Can the Heald anal stent help to reduce anastomotic or rectal stump leak in elective and emergency colorectal surgery? A single-center experience.

Anastomotic and rectal stump leaks are feared complications of colorectal surgery. Diverting stomas are commonly used to protect low rectal anastomoses but can have adverse effects. Studies have reported favorable outcomes for transanal drainage devices instead of diverting stomas. We describe our use of the Heald anal stent and its potential impact in reducing anastomotic or rectal stump leak after elective or emergency colorectal surgery. We performed a single-center retrospective analysis of patients in whom a Heald anal stent had been used to "protect" a colorectal anastomosis or a rectal stump, in an elective or emergency context, for benign and malignant pathology. Intraoperative and postoperative outcomes were reviewed using clinical and radiological records. The Heald anal stent was used in 93 patients over 4 years. Forty-six cases (49%) had a colorectal anastomosis, and 47 (51%) had an end stoma with a rectal stump. No anastomotic or rectal stump leaks were recorded. We recommend the Heald anal stent as a simple and affordable adjunct that may decrease anastomotic and rectal stump leak by reducing intraluminal pressure through drainage of fluid and gas.

Pathophysiological basis, clinical assessment, investigation and management of patients with obstruction defecation syndrome.

Obstructed defecation syndrome (ODS) is a clinical syndrome manifest as difficulty in faecal evacuation despite no mechanical obstruction. It is the final clinical pathway of a number of anatomical and physiological pathologies they can result in considerable misery to the lives of the patients it afflicts. Herein, the authors seek to breakdown the syndrome into its component parts, looking first at normal pelvic floor anatomy and physiology; followed by each pathological element; clinical features and investigation; individual management and management of the patient as a whole. It must be stated that correction of anatomy is not the sine qua non, as this does not always correlate to improvement of symptoms. There is a complex interplay of all elements, and a holistic approach appreciating the gestalt principle of "the whole is greater than the sum of its parts" is paramount. Causes of pelvic pain (levator ani syndrome, coccygodynia, proctalgia fugax and pudendal neuralgia) do not fall into ODS and are beyond the scope of this paper.

Can Cross-Sectional Imaging Reliably Determine Pathological Staging of Right-Sided Colon Cancers and Select Patients for More Radical Surgery or Neo-Adjuvant Treatment?

Purpose and research question Cross-sectional imaging with CT scanning is the most commonly performed imaging modality to stage right-sided colon cancers. There is increasing evidence for the use of neo-adjuvant chemotherapy in selected patients and debate about the role of complete mesocolic excision (CME) and central vascular ligation (CVL) in the management of locally advanced colon cancers. Predicted tumour stage and the presence of nodal metastases by CT are often used to select patients for neo-adjuvant chemotherapy and those that may benefit from CME. This study aims to compare predicted radiological T and N staging with final pathological T and N staging in elective patients having potentially curative surgery for right-sided colon cancer. Methods A retrospective analysis was carried out of a prospectively gathered database of all patients who had undergone (true) right hemicolectomy between 02/01/13 and 21/05/20. Sensitivity, specificity, positive predictive value, and negative predictive value for CT scanning with regards to the pathological nodal metastases were calculated and analysed. Results The sensitivity and specificity of radiology staging for predicting nodal status were 76.4% and 65.5% respectively. The positive predictive value of CT staging for correctly identifying nodal metastases was 55.3%, with a negative predictive value of 77.3%. Conclusions This large series adds further evidence that CT, even when reviewed by expert GI radiologists, has limited accuracy at identifying lymph node metastases in colon cancer.

Anatomy of the Mesentery.

It is clear that despite the importance of multimodal therapy, the most impactful weapon in the arsenal of treatment in a patient with colorectal cancer is high-quality surgery. This has been shown time and time again and surgery remains the bedrock in the management of visceral, and particularly colorectal, cancer. The reason for this is an anatomical one, based upon embryological planes. One cannot truly understand and perform high-quality surgery without an appreciation of the fascial and mesenteric anatomy of the abdomen and pelvis. R. J. ("Bill") Heald greatly advanced the management of rectal cancer with his description of the anatomical foundation of total mesorectal excision. He popularized usage of the term "mesorectum" and was an early pioneer in the commitment to mesenteric-based surgery. This concept has been extended by Werner Hohenberger to mesocolic excision for colon cancer surgery. These all rely on the principle that, in general, cancer tends to remain within its embryological compartment of origin, making it amenable to dissecting out as an oncological surgical envelope or package. There have been some theories put forth as to why, but it remains the fact that, far more often than not, an excision within the mesenteric plane affords better outcomes than the one that breaches it. Thus an understanding of the anatomy of the mesentery is important and is the scientific foundation of the art that is cancer surgery. Herein the author outlines the history of the development of our understanding of mesenteric anatomy and where we are today.

