Improved Accuracy of Lymph Node Staging and Long-Term Survival Benefit in Colorectal Cancer With Ex Vivo Arterial Methylene Blue Infiltration.

Introduction: Ex vivo methylene blue (MB) injection into the main supplying arteries of the colorectal specimen after surgical removal is an uncomplicated technique to support lymph node harvest during pathological evaluation. The primary aim of this randomized, interventional, bicentric trial was to evaluate the impact of MB injection on lymph node yield, with secondary aims assessing the accuracy of lymph node staging and the effect on 5-year overall survival for patients undergoing resection of colorectal cancer. Methods: In the study period between December 2013 and August 2015, 200 colorectal resections were performed at two independent onco-surgery centers of Hungary. Following surgical resection, each specimen was randomly assigned either to the control (standard pathological work-up) or to the MB staining group before formaldehyde fixation. Patient-level surgical and clinical data were retrieved from routinely collected clinical datasets. Survival status data were obtained from the National Health Insurance Fund of Hungary. Results: A total of 162 specimens, 82 in the control and 80 in the MB groups, were included for analysis. Baseline characteristics were equally distributed among study groups, except for specimen length. Both the median of total number of lymph nodes retrieved (control 11 ± 8 [0-33] nodes vs. MB 14 ± 6 [0-42] nodes; p < 0.01), and the ratio of cases with at least 12 removed lymph nodes (36/82, 43.9% vs. 53/80, 66.3%; p < 0.01) were higher in the MB group. The rate of accurate lymph node staging was non-significantly improved. As for rectal cancer, nodal staging accuracy (16/31, 51.6% vs. 23/30, 76.7%; p = 0.04) and the proportion with minimum 12 lymph node retrieval (7/31, 22.6%, vs. 18/30, 60%; p < 0.01) was improved by MB injection. In Mantel-Cox regression, a statistically significant survival benefit with methylene blue injection at 5 years post-surgery was proven (51.2% vs. 68.8%; p = 0.04). Conclusion: In our experience, postoperative ex vivo arterial methylene blue injection appears to be an uncomplicated technique, improving lymph node yield and decreasing the chance of insufficient nodal staging. The technique might also associate with a 5-year overall survival benefit.

The NHS Bowel cancer screening programme achieves the anticipated survival improvement, but participation must be improved.

Purpose The NHS Bowel cancer screening programme (NHSBCSP) aims to reduce colorectal cancer (CRC) cumulative mortality by up to 23 per cent; long-term outcomes at national level are not yet known. The purpose of this paper is to examine a local population of CRC patients of screening age for their characteristics and long-term survival in relation to their presentation, including through the NHSBCSP. Design/methodology/approach Retrospective analysis of a prospectively maintained CRC database for the years 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 528 CRC patients diagnosed in the screening age range, 144(27.3 per cent) presented through NHSBCSP, 308(58.3 per cent) electively with symptoms and 76(14.4 per cent) as emergency. NHSBCSP-diagnosed patients were younger (median 66 vs 68 and 69 years, respectively, p=0.001), had more often left-sided cancers (59(41.0 per cent) vs 82(26.6 per cent) and 24(31.6 per cent), respectively, p=0.001), more UICC-stage I (42(29.2 per cent) vs 49(15.9 per cent) and 2(2.6 per cent)), stage III (59(41.0 per cent) vs 106(34.4 per cent) and 20(26.3 per cent)) and less stage IV disease (8(5.6 per cent) vs 61(19.8 per cent) and 34 (44.7 per cent), respectively, p<0.001). Three-year overall survival was best for NHSBCSP and worst for emergency patients (87.5 per cent vs 69.0 per cent and 35.3 per cent, respectively, LogRank p<0.001). Originality/value Patients diagnosed within the NHSBCSP have improved outcome compared to both symptomatic elective and emergency presentations. A reduction in overall cumulative mortality in order of 25 per cent may well be achieved, but continuing high levels of emergency presentations and undetected right-sided disease emphasise need for further improvement in public participation in the NHSBCSP and research into more sensitive and acceptable alternative screening methods.

Volume-outcome relationship for colorectal cancer in primary care: a prospective cohort study.

