Management of Cylindrical Battery Ingestion.

Presentation A female presented to the Emergency Department following ingestion of an unknown number of cylindrical batteries. Diagnosis Abdominal X-ray confirmed the presence of multiple batteries located throughout the abdomen. Treatment A trial of conservative management was pursued, and five AA batteries were successfully passed per rectum. Serial X-rays over three weeks revealed that the majority of batteries failed to pass. A decision was made to perform a laparotomy, and 46 cylindrical batteries were removed from the stomach through a small gastrotomy. Four batteries located in the colon were milked into the rectum and removed via the transanal route. Discussion Using daily clinical exams and weekly plain films of the abdomen, conservative management is possible if a small number of batteries are ingested and make it to the stomach. However, the potential of cylindrical batteries to result in acute surgical emergencies should not be underestimated.

Mucinous and non-mucinous colorectal cancers show differential expression of chemotherapy metabolism and resistance genes.

Previous research has identified differences in mutation frequency in genes implicated in chemotherapy resistance between mucinous and non-mucinous colorectal cancers (CRC). We hypothesized that outcomes in mucinous and non-mucinous CRC may be influenced by expression of genes responsible for chemotherapy resistance. Gene expression data from primary tumor samples were extracted from The Cancer Genome Atlas PanCancer Atlas. The distribution of clinical, pathological, and gene expression variables was compared between 74 mucinous and 521 non-mucinous CRCs. Predictors of overall survival (OS) were assessed in a multivariate analysis. Kaplan-Meier curves were constructed to compare survival according to gene expression using the log rank test. The median expression of 5-FU-related genes TYMS, TYMP, and DYPD was significantly higher in mucinous CRC compared to non-mucinous CRC (p < 0.001, p = 0.003, p < 0.001, respectively). The median expression of oxaliplatin-related genes ATP7B and SRPK1 was significantly reduced in mucinous versus non-mucinous CRC (p = 0.004, p = 0.007, respectively). At multivariate analysis, age (odds ratio (OR) = 0.96, p < 0.001), node positive disease (OR = 0.49, p = 0.005), and metastatic disease (OR = 0.32, p < 0.001) remained significant negative predictors of OS, while high SRPK1 remained a significant positive predictor of OS (OR = 1.59, p = 0.037). Subgroup analysis of rectal cancers demonstrated high SRPK1 expression was associated with significantly longer OS compared to low SRPK1 expression (p = 0.011). This study highlights that the molecular differences in mucinous CRC and non-mucinous CRC extend to chemotherapy resistance gene expression. SRPK1 gene expression was associated with OS, with a prognostic role identified in rectal cancers.

Microsatellite instability and response to neoadjuvant chemoradiotherapy in rectal cancer: A systematic review and meta-analysis.

BACKGROUND: Response to neoadjuvant chemoradiotherapy (CRT) in locally advanced rectal cancer is variable. Identification of biomarkers to predict response is desirable in order to provide prognostic information and targeted therapy. Several studies have investigated microsatellite instability (MSI) as a predictor of response to CRT with contradictory results. This study aims to clarify the effect of MSI status on response to CRT in locally advanced rectal cancer through systematic review and meta-analysis. METHODS: A systematic search of PubMed, Embase and Cochrane databases was performed for all studies relating to MSI and response to CRT in rectal cancer using the search algorithm (Microsatellite Instability) AND (Chemoradiotherapy) AND (Rectal Cancer). From each included study the number of patients with MSI tumors and Microsatellite Stable (MSS) tumors and the numbers achieving pathological complete response (pCR) were recorded. Pooled outcome measures were determined using a random effects model and the odds ratio estimated with variance and 95% confidence interval. RESULTS: Nine published studies were identified reporting data on MSI and its effect on outcome after CRT for locally advanced rectal cancer. Five studies describing 5,877 patients included data on MSI and the number of patients achieving pCR. There was no significant association between MSI and pCR (MSI Vs MSS: 10.1% Vs 6.6%, OR 1.38, 95% CI: 0.7-2.72, p = 0.35). CONCLUSION: This meta-analysis concludes that there appears to be no significant difference in pCR rate following CRT in patients with MSI versus MSS rectal tumors.

