Public perception of common cancer misconceptions: A nationwide cross-sectional survey and analysis of over 3500 participants in Saudi Arabia.

Purpose/Background: Patients and healthcare providers use online health information and social media (SM) platforms to seek medical information. As the incidence of cancer rises, the popularity of SM platforms has yielded widespread dissemination of incorrect or misleading information about it. In this study, we aimed to assess public knowledge about incorrect cancer information and how they perceive such information in Saudi Arabia. Methods: A nationwide survey was distributed in Saudi Arabia. The survey included questions on demographics, SM platform usage, and common misleading and incorrect cancer information. Results: The sample (N = 3509, mean age 28.7 years) consisted of 70% females and 92.6% Saudi nationals. Most participants had no chronic illness. One-third were college graduates and less than one-quarter were unemployed. Conclusions: Differences in level of knowledge about cancer emerged in association with different demographic factors. Public trust in health information on SM also led to being misinformed about cancer, independent from educational level and other factors. Efforts should be made to rapidly correct this misinformation.

What are the outcomes in patients referred to a tertiary referral centre for Crohn's rectovaginal fistula surgery?

AIM: Rectovaginal fistulas in patients with Crohn's disease are challenging to manage, and surgical treatment remains the best option for achieving permanent closure of the fistula. Biologicals are now used routinely for patients with Crohn's disease. The aim of this study was to investigate the surgical procedures used by us to treat rectovaginal fistula in patients with Crohn's disease in the era of biologicals. METHOD: Patients with Crohn's disease who underwent surgery for a rectovaginal fistula between 2010 and 2020 were included in this retrospective study and were identified from a prospectively maintained institutional database. Collected variables included demographics, perioperative and operative variables and data regarding medications used. Success of the procedure was defined as no symptoms at least 6 months after definitive repair and/or stoma closure. RESULTS: Twenty patients (out of 80 referred for evaluation) underwent surgery with intent to close the fistula and had at least 6 months of follow-up. Mean age was 44 ± 12 years with a median follow-up duration of 33 months (range 6-130 months). Forty per cent of the patients had a history of at least two surgeries to close the fistula. The overall healing rate was 70% (14/20). The most performed procedure was a transanal rectal advancement flap (7/20), with a success rate of 85%. CONCLUSION: Rectovaginal fistula in Crohn's disease is difficult to cure; according to our results almost half of these patients have multiple surgeries due to recurrence. Multiple procedures may be offered for this challenging problem in motivated patients. Perioperative diversion should be strongly considered.

Surgical confidence when operating among residents in surgery - a cross-sectional study (SCAR study).

BACKGROUND: Self-confidence, is one of the critical variables influencing surgical resident's abilities, and lack of confidence maybe a reason for not entering medical practice immediately. Measuring the level of confidence of senior surgical residents (SSRs) is a crucial step in assessing preparedness to practice. In this study, we aim to measure their confidence level and the factors that might contribute to it. METHODS: Cross-sectional survey conducted at King Abdulaziz University Hospital on SSRs in Saudi Arabia (SA). We approached 142 SSRs, 127 responded. Statistical analysis was performed using RStudio v 3.6.2. Descriptive statistics were performed using counts and percentages for categorical variables and using mean ± standard deviation for continuous variables. Multivariate linear regression (t-statistics) was used to assess the factors associated with confidence in performing essential procedures, while the association between demographics and residency-related factor with the number of completed cases was tested using Chi-square. The level of significance was determined as 0.05. RESULTS: Response rate was 89.4%. Among surveyed residents, 66% had completed < 750 cases as a primary surgeon. More than 90% of SSRs were confident in performing appendectomy, open inguinal hernia repair, laparoscopic cholecystectomy, and trauma laparotomy, while 88% were confident in being on-call in level-I trauma center. No difference was noted in confidence level in relation to the number of performed cases. Residents from the Ministry of Health accounted for 56.3% of the study population and showed a higher confidence level compared to others. 94% of SSRs plan to pursue fellowship training program. CONCLUSION: The study showed that the confidence of SSRs in performing common general surgery procedures was as expected. However, it's important to recognize that confidence doesn't necessarily reflect competence. Considering the majority of SSRs planned to pursue fellowship training programs, it may be time to consider changing the structure of surgical training in SA to a modular format to allow earlier and more intensive exposure.

