Microsatellite instability in young patients with mucinous colorectal cancers – characterization using molecular testing, immunohistochemistry, and histological features

CONTEXT: The incidence of colorectal cancers (CRCs) in young Indian patients is higher than the international average. CRCs in young patients are commonly of mucinous type and show microsatellite instability (MSI). AIMS: To ascertain the MSI status of mucinous CRCs in patients ≤40 years of age by molecular testing and to correlate this with immunohistochemical (IHC) analysis and tumor histology. SUBJECTS AND METHODS: Archived formalin-fixed paraffin embedded tissue blocks of 30 young mucinous CRC patients were retrieved. MSI testing was done using two mononucleotide markers – BAT26 and NR24. IHC analysis was done using MLH1, MSH2, and MSH6. Histological features of all cases were studied. Data were analyzed using the SPSS software and the Pearson's chi-square test and Fisher's exact test. RESULTS: Eight out of 30 cases (26.7%) showed MSI by molecular testing. IHC identified seven of these cases. Histological features showing a statistically significant association with MSI were the presence of a well-differentiated adenocarcinoma component (P = 0.003), peritumoral lymphocytes (P = 0.002) and tumor budding (P = 0.021). CONCLUSION: The detection of defective mismatch repair (MMR) proteins using IHC for MLH1, MSH2, and MSH6 and molecular testing using BAT26 and NR24 appears to be a good protocol to detect CRCs with MSI. Histology could be useful in identifying cases that require screening for presence of MMR protein defects

Management of Crohn’s disease after intestinal resection: Look hard, act fast.

De Cruz P, Kamm MA, Hamilton AL, Ritchie KJ, Krejany EO, Gorelik A, Liew D, Prideaux L, Lawrance IC, Andrews JM, Bampton PA, Gibson PR, Sparrow M, Leong RW, Florin TH, Gearry RB, Radford-Smith G, Macrae FA, Debinski H, Selby W, Kronborg I, Johnston MJ, Woods R, Elliott PR, Bell SJ, Brown SJ, Connell WR, Desmond PV. (Department of Gastroenterology, St Vincent’s Hospital and Department of Medicine, University of Melbourne, Melbourne, Australia; Austin Health, University of Melbourne, Austin Academic Centre, Heidelberg, Australia; Department of Medicine, Imperial College London, London, UK; Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia; Centre for Inflammatory Bowel Diseases, Fremantle Hospital and The University of Western Australia, Fremantle, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital and University of Adelaide, Adelaide, Australia; Department of Gastroenterology and Hepatology, Flinders Medical Centre and Flinders University, Adelaide, Australia; Department of Gastroenterology, Monash University, Melbourne, Australia; Department of Gastroenterology, Alfred Health, Melbourne, Australia; Gastroenterology and Liver Services, Concord and Bankstown Hospitals and The University of New South Wales, Sydney, Australia; Department of Gastroenterology, Mater Health Services, University of Queensland, Brisbane, Australia; Department of Medicine, University of Otago, Christchurch, New Zealand; QIMR Berghofer Medical Research Institute, University of Queensland School of Medicine, Inflammatory Bowel Diseases Unit, Royal Brisbane and Women’s Hospital, Brisbane, Australia; Department of Colorectal Medicine and Genetics, and Department of Medicine, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia; Melbourne Gastrointestinal Investigation Unit, Cabrini Hospital, Melbourne, Australia; AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia; Department of Gastroenterology, Western Hospital, Melbourne, Australia; Department of Colorectal Surgery, St Vincent’s Hospital and Department of Medicine, University of Melbourne, Melbourne, Australia.) Crohn’s disease management after intestinal resection: A randomised trial. Lancet 2015;385:

Surgical manifestations of scrub typhus: A diagnostic dilemma.

Scrub typhus, a zoonosis caused by Orientia tsutsugamushi, is a systemic febrile illness. The disease presents with diverse clinical manifestations, ranging from subclinical disease to multiorgan failure and fatal disease. It may rarely present as an acute abdomen which may lead to a diagnostic dilemma. We describe two serologically confirmed cases of scrub typhus presenting as acute abdomen—one mimicking acute appendicitis and the other acute cholecystitis, both managed non-operatively. A high index of suspicion, along with subtle indicators in the history and clinical examination help avoid unnecessary surgery in such cases.

Anal sphincter repair for fecal incontinence: experience from a tertiary care centre .

Aim Structural anal sphincter damage may be secondary to obstetric anal sphincter injury, perineal trauma or anorectal surgery. We reviewed the spectrum of anal sphincter injuries and their outcomes in a tertiary care colorectal unit. Methods Data of patients who underwent anal sphincter repair between 2004 and 2008 were analyzed retrospectively. Outcomes were compared with respect to etiology, type of repair, previous attempts at repair and manometry findings. Outcomes were defined as good or poor based on patient satisfaction as the primary criteria. Results Thirty-four patients underwent anal sphincter repair. Twenty-two injuries were obstetric, eight traumatic, and four iatrogenic. All patients underwent overlap sphincteroplasty with six additional anterior levatorplasty and seven graciloplasty. Twenty-three (67.6%) patients had a good outcome while nine (26.4%) had a poor outcome. All patients who had augmentation anterior levatorplasty had a good outcome. Fifty percent of patients with a previous sphincter repair and 42.9% requiring augmentation graciloplasty had a poor outcome. Median resting and squeeze anal pressures increased from 57.5 to 70 cmH2O and 90.25 to 111 cmH2O in those with a good outcome. Conclusions Overlap sphincteroplasty has a good outcome in majority of the patients with incontinence due to a structural sphincter defect. Additional anterior levatorplasty may improve outcomes. Previous failed repairs or use of a gracilis muscle augmentation may have a worse outcome secondary to poor native sphincter muscle. Improvement in resting and squeeze pressures on anal manometry may be associated with a good outcome.

The abdominal cocoon and an effective technique of surgical management.

The Abdominal Cocoon is a very rare cause of small bowel obstruction. It is caused by encapsulation of the small bowel by a fibrous membrane. This tropical disease, seen in young females, has also been reported in males. This is one of the largest series of the Abdominal Cocoon, with five new patients (3 males and 2 females) being reported. The traditional surgical treatment of choice is by lysis of adhesions. All patients in this case series had small bowel intubation done in addition to adhesiolysis. Although small bowel intubation is an established procedure for various causes of recurrent small bowel obstruction, to our knowledge this is the first report of its use in the management of the Abdominal Cocoon. We report our surgical technique in the management of this rare disease.