Primary segmental omental torsion, mimicking acute appendicitis.

Primary segmental omental torsion (PSOT) is a very rare cause of acute abdominal pain, and it may often imitate the clinical picture of acute appendicitis. In instances of acute abdominal pain without anorexia, nausea, and vomiting, omental torsion should be included in the differential diagnosis. Any misdiagnosis may lead to major complications such as intraabdominal abscesses and adhesions. A 63-year-old overweight man with a body mass index (BMI) of 41 Kg/m2 presented to the emergency department on a remote island with acute abdominal pain. His medical history included type 2 diabetes mellitus managed with insulin, essential hypertension, osteoarthritis, and no previous abdominal operations. He reported a sharp pain originating in the epigastrium and the right hypochondrium that started five days prior. Physical examination revealed rebound tenderness and guarding across the abdomen with a positive McBurney sign. However, the patient did not report vomiting and was not nauseous. Vital signs were as follows: blood pressure 116/56 mmHg, heart rate 98 beats/min, respiratory rate 19 breaths/min, and a temperature of 38.2 0C. Laboratory results showed a white blood cell count of 10.6, neutrophils of 8.11, C-reactive protein (CRP) 74 mg/l, haemoglobin11.6 g/dl, and hematocrit 36.9%. Due to the absence of a radiographer at the hospital during that period, no imaging investigations were conducted. Diagnostic laparoscopy demonstrated diffused hemoperitoneum and necrotic mass at the site of the hepatic flexure. Initially suspected to be an advanced colon cancer, the decision was made to proceed with open surgery. The necrotic segment of the omentum was found at the right superior point of attachment of the omentum to the hepatic flexure. Consequently, the necrotic segment of the omentum was resected. A thorough investigation of the abdominal cavity did not detect any other abnormalities or pathologies. The patient recovered uneventfully and was transferred to the surgical ward. Torsion of the omentum is a very rare cause of acute abdominal pain. This case highlights the necessity of considering PSOT in the differential diagnosis of acute abdominal pain, especially in cases where symptoms are suggestive of appendicitis but diagnostic findings are negative.

The Role of Fish Skin Xenografts in Healing Complex Wounds: A Brief Case Report.

Non-healing wounds profoundly impact patient quality of life and present a significant financial burden. The Kerecis™ fish skin xenograft is a decellularized skin matrix that has been introduced to treat complicated wounds. The objective of this presentation is to highlight the use of fish skin xenograft in the treatment of a complex right flank wound with stool contamination, necrotizing soft tissue infection due to perforated colon cancer, and sepsis. This presentation follows the wound healing for 28 days following the operation and demonstrates the efficacy of fish skin xenografts in improved wound healing. A 61-year-old female with a past medical history of colon cancer and recent chemotherapy treatment presented with colon perforation causing right flank cellulitis and sepsis with necrotic abdominal wall tissue extending into the hip joint. She was taken for an emergent exploratory laparotomy, drainage of abdominal and retroperitoneal abscesses, open right hemicolectomy, diverting ileostomy, abdominal washout, intra-abdominal omental patch, placement of Strattice mesh, and debridement of necrotizing soft tissue infection of the right flank. After extensive debridement of her 15x10cmx5cm deep wound and placement of a Kerecis™ fish skin xenograft, the wound had completely healed with excellent granulation tissue, and the patient was scheduled for placement of a skin graft 28 days following the initial procedure. The results after xenograft application were outstanding, supporting the use of polyunsaturated fatty acid (PUFA) based xenografts in wound treatment due to their anti-inflammatory and angiogenic properties. This is definitely an option that needs to be considered in expediting the healing process for complex wounds.

Long-term mesh-related complications from minimally invasive intraperitoneal onlay mesh for small to medium-sized ventral hernias.

