Management Options of Giant Colonic Lipomas.

Colonic lipomas are rare, benign neoplasms, typically asymptomatic, and predominantly found incidentally during autopsy or routine surveillance. Symptomatic lesions are usually those greater than 2 cm in diameter while "giant" lesions are characterized as those over 4 cm. Presentations can vary from asymptomatic to more severe sequelae, including obstruction, gastrointestinal bleeding, or intussusception. Resection of these lesions has historically been restricted to large or symptomatic lesions. However, recent reports suggest lipomas may retain the ability to grow and can become symptomatic over time despite being inconsequential initially. This series provides a review of the clinical manifestations of colonic lipomas, radiographic characteristics, and a treatment recommendation for management of these lesions using minimally invasive surgical techniques whilst advocating for consideration of resection prior to the development of symptoms or more emergent complications.

The cancer testis antigens CABYR-a/b and CABYR-c are expressed in a subset of colorectal cancers and hold promise as targets for specific immunotherapy.

INTRODUCTION: Calcium-binding tyrosine phosphorylation-regulated protein (CABYR) is expressed in the human germ line but not in adult human tissues, thus, it is considered a cancer testis protein. The aim of this study is to evaluate the CABYR isoforms: a/b and c mRNA expression in colorectal cancer (CRC) and to determine if these proteins hold promise as vaccine targets. MATERIALS AND METHODS: CABYR mRNA expression in a set of normal human tissues, including the testis, were determined and compared using semi-quantitative PCR. As regards the tumor and normal mucosal samples from study patients, RNA was extracted and cDNA generated after which quantitative PCR was carried out. Analysis of CABYR protein expressions by immunohistochemistry in tumor and normal colon tissues was also performed. RESULTS: A total of 47 paired CRC and normal tissue specimens were studied. The percent of patients with a relative expression ratio of malignant to normal (M/N) tissues over 1 was 70% for CABYR a/b and 72% for CABYR c. The percent with both a M/N ratio over 1 and expression levels over 0.1% of testis was 23.4% for CABYR-a/b and 25.5% for CABYR c. CABYR expression in tumors was further confirmed by immunohistochemistry. CONCLUSIONS: CABYR a/b and c hold promise as specific immunotherapy targets, however, a larger and more diverse group of tumors (Stage 1-4) needs to be assessed and evaluation of blood for anti-CABYR antibodies is needed to pursue this concept.

Warm and Humidified Versus Cold and Dry CO2 Pneumoperitoneum in Minimally Invasive Colon Resection: A Randomized Controlled Trial.

INTRODUCTION: Peritoneal insufflation with warm-humidified (WH) CO2 gas during minimally invasive surgical procedures is purported to prevent hypothermia and peritoneal desiccation and is associated with decreased postoperative IL-6 levels. This randomized study's purpose was to determine the clinical impact of WH versus cold-dry (CD) CO2 in minimally invasive colon resection (MICR), and to assess perioperative plasma levels of IL-6, TIMP-1, sVEGF-R1, and HSP-70 after MICR. METHODS: Operative and short-term clinical data plus perioperative blood samples were collected on MICR patients randomized to receive either WH (36.7°C, 95% humidity) or CD (room temperature, 0% humidity) CO2 perioperatively. Peritoneal biopsies were taken at the start and end of surgery. Outcomes tracked included core temperature, postoperative in-hospital pain levels, analgesia requirements, and standard recovery parameters. Preoperative and postoperative days (PODs) 1 and 3 plasma protein levels were determined via ELISA. RESULTS: A total of 101 patients were randomized to WH CO2 (50) or CD CO2 (51). The WH group contained more diabetics ( P = .03). There were no differences in indication, minimally invasive surgical method used, or core temperature. Pain scores were similar; however, the WH patients required less narcotics on PODs 1 to 3 ( P < .05), and less ketorolac on PODs 1 and 2 ( P < .03). No differences in length of stay, complication rates, or time to flatus/diet tolerance were noted. Plasma levels of the 4 proteins were similar postoperatively. Though insignificant, the WH group had less marked histologic changes on "end-of-case" peritoneal biopsies. CONCLUSION: This study found significantly lower pain medication requirements for PODs 1 to 3 for the WH group; however, because there were no differences in the pains scores between the groups, firm conclusions regarding WH CO2 cannot be made.