Meta-analysis of the molecular associations of mucinous colorectal cancer.

BACKGROUND: Mucinous differentiation occurs in 5-15 per cent of colorectal adenocarcinomas. This subtype of colorectal cancer responds poorly to chemoradiotherapy and has a worse prognosis. The genetic aetiology underpinning this cancer subtype lacks consensus. The aim of this study was to use meta-analytical techniques to clarify the molecular associations of mucinous colorectal cancer. METHODS: This study adhered to MOOSE guidelines. Databases were searched for studies comparing KRAS, BRAF, microsatellite instability (MSI), CpG island methylator phenotype (CIMP), p53 and p27 status between patients with mucinous and non-mucinous colorectal adenocarcinoma. A random-effects model was used for analysis. RESULTS: Data from 46 studies describing 17 746 patients were included. Mucinous colorectal adenocarcinoma was associated positively with KRAS (odds ratio (OR) 1·46, 95 per cent c.i. 1·08 to 2·00, P = 0·014) and BRAF (OR 3·49, 2·50 to 4·87; P < 0·001) mutation, MSI (OR 3·98, 3·30 to 4·79; P < 0·001) and CIMP (OR 3·56, 2·85 to 4·43; P < 0·001), and negatively with altered p53 expression (OR 0·46, 0·31 to 0·67; P < 0·001). CONCLUSION: The genetic origins of mucinous colorectal adenocarcinoma are predominantly associated with BRAF, MSI and CIMP pathways. This pattern of molecular alterations may in part explain the resistance to standard chemotherapy regimens seen in mucinous adenocarcinoma.

Thirty-seven-year Population-based Study of Colorectal Cancer Rates in Renal Transplant Recipients in Ireland.

BACKGROUND: Renal transplantation is associated with an increased risk of neoplasia, including colorectal cancer (CRC). Advances in surgical techniques and immunosuppressive medications have resulted in increased survival rates of both patients and grafts, but the incidence of CRC in the Irish renal transplant population is currently unknown. The aim of this study is to review the incidence of CRC in the Irish renal transplant population and compare it to the general population. METHODS: A retrospective review of a prospectively maintained database of all renal transplant recipients in Ireland between January 1980 and July 2017 was performed. RESULTS: Thirty-three out of 4230 transplant recipients (men = 20, women = 13) developed CRC subsequent to transplantation and were eligible for inclusion in the series. The mean age at transplantation was 51.5 years, with patients developing CRC on average 10.9 years post-transplantation; 6.1% (n = 2/33) had stage IV disease at diagnosis. The majority of patients (87.8%) had a pathologic T stage of T3/T4 and 45.5% had involvement of locoregional lymph nodes (N1/N2); 42.4% also had a mucinous component at histopathologic assessment. The incidence of CRC was higher in the transplant population compared to the general population. CONCLUSION: This is the first population-based assessment of CRC development in the Irish renal transplant population. Our data suggest that Irish transplant recipients have an increased risk of being diagnosed with a more advanced tumor than the general population, with most being diagnosed almost a decade after transplantation. This highlights the need for increased awareness among patients and clinicians and the potential need for coordinated lifelong surveillance of this patient population to ensure early detection and treatment.

Adherence to clinical guidelines and the potential economic benefits of admission avoidance for acute uncomplicated diverticulitis.

BACKGROUND: The treatment paradigm for acute diverticulitis is changing. There is an increasing trend towards managing patients with uncomplicated diverticulitis in the community. AIMS: The aim of this study was to analyse how acute diverticulitis is managed in our institution and also to analyse national data pertaining to treatment of acute diverticulitis. METHODS: A prospective database of all patients admitted to our institution over a 2-year period (2014-2016) with acute diverticulitis was maintained. Severity of disease, treatment received and average length of stay (LOS) were analysed for all patients. Contemporaneous hospital inpatient enquiry (HIPE) data was interrogated to analyse current management for acute diverticulitis at a national level. RESULTS: One hundred twenty-six patients were admitted to our institution with acute diverticulitis during the study period (inpatient stay = €1277/night). Of patients, 59.5% had uncomplicated diverticulitis while 40.5% had complicated disease. The median LOS was 4 (range 1-34) days and 8 (range 2-51) days in the uncomplicated and complicated group, respectively. Based on HIPE data, there were 11,357 patients with uncomplicated diverticulitis and 526 patients with complicated diverticulitis admitted to Irish hospitals in the year 2015. Nationally, the median LOS for those with uncomplicated diverticulitis was 3 (range 1-142) days and for those with complicated diverticulitis the median LOS was 7 (range 1-308) days. Projected total cost for hospital stay nationally for uncomplicated diverticulitis amounted to €43.5 million for the year 2015. CONCLUSIONS: At present, uncomplicated diverticulitis in Ireland is not being managed as per evidence-based guidelines. Changing practice could result in significant cost savings for surgical departments.