INTRODUCTION: Intraperitoneal onlay mesh (IPOM) placement for small to medium-sized hernias has garnered negative attention due to perceived long-term risk of mesh-related complications. However, sparse data exists supporting such claims after minimally invasive (MIS) IPOM repairs and most is hindered by the lack of long-term follow-up. We sought to report long-term outcomes and mesh-related complications of MIS IPOM ventral hernia repairs. METHODS AND PROCEDURES: Adult patients who underwent MIS IPOM ventral hernia repair at our institution were identified in the Abdominal Core Health Quality Collaborative database from October 2013 to October 2020. Outcomes included hernia recurrence and mesh-related complications or reoperations up to 6 years postoperatively. RESULTS: A total of 325 patients were identified. The majority (97.2%) of cases were elective, non-recurrent (74.5%), and CDC class I (99.4%). Mean hernia width was 4.16 ± 3.86 cm. Median follow-up was 3.6 (IQR 2.8-5) years. Surgeon-entered or patient-reported follow-up was available for 253 (77.8%) patients at 3 years or greater postoperatively. One patient experienced an early small bowel obstruction and was reoperated on within 30 days. Two-hundred forty-five radiographic examinations were available up to 6 years postoperatively. Twenty-seven patients had hernia recurrence on radiographic examination up to 6 years postoperatively. During long-term follow-up, two mesh-related complications required reoperations: mesh removed for chronic pain and mesh removal at the time of colon surgery for perforated cancer. Sixteen additional patients required reoperation within 6 years for the following reasons: hernia recurrence (n = 5), unrelated intraabdominal pathology (n = 9), obstructed port site hernia (n = 1), and adhesive bowel obstruction unrelated to the prosthesis (n = 1). The rate of reoperation due to intraperitoneal mesh complications was 0.62% (2/325) with up to 6 year follow-up. CONCLUSION: Intraperitoneal mesh for repair of small to medium-sized hernias has an extremely low rate of long-term mesh-related complications. It remains a safe and durable option for hernia surgeons.

Beyond a vestigial organ: effects of the appendix on gut microbiome and colorectal cancer.

The role of appendectomy in the pathogenesis of colorectal cancer (CRC) is a recent topic of contention. Given that appendectomy remains one of the most commonly performed operations and a first-line management strategy of acute appendicitis, it is inherently crucial to elucidate the association between prior appendectomy and subsequent development of CRC, as there may be long-term health repercussions. In this review, we summarize the data behind the relationship of CRC in post-appendectomy patients, discuss the role of the microbiome in relation to appendectomy and CRC pathogenesis, and provide an appraisal of our current understanding of the function of the appendix. We seek to piece together the current landscape surrounding the microbiome and immunological changes in the colon post-appendectomy and suggest a direction for future research involving molecular, transcriptomic, and immunologic analysis to complement our current understanding of the alterations in gut microbiome.

Inadvertent laparoscopic lavage of perforated colon cancer: a systematic review.

BACKGROUND: Although laparoscopic lavage for perforated diverticulitis with peritonitis has been grabbing the headlines, it is known that the clinical presentation of peritonitis can also be caused by an underlying perforated carcinoma. The aim of this study was to determine the incidence of patients undergoing inadvertent laparoscopic lavage of perforated colon cancer as well as the delay in cancer diagnosis. METHODS: The PubMed database was systematically searched to include all studies meeting inclusion criteria. Studies were screened through titles and abstracts with potentially eligible studies undergoing full-text screening. The primary endpoints of this meta-analysis were the rates of perforated colon cancer patients having undergone inadvertent laparoscopic lavage as well as the delay in cancer diagnosis. This was expressed in pooled rate % and 95% confidence intervals. RESULTS: Eleven studies (three randomized, two prospective, six retrospective) totaling 642 patients met inclusion criteria. Eight studies reported how patients were screened for cancer and the number of patients who completed follow-up. The pooled cancer rate was 3.4% (0.9%, 5.8%) with low heterogeneity (Isquare2 = 34.02%) in eight studies. Cancer rates were 8.2% (0%, 3%) (Isquare2 = 58.2%) and 1.7% (0%, 4.5%) (Isquare2 = 0%) in prospective and retrospective studies, respectively. Randomized trials reported a cancer rate of 7.2% (3.1%, 11.2%) with low among-study heterogeneity (Isquare2 = 0%) and a median delay to diagnosis of 2 (1.5-5) months. CONCLUSIONS: This systematic review found that 7% of patients undergoing laparoscopic lavage for peritonitis had perforated colon cancer with a delay to diagnosis of up to 5 months.

