Colorectal cancer surgery in octogenarians: real-world long-term results.

AIMS: Colon cancer is the most common intra-abdominal cancer in older people. In the elderly with cancer, clinical decision making is often complicated by the effects of aging. However, as life expectancy continues to rise, more people aged 80 and older will present with colorectal cancer and may need major surgery. METHODS: Between 2000 and 2020 we operated on 352 patients aged 80 and older for colorectal cancer. We reviewed the case-notes of these patients and made a survival analysis for those patients who had a surgical resection of the tumor. RESULTS: In 20 patients a palliative procedure was performed. Three hundred and thirty-two (332) patients had a colorectal cancer resected. Of these, 57 patients died within 90 days postoperatively. Survival analysis was done for 275 patients who were alive longer than 90 days postoperatively. The overall 5-year survival in this group is 41.5%. There was no significant difference in postoperative survival between patients over the age of 85 and patients aged 80-84 at the time of operation. The survival of patients with stage IV colorectal adenocarcinoma is significantly worse than survival in stage I-III patients (Cox-Mantel log-rank test p < 0.001). CONCLUSIONS: After exclusion of the patients in the 90-day mortality group the overall 5-year survival in octogenarians who had a resection of a colorectal cancer was 41.5%. The most difficult problem is to choose the right treatment for the right patient. Optimal surgical and adjuvant treatment should not be denied to these older patients.

Perineal bowel evisceration after extralevator abdominoperineal excision and vertical rectus abdominis myocutaneous flap closure.

INTRODUCTION: Perineal bowel evisceration is a rare complication after extralevator abdominoperineal excision (ELAPE). This surgical technique is used to resect low rectal and anal cancer, with a lower likelihood of positive surgical margins, but resulting in a larger perineal defect. A vertical rectus abdominis myocutaneous (VRAM) flap allows filling of the empty pelvic space and closure of the defect in the pelvic floor. CASE PRESENTATION: A 77-year-old woman, with a hysterectomy in her medical history, underwent an ELAPE followed by reconstruction of the perineal defect with a VRAM flap after neoadjuvant radiotherapy for a moderately differentiated invasive adenocarcinoma of the distal rectum. The postoperative course was complicated with a herniation of the perineal wound and evisceration of a bowel loop. CONCLUSION: Closure of the perineal defect after ELAPE remains a challenge, especially in cases where several risk factors for delayed wound healing, flap failure and perineal herniation are present.

A large retroperitoneal Mullerian cyst: case report and review of the literature.

BACKGROUND: Mullerian duct cysts are considered to be part of the urogenital cysts. Mullerian cysts, anatomically distant to the genitourinary organs or the pelvis, are extremely rare entities. MATERIAL AND METHODS: Case report and review of the literature using key word "Mullerian cyst", "retroperitoneal" and "mediastinal". RESULTS: A 48-year-old woman with abdominal discomfort and nausea was referred to our hospital. Further work-up with CT and MRI showed a large retrogastric, retropancreatic cyst, herniating through the diaphragm in the mediastinum. As etiology was unsure, a laparoscopic cystectomy was performed. Histological examination showed a benign cyst of Mullerian origin. A review of the literature confirmed that extrapelvic Mullerian cysts are rare, with only 28 mediastinal cysts and 12 extrapelvic retroperitoneal cysts being described. CONCLUSION: Retroperitoneal Mullerian cysts outside the pelvis have infrequently been described in the literature. As correct preoperative diagnosis is seldom possible, surgical resection is the gold standard of treatment.

A primary extraskeletal osteosarcoma of the mesentery: a case report.

Extraskeletal osteosarcoma is a rare and invasive malignancy, typically located in the soft tissue without attachment to the skeleton. The present study reports a case of a primary mesenteric extraskeletal osteosarcoma of a 71-year-old woman. The patient complained of an incomplete defecation. Colonoscopy showed an ulcer with impression of external compression of the sigmoid. An additional abdominal computed tomography (CT) scan revealed a large, almost completely calcified, mass in the left lower abdomen causing hydronephrosis of the left kidney. The patient underwent surgery and the mass was resected completely. The histopathological diagnosis was a primary abdominal extraskeletal osteosarcoma arising from the mesocolon with local invasion of the sigmoid. She was in follow-up without adjuvant chemo- or radiotherapy. Five months after initial surgery the tumor recurred with widespread peritoneal metastasis.

