Post-operative Surveillance Following Curative Resection of Colorectal Cancer in the Elderly Population in the United Kingdom: An Observational Study.

Background Colorectal cancer most commonly affects the elderly population. Post-colorectal cancer surveillance aims to reduce cancer incidence and mortality, but its necessity and effectiveness are debated, especially in the elderly population. This study explores the relevance of computer tomography (CT) and colonoscopy surveillance in patients aged 75 and over who have undergone curative resection for colorectal cancer. Methods A retrospective analysis of prospectively collected data was conducted on patients aged 75 and over who had undergone surgical resection of colorectal cancer between November 2014 and August 2021. Data on demographics, treatment, survival, and surveillance were gathered from electronic patient records. The primary outcome was adherence to follow-up colonoscopy and CT-scan surveillance following surgery. Results A total of 417 patients underwent colorectal cancer surgery, with 334 included for analysis. The cohort had an average age of 81 years, with the majority receiving laparoscopic surgery and primary anastomosis. Twelve-month CT surveillance showed normal results in 281 patients (91.8%), while 24-month CT surveillance demonstrated normal findings in 244 patients (88.7%). Only 175 patients (52.4%) had colonoscopy follow-up, with 94 (53.7%) showing normal results, 74 (42.3%) demonstrating benign polyps, and two patients (1.1%) having histologically proven cancer. Reasons for not undergoing colonoscopy included declining invitations (30 patients, 19.1%) and being too frail (45 patients, 28.7%). Conclusion This study reinforces the notion that colonoscopy surveillance for patients over the age of 75 may have limited benefits. In an ageing population, the benefits of surveillance in terms of early detection of recurrence must be balanced against the risks of harm from the procedure, the availability of further management, cost-effectiveness, and patient preferences. An individualised approach should be adopted, potentially with colonoscopy surveillance only recommended in patients of higher risk (extramural venous invasion (EMVI)) and a low frailty score with a life expectancy over 10 years.

Operative and Pathological Factors in Right-Sided Colon Cancers: How Can We Improve the Outcomes?

INTRODUCTION: Though the tumour-node-metastasis staging classification is the standard approach to risk stratification in patients with colorectal cancer, several other important variables including the presence of extramural venous invasion (EMVI), the tumour mismatch repair status, as well as surgical technique and its influence on lymph node yield all have an impact on long-term survival. This study aims to review both the impact of the type of operation on lymph node yield: complete mesocolic excision (CME) versus right hemicolectomy, and the impact of EMVI and microsatellite instability in predicting overall survival in patients undergoing a right hemicolectomy for colon cancer. METHODS: Data of all patients who underwent an elective or emergency right hemicolectomy with curative intent for colon cancer between January 2013 and June 2022 (inclusive) was collected for this single-centre retrospective study. Kaplan-Meier survival curves were calculated using the Statistical Package for the Social Sciences (SPSS version 28, IBM Corp., Armonk, NY) software, and the log-rank (Mantel-Cox) test was used to compare survival distribution between different groups. RESULTS: A total of 421 patients underwent a right hemicolectomy for colon cancer with curative intent during the study period. EMVI was present in 173 (41%) tumours. Survival analysis showed significantly reduced cancer-related survival in patients with EMVI-positive tumours (p < 0.001), with five-year survival rates of 70% in EMVI-positive groups versus 96% in EMVI-negative groups. Subgroup analysis showed a significant difference in survival between node-positive and node-negative tumours in cancers found to have EMVI (p < 0.001). Mean lymph node yield was significantly higher in the CME group versus the standard right hemicolectomy group (p < 0.001). We found no significant difference in survival between patients with microsatellite instability-high (MSI-H) tumours and microsatellite stable (MSS) tumours (p = 0.432). CONCLUSION: Consideration of tumour biology and adopting the optimum surgical technique are factors that may influence long-term survival in patients with colorectal cancer. Extramural venous invasion is an important prognostic indicator of adverse outcomes in patients with right-sided colon cancer. Our study demonstrates a reduction in survival in patients with EMVI-positive tumours when undertaking subgroup analysis by the presence or absence of nodal disease. Further research needs to be undertaken to compare the relative efficacy of neoadjuvant versus adjuvant chemotherapy in right-sided cancers known to be EMVI-positive as some patients will fail to have adjuvant chemotherapy due to postoperative complications, thereby delaying recovery and missing the optimum window for treatment.