Pseudo-submucosal tumor in the colon: seeing is believing.

A 65-year-old woman was admitted to our hospital with complaints of lower abdominal pain. Her physical examination was unremarkable. The results of routine laboratory testing were within the normal limits. In addition, abdominal CT was normal. Colonoscopy showed a cecum submucosal tumor with a pale yellow surface. Endoscopic ultrasound revealed homogeneous hypoechoic lesions originated from submucosal layer. ESD was subsequently performed to remove the submucosal lesion. During the ESD procedure, fecal outflowed from appendix opening . Yellow fecal-like material was visible after submucosal incision. The trap electrocut surface uplift showed more fecal attachment on the lamina propria surface, and myolayer integrity after clean the fecal (Fig1c), The final pathology of the surface bulge suggested hyperplasia (Fig1d). Patients were discharged with relieved lower abdominal pain. The final diagnosis was submucosal fecalith mimicking a submucosal tumor, eventually leads to chronic appendicitis. Common causes of cecal submucosal tumor include neuroendocrine tumors, lipomas, etc. There was few report about fecalith mimicking a submucosal tumor. ERTA is currently an effective endoscopic method for treating appendicitis combined with fecalith blockage. To our knowledge, this is the first report on a case of cecum submucosal fecalith mimicking a submucosal tumor and was successfully removed using endoscopy.

Prognostic impact and survival outcomes of colon perforation in patients with metastatic colorectal cancer: a multicenter retrospective cohort study.

BACKGROUND: Colon perforation caused by colorectal cancer (CRC) is a fatal condition requiring emergency intervention. For patients with metastatic lesions, surgeons face difficult decisions regarding whether to resect the primary and metastatic lesions. Moreover, there is currently no established treatment strategy for these patients. This study aimed to investigate the clinical practice and long-term outcomes of patients with metastatic CRC diagnosed with the onset of colon perforation. METHODS: We performed a population-based multicenter cohort study. Consecutive patients diagnosed with stage IV CRC between 2008 and 2015 at all designated cancer hospitals in Fukushima Prefecture, Japan, were enrolled in this study. We evaluated the impact of colon perforation on the survival outcomes of patients with metastatic CRC. The main outcome was the adjusted hazard ratio (aHR) of perforation for overall survival (OS). Survival time and HRs were estimated using Kaplan‒Meier and Cox proportional regression analyses. RESULTS: A total of 1258 patients were enrolled (perforation: n = 46; non-perforation: n = 1212). All but one of the patients with perforation underwent primary resection or colostomy and 25 cases were able to receive chemotherapy. The median OS for the perforation and non-perforation groups was 19.0 and 20.0 months, respectively (p = 0.96). Moreover, perforation was not an independent prognostic factor (aHR: 0.99; 95% confidence interval: 0.61-1.28). CONCLUSIONS: In metastatic CRC, perforation is not necessarily a poor prognostic factor. Patients with perforation who undergo primary tumor resection or colostomy and prompt initiation of systemic chemotherapy might be expected to have a survival time similar to that of patients with non-perforated colon.