Body Microbiota and Its Relationship With Benign and Malignant Breast Tumors: A Systematic Review.

Breast cancer is the most frequent type of cancer as well as one of the main causes of cancer-related mortality in women. Human microbial dysbiosis, which has been related to a range of malignancies, is one of the variables that may impact the chance of developing breast disorders. In this review, we aimed to investigate the relationship between breast cancer and benign breast tumors with dysbiosis of the microbiome at different body sites. We performed a systematic review of MEDLINE, Scopus, Ovid, and Cochrane Library to identify original articles published until July 2020 that reported studies of breast disease and microbiota. Twenty-four original articles were included in the study, which looked at the features and changes in breast, gut, urine, lymph node, and sputum microbial diversity in patients with benign and malignant breast tumors. In breast cancer, the breast tissue microbiome demonstrated changes in terms of bacterial load and diversity; in benign breast tumors, the microbiome was more similar to a malignant tumor than to normal breast tissue. Triple-negative (TNBC) and triple-positive (TPBC) types of breast cancer have a distinct microbial pattern. Moreover, in breast cancer, gut microbiota displayed changes in the compositional abundance of some bacterial families and microbial metabolites synthesis. Our review concludes that breast carcinogenesis seems to be associated with microbial dysbiosis. This information can be further explored in larger-scale studies to guide new prophylactic, diagnostic, and therapeutic measures for breast cancer.

Outcomes of Cytoreduction and Oxaliplatin-Based Hyperthermic Intraperitoneal Chemotherapy in Patients With Peritoneal Carcinomatosis From Colorectal Cancer.

Among patients with metastatic colorectal cancer, 25% have isolated peritoneal carcinomatosis. We performed a systematic review and meta-analysis to assess the disease-free survival (DFS) and overall survival (OS) of patients undergoing hyperthermic intraperitoneal chemotherapy with oxaliplatin. Eleven studies were included in the final assessment. Pooled three- and five-year OS rates were 58.60% and 42.19%, respectively. The estimated pooled three- and five-year DFS rates were 23.47% and 14.26%, respectively.

Short-Term Outcomes of Inguinal Hernia Repair in Older Patients: A Retrospective Review at a Tertiary Center.

Objectives Although inguinal hernia (IH) repair is low-risk surgery, older patients are occasionally offered watchful waiting because of their functional status and comorbidities. This study reviewed the surgical outcomes of IH repair in older patients in comparison with outcomes in younger patients. Methods This retrospective study included all patients who had IH repair from 2010 to 2020. The primary outcomes of interest were postoperative complications and recurrence. Results A total of 262 patients underwent IH repair during the study period; 40% were ≥60 years old. One patient had a recurrence. Among the 8% of patients who had postoperative complications, groin pain was the most common one (1.9%). Female patients had a significantly higher rate of complications than male patients did (38.5% female versus 6.4% male, p<0.001). The rate of complications was also higher for emergency surgery than for elective surgery (22.6% emergency versus 6.1% elective, p<0.001), as well for patients who needed concomitant bowel resection compared with those who did not. Patients who had emergency surgery or postoperative complications had a prolonged hospital stay.  Conclusions IH repair in older patients is low-risk surgery, comparable to that in younger patients. In this study, emergency surgery was more common in older than in younger patients and posed a higher risk of complications. We recommend offering elective hernia repair to older patients to avoid the higher complication rate associated with emergency repair.

Locally Advanced Breast Cancer: Treatment Patterns and Predictors of Survival in a Saudi Tertiary Center.

