Trends in the management of anorectal melanoma: A multi-institutional retrospective study and review of the world literature.

BACKGROUND: Anorectal melanoma (ARM) is a rare disease with a poor prognosis. Evidence on optimal treatment is limited and surgical management varies widely. We hypothesized that the frequency of abdominoperineal resection used as primary treatment of ARM has decreased over the past several decades. AIM: To update our understanding of outcomes for patients with ARM and analyze management trends around the world. METHODS: This is a multi-institutional, retrospective study of patients treated for ARM at 7 hospitals. Hospitals included both large, academic, tertiary care centers and smaller, general community hospitals. Using prospectively maintained institutional tumor registries, we identified 24 patients diagnosed with ARM between January 2000 and May 2019. We analyzed factors prognostic for recurrence and survival. We then used Cox regression to measure overall survival (OS) and melanoma-specific survival. We also performed a literature review to assess trends in surgical management and outcomes. RESULTS: Of the 24 patients diagnosed with ARM, 12 (50.0%) had local, 8 (33.3%) regional, and 4 (16.7%) distant disease at diagnosis. Median time to recurrence was 10.4 mo [interquartile range (IQR) 7.5-17.2] with only 2 patients (9.3%) not developing recurrence following surgical resection. Median OS was 18.8 mo (IQR 13.5-33.9). One patient is still alive without recurrence at 21.4 mo from diagnosis; no other patient survived 5 years. Primary surgical management with abdominoperineal resection (APR) vs wide excision (WE) did not lead to differences in OS [hazard ratio = 1.4 (95%CI: 0.3-6.8)]. Review of the literature revealed geographic differences in surgical management of ARM, with increased use of WE in the United States and Europe over time and more frequent use of APR in Asia and India. There was no significant improvement in survival over time. CONCLUSION: There is wide variation in the management of ARM and survival outcomes remain poor regardless of approach. Surgical management should aim to minimize morbidity.

Population Based Paternity Rate and Partner Birth Outcomes Among Utah Men With Inflammatory Bowel Disease.

OBJECTIVES: Crohn's disease (CD) and ulcerative colitis (UC) impact an estimated 350,000 reproductive age men in the United States. The reproductive consequences are largely unknown. The objective of this study was to evaluate the effects of CD and UC on reproductive outcomes. METHODS: From the Utah Population Database, we identified a cohort of male patients with CD (1,245) and UC (1,368). Male-sibling controls were identified, and birth outcome data from offspring were obtained. Analyses for CD and UC were completed separately. RESULTS: Among UC patients (473) with at least one male sibling (1,020), 66% had offspring, which was not different compared with siblings (61%, P=0.16). Birth outcomes were not different between UC patients and male siblings: congenital malformations (UC 6% vs. 6%, P=0.99), perinatal complications (UC 35% vs. 31%, P=0.23), mean birth weight (UC 3,347 vs. 3,357 g, P=0.53), mean length of gestation (UC 39.0 vs. 39.1 weeks, P=0.54). Among CD patients (421) with at least one male sibling (833), 58% had offspring, which did not differ compared with siblings (57%, P=0.77). Similarly, there were no differences in partner birth outcomes: congenital malformations (CD 7% vs. 6%, P=0.27), perinatal complications (CD 35% vs. 32%, P=0.12), mean birth weight (CD 3,276 vs. 3,324 g, P=0.13), or mean length of gestation (38.8 vs. 39 weeks, P=0.24). CONCLUSIONS: We found no differences in paternity rate or female partner birth outcomes in Utah men with UC or CD compared with male-sibling controls. UC and CD do not appear to affect the reproductive outcomes of men in Utah.

Population-based Semen Analysis Results and Fertility Among Patients With Inflammatory Bowel Disease: Results From Subfertility Health Assisted Reproduction and the Environment (SHARE) Study.

