Current Treatment Approaches and Outcomes in the Management of Rectal Cancer Above the Age of 80.

BACKGROUND: The number of cases of rectal cancer in our older cohort is expected to rise with our ageing population. In this study, we analysed patterns in treatment and the long-term outcomes of patients older than 80 years with rectal cancer across a health district. METHODS: All cases of rectal cancer managed at the Illawarra Cancer Care Centre, Australia between 2006 and 2018 were analysed from a prospectively maintained database. Patients were stratified into three age groups: ≤65 years, 66-79 years and ≥80 years of age. The clinicopathological characteristics, operative and non-operative treatment approach and survival outcomes of the three groups were compared. RESULTS: Six hundred and ninety-nine patients with rectal cancer were managed, of which 118 (17%) were aged 80 and above. Patients above 80 were less likely to undergo surgery (71% vs. 90%, p < 0.001) or receive adjuvant/neoadjuvant chemoradiotherapy (p < 0.05). Of those that underwent surgical resection, their tumours were on average larger (36.5 vs. 31.5 mm, p = 0.019) and 18 mm closer the anal verge (p = 0.001). On Kaplan-Meier analysis, those above 80 had poorer cancer-specific survival when compared to their younger counterparts (p = 0.032), but this difference was no longer apparent after the first year (p = 0.381). CONCLUSION: Patients above the age of 80 with rectal cancer exhibit poorer cancer-specific survival, which is accounted for in the first year after diagnosis. Priority should be made to optimise care during this period. There is a need for further research to establish the role of chemoradiotherapy in this population, which appears to be underutilised.

Low-Dose Pre-Operative Botulinum Toxin A Effectively Facilitates Complex Ventral Hernia Repair: A Case Report and Review of the Literature.

Background: Complex ventral hernias following laparotomy present a unique challenge in that repair is hindered by the lateral tension of the abdominal wall. A novel approach to overcome this is the "chemical component separation" technique. Here, botulinum toxin A (BTA) is instilled into the muscles of the abdominal wall. This induces flaccid paralysis and effectively reduces tension in the wall, allowing the muscles to be successfully joined in the midline during surgery. We describe a method where a large incisional hernia was repaired using this technique and review the variations in methodology. Case report: A woman in her mid-40s developed a ventral hernia in the setting of a previous laparotomy for a small bowel perforation. Computed tomography (CT) of the abdomen demonstrated an 85 (Width) × 95 mm (Length) ventral hernia containing loops of the bowel. Pre-operative botulinum toxin A administration was arranged at the local interventional radiology department. A total of 100 units of BTA were instilled at four sites into the muscular layers of the abdominal wall under CT-fluoroscopic guidance. She underwent an open incisional hernia repair 4 weeks later, where the contents were reduced and the abdominal wall layers were successfully joined in the midline. There was no clinical evidence of hernia recurrence at 3-months follow-up. Conclusion: Low-dose BTA effectively facilitates the surgical management of large ventral incisional hernias. There is, however, significant variation in the dosage, concentration and anatomical landmarks in which BTA is administered as described in the literature. Further studies are needed to assess and optimise these variables.

A case of an asymptomatic sacrococcygeal teratoma diagnosed in adulthood.

Sacrococcygeal teratomas are rare congenital tumours that are even more uncommon when present in adulthood. They are derived from residual stem cells in the presacral space that differentiate into clusters of somatic cell. We present the diagnosis, management and post-operative follow-up in a 37-year-old gentleman referred to our department with an incidental finding of a lobulated presacral cystic mass on computed tomography imaging. Magnetic resonance imaging and fluorodeoxyglucose (FDG)-positron emission tomography (PET) scans were performed to further characterize the lesion. The decision was then made for surgical excision and the specimen along with the coccyx was retrieved en-bloc via a trans-sacral surgical approach. Histopathology of the mass uncovered the presence of squamous, respiratory and prostatic epithelium consistent with the diagnosis of a sacrococcygeal teratoma.

How to deal with complex anal fistula in an immunosuppressed patient.

We describe a practical approach to the management of complex anal fistula in an immunocompromised patient. We define our treatment motifs: to close the internal opening, maintain external drainage until internal opening and tract healed; minimize sphincter damage. We hope other authors can build on this case technique to improve fistula surgery outcomes.

Deficiencies in pathological reporting of colorectal cancer in Victoria.

BACKGROUND: Colorectal cancer (CRC) pathological reporting deficiencies have been shown to be common, with deviations from the suggested minimum dataset. Information from both surgeon and pathologist is necessary for a complete report. These deficiencies have been shown to be correctable with the use of synoptic reporting. We carried out an audit on a random sample of CRC pathological reports from the first 6 months of 2004 in Victoria, Australia, with the aim of documenting current CRC pathological reporting deficiencies. METHODS: A random sample of pathological reports for CRC was obtained from the Cancer Council of Victoria. One hundred and sixteen of these reports were reviewed by a team of surgical and pathology trainees. Presence or absence of the various fields of the 1999 National Health and Medical Research Council minimum dataset for CRC reporting was recorded. RESULTS: There were deviations from the minimal dataset. Most notable was the absence of the information on the apical node, the presence of distant metastasis and perineural invasion. CONCLUSIONS: The opportunity exists for improvement in the pathological reporting of CRC in Victoria through the uniform introduction of synoptic reporting.

Protocol-based approach to suspected appendicitis, incorporating the Alvarado score and outpatient antibiotics.

BACKGROUND: There is evidence that antibiotics can be used as primary treatment for appendicitis, however, delayed surgical treatment might still be associated with perforation. Most patients at risk of perforation have high Alvarado scores. We designed a protocol-based approach to suspected appendicitis, in which the Alvarado score was used to select patients for early treatment with surgery or outpatient antibiotics. METHODS: Patients included in the present study were adults and children referred to the surgical service at John Hunter Hospital (Newcastle, Australia) with suspected appendicitis in the 12 months from July 2000. Treatment groups: no treatment (Alvarado score 1-4); antibiotics alone (Alvarado 5-7); early surgery (Alvarado 8-10). OUTCOME MEASURES: time to operation; duration of hospital stay; non-therapeutic operations; delayed treatment in association with perforation; recurrent appendicitis (for those treated with antibiotics). Comparison group: 142 patients managed with 'best clinical practice' as part of an earlier trial. RESULTS: One hundred and twenty-two patients were enrolled. Median time to operation was 3.9 h (comparison group 7.3 h, P = 0.014). Median length of stay was 38.5 h (comparison group 44.2 h, P = 0.041). There were two cases of delayed treatment in association with perforation (2/122 = 1.6%, comparison group 2/142 = 1.4%, P = 0.88) and 10 non-therapeutic operations (10/122 = 8.1%, comparison group 15/142 = 10.6%, P = 0.51). Of those whose initial illness was treated successfully with antibiotics, 2/42 (4.8%) subsequently required appendicectomy. CONCLUSIONS: This protocol-based approach to suspected appendicitis is feasible. A prospective controlled study would be required to confirm potential benefits (in terms of short hospital stay) and to confirm that there is not an increase in adverse outcomes.