Association of Postoperative Clinical Outcomes With Sarcopenia, Frailty, and Nutritional Status in Older Patients With Colorectal Cancer: Protocol for a Prospective Cohort Study.

BACKGROUND: Older patients account for a significant proportion of patients undergoing colorectal cancer surgery and are vulnerable to a number of preoperative risk factors that are not often present in younger patients. Further, three preoperative risk factors that are more prevalent in older adults include frailty, sarcopenia, and malnutrition. Although each of these has been studied in isolation, there is little information on the interplay between them in older surgical patients. A particular area of increasing interest is the use of urine metabolomics for the objective evaluation of dietary profiles and malnutrition. OBJECTIVE: Herein, we describe the design, cohort, and standard operating procedures of a planned prospective study of older surgical patients undergoing colorectal cancer resection across multiple institutions in the United Kingdom. The objectives are to determine the association between clinical outcomes and frailty, nutritional status, and sarcopenia. METHODS: The procedures will include serial frailty evaluations (Clinical Frailty Scale and Groningen Frailty Indicator), functional assessments (hand grip strength and 4-meter walk test), muscle mass evaluations via computerized tomography morphometric analysis, and the evaluation of nutritional status via the analysis of urinary dietary biomarkers. The primary feasibility outcome is the estimation of the incidence rate of postoperative complications, and the primary clinical outcome is the association between the presence of postoperative complications and frailty, sarcopenia, and nutritional status. The secondary outcome measures are the length of hospital stay, 30-day hospital readmission rate, and mortality rate at days 30 and 90. RESULTS: Our study was approved by the National Health Service Research Ethics Committee (reference number: 19/WA/0190) via the Integrated Research Application System (project ID: 231694) prior to subject recruitment. Cardiff University is acting as the study sponsor. Our study is financially supported through an external, peer-reviewed grant from the British Geriatrics Society and internal funding resources from Cardiff University. The results will be disseminated through peer-review publications, social media, and conference proceedings. CONCLUSIONS: As frailty, sarcopenia, and malnutrition are all areas of common derangement in the older surgical population, prospectively studying these risk factors in concert will allow for the analysis of their interplay as well as the development of predictive models for those at risk of commonly tracked surgical complications and outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/16846.

Circulating levels of anti-angiogenic VEGF-A isoform (VEGF-Axxxb) in colorectal cancer patients predicts tumour VEGF-A ratios.

PURPOSE: Bevacizumab as an adjunct to chemotherapy improves survival for some patients with metastatic colorectal cancer. Immunohistochemical staining of samples from the registration ECOG E3200 trial of bevacizumab with FOLFOX demonstrated that only patients with carcinomas expressing low levels of VEGF-A165b, an anti-angiogenic splice variant of the Vascular Endothelial Growth Factor family of proteins, benefited from bevacizumab treatment. To identify a more useful biomarker of response we tested the hypothesis that circulating VEGF-A165b levels correlate with immunohistochemical staining. EXPERIMENTAL DESIGN: 17 patients with biopsy proven colorectal adenocarcinoma had pre-operative blood samples drawn. They underwent resection and had post-resection blood drawn. The plasma was analysed for levels of VEGF-Axxxb using enzyme-linked immunosorbent assay (ELISA) and the tumour blocks stained for VEGF-Axxxb and pan-VEGF-A. The normalised ratio of VEGF-Axxxb expression to that of panVEGF-A expression scored by IHC was calculated and correlated with plasma VEGF-A165b levels. RESULTS: Plasma levels of VEGF-Axxxb significantly correlated with the VEGF-Axxxb:panVEGF-A ratio (r=0.594, P<0.02) in colorectal cancers. Median plasma VEGF-Axxxb levels were 151 pg/ml. The mean (1.5±0.17) and median, IQR (1.8, 1-2) IHC scores of the patients with greater than median plasma VEGF-Axxxb were significantly greater than those with less than median plasma VEGF-Axxxb levels (mean ± SEM=0.85±10.12, median, IQR=1, 0.54-1). CONCLUSION: These results suggest that plasma VEGF-Axxxb levels could be an effective biomarker of response to Bevacizumab. These results indicate that a prospective trial is warranted to explore the use of plasma VEGF-Axxxb levels to stratify patients for colorectal cancer treatment by bevacizumab.

Multidisciplinary perspective on the management of appendiceal adenocarcinoma: case review of 10 patients from a university hospital and current considerations.