Purpose Higher caseloads are associated with better outcomes for many conditions treated in secondary and tertiary care settings, including colorectal cancer (CRC). There is little known whether such volume-outcome relationship exist in primary care settings. The purpose of this paper is to examine general practitioner (GP) CRC-specific caseload for possible associations with referral pathways, disease stage and CRC patients' overall survival. Design/methodology/approach The paper retrospectively analyses a prospectively maintained CRC database for 2009-2014 in a single district hospital providing bowel cancer screening and tertiary rectal cancer services. Findings Of 1,145 CRC patients, 937 (81.8 per cent) were diagnosed as symptomatic cancers. In total, 210 GPs from 44 practices were stratified according to their CRC caseload over the study period into low volume (LV, 1-4); medium volume (MV, 5-7); and high volume (HV, 8-21 cases). Emergency presentation (LV: 49/287 (17.1 per cent); MV: 75/264 (28.4 per cent); HV: 105/386 (27.2 per cent); p=0.007) and advanced disease at presentation (LV: 84/287 (29.3 per cent); MV: 94/264 (35.6 per cent); HV: 144/386 (37.3 per cent); p=0.034) was more common amongst HV GPs. Three-year mortality risk was significantly higher for HV GPs (MV: (hazard ratio) HR 1.185 (confidence interval=0.897-1.566), p=0.231, and HV: HR 1.366 (CI=1.061-1.759), p=0.016), but adjustment for emergency presentation and advanced disease largely accounted for this difference. There was some evidence that HV GPs used elective cancer pathways less frequently (LV: 166/287 (57.8 per cent); MV: 130/264 (49.2 per cent); HV: 182/386 (47.2 per cent); p=0.007) and more selectively (CRC/referrals: LV: 166/2,743 (6.1 per cent); MV: 130/2,321 (5.6 per cent); HV: 182/2,508 (7.3 per cent); p=0.048). Originality/value Higher GP CRC caseload in primary care may be associated with advanced disease and poorer survival; more work is required to determine the reasons and to develop targeted intervention at local level to improve elective referral rates.

Adipose Tissue-Derived Regenerative Cell-Enhanced Lipofilling for Treatment of Cryptoglandular Fistulae-in-Ano: The ALFA Technique.

BACKGROUND: The treatment of complex fistulae-in-ano is challenging and often includes a number of operations due to high rates of recurrence. Recently, techniques using in vitro expanded adipose tissue-derived stem cells have been described. We describe a novel treatment for cryptoglandular fistulae used in 7 patients, using a combination of surgical closure of the internal opening and real-time autologous adipose tissue-derived regenerative cells (ADRC)-enhanced lipofilling, without need for in vitro expansion. METHODS: Following exclusion of active perianal sepsis, patients underwent a standard tumescent liposuction procedure, harvesting ~300 to 400 mL of raw lipoaspirate. The lipoaspirate was prepared in real time, using the Celution 800/CRS system to obtain the stromal vascular fraction containing ADRCs. After excision of the fistula tract and closure of the internal orifice, fresh ADRC-enhanced lipoaspirate was injected into and around the fistula tract. RESULTS: At 6-months' follow-up, 5 of 7 (71.4%) patients showed clinical signs of fistula closure; one of these patients had a recurrence at 10 months due to sepsis. The remaining 4 patients (57.1%) all had complete fistula closure at a median of 46 months' follow-up. There were no adverse events associated with the technique, and no new incontinence. CONCLUSION: Treatment of cryptoglandular fistulae-in-ano with ADRC-enhanced lipofilling appears feasible and safe, and may add to the range of procedures that can be used to treat this difficult problem.

Intestinal complications of Behçet's disease.

We report a case of a young female patient with long-standing oral and genital Behçet's disease (BD), who presented with progressive severe colonic inflammation and perforation, requiring multiple laparotomies. The case had ultimately a favourable outcome despite posing a number of diagnostic and therapeutic challenges. Intestinal complications, although rare, should be considered as important differential diagnoses in patients with BD presenting with abdominal pain, and is a difficult-to-prove differential diagnosis to Crohn's disease.

Autologous adipose-tissue derived regenerative cells for the treatment of complex cryptoglandular fistula-in-ano: a report of three cases.

