Carcinosarcoma of the Rectum: Report of a Rare Colorectal Malignancy and Review of the Literature.

Carcinosarcoma (CS) is a rare mixed mesodermal malignancy most commonly affecting the female reproductive organs, respiratory tract, head, and neck. Though infrequent, it may affect the gastrointestinal tract, most often the oesophagus and only very rarely the rectum. Histologically, it is composed of two distinct elements of epithelial and mesenchymal origin. Clinically, it is a very aggressive tumour with many patients presenting with metastatic lymph nodes or distant metastases at the time of diagnosis. Prognosis is poor despite intervention with the majority of patients dying within six months. Due to the rarity of this condition, there are no specific treatment guidelines presently available. We describe the case of an 80-year-old patient with carcinosarcoma of the rectum with discussion of the immunohistochemistry and review the available literature pertaining to this rare presentation.

Obesity increases the risk of postoperative peripheral neuropathy after minimally invasive colon and rectal surgery.

BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twenty-three patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures.

Endoclip closure of a large colonic perforation following colonoscopic leiomyoma excision.

BACKGROUND AND OBJECTIVE: Endoscopic removal of large colonic submucosal lesions can lead to a higher risk of perforation. Although not as common following diagnostic and therapeutic colonoscopy, it does occur more often following therapeutic colonoscopy. We present a case of a large submucosal mass excised endoscopically, resulting in a large perforation that was closed using endoclips. While endoclips are typically used for smaller perforations, we have found that they can be used safely on a larger defect. METHODS: A 68-y-old woman presented with a 2.9-cm benign submucosal mass found in the hepatic flexure. It was removed via endoscopic polypectomy, leaving a perforation of 3cm x 3cm. The perforation was closed with endoscopic clips. RESULTS: Histology of the specimen showed clear margins. At 4-wk follow-up, the patient had no complications. A colonoscopy at 6-mo follow-up showed only a scar at the procedure site with no complaints. CONCLUSIONS: Large iatrogenic colonic perforations can be managed successfully using endoclips, particularly in a prepped colon.

Randomized clinical trial comparing two mastectomy techniques.

BACKGROUND: The unit was considering the routine use of diathermy scissors for standard mastectomy surgery. We therefore aimed to assess scientifically the outcome of patients following the use of this instrument in their operation before accepting it as a routine procedure. METHODS: A single blind randomized control trial compared the outcome of patients undergoing simple mastectomy using either the standard scalpel blade technique or the bipolar cutting scissors technique. Each arm of the trial contained 30 patients. RESULTS: The two primary outcome measures were blood loss intraoperatively and the operating time. There was a significant difference between the two groups, with a statistically significant benefit in the scissors group in terms of the secondary outcome measures of chest wall clearance and skin flap development as assessments of surgical completeness of mastectomy. There is no evidence of any other secondary outcome measures differing between the treatment groups. CONCLUSION: There is strong evidence that using electric scissors reduces intraoperative blood loss and operating time. There is some evidence that the scissors may provide better surgical completeness of mastectomy.

Modified wise pattern skin reduction for plexiform neurofibromatosis of the breast.

Von Recklinhausen's neurofibromatosis is an autosomal dominant condition occurring typically with café au lait patches, axillary freckling, multiple fibromata, and Lisch nodules. We present a case of a 36-year-old female who presented with severe neurofibromatosis involving the lower half of the breast. The patient was not keen on mastectomy and pedicle flap reconstruction. A modified wise pattern incision was employed to remove the lower half of the breast and neurofibromatosis leading to a reasonable result.

Hernia through an iliac crest bone graft site: report of a case and review of the literature.

The iliac crest is a common donor site for autogenous bone graft as it offers the advantage of easy access and a relatively large and safe supply of bone. One of the less frequently reported complications of harvesting bone grafts from the iliac crest is a graft-site hernia. In the last decade less than 15 cases have been reported, however the true incidence of this complication is unknown. We report a case of iliac crest bone graft hernia in an obese diabetic female. The significant feature of this case was a large swelling six weeks postoperatively that was thought to be a hematoma. The actual diagnosis of hernia was made on the operating table during an attempt to evacuate the hematoma. Hence a high degree of suspicion is needed to diagnose a hernia following an iliac crest bone graft, particularly in obese patients and the suspicion should lead to confirmation by a CT scan.

Necrotizing fasciitis in a postmastectomy wound.

Necrotizing fasciitis is a rare, life-threatening condition, characterized by progressive gangrene of the subcutaneous tissue with subsequent death of the overlying skin. It is associated with a high mortality rate. We describe a patient who developed this condition after elective mastectomy and survived. Necrotizing fasciitis is known to occur in any part of the body, including the breast, and also following any kind of surgery, however, to the best of our knowledge this condition has never been described after a mastectomy. The diagnosis and management algorithm of this condition is discussed.