BACKGROUND: Adenocarcinoma of the vermiform appendix is rare. It constitutes less than 0.5% of all gastrointestinal malignancies. Pathologically, appendiceal neoplasms are categorized into various subtypes depending on cell lineage. PATIENTS AND METHODS: We considered a case series of appendiceal invasive adenocarcinomas from 2004 to 2013 managed in a teaching hospital. We discuss our management dilemmas, given the lack of randomized controlled trial data that exist. A detailed look at the histopathology, case series, and literature is presented. RESULTS: Ideal standards ought to be constructed for the management of this rare pathology, with a particular focus on exploring the indications and potential benefits, as well as difficulties, of ileocolic lymphadenectomy. CONCLUSION: Appendiceal adenocarcinoma ought to be managed in the same way as a cecal adenocarcinoma.

Perforated jejunal ulcer associated with gastric mucosa in a jejunal diverticulum.

Jejunal diverticula are rare and subsequent complications even more so. The usual small bowel diverticulum encountered by general surgeons is a Meckel's. These are embryological remnants of the vitello-intestinal duct and are on the anti-mesenteric surface of the terminal ileum. They may contain heterotopic gastric or pancreatic mucosa. Herein we explore the case of a young girl who presented with features of peritonitis secondary to a complication from a jejunal diverticulum. The case, pathology, complications and treatment of jejunal diverticulosis and heterotopic gastric mucosa in the jejunum are explored.

Hydrocele of the canal of Nuck--an old problem revisited.

Herein the authors describe the case of a young woman presenting with a tender lump in her groin. Clinically the differential was of either a reactive lymph node or a femoral hernia. Ultrasound scan was urgently arranged and showed a cystic lesion. Surgical exploration was carried out and revealed this to be a hydrocele of the canal of Nuck. This was excised and the patient's symptoms resolved and she was discharged home the following day. We explore the embryology, pathophysiology and management of this rare entity.

Caution: laparoscopic biopsy of a large pelvic mass may result in disaster.

Anterior sacral meningocele is a rare cause of a pelvic mass. Herein the authors describe the case of a young patient presenting with chronic pelvic pain undergoing diagnostic laparoscopy. She was found to have a retrorectal mass confirmed as an anterior sacral meningocele on subsequent MRI. The authors explore the case, describe a method of intraoperative management to minimize the risk of severe complications and include a discussion of the differential diagnosis. Central to this is an emphasis on advocating a cautious approach when confronted with an incidental unknown pelvic mass, as deleterious consequences may occur from biopsy of such a lesion.

Perihepatic abscess secondary to retained appendicolith: A rare complication managed laparoscopically.

Appendicectomy is one of the commonest emergency operations performed worldwide. In cases of perforated appendicitis, the prevalence of post-operative abscess formation is up to 20 per cent (1). Most cases can be managed with drainage and antibiotics. However, a minority of these will leave a retained appendicolith. We present a case of a 17 year old female patient who presented 1 year after laparoscopic appendicectomy for perforated appendicitis, with right upper quadrant pain and sepsis. Computed tomography (CT) of the abdomen was performed and revealed a retained appendicolith with perihepatic abscess formation in the right upper quadrant. She underwent laparoscopic drainage of this perihepatic abscess and removal of the faecolith. She was discharged home the following day and remains well.

The squelching hip: a sign of life-threatening sepsis following haemorrhoidectomy.

We report a case of fulminating infection tracking from the left ischiorectal fossa to the popliteal fossa as a consequence of rectal perforation 11 days following traditional Milligan-Morgan haemorrhoidectomy. The case presented as a loud squelching noise coming from the hip on walking. Extensive cellulitis was evident over the posterior aspect of the thigh, with a deep fluctuant collection in the left buttock that communicated with the posterior compartment of the thigh. Per rectal examination revealed a defect in the rectal wall, with a foul-smelling discharge. Extensive thigh incision and drainage, defunctioning colostomy, multiple washouts, and split skin grafting procedures were performed. The patient has now recovered.

Colonic perforation following mild abdominal trauma in a patient with Crohn's disease: a case report.

Colonic perforation following mild abdominal trauma in patients with Crohn's disease is a rare occurrence. We present a case of a 21 year old Crohn's sufferer, who presented to the emergency department with signs of shock and peritonitis following minor abdominal trauma. A computed tomography (CT) scan revealed ascending colonic perforation and he underwent a subsequent right hemicolectomy. This is the first UK report of a patient with inflammatory bowel disease suffering colonic perforation following minimal trauma.

Laparoscopic assisted right hemicolectomy for caecal volvulus.

A case of acute caecal volvulus is presented where laparoscopy was used to avoid a major laparotomy. A technique is described for safe deflation of the caecum, which allowed a small incision for resection and anastomosis.