Polymerase chain reaction for Enterococcus faecalis in drain fluid: the first screening test for symptomatic colorectal anastomotic leakage. The Appeal-study: analysis of parameters predictive for evident anastomotic leakage.

PURPOSE: With current diagnostic methods, the majority of patients with symptomatic colorectal anastomotic leakage(CAL) is identified approximately 1 week after operation.The aim of this study is to determine whether real-time polymerase chain reaction (RT-PCR) for detection of Escherichia coli and Enterococcus faecalis on drain fluid can serve as a screening test for CAL in the early postoperative phase. METHODS: All patients included in this multicenter prospective observational study underwent left-sided colorectal resection for both malignant and benign diseases with construction of an anastomosis. In all patients, an intra-abdominal drain was placed during operation. During the first five postoperative days, drain fluid was processed for RT-PCR. The quantitative results of the RT-PCR on days 2 to 5 were compared to the results of day 1 in order to detect concentration changes. RESULTS: In total, 243 patients, with both benign and malignant diseases, were included of whom 19 (7.8 %) developed symptomatic CAL. An increase in E. coli concentration was found insignificantly more patients with CAL on day 4 and 5 [p =0.0004; diagnostic odds ratio (DOR) 7.9]. For E. faecalis, this result was found for days 2, 3, and 4 (p <0.003) with highest DOR on day 3 (31.6). Sensitivity and negative predictive values were 92.9 and 98.7 %, respectively, virtually ruling out CAL in case of negative test results on the third postoperative day. CONCLUSION: Quantitative PCR for E. faecalis performed on drain fluid may be an objective, affordable and fast screening tool for symptomatic colorectal anastomotic leakage.

Atypical fundal perforation: a case report.

Gastric perforations typically occur in the distal stomach, along the greater curvature or the antrum. The vast majority of upper gastrointestinal (GI) perforations are caused by peptic ulcer disease. We present a case of an atypical location of gastric perforation. A 31-year-old patient was experiencing nausea and severe abdominal pain. Explorative laparoscopy revealed a large fundal perforation. The patient underwent an abdominoplasty 5 days before with revisional surgery for hemorrhage. He had recently lost 42 kg after endoscopic sleeve gastroplasty (ESG) 8 months before. ESG is a minimally invasive alternative for bariatric surgery. Since its implementation, several studies have been published indicating the procedure as safe. However, some major adverse events, such as upper GI-bleeding, peri-gastric leak, and pneumoperitoneum, have been described. The atypical location of the perforation might be explained by a combination of events such as surgical stress, revisional surgery, major weight loss, and the history of ESG.

High-dose lanreotide in the treatment of poorly differentiated pancreatic neuroendocrine carcinoma: a case report.

Pancreatic neuroendocrine tumors (NETs), including poorly differentiated carcinomas (NECs), are rarely encountered. The majority of these tumors do not secrete excess hormones, but functioning NETs produce large amounts of vasoactive peptides and may cause carcinoid syndrome. Synthetic somatostatin analogs (SSAs) have been widely used in NETs for control of hormonal syndromes. Here, we present a case of poorly differentiated, grade 3 pancreatic NEC associated with carcinoid syndrome, for which adequate symptom control was achieved for 2 years and 4 months using the long-acting SSA lanreotide Autogel(®). In February 2009, a 55-year-old woman presented with episodes of flushing, diarrhea and epigastric pain. Imaging techniques revealed the presence of a metabolically active mass expressing somatostatin receptors in the hilar area of the liver. Histopathological examination confirmed the malignant nature of the mass, which was identified as a poorly differentiated grade 3 pancreatic NEC (TNM staging: T4NxM0). Therapeutic options were limited for the patient because of the extent of the primary mass involving the celiac axis, severe gastrointestinal toxicity experienced as a side effect of chemotherapy with cisplatin-etoposide and, later in the course of the disease, extensive liver metastases and carcinoid heart syndrome. Along with a palliative debulking surgery and right portal vein embolization, biotherapy with a high dose of lanreotide Autogel (120 mg/14 days) contributed to alleviation of symptoms caused by hormone overproduction, even after the development of liver metastases. These results suggest that patients with poorly differentiated NECs who exhibit signs of carcinoid syndrome can benefit from treatment with somatostatin analogs.

Acute phase proteins in drain fluid: a new screening tool for colorectal anastomotic leakage? The APPEAL study: analysis of parameters predictive for evident anastomotic leakage.