Risk factors for superficial surgical site infection after elective rectal cancer resection: a multivariate analysis of 8880 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Superficial surgical site infection (sSSI) is one of the most common complications after colorectal resection. The goal of this study was to determine the comorbidities and operative characteristics that place patients at risk for sSSI in patients who underwent rectal cancer resection. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried (via diagnosis and Current Procedural Terminology codes) for patients with rectal cancer who underwent elective resection between 2005 and 2012. Patients for whom data concerning 27 demographic factors, comorbidities, and operative characteristics were available were eligible. A univariate and multivariate analysis was performed to identify possible risk factors for sSSI. RESULTS: A total of 8880 patients met the entry criteria and were included. sSSIs were diagnosed in 861 (9.7%) patients. Univariate analysis found 14 patients statistically significant risk factors for sSSI. Multivariate analysis revealed the following risk factors: male gender, body mass index (BMI) >30, current smoking, history of chronic obstructive pulmonary disease (COPD), American Society of Anesthesiologists III/IV, abdominoperineal resection (APR), stoma formation, open surgery (versus laparoscopic), and operative time >217 min. The greatest difference in sSSI rates was noted in patients with COPD (18.9 versus 9.5%). Of note, 54.2% of sSSIs was noted after hospital discharge. With regard to the timing of presentation, univariate analysis revealed a statistically significant delay in sSSI presentation in patients with the following factors and/or characteristics: BMI <30, previous radiation therapy (RT), APR, minimally invasive surgery, and stoma formation. Multivariate analysis suggested that only laparoscopic surgery (versus open) and preoperative RT were risk factors for delay. CONCLUSIONS: Rectal cancer resections are associated with a high incidence of sSSIs, over half of which are noted after discharge. Nine patient and operative characteristics, including smoking, BMI, COPD, APR, and open surgery were found to be significant risk factors for SSI on multivariate analysis. Furthermore, sSSI presentation in patients who had laparoscopic surgery and those who had preoperative RT is significantly delayed for unclear reasons.

The identification of risk factors for venous thromboembolism in gastrointestinal oncologic surgery.

BACKGROUND: The aim of this study was to examine the incidence and factors associated with occurrence of venous thromboembolism (VTE) in patients undergoing major gastrointestinal (GI) surgery for malignancy. METHODS: The American College of Surgeon's National Surgical Quality Improvement Program, Participant User File database was queried from 2005 to 2012 to study major GI operations performed for cancer. Predictors of VTE and their relation to survival were studied. RESULTS: In 79,300 patients, the incidence of deep venous thrombosis was 1.7%, and pulmonary embolism was 0.9% during the 30-d postoperative period. The highest rate of VTE occurred after esophagectomy (5.9%) followed by pancreatectomy (3.2%), hepatectomy (3.2%), gastrectomy (2.5%), enterectomy (2.3%), colectomy, and proctectomy (2.0%). On multivariate analysis, disseminated cancer, age ≥ 80 y, body mass index > 35 kg/m(2), functional status, post operative sepsis, pulmonary dysfunction, and longer operative time were associated with occurrence of VTE. Occurrence of VTE was associated with mortality on multivariate analysis (odds ratio 2.4, 95% confidence interval 2.0-3.0, P < 0.001). CONCLUSIONS: Absolute incidence of VTE after major GI surgery is low but is associated with significant mortality and postoperative complications. Disseminated cancer, post operative sepsis, longer operative time, and increased body mass index >35 kg/m(2) further increased the risk of VTE in patients undergoing surgery for malignancy. Surveillance strategies should be implemented for those cancer patients who have multiple risk factors for VTE.

Two novel mutations identified in an african-american child with chediak-higashi syndrome.

Background. Chediak-Higashi syndrome (CHS) is a rare, autosomal recessive disorder characterized by oculocutaneous albinism, immunodeficiency, coagulopathy and late-onset, progressive neurological dysfunction. It also has an "accelerated phase" characterized by hemophagocytic lymphohistiocytosis (HLH). The disease is caused by mutations in the CHS1/LYST gene located on chromosome 1, which affects lysosome morphology and function. We report the case of an African-American child with CHS in Case. This 16-month old African-American girl presented with fever and lethargy. The proband had pale skin compared to her parents, with light brown eyes, silvery hair and massive hepatosplenomegaly. Her laboratory evaluation was remarkable for pancytopenia, high serum ferritin and an elevated LDH. Bone marrow aspirate revealed large inclusions in granulocytes and erythrophagocytosis consistent with HLH. Genetic evaluation revealed two novel nonsense mutations in the CHS1 gene: c.3622C > T (p.Q1208X) and c.11002G > T (p.E3668X). Conclusions. Our patient is one of the few cases of CHS reported in the African American population. We identified 2 nonsense mutations in the CHS1 gene, the first mutation analysis published of an African-American child with Chediak-Higashi Syndrome. These two mutations predict a severe phenotype and thus identification of these mutations has an important clinical significance in CHS.