Adjuvant Hyperthermic Intraperitoneal Chemotherapy in Patients With Locally Advanced Colon Cancer (COLOPEC): 5-Year Results of a Randomized Multicenter Trial.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.Whether adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) might prevent peritoneal metastases after curative surgery for high-risk colon cancer is an ongoing debate. This study aimed to determine 5-year oncologic outcomes of the randomized multicenter COLOPEC trial, which included patients with clinical or pathologic T4N0-2M0 or perforated colon cancer and randomly assigned (1:1) to either adjuvant systemic chemotherapy and HIPEC (n = 100) or adjuvant systemic chemotherapy alone (n = 102). HIPEC was performed using a one-time administration of oxaliplatin (460 mg/m2, 30 minutes, 42°C, concurrent fluorouracil/leucovorin intravenously), either simultaneously (9%) or within 5-8 weeks (91%) after primary tumor resection. Outcomes were analyzed according to the intention-to-treat principle. Long-term data were available of all 202 patients included in the COLOPEC trial, with a median follow-up of 59 months (IQR, 54.5-64.5). No significant difference was found in 5-year overall survival rate between patients assigned to adjuvant HIPEC followed by systemic chemotherapy or only adjuvant systemic chemotherapy (69.6% v 70.9%, log-rank; P = .692). Five-year peritoneal metastases rates were 63.9% and 63.2% (P = .907) and 5-year disease-free survival was 55.7% and 52.3% (log-rank; P = .875), respectively. No differences in quality-of-life outcomes were found. Our findings implicate that adjuvant HIPEC should still be performed in trial setting only.

Fournier's Gangrene Secondary to Perforated Sigmoid Adenocarcinoma Within an Incarcerated Inguinal Hernia.

Colon cancer is the third most common cancer worldwide. Approximately one-fifth of colon cancers will present emergently due to obstruction or perforation. Necrotizing soft tissue infection is a rare presentation of perforated colon cancer and represents a surgical emergency due to high mortality rate.  A man in his 80s presented with several days of scrotal pain and weakness. On physical exam he was found to have scrotal edema and erythema and bilateral inguinal hernias. Imaging revealed a large scrotal abscess and concern for necrotizing soft tissue infection. He was taken to the operating room for surgical debridement and exploration and was discovered to have perforated colon within an incarcerated inguinal hernia. He underwent exploratory laparotomy with sigmoid resection and end colostomy creation. Pathology returned demonstrating invasive sigmoid adenocarcinoma. Fournier's gangrene requires a high index of suspicion. It is a rapidly progressing infection associated with high mortality. Early initiation of antibiotics and surgical debridement are mainstays of treatment. When associated with perforated colonic malignancy, workup must include imaging of the chest, abdomen, and pelvis as well as carcinoembryonic antigen (CEA) level to complete staging. Fournier's gangrene secondary to perforated sigmoid adenocarcinoma is a unique presentation. Treatment first involves antibiotics and aggressive surgical debridement. Once the patient is stabilized, further oncologic workup should be completed to determine treatment course.

Necrotizing fasciitis of the thigh: An unexpected route to discover an infected colonic cancer.

Introduction: Necrotizing fasciitis (NF) is a rare but potentially fatal soft tissue infection characterized by its aggressive nature. This case report highlights a unique and atypical presentation of NF associated with colorectal cancer. Case presentation: A 76-year-old male with no significant medical history presented with left knee pain and rapidly progressing septic shock. Clinical examination revealed skin necrosis, inflammation, and swelling in the left thigh and inguinal region. Laboratory investigations showed leukocytosis and elevated C-reactive protein levels. Computed tomography angiography revealed fluid and gas tracking along fascial planes in the left thigh. Surgical intervention revealed NF in the thigh and abdominal wall, with the underlying cause being a perforated sigmoid colon cancer. Conclusion: Recognizing the polymorphic clinical manifestations of NF and its potential association with underlying abdominal pathology can aid in early diagnosis and improve patient outcomes. This report serves as a reminder of the life-threatening nature of NF and the necessity for rapid and comprehensive management.

