Performance of CT in the locoregional staging of colon cancer: detailed radiology-pathology correlation with special emphasis on tumor deposits, extramural venous invasion and T staging.

PURPOSE: To investigate the performance of computed tomography (CT) in the local staging of colon cancer in different segments, with emphasis on parameters that have been found to be significant for rectal cancer, namely, extramural venous invasion (EMVI) and tumor deposits (TDs). METHODS: CT and pathology data from 137 patients were independently reviewed by radiology and pathology teams. The performance of CT in categorizing a given patient into good, versus poor prognostic groups was assessed for each segment, as well as the presence of lymph nodes (LNs), TDs and EMVIs. Discordant cases were re-evaluated to determine potential sources of error. Elastic stain was applied for EMVI discordance. RESULTS: The T staging accuracy was 80.2%. For T stage stratification, CT performed slightly better in the left colon, and the lowest accuracy was in the transverse colon. Under-staging was more common (in 12.4%), and most of the mis-staged cases were in sigmoid colon. According to the first comprehensive correlative analysis, the sensitivity, specificity, and accuracy of CT for detecting TDs were found to be 57.9%, 92.4%, 87.6%, respectively. These figures were 44.7%, 72.7%, and 63.5% for LN, and 58.5%, 82.1% and 73% for EMVI. The detection rate was better for multifocal EMVI. The detection rate was also comparable (although substantially underestimated) for LNs, with the half of the LNs missed by CT being < 5 mm. Four patients that were classified as TD by CT, disclosed to be LNs by pathology. Correlative analysis led to refinement of the pathology criteria, with subsequent modifications of the initial reports in 13 (9.5%) patients. CONCLUSION: Overall, CT performed well in the evaluation of colon cancer, as did TD and EMVI. It is advisable to include these parameters in CT-based staging. Radiologists should be aware of the pitfalls that occur more commonly in different segments.

A case of seatbelt-induced mesenteric injury and delayed colon ischemia after a car accident.

Trauma is the sixth leading cause of death globally and the leading cause of morbidity and mortality in young patients. Blunt bowel and mesenteric injuries are rare, occuring in only 1-5% of blunt abdominal traumas, and are associated with high morbidity and mortality. In this report, we present a case of a patient with sigmoid colon perforation due to ischemia caused by mesenteric injury, who was admitted to the hospital with abdominal pain two days after a car accident. A twenty-one-year-old man was admitted to the emergency department with abdominal pain and vomiting, having been involved in a car accident as a driver two days prior. Computed tomogra-phy revealed free air in the abdomen, originating from the perforation of the sigmoid colon wall, and free fluid in the pelvic area. The patient underwent immediate laparotomy. Exploration revealed a rupture in the sigmoid mesocolon, causing ischemia and perforation. Additionally, there was a rupture in the mesentery of the terminal ileum close to the ileocecal valve, but without ischemia. Partial sig-moid colon and ileal resections were performed, followed by colocolic anastomosis and double-barrel ileostomy. He was discharged in good health after a 20-day hospital stay. Thorough clinical examination and radiological evaluation can aid in detecting visceral injuries in trauma patients. Early recognition and repair of intestinal damage can prevent severe complications.

Multimodal assessment after total neoadjuvant therapy versus standard neoadjuvant chemoradiotherapy in locally advanced rectal cancer accurately predicts complete responders.