Background  Breast cancer (BC) is the most common cancer in the Kingdom of Saudi Arabia (KSA) and the second leading cause of cancer-related mortality. About 40% of BC in KSA is locally advanced BC (LABC), which has been associated with poorer survival compared with early diagnosed BC. Objective To review the presentation and outcomes of LABC, including the characteristics of the disease, different treatment modalities, overall survival (OS), disease-free survival (DFS), and local recurrence in relation to different radiotherapy (RT) techniques. Methods  We retrospectively reviewed the medical records of 153 female patients with pathologically proven LABC diagnosed at King Abdulaziz University Hospital, Jeddah, KSA, between 2009 and 2017. We obtained data on patient demographics, stage of cancer at diagnosis, tumor characteristics (subtype and receptor status), type of surgery, systemic treatments received (hormonal, targeted therapy, and chemotherapy), RT variables, and recurrence and death dates. Data were analyzed to assess OS and DFS by using Kaplan-Meier analyses and the log-rank test. Univariate and multivariate Cox proportional hazard regression analyses were used to explore and identify factors associated with survival. Results  The median survival time in the study population was 9.16 years. Older age (65+ years) was associated with worse OS and DFS than was younger age (<65 years) (hazard ratio (HR) 3.20, 95% CI 1.48-6.90, P = 0.003 and HR 2.21, 95% CI 1.12-4.36, P = 0.022, respectively). Regarding the type of surgery, having a mastectomy was associated with worse OS and DFS than was having a lumpectomy (HR 2.44, 95% CI 0.97-6.12, P = 0.05 and HR 2.41, 95% CI 1.13-5.14, P = 0.023, respectively). Positive estrogen and progesterone receptor status was associated with better OS and DFS than was a negative estrogen or progesterone receptor status (HR 0.13, 95% CI 0.05-0.30, P < 0.001 and HR 0.21, 95% CI 0.11-0.41, P < 0.001, respectively). Patients who received RT had a lower risk of recurrence than did those who did not receive RT (P = 0.011). Moreover, three-dimensional conformal RT was associated with lower local recurrence than intensity-modulated RT or volumetric-modulated arc therapy (P = 0.003). Conclusion  Multiple factors can affect the OS and DFS in LABC. Younger patients, having hormone-positive disease, and undergoing lumpectomy were associated with better outcomes. Adjuvant RT may improve local control and the use of three-dimensional conformal RT was superior for local control. Prospective studies with larger sample sizes are needed to further highlight these findings and to assess the role of chemotherapy and targeted therapy in patients with LABC.

Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis.

BACKGROUND: With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients. METHODS: We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates. RESULTS: We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I2 = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I2 = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I2 = 79.3%, P < 0.001). CONCLUSION: The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.

Gastrointestinal Perforation With an Intraluminal Stent and Bevacizumab use in Advanced Metastatic Colorectal Cancer.

Intestinal obstruction is a common acute presentation of advanced rectal cancer, which could be managed with surgical or non-surgical techniques including metallic stenting. Bevacizumab has been gaining popularity in the treatment of advanced colorectal cancer (CRC) in combination with different chemotherapeutic agents, to improve the overall survival rate; however, data regarding the adverse effects of bevacizumab in combination with other treatment modalities have been insufficient. Herein, we present a case of a 37-year-old man diagnosed with advanced rectal cancer with concurrent liver and lung metastases. He was started on Xelox (capecitabine plus oxaliplatin) chemotherapy in combination with bevacizumab for palliative care. He developed an episode of bowel obstruction, which was managed with emergent placement of a metallic stent. Soon after that, the patient presented emergently with signs and symptoms of intestinal perforation. He underwent emergent surgical intervention with stoma creation and a complicated hospital course. Despite the oncological benefits of bevacizumab for treating metastatic CRC, complications can occur resulting in a devastating outcome, with intestinal perforation being the most serious rare complication.

Diverticular Colovaginal Fistulas: What Factors Contribute to Successful Surgical Management?