Apendicitis aguda por intususcepción secundaria a endometriosis. Reporte de caso / Acute appendicitis due to intussusception secondary to endometriosis. Case report

Introducción. La intususcepción del apéndice corresponde a su invaginación en el ciego. Existen varias causas, pero la endometriosis ha sido informada pocas veces. Aunque el diagnóstico se debe sospechar clínicamente, por lo general su causa solo se determina en el intraoperatorio, donde se deben tener en cuenta causas oncológicas que requieran una resección amplia. Caso clínico. Mujer de 21 años que consultó por dolor abdominal agudo generalizado. Se practicó una tomografía computarizada de abdomen, observando una intususcepción del apéndice en el ciego, estriación de la grasa pericecal y adenomegalias. Se realizó laparoscopia diagnóstica encontrando intususcepción casi completa del apéndice cecal, de aspecto neoplásico. Se convirtió a laparotomía para proceder a hemicolectomía derecha, con vaciamiento ganglionar y anastomosis del íleon al colon transverso. Discusión. La sospecha clínica de intususcepción debe corroborarse mediante ecografía, tomografía o estudios baritados. El tratamiento siempre es quirúrgico, como en el caso de nuestra paciente, quien evolucionó de forma adecuada y continuó asintomática después de un año de seguimiento. Conclusión. El diagnóstico temprano de la intususcepción permite realizar tratamientos quirúrgicos menos agresivos y disminuye el riesgo de filtración de la anastomosis. Se debe tener en cuenta el diagnóstico de endometriosis como posible causa. Se debe realizar el manejo complementario por parte de ginecología.

Introduction. The intussusception of the appendix corresponds to its invagination in the cecum. There are several causes, endometriosis being rarely reported. Although the diagnosis must be suspected clinically, its cause is generally only determined intraoperatively, where oncological causes that require extensive resection must be taken into account. Clinical case. A 21-year-old woman who consulted due to acute generalized abdominal pain, an abdominal tomography was performed, finding an intussusception of the appendix in the cecum, striation of pericecal fat, and lymph nodes. A diagnostic laparoscopy was performed, finding almost complete intussusception of the appendix, with a neoplastic appearance. She was converted to laparotomy to perform a right hemicolectomy, with lymph node dissection and ileal to transverse anastomosis. Discussion. Clinical suspicion of intussusception should be confirmed by ultrasound, abdominal tomography, or barium studies. Treatment is always surgical, as in the case of our patient, who evolved adequately and remained asymptomatic after one year of follow-up. Conclusion. Early diagnosis of intussusception allows for less aggressive surgical treatment and decreases the risk of anastomosis leakage. The diagnosis of endometriosis should be taken into account as a possible cause. Complementary management by gynecologists should be performed.

Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Long term oncologic outcomes from the international PSOGI registry.

The laparoscopic approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (L-CRS + HIPEC) in highly selected patients was previously reported from the PSOGI registry with a demonstrable reduction in length of stay and post-operative morbidity. This study aims to update this international PSOGI registry with a larger cohort of patients and a longer follow-up period. METHODS: An international registry was designed through a networking database (REDCAP®). All centers performing L-CRS + HIPEC were invited through PSOGI to submit data on their cases. Variables such as demographics, clinical outcomes, and survival were analyzed. RESULTS: A total of 315 L-CRS + HIPEC cases were provided by 14 worldwide centers. A total of 215 patients were included in the L-CRS + HIPEC group. The median peritoneal cancer index (PCI) was 3 (3-5). The median length of stay was 7 days (5-10) and the major morbidity (Clavien-Dindo ≥3) was 6.1% after 30 days. The 5-year disease-free survival (DFS) per tumor origin was: 94% for PMP-LG, 85% for PMP-HG, 100% for benign multicyst peritoneal mesothelioma (MPM), 37.4% for colonic origin, and 54%(at 3 years) for ovarian origin. The 5 years overall survival (OS) per tumor origin was: 100% for PMP-LG, PMP-HG and MPM; 61% for colonic origin, and 74% (at 3 years) for ovarian origin. In addition, a total of 85 patients were analyzed in the laparoscopic risk-reducing HIPEC (L-RR + HIPEC). The median length of stay was 5 days (4-6) and the major morbidity was 6% after 30 days. The 5-year DFS per tumor origin was: 96% for perforated low grade appendiceal mucinous neoplasm (LAMN II) and 68.1% for colon origin. The 5 years OS per tumor origin was: 98% for LAMN II and 83.5% for colonic origin. CONCLUSIONS: Minimally invasive CRS + HIPEC is a safe procedure for selected patients with peritoneal carcinomatosis in specialized centers. It improves perioperative results while providing satisfactory oncologic outcomes. L-RR + HIPEC represents a promising strategy that could be evaluated in patients with high risk of developing peritoneal carcinomatosis into prospective randomized trials.