PURPOSE: This study aimed to compare local regrowth rates after total neoadjuvant therapy (TNT) versus standard neoadjuvant chemoradiotherapy (SNCRT) in locally advanced rectal cancer (LARC) patients that were strictly selected and assessed with a multimodal approach. Secondary outcomes were 4-year disease-free (DFS) and overall survival (OS) rates. METHODS: Locally advanced rectal cancer patients without distant metastases treated at Koç Healthcare Group between January 2014 and January 2021 were included. Patients were assessed for complete response with a combination of digital rectal exam, endoscopy, and magnetic resonance imaging with a dedicated rectum protocol. The systemic evaluation was performed with an upper abdomen MRI using intravenous hepatobiliary contrast agent and a thorax CT. RESULTS: Of the 270 patients with LARC, 182 fulfilled the inclusion criteria. Ninety-seven (53.3%) underwent TNT, while 85 (46.7%) underwent SNCRT. A cumulative combination of pathological and sustained clinical complete response was significantly higher in the TNT group than in the SNCRT (45.4% vs. 20.0%, p < 0.0001). After a median follow-up of 48 months, seven patients in the W&W group had regrowth [TNT: 4 (10.8%) vs. SNCRT: 3 (23.1%), p = 0.357]. Based on pathological examination, complete/near complete mesorectum rates (p = 1.000) and circumferential resection margin positivity rates (p = 1.000) were similar between the groups. The 4-year DFS and OS rates were comparable. The patients with clinical or pathological complete response had significantly longer overall survival (p = 0.017) regardless of the type of neoadjuvant treatment. CONCLUSIONS: Multimodal assessment after TNT effectively detects complete responders, resulting in low local recurrence and increased cumulative complete response rates. However, these outcomes did not translate into a survival advantage.

Pancreatic surgery in elderly patients: results of 329 consecutive patients during 10 years.

Introduction: There is a progressive shift from a younger population to an older population throughout the world. With the population age shift, surgeons will be more encountered with older patient profiles. We aim to determine age-related risk factors of pancreatic cancer surgery and the effect of patient age on outcomes after pancreatic surgery. Materials and methods: A retrospective review was conducted with data obtained from consecutive 329 patients whose pancreatic surgery was performed by a single senior surgeon between January 2011 and December 2020. Patients were divided into three groups based on age: patients younger than 65 years old, between 65 and 74 years old, and older than 74 years old. Demographics and postoperative outcomes of the patients were evaluated and compared between these age groups. Results: The distribution of a total of 329 patients into the groups was 168 patients (51.06%) in Group 1 (age <65 years old), 93 patients (28.26%) in Group 2 (age ≥65 and <75 years old), and 68 patients (20.66%) in Group 3 (age ≥75 years old). The overall postoperative complications were statistically significantly higher in Group 3 than in Group 1 and Group 2 (p = 0.013). The comprehensive complication index of the patients in each group was 23.1 ± 6.8, 20.4 ± 8.1, and 20.5 + 6.9, respectively (p = 0.33). Fisher's exact test indicated a significant difference in morbidity in patients with ASA 3-4 (p = 0.023). In-hospital or 90-day mortality was observed in two patients (0.62%), one from Group 2 and one from Group 3. The 3-year survival rates for each group were 65.4%, 58.8%, and 56.8%, respectively (p = 0.038). Conclusion: Our data demonstrate that comorbidity, ASA score, and the possibility of achieving a curative resection do have significantly more impact than age alone.

Is there no need to discuss adjuvant chemotherapy in stage II colon cancer patients with high tumor budding and lymphovascular invasion?

PURPOSE: The aim of this study is to evaluate the clinicopathologic associations of tumor budding (Bd) as well as other potential prognosticators including lymphovascular invasion (LVI) in T3/4aN0 colon cancer patients and to investigate their impact on the outcome. METHODS: The patients were enrolled in three groups according to the number of budding as Bd1 (0-4 buds), Bd2 (5-9 buds), and Bd3 (> 10 buds). These groups were retrospectively compared in terms of demographic features, other tumor characteristics, operative outcomes, recurrences, and survival. The mean follow-up time was 58 ± 22 months. RESULTS: A total of 194 patients were divided as follows: 97 in Bd1, 41 in Bd2, and 56 in Bd3 groups. The Bd3 group was associated with significantly higher LVI and larger tumor size. The rate of recurrence increased progressively from 5.2% in Bd1 to 9.8% in Bd2 and to 17.9% in Bd3 group (p = 0.03). More importantly, the 5-year overall survival (OS: Bd1 = 92.3% vs. Bd2 = 88% vs. Bd3 = 69.5%, p = 0.03) and disease-free survival (DFS: Bd1 = 87.9% vs. Bd2 = 75.3% vs. Bd3 = 66%, p = 0.02) were significantly worse in Bd3 group. In addition, in the subgroup of patients with the presence of Bd3 and LVI together, the 5-year OS (60% vs. 92%, p = 0.001) and DFS (56.1% vs. 85.4%, p = 0.001) were significantly worse. In multivariate analysis, Bd3+LVI was significantly associated with poor OS and DFS (p < 0.001). CONCLUSION: In patients with T3/4aN0 colon cancer, high tumor budding negatively affects long-term oncological outcomes. These findings strongly suggest that adjuvant chemotherapy be considered for the patients with Bd3 and LVI together.