Can Cross-Sectional Imaging Reliably Determine Pathological Staging of Right-Sided Colon Cancers and Select Patients for More Radical Surgery or Neo-Adjuvant Treatment?

Purpose and research question Cross-sectional imaging with CT scanning is the most commonly performed imaging modality to stage right-sided colon cancers. There is increasing evidence for the use of neo-adjuvant chemotherapy in selected patients and debate about the role of complete mesocolic excision (CME) and central vascular ligation (CVL) in the management of locally advanced colon cancers. Predicted tumour stage and the presence of nodal metastases by CT are often used to select patients for neo-adjuvant chemotherapy and those that may benefit from CME. This study aims to compare predicted radiological T and N staging with final pathological T and N staging in elective patients having potentially curative surgery for right-sided colon cancer. Methods A retrospective analysis was carried out of a prospectively gathered database of all patients who had undergone (true) right hemicolectomy between 02/01/13 and 21/05/20. Sensitivity, specificity, positive predictive value, and negative predictive value for CT scanning with regards to the pathological nodal metastases were calculated and analysed. Results The sensitivity and specificity of radiology staging for predicting nodal status were 76.4% and 65.5% respectively. The positive predictive value of CT staging for correctly identifying nodal metastases was 55.3%, with a negative predictive value of 77.3%. Conclusions This large series adds further evidence that CT, even when reviewed by expert GI radiologists, has limited accuracy at identifying lymph node metastases in colon cancer.

Hypercalcemia secondary to excessive self-medication with antacids causing acute pancreatitis: a case report.

Excessive self-medication with over-the-counter drugs is an issue commonly encountered by health care professionals. It can result in uncommon presentations of life-threatening illnesses. These medications are frequently overlooked by clinicians when taking histories from patients, and their risks are often downplayed. We present the case of a 35-year-old woman with acute pancreatitis secondary to hypercalcemia. This condition occurred due to long-term excessive self-administration of calcium-rich antacid tablets. Her clinical course involved multifactorial rebound hypocalcemia after treatment and multiple complications from the abuse of other non-prescription medications. Acute pancreatitis secondary to antacid-induced milk-alkali syndrome has been minimally reported in the literature. There are no reports describing rebound hypocalcemia as a complication of its treatment or presenting this pathology in the context of multiple over-the-counter drug abuse. This case highlights the importance of taking thorough drug histories, including non-prescription medications, in acute clinical assessments.

Appendiceal neuroendocrine neoplasms in the era of laparoscopic appendicectomy.

BACKGROUND: Incidental appendiceal neuroendocrine neoplasms are identified in 1% of surgical resections for suspected appendicitis. A proportion of these patients will require further surgery because of high risk features, which include mesoappendiceal involvement or an involved margin. While an open appendicectomy technique usually involves en bloc mesoappendiceal resection, the increasingly common laparoscopic method often skeletonizes the appendix, leaving the mesoappendix in situ. This retrospective observational study investigates whether routine resection of the mesoappendix rather than skeletonization would reduce the need for further surgery in patients with an incidental finding of appendiceal neuroendocrine neoplasm. METHODS: We included appendicectomies performed over an 11-year period at Auckland City Hospital and identified all cases of incidental appendiceal neuroendocrine neoplasms. Histological data were collected to assess the risk of lymphatic spread and need for further surgery. Mesoappendix resection versus preservation and its effect on the recommendation for further surgery was recorded. RESULTS: An appendiceal neuroendocrine neoplasm was present in 73 (1%) of 7109 appendicectomy specimens. Of these, 10 patients (14%) required right hemicolectomy. Five of these could potentially have been spared the need for further surgery had the mesoappendix been removed en bloc with the appendix. DISCUSSION: We recommend en bloc mesoappendix resection during appendicectomy in order to better stage the neoplasm and reduce the need for unnecessary further surgery.