Necrotising fasciitis secondary to a perforated hepatic flexure tumour - A case report.

INTRODUCTION AND IMPORTANCE: Necrotising fasciitis caused by a perforated colon cancer is a very rare occurrence and can be very life threatening needing urgent intervention involving tissue salvage and oncological treatment. There is not enough evidence in the literature regarding management of the same. This case report highlights one such case along with management principles. PRESENTING CASE: We present a 66 year old male with 3 weeks of a progressive right lower quadrant lump and constitutional symptoms. He had a computed tomography scan demonstrating a complex collection in the right anterior abdominal wall, containing multiple locules of gas and air fluid levels near an abnormally thickened hepatic flexure. He was taken for an urgent debridement followed by laparotomy which demonstrated extensive abdominal wall necrotising fasciitis secondary to a perforated hepatic flexure tumour invading into the duodenum. He was given a diverting ileostomy. He had a relook laparotomy the next day for a right hemicolectomy and part of the duodenum resected with a refashioned end ileostomy. He was subsequently managed on the ward for two weeks and then discharged home. He remains well and has been referred to medical oncology for adjuvant chemotherapy. CLINICAL DISCUSSION: A two step surgical approach was key in this case, first step for source control and the second step focused on an oncological resection. CONCLUSION: This case explains the importance of excluding malignant causes of necrotising fasciitis. Perforated cancers can manifest as necrotising fasciitis and management should include timely debridement as well as oncological principles.

Metastatic Seeding of Abdominal Wall After Drainage of Perforated Colorectal Cancer in a Presumed Complicated Diverticular Disease.

A 37-year-old male presented multiple times for abdominal pain with a persistent diverticular abscess on imaging that was managed previously with antibiotics and percutaneous drainages. Due to unrelenting abdominal pain and multiple presentations of unresolved acute complicated diverticulitis, the patient underwent an exploratory laparotomy. A colonic mass was discovered, and the patient had a colonic resection. Pathology revealed invasive transverse colonic adenocarcinoma with perforation and involvement of the stomach. Imaging showed no distant metastatic disease and chemotherapy was started. Months after treatment, the patient developed skin lesions and a palpable mass at the previous drain site. Biopsy showed metastatic adenocarcinoma consistent with colonic origin. Colonic adenocarcinoma with metastasis to the abdominal wall after drainage of presumed diverticular abscess is rare. Clinicians should consider malignancy when a patient has a recurrent diverticular abscess that has failed medical management and multiple drainages. Clinicians should remain vigilant of the risk of seeding colonic adenocarcinoma to the abdominal wall when repeated drainage is performed.

Complicated Diverticulitis and Pelvic Radiation Leading to Colonic Stricture, Colorectal Fistula, and Anal Stenosis.

The purpose of this case is to highlight a rare case of sigmoid colon-to-rectum fistula. A 66-year-old man with a history of pelvic radiation and diverticulosis presented to the emergency department with a 3-week history of abdominal pain and watery diarrhea. Computed tomography (CT) imaging was significant for a sigmoid-to-rectum fistula with sigmoid stricture. The patient underwent a laparoscopic colectomy with end colostomy. Pathology revealed perforated diverticulitis. To date, there have been no cases reported in literature describing sigmoid-to-rectum fistula. In conclusion, it is important to consider the development of complex diverticular disease in patients with history of pelvic radiation.