The treatment of complex fistulae-in-ano is challenging and often includes a number of operations due to high rates of recurrence. We report the successful treatment of three consecutive patients with long-standing cryptoglandular fistula-in-ano with a novel combination of mucosal advancement flap and adipose-tissue derived regenerative cells (ADRCs) from the stromal vascular fraction (SVF) obtained from a simple lipoaspiration procedure, using Celution technology. There was no operative morbidity; one patient who had a colostomy for faecal diversion has since undergone restoration of bowel continuity. All thee fistulae remain healed at 2-3-year follow-up. Lipofilling of cryptoglandular fistulae-in-ano with ADRC-enhanced lipofilling appears feasible and safe, and may add to the range of procedures that can be used to treat this difficult problem.

Unusual presentation of spontaneous splenic haematoma due to severe pancreatitis: a cautionary tale.

We report the case of a patient with multiple splenic complications from chronic pancreatitis with pseudocyst formation, including splenic vein thrombosis, subcapsular splenic haematoma and splenic artery pseudoaneurysm. The initial presentation was associated with pleuritic chest pain, clinically resembling symptoms of pulmonary embolism. The patient was treated with therapeutic low-molecular-weight heparin, without confirmatory imaging. However, the latter arranged computed tomographic pulmonary angiogram was negative, while the abdominal sequences of the CT revealed the splenic haematoma as causative pathology. The patient was initially treated conservatively, and discharged from inpatient care. On a subsequent CT, a pseudoaneurysm of the splenic artery was found and treated with coil embolisation. The patient is currently awaiting definitive management of the pancreatic pseudocyst.

Colonic obstruction caused by intraluminal haematoma.

We report a rare case of caecal obstruction in an anticoagulated elderly patient, who presented with abdominal pain and per-rectal bleeding. CT revealed obstruction in the ascending colon. The patient subsequently underwent a right hemicolectomy for a massively distended caecum containing a large intraluminal haematoma causing obstruction.

The two-week rule for suspected colorectal cancer: patient experience and psychological impact.

PURPOSE: There has been considerable interest in the "two-week rule" referral pathway efficacy for patients with suspected colorectal cancer. This study aims to explore the psychological impact on these patients. DESIGN/METHODOLOGY/APPROACH: Consecutive patients referred for urgent investigations under the "two-week rule" were invited to take part in semi-structured interviews using interpretative phenomenological analysis (IPA). Interviews were audio-taped, transcribed verbatim and analysed using investigator triangulation to enhance data trustworthiness. FINDINGS: Ten out of 23 (43.5 per cent) patients consented to interviews; none were diagnosed with cancer. Four super-ordinate themes were explored, referring to the "making sense of the threat to health", impact on self, impact on others, reflections on the "two-week rule" referral, and its investigative process. Participants reported their anxiety, fear, vulnerability and coping mechanisms, but also raised concerns about the communication received during the "two-week rule" referral process. Female participants preferred a female endoscopist. ORIGINALITY/VALUE: This study is the first of its kind exploring the psychological effects of the "two-week rule" process for colorectal cancer, highlighting potential areas for improvement in patient information, and satisfaction with the referral process.

Risk factors in laparoscopic cholecystectomy: a multivariate analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS: All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS: 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION: Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

Haemoperitoneum caused by perforation of Meckel's diverticulum in a 5-year-old child.

Common complications of Meckel's diverticulum in children include gastrointestinal haemorrhage, intestinal obstruction or intussuception and diverticulitis. Here, the rare case of a perforated, non-inflamed Meckel's diverticulum causing significant haemoperitoneum in a young child, is reported. The case highlights the potential for rapid deterioration of patients with complications form vitelline duct abnormalities, for which surgical exploration should not be delayed.

Unusual presentation of blunt laryngeal injury with cricotracheal disruption by attempted hanging: a case report.

The management of a patient with traumatic disruption of the cricotracheal junction in an attempted suicide by hanging is described. Such injury is uncommon, and many patients die at the scene; detailed radiologic imaging is rare because of the urgency of airway management. The delayed complete disruption of the major airway in this patient allowed adequate imaging and corrective management. Associated soft-tissue injuries of the great vessels of the neck are also described.