Laparoscopic adult colorectal surgeon and adolescents with inflammatory bowel disease: a safe combination?

INTRODUCTION: A multidisciplinary tertiary service for adolescents with inflammatory bowel disease (IBD) was commenced in April 2008, aiming to provide specialist treatment for adolescent patients and bridge the gap between existing paediatric and adult surgical services. A single laparoscopic colorectal surgeon who normally treats adult patients has been part of the multidisciplinary team since its inception. AIM: To analyse outcomes for those patients requiring surgical resection during the first 2 years of service. METHODS: In this service evaluation study, all data for patients undergoing surgery from 1 April 2008 to 31 March 2010 were prospectively collected on a dedicated electronic database. RESULTS: Nineteen patients underwent surgical resection (15 laparoscopic and four open) over the 2-year period. Median patient age was 15 years (range 11-16), and 14 patients were female. Of the 15 laparoscopic resections, eight were subtotal colectomy and ileostomy and seven ileocaecal resection/right hemicolectomy. There was one (6.7%) conversion due to a pericolic abscess. There were four planned open cases, including two subtotal colectomy and ileostomy and two small bowel resections. Median operating time was 150 and 172.5 min in the open and laparoscopic groups respectively. Median length of stay was 6 days (range 3-16) in the laparoscopic group, and 8 days (range 5-13) in the open group. There were three (15.8%) post-operative complications, one (5.3%) readmission within 30 days and no mortality. CONCLUSION: This study suggests that an adult colorectal surgeon can provide a safe and effective service for adolescents with IBD, including the provision of laparoscopic resection in this challenging patient group.

Appendiceal mucinous adenocarcinoma presenting as an enterocutaneous fistula in an incisional hernia.

A 68-year-old woman with a history of bone-graft harvesting from the right iliac crest presented with an incisional hernia and abscess at the graft donor site. Following incision and drainage of the abscess, CT demonstrated an enterocutaneous fistula between the appendix and bone-graft incision with appendicitis assumed to be the original cause of the abscess. At laparoscopy, the appendix was adherent to the hernia sac with mucinous material at the superficial orifice of the fistula site but not in the peritoneal cavity. Laparoscopic appendicectomy with fistula track excision was performed. Histological evaluation confirmed a well-to-moderately differentiated mucinous adenocarcinoma arising on a background of dysplastic villous adenoma. Tumour extended along the fistula track to involve the surface skin. A laparoscopic right hemicolectomy, lymph node dissection and wide local excision of the fistula track were carried out at a second procedure. Final histology confirmed pT4N1 tumour with clear resection margins.

Torsion of parietal-peritoneal fat mimicking acute appendicitis: a case report.

INTRODUCTION: Infarctions of the greater omentum and appendices epiploicae are uncommon, but well documented causes of acute abdominal pain. We present a rare case of torted fat on the parietal peritoneum over the anterior abdominal wall, mimicking clinical signs of acute appendicitis, which was diagnosed at laparoscopy. We are aware of only two other similar reported cases, both of which were diagnosed at the time of laparotomy. CASE PRESENTATION: A 41-year-old Caucasian woman presented with clinical signs of acute appendicitis. On diagnostic laparoscopy, a non-inflamed appendix was found. Further exploration revealed a necrotic torted appendage of fat overlying the parietal peritoneum of the right iliac fossa of the anterior abdominal wall. CONCLUSION: Torted fatty appendages can be a diagnostic dilemma often mimicking more common causes of an acute abdomen. Laparoscopy is an excellent tool making the correct diagnosis in such cases.

Apoptosis in the colonic crypt, colorectal adenomata, and manipulation by chemoprevention.

This review discusses the biology and the methods of assessment of apoptosis, of which, the monoclonal antibody M30 would seem to be the most useful; the role of apoptosis in the etiology of colorectal cancer; and its use as a marker to monitor the beneficial effects of chemopreventative interventions to reduce the development of colorectal cancer within the context of clinical trials.