Cytoreductive Surgery and Hyperthermic Peritoneal Chemotherapy in Appendiceal and Colorectal Cancer: Outcomes and Survival.

BACKGROUND: We reviewed outcomes following cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with appendiceal or colorectal neoplasms and evaluated key prognostic indicators for treatment. METHODS: All patients who underwent cytoreductive surgery/HIPEC for appendiceal and colorectal neoplasms were identified from an IRB-approved database. Patient demographics, operative reports, and postoperative outcomes were reviewed. RESULTS: 110 patients [median age 54.5 (18-79) years, 55% male] were included. Primary tumor location was colorectal (58; 52.7%) and appendiceal (52; 47.3%). 28.2%, .9%, and 12.7% had right, left, and sigmoid tumors, respectively; 11.8% had rectal tumors. 12/13 rectal cancer patients underwent preoperative radiotherapy. Mean Peritoneal Cancer Index was 9.6 ± 7.7; complete cytoreduction was achieved in 90.9%. 53.6% developed postoperative complications. Reoperation, perioperative mortality, and 30-day readmission rates were 1.8%, .09%, and 13.6%, respectively. Recurrence at a median of 11.1 months was 48.2%; overall survival at 1 and 2 years was 84% and 56.8%, respectively; disease-free survival was 60.8% and 33.7%, respectively, at a median follow-up of 16.8 (0-86.8) months. Univariate analysis of preoperative chemotherapy, primary malignancy location, primary tumor perforated or obstructive, postoperative bleeding complication, and pathology of adenocarcinoma, mucinous adenocarcinoma and negative lymph nodes were identified as possible predictive factors of survival. Multivariate logistic regression analysis showed that preoperative chemotherapy (P < .001), perforated tumor (P = .003), and postoperative intra-abdominal bleeding (P < .001) were independent prognostic indicators for survival. CONCLUSIONS: Cytoreductive surgery/HIPEC for colorectal and appendiceal neoplasms has low mortality and high completeness of cytoreduction score. Preoperative chemotherapy, primary tumor perforation, and postoperative bleeding are adverse risk factors for survival.

Peritonitis with bacteremia due to Christensenella hongkongensis identified via ribosomal RNA sequencing in a Japanese patient with advanced colorectal adenocarcinoma: A case report.

Background: Christensenella hongkongensis is an obligately anaerobic, catalase-positive, motile, non-sporulating, gram-positive coccobacillus. Human infections are rare and have not been previously reported in Japan. Herein, we report the first case of perforated peritonitis with C. hongkongensis bacteremia in Japan. Case presentation: A 61-year-old Japanese man with advanced colorectal adenocarcinoma presented with fever and abdominal pain. Abdominal computed tomography revealed a low-density area with thinning of the sigmoid colon wall and air outside the intestinal tract, which was diagnosed as perforated peritonitis. Cultures of the ascitic fluid isolated Bacteroides fragilis, Bacteroides eggerthii, Parabacteroides distasonis, Enterococcus avium, and Candida albicans. Gram-positive rods were detected in the blood culture on admission after 4 days. The isolate was identified as C. hongkongensis via 16S ribosomal RNA (16S rRNA) sequencing. The patient underwent open abdominal washout and drainage via a transverse colon bifurcation colostomy. Intravenous meropenem (3 g/day) was administered for 5 days, followed by intravenous piperacillin-tazobactam (9 g/day) for 6 days, and then levofloxacin (500 mg/day) and metronidazole (1500 mg/day) intravenously for 15 days. Postoperatively, the patient gradually recovered. He was transferred to another palliative care hospital on day 38 after admission for worsening advanced colorectal cancer condition. Conclusion: Bacteremia caused by C. hongkongensis is rare. 16S rRNA sequencing should be considered for the identification of gram-positive anaerobic rods that are difficult to diagnose by conventional methods.

Case report on a rare complication after transanal total mesorectal excision (TaTME) for rectal malignancy vesicorectal fistula.