BACKGROUND: We aim to determine if C-reactive protein (CRP), lipopolysaccharide-binding protein (LBP), and procalcitonin (PCT) in drain fluid can serve as screening tools for colorectal anastomotic leakage (CAL). METHODS: Patients included in this multicenter prospective observational study underwent left hemicolectomy, sigmoid resection, high anterior resection, low anterior resection, or subtotal colectomy. During the first 5 postoperative days, CRP, LBP, and PCT were determined on drain fluid. RESULTS: In total 243 patients were included, of whom 19 (8%) developed CAL. CRP levels were higher in patients with leakage on day 3 and day 5, levels of LBP were higher on days 2, 3, and 4, and PCT levels were higher on day 5. Multivariate analysis showed LBP to be significantly related to CAL. An increase in the average initial value at the first postoperative day with 1 standard deviation increased the risk of leakage by 1.6 times. CONCLUSION: Increased concentrations of LBP in drain fluid are significantly associated to a higher chance of CAL and could contribute in a future prognostic model for CAL.

Long-term and perioperative corticosteroids in anastomotic leakage: a prospective study of 259 left-sided colorectal anastomoses.

OBJECTIVE: To determine the risk factors for symptomatic anastomotic leakage (AL) after colorectal resection. DESIGN: Review of records of patients who participated in the Analysis of Predictive Parameters for Evident Anastomotic Leakage study. SETTING: Eight health centers. PATIENTS: Two hundred fifty-nine patients who underwent left-sided colorectal anastomoses. INTERVENTION: Corticosteroids taken as long-term medication for underlying disease or perioperatively for the prevention of postoperative pulmonary complications. MAIN OUTCOME MEASURES: Prospective evaluations for risk factors for symptomatic AL. RESULTS: In 23% of patients, a defunctioning stoma was constructed. The incidence of AL was 7.3%. The clinical course of patients with AL showed that in 21% of leaks, the drain indicated leakage; in the remaining patients, computed tomography or laparotomy resulted equally often in the detection of AL. In 50% of patients with AL, a Hartmann operation was needed. The incidence of AL was significantly higher in patients with pulmonary comorbidity (22.6% leakage), patients taking corticosteroids as longterm medication (50% leakage), and patients taking corticosteroids perioperatively (19% leakage). Perioperative corticosteroids were prescribed in 8% of patients for the prevention of postoperative pulmonary complications. CONCLUSIONS: We found a significantly increased incidence of AL in patients treated with long-term corticosteroids and perioperative corticosteroids for pulmonary comorbidity. Therefore, we recommend that in this patient category, anastomoses should be protected by a diverting stoma or a Hartmann procedure should be considered to avoid AL. TRIAL REGISTRATION: trialregister.nl Identifier: NTR1258

The need for interval appendectomy after resolution of an appendiceal mass questioned.

BACKGROUND: Our current treatment of an appendiceal mass is initially conservative, followed by an interval appendectomy. The necessity of this routine interval appendectomy is debatable. A study was conducted to evaluate whether surgical factors and pathological features of the excised appendices support interval appendectomy. METHODS: We performed a retrospective study at the University Hospital Groningen and the Deventer Ziekenhuis. All patients diagnosed with an appendiceal mass in the period January 1991 to January 1997 were identified using the hospital database. The medical records of all these patients (n = 233, 108 M, 125 F) were reviewed. The clinical course of the appendiceal mass patients was split up into three distinct episodes: initial diagnosis and treatment of the appendiceal mass, the interval period and the interval appendectomy. Presenting symptoms, findings at clinical examination and additional imaging (ultrasound) were registered, as well as the course of the primary hospitalisation, the interval period, and the interval appendectomy. Results of histological examination of all resected specimens were reviewed. RESULTS: It was found that clinical findings alone were not specific enough to diagnose an appendiceal mass; 47% had a palpable abdominal mass and the median temperature was 38.2 degrees C ranging from 36 to 40.5 degrees C. Ultrasound examination was done in 69% of patients and showed an appendiceal mass in 72%. During the interval period, 4 patients presented with an appendiceal mass needing drainage, and 3 with acute appendicitis requiring emergency appendectomy. At interval appendectomy, histological examination of resection specimen showed a normal appendix without signs of previous inflammation in 30% of cases. In addition, complications due to interval appendectomy were seen in 18% of patients, including sepsis, bowel perforation, small bowel ileus, and various wound abscesses. CONCLUSIONS: We conclude that when causes for the appendiceal mass other than appendicitis are excluded, interval appendectomy seems unnecessary in patients who respond well to initial conservative treatment.