BACKGROUND: Diverticular disease is the leading cause of colovaginal fistulas. Surgery is challenging given the inflammatory process that makes dissection difficult. To date, studies are small and include fistula secondary to multiple etiologies. OBJECTIVE: The objectives of this study were to examine surgical outcomes of diverticular colovaginal fistulas and to identify variables associated with successful closure. DESIGN: This was a retrospective study of a prospectively maintained clinical database. SETTINGS: The study was conducted at a single tertiary referral center. PATIENTS: Women with diverticular colovaginal fistulas, who underwent surgical repair with intent to close the fistula, were included. INTERVENTIONS: Repair of colovaginal fistula through minimally invasive or open techniques was involved. MAIN OUTCOME MEASURES: Successful closure of fistula, defined as resolution of symptoms and no stoma, was measured. RESULTS: Fifty-two patients underwent surgical treatment of diverticular colovaginal fistula, 23 (44%) of whom underwent a minimally invasive approach (conversion rate of 22%). Ostomy construction and omental pedicle flaps were used in 28 (54%) and 38 patients (73%). Surgery was successful in 47 patients (90%). Accounting for secondary operations, ultimate success and failure rates were 49 (94.0%) and 3 (5.7%). There was no difference in postoperative morbidity between the 2 groups (5 patients with Clavien-Dindo III/IV complications in the success group versus 2 patients in the failure group; 10.6% vs 40.0%; p = 0.44). Failure to achieve fistula closure was not associated with perioperative variables, age, BMI, diabetes mellitus, ASA grade, steroid use, previous abdominal surgery or hysterectomy, use of omentoplasty, or ostomy. Patients who failed were more likely to be smokers (60.0% vs 12.8%; p = 0.03). LIMITATIONS: Limitations include the retrospective design and lack of power. CONCLUSIONS: Surgery is effective in achieving successful closure of diverticular colovaginal fistula. Smokers should be encouraged to stop before embarking on an elective repair. Although the use of fecal diversion and omental pedicle flaps did not correlate with success, they should be used when clinically appropriate. See Video Abstract at http://links.lww.com/DCR/A983. FÍSTULAS COLOVAGINALES DIVERTICULARES ¿QUÉ FACTORES CONTRIBUYEN AL ÉXITO DEL TRATAMIENTO QUIRÚRGICO?: La enfermedad diverticular es la causa principal de fístulas colovaginales. La cirugía es un reto dado el proceso inflamatorio que dificulta la disección. Hasta la fecha, los estudios son pequeños e incluyen fístulas secundarias a múltiples etiologías. OBJETIVO: 1) Examinar los resultados quirúrgicos de las fístulas colovaginales diverticulares; 2) Identificar variables asociadas a un cierre exitoso. DISEÑO:: Estudio retrospectivo de una base de datos clínicos prospectivamente mantenida. CONFIGURACIÓN:: Centro de referencia superior. PACIENTES: Mujeres con fístulas colovaginales diverticulares, que se sometieron a una reparación quirúrgica con la intención de cerrar la fístula. INTERVENCIONES: Reparación de la fístula colovaginal mediante técnicas mínimamente invasivas o abiertas. MEDIDAS DE RESULTADOS PRINCIPALES: Cierre exitoso de la fístula definida como resolución de los síntomas y sin estoma. RESULTADOS: Cincuenta y dos pacientes se sometieron a tratamiento quirúrgico de la fístula colovaginal diverticular, 23 (44%) de los cuales se sometieron a un acceso mínimamente invasivo (tasa de conversión del 22%). La construcción de la ostomía y los pedículos omentales se utilizaron en 28 (54%) y 38 pacientes (73%), respectivamente. La cirugía fue exitosa en 47 pacientes (90%). Tomando en cuenta las operaciones secundarias, las tasas finales de éxito y fracaso fueron 49 (94.0%) y 3 (5.7%). No hubo diferencias en la morbilidad postoperatoria entre los dos grupos (5 pacientes con complicaciones de Clavien-Dindo III / IV en el grupo de éxito versus a 2 pacientes en el grupo de fracaso, 10.6% versus a 40.0%; p = 0.44). El fracaso para lograr el cierre de la fístula no se asoció con variables perioperatorios, edad, IMC, diabetes, grado ASA, uso de esteroides, cirugía abdominal previa o histerectomía, uso de omentoplastia u ostomía. Los pacientes que fracasaron eran más propensos a ser fumadores (60.0% versus a 12.8%; p = 0.03). LIMITACIONES: Las limitaciones incluyen el diseño retrospectivo y la falta de poder. CONCLUSIONES: La cirugía es efectiva para lograr el cierre exitoso de la fístula colovaginal diverticular. Se debe aconsejar a los fumadores a parar de fumar antes de embarcarse en una reparación electiva. Mientras el uso de desviación fecal y pedículos omentales no se correlacionó con el éxito, deberían utilizarse cuando sea clínicamente apropiado. Consulte el Video del Resumen en http://links.lww.com/DCR/A983.