INTRODUCTION AND IMPORTANCE: Transanal Total Mesorectal Excision (TaTME) represents the latest surgical approach in rectal cancer management. We present a rare case of vesicorectal fistula (VRF) following a complication of TaTME surgery. CASE PRESENTATION: A 67-year-old male underwent a Hartmann's procedure for perforated rectosigmoid cancer in 2019. He was lost to follow-up and re-presented in 2021 with synchronous cancer of the transverse colon and rectum. A two-team surgical approach was utilized: open subtotal colectomy (transabdominal approach) with concurrent excision of rectal stump (TaTME approach). Intraoperatively, an inadvertent bladder injury was identified and repaired. 8 months later, he re-presented with the passage of urine per rectum. Imaging and endoscopy revealed a VRF with cancer recurrence at the rectal stump. CLINICAL DISCUSSION: VRF is an uncommon complication of TaTME that carries a significant physical and psychological impact on the patient. While shown to be a safe and useful technique, the long-term oncological outcomes of TaTME are still awaited. Unique complications have been reported with TaTME, including gas embolism and injuries to the genitourinary structures, in which the latter caused the eventual VRF formation in our patient. CONCLUSION: Revisional surgery for recurrent disease is challenging and can result in rare complications, especially in patients with distorted anatomy and when new surgical techniques are utilized. Radiotherapy further causes unpredictable tissue healing quality. The challenge remains for proper patient selection with individualization of surgical approaches, while keeping a close eye on the oncological outcomes of the patient.

The role of screening colonoscopy after appendicitis in patients over 40 years of age.

BACKGROUND: There is some evidence of the association between acute appendicitis and colorectal neoplasm in patients over the age of 40 years. Despite this, few centres routinely evaluate the colon endoscopically following an episode of appendicitis in these patients. Our aim was to investigate the incidence of colorectal neoplasm in patients aged 40 years and over who underwent screening colonoscopy following acute appendicitis. METHODS: Retrospective cohort study of patients aged 40 years and over who were diagnosed with acute appendicitis via imaging or histology between January 2015 and May 2022. Findings on subsequent screening colonoscopy were evaluated and classified according to adenomatous and non-adenomatous lesions. RESULTS: A total of 176 patients met inclusion criteria, with a median age of 54 years (range 40-92) and female to male ratio of 1:1.3. One hundred patients (56%) had a colonoscopy following their admission, at a mean duration of 3.5 months post discharge. 15% of patients had an adenomatous polyp detected (10 adenomas, 4 advanced adenomas, and 1 sessile serrated adenoma), and 9% had a non-adenomatous lesion detected (8 hyperplastic polyps and 1 lipoma). CONCLUSION: Adenoma detection rate in patients aged 40 years and over undergoing colonoscopy after acute appendicitis was 15% in our cohort. This high adenoma detection rate supports the view of appendicitis as an indication for screening faecal immunochemical testing or colonoscopy in patients above 40 years.

Management of Perforated Sigmoid Colon Cancer in an Incarcerated Inguinal Hernia Using a Combined Abdominal and Inguinal Approach.

The ideal management of perforated colorectal cancer in the hernia sac remains a challenge for general surgeons. We report such a case requiring a combined-incision surgical approach and two-stage operation. A male patient in his 80s presented with fatigue and a bulge in his left groin. Contrast-enhanced CT scan revealed a sigmoid colon perforation within the left inguinal hernia sac. A combination of midline abdominal and inguinal incisions was performed for the iliopubic tract repair and Hartmann procedure. Six months later, the recurrent inguinal hernia was repaired using the Kugel mesh. The treatment strategy for colonic perforation into the inguinal hernia remains nonstandardized, compared to those for nonperforated cases. Combined inguinal and midline abdominal incisions might be necessary for infected lesion removal and colon mesentery resection; using mesh to repair hernia is a rare option. Hernia repair using mesh can be performed in two stages when recurrence occurs.