OBJECTIVE: To evaluate male fertility in Crohn disease (CD) and ulcerative colitis (UC) by examining semen analysis results and paternity from the SHARE study (Subfertility Health Assisted Reproduction and the Environment), a population-based cohort of semen analysis results from Utah men. METHODS: A population-based cohort of men with CD or UC was identified using the Utah Population Database (contains person-level linked demographic, genealogical, and medical record information for 85% of Utahans) from 1996 to 2014, and validated by clinical chart review. This cohort was then cross-linked (n = 55) to the SHARE population dataset of semen analysis results. Men with CD or UC were compared with population-based, age-matched, paired (1:1) controls (n = 47). Paternity was evaluated though presence and number of linked offspring and inter-birth interval. RESULTS: Offspring were identified in 71% of UC patients (mean of 1.8 children) and 61% of CD patients (mean of 1.2 children). Compared with matched controls, there were no differences in number of offspring, mean inter-birth interval, or any of the evaluated semen analysis parameters among either men with CD or UC. CONCLUSION: Fertility and semen analysis values among men with UC or CD are not significantly impacted compared with population-based, age-matched controls.

When body mass index fails to measure up: perinephric and periumbilical fat as predictors of operative risk.

BACKGROUND: Obesity has been associated with worse outcomes and increased surgical technical difficulty. Perinephric fat (PNF) and periumbilical fat (PUF) are alternative metrics to body mass index. We hypothesized that PUF and PNF would offer improved prediction of perioperative risk. METHODS: 249 patients were retrospectively reviewed after elective, pelvic colorectal resections. PNF and PUF were collected using axial imaging. Operative risk measurements included estimated blood loss (EBL) and operative time (OT). RESULTS: In multivariate analyses of women, PUF and PNF were significant predictors of EBL; PNF was a significant predictor of OT. A 4.7-mm increase in PNF predicted a 15-minute increase in OT and 55-cc increase in EBL. An 8.6-mm increase in PUF predicted a 55-cc increase in EBL. In men, no metric was predictive. CONCLUSIONS: In women, PNF and PUF may offer improved metrics for risk stratification, which can have important clinical and financial implications.

Unresectable Pancreatic Adenocarcinoma: Eight Years Later.

Pancreatic cancer is the fourth leading cause of cancer deaths in the United States, and is considered uniformly fatal when patients present with unresectable, advanced-stage disease at the time of diagnosis. Long-term survival of patients with advanced-stage pancreatic adenocarcinoma remains rare, despite advances in adjuvant chemoradiation protocols. A 73-year-old male presented to our emergency department with abdominal pain and a history of biopsy-proven, stage III pancreatic adenocarcinoma. His initial staging CT scan and trans-duodenal ultrasound had demonstrated a stage IIa (T3, N0, Mx) lesion. On surgical exploration, he was up-staged to stage III (T4, N0, Mx), noting encasement of the superior mesenteric vessels and involvement of the portal vein. He underwent palliative choledochojejunostomy and was treated with 4 months of oxaliplatin and capecitabine, with concurrent radiation therapy (50.4 Gy), followed by 4 months of gemcitabine. After 7 months, the patient withdrew from therapy due to treatment intolerance. He then turned to self-medication with non-traditional herbal therapies. After 3 years of surveillance, he was lost to follow-up until presenting to our facility with abdominal pain 8 years after his initial diagnosis. On diagnostic CT scan during his current presentation for abdominal pain, he was found to have no evidence of pancreatic cancer. Based on our review of the literature, we present the longest known survival of a patient with surgically unresectable pancreatic adenocarcinoma. Further study of this patient's phenotypic or genotypic characteristics may provide insight into better therapeutic agents, or a predictive subset of patients who will benefit from specific chemotherapeutic options.

Long-Term Surgical Management of Severe Pelvic Injury and Resulting Neurogenic Bladder From an Improvised Explosive Device.

Reconstructive surgery can help veterans improve their quality of life and live free of chronic indwelling catheters following injury from an improvised explosive device.

Routine endoscopic surveillance for local recurrence of rectal cancer is futile.

BACKGROUND: National Comprehensive Cancer Network guidelines for rectal adenocarcinoma regarding routine surveillance with proctoscopy for local recurrence have been evolving. The purpose of this study was to examine the utility of rectal surveillance. METHODS: This is a single-center, retrospective review of patients (2004 to 2011) who underwent total mesorectal excision for rectal cancer. The primary end point was cancer recurrence, with detection method(s) noted. The number of surveillance procedures was collected. RESULTS: The study included 112 patients. There were no local recurrences identified by rectal surveillance. There were 1 local recurrence and 17 distant recurrences (16%). The local recurrence was identified by carcinoembryonic antigen and symptoms. There were 20 anoscopies, 44 proctoscopies, and 495 flexible sigmoidoscopies performed, with estimated charges of $266,000. CONCLUSIONS: Rectal surveillance at this center was not beneficial. This study supports the recent (2015) change in the National Comprehensive Cancer Network guidelines, which no longer recommend routine rectal surveillance and challenge other society guidelines.