Effects of the Largest Metastatic Lymph Node Size on the Outcomes of Patients who Underwent Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma.

Objectives: Prognostic importance of metastatic lymph nodes in pancreatic cancer is always garnered attention due to dismal prognosis, with some quantitative factors drawing attention for significantly predicting outcomes. Size is one of the easy approach morphological characteristics of the lymph node, and data for effect of largest metastatic lymph node (LMLN) size on survival outcomes are lacking in pancreatic cancer. We aim to evaluate the effect of LMLN size on the prognosis of patients with pancreatic ductal adenocarcinoma (PDAC). Methods: This retrospective study evaluates the effect of LMLN size on survival outcomes by grouping the patients who were surgically treated for PDAC, according to their lymph node stage and calculated cutoff value for LMLN size, between February 2015 and May 2020. Results: In the study cohort of 131 patients, the mean age was 63.9±10.8 years and 77 patients were female. Ninety-nine of the patients had pN1, 32 had pN2 stage disease. The optimal cutoff point of LMLN size for predicting the prognosis was calculated as 7.5 mm (sensitivity = 81% and specificity = 81%). 34 (34.3%) of pN1 and 7 (21.9%) of pN2-staged patients had lymph node smaller than 7.5 mm. Three-year survival was significantly longer for patients whose LMLN size was <7.5 mm (56.2-18.2%, p<0.001). Whereas, the patients with LMLN size <7.5 mm had statistically significant longer median survival rate in the subgroup of patients with pN1 lymph node stage, no significant difference in median survival rates was observed between subgroups of pN2 patients (p=0.237). Conclusion: The present study demonstrated that the LMLN size was one of the potential predictors of survival in patients with PDAC.

Right paraduodenal hernia accompanying superior mesenteric vein thrombosis: a rare case.

A 59-year-old man with abdominal pain was admitted to the emergency department. Investigations had revealed a right-sided paraduodenal hernia and superior mesenteric vein (SMV) twisting around the superior mesenteric artery in rotation, the 'whirlpool sign'. Owing to the increasing severity of abdominal pain and the presence of SMV thrombosis complicated with strangulated paraduodenal herniation associated with high mortality rates, diagnostic laparoscopy was performed. Resection of the intestines was not needed and paraduodenal hernia was repaired. The patient was uneventfully discharged.

Open mesh and laparoscopic total extraperitoneal inguinal hernia repair under spinal and general anesthesia.

INTRODUCTION: Mesh placement is the main standard in repair of inguinal hernia, and laparoscopic repair is the standard of care via spinal, epidural, or combined anesthesia. Here, we compared open and laparoscopic total extraperitoneal (TEP) repairs under general (GA) and spinal anesthesia (SA). METHODS: Inguinal hernia patients (n=440) were analyzed retrospectively. There were four groups: Group 1 was TEP under GA (TEP-GA) (n=111); Group 2 was open mesh repair (OM) under SA (n=116) (OM-SA); Group 3 was open mesh repair under GA (n=117) (OM-GA); Group four was TEP under SA (n=96) (TEP-SA). The age, body mass index, duration of operation, hospital stay, postoperative Visual Analog Scale scores, recurrence, postoperative pain, urinary retention, headache, and patient satisfaction were all recorded. RESULTS: There was no significant difference in terms of hypotension, vomiting, seroma and scrotal edema, recurrence, and wound infection incidence between the groups. However, the operation duration, hospital stay period, headache, urinary retention, postoperative Visual Analog Scale scores, chronic pain, and patient satisfaction showed significant differences between groups. CONCLUSION: Laparoscopic TEP hernia repair is a safe and effective method along with its advantages of shorter hospital stay, less recurrence, less postoperative pain, higher patient satisfaction, and similar postoperative complication rates. SA has the disadvantage of higher incidence of headache and urinary retention compared to GA.