Delayed metastatic endometrial carcinoma mimicking primary colon adenocarcinoma: A surprise histopathological finding.

Key Clinical Message: Colorectal cancer is the third most common malignancy worldwide, with an increasing incidence. Colonic metastasis is a rare occurrence; thus, misdiagnosis is common. Immunohistochemistry facilitates accurate diagnosis and subsequent management. Abstract: Most cancers in the colon are primary colorectal cancers, however metastasis from another primary is possible, albeit rare. Endometrial cancer metastasis to the colon is a rare occurrence and is only described in a handful of cases. We describe a rare case of metastatic endometrial cancer in the colon presenting 5 years post radical hysterectomy and adjuvant radiotherapy in a 62-year-old female. She presented with a 1-week history of right upper quadrant pain, with no other associated symptoms. She was presumed to have a primary colorectal cancer based on her colonoscopy and CT findings; later proven otherwise by immunohistochemistry (IHC). Endometrial cancer metastasis to the colon is rare, thus misdiagnosis can easily occur. Currently, there are 6 similar cases reported in the literature, all occurring in the absence of colorectal endometriosis. This case illustrates the relative importance of considering colon as a potential site for metastasis of endometrial cancer and the utility of IHC in aiding diagnosis and guiding further management.

Time to interval cholecystectomy and associated outcomes in a population aged 50 and above with mild gallstone pancreatitis.

BACKGROUND: Cholecystectomy on index admission for mild gallstone pancreatitis (GSP) is recommended, although not always feasible. This study examined rates and outcomes of people aged ≥ 50 years who underwent interval (delayed) cholecystectomy at increasing time points. METHODS: Hospitalisation and death data were linked for individuals aged ≥ 50 years admitted to hospital in New South Wales, Australia with mild GSP between 2008-2018. Primary outcome was interval cholecystectomy timing. Secondary outcomes included mortality, emergency readmission for gallstone-related disease (GSRD) (28 and 180-day), and length of stay (LOS) (index admission and total six-month GSRD). RESULTS: 3,003 patients underwent interval cholecystectomy: 861 (28.6%) at 1-30, 1,221 (40.7%) at 31-90 and 921 (30.7%) at 91-365 days from index admission. There was no difference in 365-day mortality between groups. Longer delay to cholecystectomy was associated with increased 180-day emergency GSRD readmission (17.5% vs 15.8% vs 19.9%, p < 0.001) and total six-month LOS (5.9 vs 8.4 vs 8.3, p < 0.001). Endoscopic retrograde cholangiopancreatography (ERCP) was increasingly required with cholecystectomy delay (14.5% vs 16.9% vs 20.4%, p < 0.001), as were open cholecystectomy procedures (4.8% vs 7.6% vs 11.3%, p < 0.001). Extended delay was associated with patients of lower socioeconomic status, regional/rural backgrounds or who presented to a low volume or non-tertiary hospital (p < 0.001). CONCLUSION: Delay to interval cholecystectomy results in increased rates of emergency readmission, overall LOS, risks of conversion to open surgery and need for ERCP. Index admission cholecystectomy is still recommended, however when not possible, interval cholecystectomy should be performed within 30 days to minimise patient risk and healthcare burden.

Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures.

OBJECTIVES: To estimate the proportions of people aged 50 years or more with mild gallstone pancreatitis who undergo index cholecystectomy (during their initial hospital admission) or interval cholecystectomy (during a subsequent admission); to compare outcomes following index and interval cholecystectomy; and to identify factors associated with undergoing interval cholecystectomy. DESIGN, SETTING, PARTICIPANTS: Analysis of linked hospitalisation and deaths data for all people aged 50 years or more with mild gallstone pancreatitis who underwent cholecystectomy in New South Wales within twelve months of their index admission, 1 July 2008 - 30 June 2018. MAIN OUTCOME MEASURES: Cholecystectomy classification (index or interval). SECONDARY OUTCOMES: all-cause mortality (30-365 days), emergency re-admissions with gallstone-related disease (within 28 or 180 days of discharge); hospital lengths of stay (index admission, and all admissions with gallstone-related disease over six months). RESULTS: A total of 1836 patients underwent index cholecystectomy (37.9%) and 3003 interval cholecystectomy (62.1%). Mortality to twelve months was similar in the two groups. Larger proportions of people who underwent interval cholecystectomy were re-admitted within 28 days (246, 8.2% v 23, 1.3%) or 180 days (527, 17.6% v 59, 3.2%), or required open cholecystectomy (238, 7.9% v 69, 3.8%). Mean index admission length of stay was longer for index than interval cholecystectomy (7.7 [SD, 4.7] days v 5.3 [SD, 3.9] days), but six-month total length of stay was similar (8.2 [SD, 5.6] days v 7.9 [SD, 5.8] days). Interval cholecystectomy was more likely for patients with three or more comorbid conditions (adjusted odds ratio [aOR], 1.29; 95% CI, 1.08-1.55) or private health insurance (aOR, 1.31; 95% CI, 1.13-1.51), and for those admitted to low surgical volume hospitals (aOR, 1.84; 95% CI, 1.03-3.31). CONCLUSIONS: Most NSW people over 50 with mild gallstone pancreatitis did not undergo index cholecystectomy, despite recommendations in international guidelines. Delayed cholecystectomy was associated with more frequent open cholecystectomy procedures and gallstone disease-related emergency re-admissions, as well as with low or medium hospital surgical volume, comorbidity, and having private insurance.

Risk Factors for Early Pancreatic Allograft Thrombosis Following Simultaneous Pancreas-Kidney Transplantation: A Systematic Review.

Simultaneous pancreas-kidney (SPK) transplantation remains the most effective treatment for providing consistent and long-term euglycemia in patients having type 1 diabetes with renal failure. Thrombosis of the pancreatic vasculature continues to contribute significantly to early graft failure and loss. We compared the rate of thrombosis to graft loss and systematically reviewed risk factors impacting early thrombosis of the pancreas allograft following SPK transplantation. We searched the MEDLINE, EMBASE, The Cochrane Library, and PREMEDLINE databases for studies reporting thrombosis following pancreas transplantation. Identified publications were screened for inclusion and synthesized into a data extraction sheet. Sixty-three studies satisfied eligibility criteria: 39 cohort studies, 22 conference abstracts, and 2 meta-analyses. Newcastle-Ottawa Scale appraisal of included studies demonstrated cohort studies of low bias risk; 1127 thrombi were identified in 15 936 deceased donor, whole pancreas transplants, conferring a 7.07% overall thrombosis rate. Thrombosis resulted in pancreatic allograft loss in 83.3% of reported cases. This review has established significant associations between donor and recipient characteristics, procurement and preservation methodology, transplantation technique, postoperative management, and increased risk of early thrombosis in the pancreas allograft. Further studies examining the type of organ preservation fluid, prophylactic heparin protocol, and exocrine drainage method and early thrombosis should also be performed.