Does travel distance influence length of stay in elective colorectal surgery?

BACKGROUND: Length of stay following elective colorectal surgery is being reported as a quality measure in surgical outcome registries, such as the National Surgical Quality Improvement Program. Regional referral centers with large geographic catchment areas attract patients from significant distances. OBJECTIVE: The aim of this study was to examine the effect of patient distance traveled, from primary residence to a tertiary care hospital, on length of stay in elective colorectal surgery patients. DESIGN: Retrospective population-based cohort study uses data obtained from the National Surgical Quality Improvement Program database. SETTINGS: This study was conducted at a tertiary referral hospital. PATIENTS: Data on 866 patients undergoing elective colorectal surgery from May 2003 to April 2011 were reviewed. MAIN OUTCOME MEASURES: Demographics, surgery-related variables, and distance traveled were analyzed relative to the length of stay. RESULTS: Of the 866 patients, 54% were men, mean age was 57 years, mean distance traveled was 145 miles (range, 2-2984 miles), and mean length of stay was 8.8 days. Univariate analysis showed a significant increase in length of stay with increased distance traveled (p = 0.02). Linear regression analysis revealed a significant association between increased length of stay and male sex (p = 0.006), increasing ASA score (p = 0.000), living alone (p = 0.009), and increased distance traveled (p = 0.028). For each incremental increase in log distance traveled, the length of stay increases by 2.5%. LIMITATIONS: This is a retrospective review that uses National Surgical Quality Improvement Program data. It is not known how many patients left the hospital and did not return to their primary residence. CONCLUSIONS: In a model that controlled for variables, increased travel distance from a patient's residence to the surgical hospital was associated with an increase in length of stay. If length of stay is a reportable quality measure in patients undergoing colorectal surgery, significant travel distance should be accounted for in the risk adjustment model calculations.

An unusual presentation of a rectal duplication cyst.

INTRODUCTION: Intestinal duplications are rare developmental anomalies that can occur anywhere along the gastrointestinal tract. Rectal duplication cysts account for approximately 4% of all duplication cysts. They usually present in childhood with symptoms of mass effect, local infection or more rarely with rectal bleeding from ectopic gastric mucosa. PRESENTATION OF CASE: A 26year old male presented with a history of bright red blood per rectum. On examination a mucosal defect with an associated cavity adjacent to the rectum was identified. This was confirmed with rigid proctoscopy and CT scan imaging. A complete transanal excision was performed. DISCUSSION: Rectal duplication cysts are more common in pediatric patients. They more frequently present with symptoms of mass effect or local infection than with rectal bleeding. In adult patients they are a rare cause of rectal bleeding. Definitive treatment is with surgical excision. A transanal, transcoccygeal, posterior sagittal or a combined abdominoperineal approach may be used depending on anatomic characteristics of the duplication cyst. CONCLUSION: We present a rare case of a rectal duplication cyst presenting in adulthood with rectal bleeding, managed with transanal excision.

Incidence of fertility counseling of women of child-bearing age before treatment for colorectal cancer.

BACKGROUND: The incidence of colorectal cancer in women of reproductive age is low. Physicians lack awareness of infertility difficulties in these patients. We studied the frequency of women of child-bearing age with colorectal cancer receiving pretreatment fertility counseling. METHODS: This retrospective review from 1996 to 2004 screened women of reproductive age treated for colorectal cancer for documentation of fertility counseling or referral to fertility specialists before initiating treatment. RESULTS: Twenty-one women met the age criteria (range, 18-45 y). Eight patients were excluded for prior sterilization procedures or tumor involvement of reproductive organs. In the 13 remaining women, 2 had pretreatment fertility counseling documentation. These 2 patients had fewer than 2 children and had rectal tumors. Thirty-eight percent had pregnancy or menses difficulty after treatment. CONCLUSIONS: Few young women with colorectal cancer had pretreatment fertility counseling, whereas several had fertility complications posttreatment. Physicians need to discuss infertility concerns with their female colorectal cancer patients before intervention.