What Is the Best Surgical Treatment of Pouch-Vaginal Fistulas?

BACKGROUND: Pouch-vaginal fistula is a debilitating condition with no single best surgical treatment described. Closure of these fistulas can be incredibly difficult, and transanal, transabdominal, and transvaginal approaches have been reported with varying success rates. Recurrence is a major problem and could eventually result in repeat redo pouch or permanent diversion. OBJECTIVE: The aim of our study was to investigate healing rates for procedures done for pouch-vaginal fistula closure. DESIGN: This is a retrospective analysis of a prospectively maintained database complemented by chart review. SETTINGS: This study reports data of a tertiary referral center. PATIENTS: Patients who underwent surgery for pouch-vaginal fistula from 2010 to 2017 were identified. Patients who underwent surgery with intent to close the fistula were included, and patients who had inadequate follow-up to verify fistula status were excluded. INTERVENTIONS: Patients included underwent surgery to close pouch-vaginal fistula. MAIN OUTCOME MEASURES: Success of the surgery was the main outcome measure. Success was defined as procedures with no reported recurrence of fistula on last follow-up. RESULTS: A total of 70 patients underwent surgery with an intent to close the pouch-vaginal fistula, 65 of whom had undergone index IPAA for ulcerative colitis, but 13 of these patients later had the diagnosis changed to Crohn's disease. Thirty-nine patients (56%) had a fistula originating from anal transition zone to dentate line to the vagina (not at the pouch anastomosis). In the total group of 70 patients, our successful closure rate was 39 (56%) of 70. Procedures with the highest success rates were perineal ileal pouch advancement flap and redo IPAA (61% and 69%). LIMITATIONS: The retrospective nature and small number of cases are the limitations of the study. CONCLUSIONS: Although numerous procedures may be used in an attempt to close pouch-vaginal fistula, pouch advancement and redo pouch were the most successful in closing the fistula. See Video Abstract at http://links.lww.com/DCR/A841.

Clinically Node Negative, Pathologically Node Positive Rectal Cancer Patients Who Did Not Receive Neoadjuvant Therapy.

PURPOSE: Neoadjuvant chemoradiotherapy is the preferred standard of care for clinical stages II-III rectal cancer. It is uncertain whether clinically node negative (cN-) tumors found to be pathologically stage III could be optimally treated with surgery alone and avoid adjuvant treatments. The aim of our study was to define the outcomes of such patients. METHODS: Patients undergoing radical surgery using total mesorectal excision (TME) techniques for rectal cancer (≤12 cm from the anal verge) with curative intent during 2000-2012 and found to have stage III disease on final pathology were identified from a prospectively maintained database. Patients were staged with abdominopelvic CT, transrectal endoscopic ultrasound, and/or pelvic MRI. Exclusion criteria were cN+ without neoadjuvant chemoradiotherapy, hereditary colorectal syndromes, inflammatory bowel diseases, lack of preoperative nodal staging, intraoperative radiotherapy, and follow-up <3 years. We compared cN-/pN+ patients according to the postoperative treatment received (group 1 if no further treatment, group 2 if any postoperative treatments), using ypN+ patients (neoadjuvant chemoradiotherapy + surgery) as controls (group 3). Oncological outcomes evaluated included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), local recurrence (LR), and distant recurrence (DR). RESULTS: Out of 218 patients included in the study, 77 cN- patients underwent initial surgery with a pN+ surgical specimen. Eighteen of these patients received no postoperative treatment due to associated comorbidity, patient preference, or postoperative complications while the remaining 59 (group 2) patients received chemoradiotherapy (n = 21) or chemotherapy alone (n = 38), respectively, and group 3 included 141 patients. Distal, radial resection margins and TME grading when available were comparable among groups. cN-/pN+ patients treated with surgery alone were associated with significantly poorer cancer outcomes compared with cN-/pN+ patients who received any form of adjuvant therapy and to ypN+ patients. CONCLUSION: TME surgery is not sufficient to optimize outcomes among rectal cancer patients believed to be node negative and found to be stage III based on specimen pathology.