV negative cases (mean 52.2 ± 9.35 vs. 62.8 ± 11.61, P < 0.001); 46% of cases were classified as intra-anal, 29% perianal and 25% both; 52% were > 2 cm at diagnosis. At presentation, intra-anal cases were larger and more advanced than perianal cases (P = 0.049). Compared with the period 2000-2009, anal cancers presented more commonly in 2010-2019 (148 vs. 76), were more likely to occur in HIV-negative people and to be diagnosed at a similar stage. CONCLUSION: The number of anal cancer cases almost doubled over the study period and people living with HIV presented 10 years younger than others. Perianal cases presented earlier than those originating in intra-anal locations. Together with the large size at diagnosis, this suggests the potential value of screening, particularly for intra-anal cancers in those at high risk.

Acute Cytomegalovirus Infection Associated With Splenic Infarction: A Case Report and Review of the Literature.

Splenic infarction associated with acute cytomegalovirus infection (CMV) in immunocompetent patients was initially described as a very rare occurrence but has been reported in recent years with increasing frequency. Many cases undergo multiple investigations only to leave acute CMV as the likely cause. There is a risk of splenic rupture and, although this complication is rare, fatalities have occurred. Although the exact mechanism of CMV as a vascular pathogen is unclear, there are now multiple reports describing venous thrombosis and arterial infarction in the presence of this acute viral infection. Our case prompted a review of the literature, and we suggest splenic infarction should be recognised as a possible complication of acute CMV.

Multimedia article. An improved technique for end stoma creation in obese patients.

PURPOSE: The formation of an end colostomy in obese patients can be technically demanding and often requires the creation of a particularly large defect in the abdominal wall. This is because of the thickness of the subcutaneous fat and mesenteric fat, and increased resistance or friction while negotiating the bowel and mesentry through the abdominal wall. METHODS: The use of an Alexis Wound Protector to circumferentially retract the abdominal wall defect and, thus decrease resistance or friction during stoma formation, is described (see Video, Supplemental Digital Content 1 and 2, which demonstrates the technique, http://links.lww.com/A997 and http://links.lww.com/A998). RESULTS: This technique has been used in eight obese patients who have undergone end stoma formation. In each patient, the efficacy of the wound protector was immediately obvious, resulting in a smaller than usual defect in the abdominal wall and less trauma to the bowel. CONCLUSIONS: The use of a wound protector has decreased the size of the abdominal wall defect necessary for stoma creation in obese patients and hopefully will decrease the risk and rate of parastomal hernia formation.

Circumferentially oversewn inverted stapled anastomosis.

BACKGROUND: Leak rates of over 5% following anastomoses between the ileum and colon continue to be reported in large series and are associated with substantial morbidity and with mortality rates of 10-20%. In 1994, we began performing circumferentially oversewn inverted stapled anastomoses in patients undergoing ileo-colic anastomoses or ileostomy closure. It has become increasingly apparent that this method is associated with a low risk of leakage, which we should report. METHODS: The anastomotic technique described was used in all patients undergoing ileo-colic anastomosis or closure of ileostomy by surgeon 1 (1994-2015) and in all ileo-colic anastomoses by surgeon 2 (2007-2015). All patients had a widely patent anastomosis constructed by two firings of a linear cutting stapler, as previously described. Additionally, the entire staple line was carefully oversewn with interrupted, inverting 4/0 polydioxanone sutures. Anastomotic leak was defined as a patient requiring re-operation or radiological drainage. RESULTS: One thousand and twelve patients underwent ileo-colic anastomosis and 685 patients underwent closure of ileostomy by surgeon 1, and 165 patients underwent ileo-colic anastomosis by surgeon 2. None of the 1862 patients required re-operation or radiological drainage for a leak (event rate 0%, 95% confidence interval 0-0.2%). However, there were three possible contained leaks treated successfully conservatively. The time taken to perform the actual anastomosis was measured in the last 30 ileo-colic resections. The median time was 42 min. CONCLUSION: While this method may well be too slow to gain widespread adoption, we hope this report encourages increased research into finding techniques with similar low leak rates.

Neuromuscular and vascular hamartoma as an unusual cause of small bowel obstruction.

INTRODUCTION: Neuromuscular and vascular hamartoma (NMVH) is a rare, controversial lesion of the intestine, with only 23 cases reported in the English literature since its initial description in 1982. PRESENTATION OF CASE: A 59year old female suffering from longstanding Crohn's disease with chronic stricture presented with symptoms of small bowel obstruction. Contrast studies demonstrated massive dilatation of the proximal small bowel. Laparotomy identified a 5cm long stenotic segment of ileum, with grossly distended jejunum and ileum proximally. Pathology determined the stricture's aetiology as a neuromuscular and vascular hamartoma of the small intestine. DISCUSSION: NMVH is a benign lesion of hamartomatous origin. Its very existence is questionable due to histological similarities with several reactive pathologies, such as Crohn's and diaphragm diseases. CONCLUSION: NMVH could be confused with a spectrum of chronic inflammatory bowel conditions, but this report establishes it as a distinct cause of chronic bowel obstruction.