A randomized trial of nicotine enemas for active ulcerative colitis.

BACKGROUND & AIMS: Ulcerative colitis (UC) is largely a disease of nonsmokers in which transdermal nicotine improves the symptoms but often causes adverse events (AEs). Nicotine enemas cause fewer AEs and were used as supplemental treatment for active UC. METHODS: We treated 104 patients with active UC with either 6-mg nicotine enemas or placebo enemas for 6 weeks in a randomized double-blind study. Patients continued their oral therapy, if any, for UC: 68 patients were taking mesalamine, 15 patients were taking prednisolone, and 12 patients were taking thiopurines during the study. Clinical, sigmoidoscopic, and histologic assessments were made at baseline and at the end of the study and symptoms were recorded daily on a diary card. The primary end point was induction of clinical remission and clinical improvement also was measured by the UC disease activity index. After the study, patients then used nicotine enemas daily for 4 weeks and sigmoidoscopy with a biopsy examination was repeated. AEs and salivary cotinine levels were monitored throughout the study. RESULTS: Clinical remission was achieved in 14 of 52 (27%) patients on active treatment and 14 of 43 (33%) patients on placebo (P = .55). The UC disease activity index improved by 1.45 points in the active group and by 1.65 points for those on placebo (P = .88). Only 1 patient discontinued treatment because of an AE (abdominal pain). In the 47 patients taking mesalamine only, active treatment conferred benefit that was not statistically significant; disease remission occurred in 9 of 25 patients on active therapy and 4 of 21 patients on placebo (P = .20). CONCLUSIONS: Six-milligram nicotine enemas were well tolerated but were not found to be efficacious for active UC.

Eight years experience of high-powered endoscopic diode laser therapy for palliation of colorectal carcinoma.

PURPOSE: Endoscopic laser therapy using neodymium: yttrium-aluminum-garnet (Nd:YAG) laser has been shown to be effective in palliating symptoms of obstruction, bleeding, and discharge in patients with colorectal cancer. These patients usually have advanced inoperable disease at presentation or are unfit for surgery. We have used high-powered diode laser to palliate patients with inoperable colorectal cancer since 1994. This study was designed to determine the success rate of high-powered diode laser in palliating inoperable colorectal carcinoma and compare these figures with those published for Nd:YAG laser. METHODS: A retrospective analysis was performed of all patients undergoing high-powered diode laser therapy for colorectal carcinoma between June 1994 and October 2002 (inclusive) at St. George's Hospital, London, United Kingdom. Patient's notes and endoscopy records were reviewed to determine the indications for treatment, success of symptom palliation, complications, and survival for each patient. RESULTS: Fifty-seven patients (28 males), with a median age at first treatment of 82 (range, 51-93) years, were identified who had been palliated with high-powered diode laser therapy for colorectal carcinoma. The median number of treatments received by each patient was three (range, 1-16 treatments), with a median interval between treatments of 9.5 (range, 1-25) weeks. Lifelong palliation of symptoms occurred in 51 patients (89 percent). Major complications were two perforations and one hemorrhage, giving an overall complication rate of 5.3 percent. One of the patients who experienced perforation died, giving an overall mortality rate of 1.8 percent for the procedure. The median survival of the 51 patients palliated completely by laser therapy was 8.5 (range, 0.6-52) months, with a probability of survival at 24 months of 15 percent. CONCLUSIONS: High-powered diode laser therapy is an effective method of providing palliation for obstruction, bleeding, and discharge in those patients with inoperable colorectal carcinoma. It produces results comparable to therapy with Nd:YAG laser and the equipment is cheaper, more compact, and portable.

28-Day emergency surgical re-admission rates as a clinical indicator of performance.

With the introduction of clinical governance, the NHS Executive has identified 28-day emergency re-admission rates as a clinical indicator to be used to assess and compare performance between NHS trusts. We undertook a 3-month retrospective audit of patients identified from the trust computer as having been re-admitted as an emergency within 28 days of discharge from the general surgical division. We wanted to examine reasons for re-admission, possible errors in coding and any preventable factors in these patients subsequently re-admitted acutely.