C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer.

AIM: Anastomotic leak (AL) after anterior resection results in increased morbidity, mortality and local recurrence. The aim of this study was to assess the ability of C-reactive protein (CRP) to predict AL in the first week after anterior resection for rectal cancer. METHOD: A retrospective review of a prospectively maintained database that included all patients undergoing anterior resection between January 2008 and December 2013 was performed. The ability of CRP to predict AL was assessed using area under the receiver-operating characteristics (AUC) curves. The severity of AL was defined using the International Study Group of Rectal Cancer (ISREC) grading system. RESULTS: Two-hundred and eleven patients were included in the study. Statistically significant differences in mean CRP values were found between those with and without an AL on postoperative days 5, 6 and 7. A CRP value of 132 mg/l on postoperative day 5 had an AUC of 0.75, corresponding to a sensitivity of 70%, a specificity of 76.6%, a positive predictive value of 16.3% and a negative predictive value of 97.5%. Multivariable analysis found that a CRP of > 132 mg/l on postoperative day 5 was the only statistically significant patient factor that was linked to an increased risk of AL (HR = 8.023, 95% CI: 1.936-33.238, P = 0.004). CONCLUSION: Early detection of AL may minimize postoperative complications. CRP is a useful negative predictive test for the development of AL following anterior resection.

Endoscopic tattooing to aid tumour localisation in colon cancer: the need for standardisation.

BACKGROUND/AIMS: An increasing number of colon and rectal tumours are being resected using laparoscopic techniques. Identifying these tumours intraoperatively can be difficult. The use of tattooing can facilitate an easier resection; however, the lack of standardised guidelines can potentially lead to errors intraoperatively and potentially result in worse outcomes for patients. The aim of this study was to identify the most reliable method of preoperative tumour localisation from the available literature to date. METHODS: A literature review was undertaken to identify any articles related to endoscopic tattooing and tumour localisation during colorectal surgery. RESULTS: To date there is still mixed evidence regarding tattooing techniques and the choice of ink that should be used. There are numerous studies demonstrating safe tattooing techniques and highlighting the risks and benefits of different types of ink available. CONCLUSION: Based on the available studies we have recommended a standardised approach to endoscopic tattooing of colorectal tumours prior to laparoscopic resection.

Dislocation following total hip replacement.

An analysis of 142 dislocations from a multicentre study of 6774 total hip replacements is reported. The incidence of dislocation was 2.1 per cent. Patients with neuromuscular disorder, those in a confused mental state, and those undergoing revision operations are at special risk. The commonest surgical error, present in nearly half the patients, was placing the acetabular cup too vertically or too anteverted. A less common fault was placing the femoral component too anteverted. Neither the original pathology nor the approach to the hip appeared to affect the likelihood of dislocation. The dislocations were divided into early and late, single and recurrent, and the success rate of treatment is described in these groups. One hundred and eleven patients (78.2 per cent) eventually obtained stability. Of those with a single dislocation, 62 per cent remained stable after a single manipulation. Thirty-four per cent of the patients required an open operation to achieve stability and it is suggested that, in many cases, open reduction alone is not enough; the mechanical fault needs to be corrected.

Dorsal radiocarpal dislocation.

Dorsal radiocarpal dislocation is rare. Large forces are necessary to produce such injuries and the majority of these patients have severe associated injuries and are unable to remember exactly how they occurred. A case is reported in which there was an isolated dorsal radiocarpal fracture-dislocation associated with contusion of the median nerve. The manner of injury is well demonstrated.