Is low serum albumin associated with postoperative complications in patients undergoing oesophagectomy for oesophageal malignancies?

A best evidence topic was written according to a structured protocol. The question addressed was: in patients undergoing oesophagectomy for oesophageal malignancy, is low serum albumin associated with postoperative complications? Altogether, 87 papers were found using the reported search, of which 16 demonstrated the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This paper includes 2 level 2 papers, 12 level 3 papers and 2 level 4 papers. All the papers compared either all or some of the following postoperative complications: mortality, morbidity, anastomotic leak, respiratory and non-respiratory complications, and length of hospital stay. Eleven of the 16 papers found an association between low serum albumin and postoperative complications. Of these, one study showed that low serum albumin combined with low fibrinogen levels (FA score) was predictive of postoperative recurrence of oesophageal cancer. Another study showed that when combined with white cell count and C-reactive protein (CRP, NUn score), serum albumin had a high diagnostic accuracy for major complications after postoperative day 3. The largest study compared the in-hospital mortality in 7227 patients who underwent oesophageal surgery for malignancy. The percentage of in-hospital mortality was associated with low serum albumin (<15.0 vs >35.0 g/l, 21.0 vs 11.3%, P <0.001). Five of the 16 papers found no significant association between low serum albumin and postoperative complications. Of these papers, one showed that low serum albumin was not an independent risk factor, while four others found no association between low serum albumin with respiratory complications, anastomotic leak and postoperative mortality. Instead, these studies found other factors responsible for postoperative complications such as: CRP, smoking, disease duration, malnutrition and low T-cell levels. Taken together, while low serum albumin is associated with postoperative complications, opinion regarding the prognostic value of low serum albumin and nutritional support remains conflicted. Because of the confounding factors encountered in these studies, the clinician should consider the finding of low serum albumin in patients, together with disease and surgical factors to provide optimal care for these patients.

A safe technique for the insertion of the Hasson cannula.

BACKGROUND: Most techniques of Hasson cannula insertion still involve a significant risk of visceral or vascular damage. This is true even for the modified open techniques of cannulation. METHODS: A technique of sequential clipping and elevation of abdominal wall layers is described, which permits safer Hasson cannulation at the umbilicus or at other sites on the abdomen even in the presence of underlying adhesions. RESULTS: Eight hundred and seventy-six patients underwent laparoscopic cholecystectomy using this technique of Hasson cannulation. Forty-two of these patients had the cannula placed at other sites other than the umbilicus because of previous surgery and suspected adhesions. Using this technique there were no major complications. Specifically, this technique did not incur any cases of visceral or vascular damage. CONCLUSIONS: The technique of sequential clipping and elevation of all layers of the abdominal wall during the insertion of the Hasson cannula allows for safer entry into the peritoneal cavity.

Evaluating informed consent for colonoscopy.

BACKGROUND: This study aimed to collect and analyze data on patient knowledge of colonoscopy and their preferences regarding the provision of information about the procedure. Specifically, how much detail patients know about different aspects of the procedure and through which methods they best understand risk are evaluated and demographic correlations identified. MATERIALS AND METHODS: The study sample consisted of colonoscopy patients from 2 colorectal surgeons and a gastroenterologist at St Vincent's Public Hospital, Sydney for the period August 1 to November 1, 2010. A voluntary questionnaire was performed in the waiting room before colonoscopy. The questionnaire collected data on patient demographics; patient-perceived knowledge of the procedure; and understanding and preferences of various communication formats. RESULTS: Measures of patient-perceived knowledge about colonoscopy were significantly lower than those that would be preferred by patients (P=0.002). Those with higher levels of education preferred communication of colonoscopy-related information via a leaflet form, whereas those with lower levels preferred verbal information from a doctor or nurse (P=0.049). The most preferred format for explaining the risk of perforation was the pie graph, followed by both the 1000-person pictograph and absolute risk ratios. CONCLUSIONS: Patients received suboptimal levels of information about colonoscopy compared with their preferences. Key areas for improvement include providing more understandable information about the risks of colonoscopy. A combination of written information, diagrams and graphs, and then a discussion of this information to check the understanding is likely to be most effective. Further research into the communication of risk, with larger groups of patients, is likely to help clinicians in gaining fully informed consent in all patients.