Retrospective cohort study of the impact of faecoliths on the natural history of acute appendicitis.

BACKGROUND: Despite acute appendicitis is one of the most common surgical emergencies, its aetiology remains incompletely understood. AIM: This study aimed to assess the rate at which faecoliths were present in acute appendicitis treated with appendicectomy and whether their presence was associated with complicated appendicitis. METHODS: All adult patients who underwent appendicectomy for acute appendicitis in a 2 years period (January 2018 and December 2019) at a single institution were retrospectively reviewed. The presence of a faecolith was identified by at least one of three methods: pre-operative CT scan, intraoperative identification, or histopathology report. Patients were grouped according to the presence or absence of a faecolith and demographics, type of appendicitis and surgical outcomes analysed. Complicated appendicitis was defined as appendicitis with perforation, gangrene and/or periappendicular abscess formation. RESULTS: A total of 1035 appendicectomies were performed with acute appendicitis confirmed in 860 (83%), of which 314 (37%) were classified as complicated appendicitis. Three hundred thirty-nine (35%) of the appendicitis cases had faecoliths (complicated 165/314 cases; 53%; uncomplicated 128/546; 23%, p < 0.001). The presence of a faecolith was associated with higher complications and a subsequent longer post-operative stay. CONCLUSION: The rigorous methodology of this study has demonstrated a higher rate of faecolith presence in acute appendicitis than previously documented. It reinforces the association of faecoliths with a complicated disease course and the importance in prioritising emergency surgery and postoperative monitoring for complications.

Risk of colorectal cancer in patients with appendicitis over the age of 40 years.

AIM: Acute appendicitis in late adulthood is hypothesized to be associated with an increased risk of colorectal cancer (CRC). This study aimed to establish whether patients over the age of 40 years presenting with appendicitis had an increased risk of being diagnosed with CRC over the subsequent 3 years. METHOD: This is a retrospective review of patients aged 40 years and over presenting to Canterbury District Health Board with appendicitis from January 2010 to December 2015. Clinical details were obtained for these patients and cross-referenced with the New Zealand Cancer Registry for the 3 years following diagnosis. The incidence ratio rate (IRR) and standardized incidence ratio (SIR) were calculated by establishing the incidence of CRC in this cohort and comparing it with the Canterbury population data. RESULTS: A total of 1099 patients met the inclusion criteria. The majority (75%) underwent CT as part of their initial work-up. The rate of colonoscopy increased with age from around 10% between 40 and 49 years to 27% for those 70 years and over. Eleven cases of CRC were identified, resulting in an IRR 2.35 (95% CI 1.17-4.21). The SIR for this population was 3.28 (95% CI 1.82-5.92). CONCLUSION: The rate of CRC is significantly increased compared with the background population in this cohort. The results of this study support luminal investigation of adults aged 40 years and over who present with acute appendicitis as CT alone was insufficient to detect the pathology.

Self-expandable metal stent (SEMS) placement or emergency surgery as palliative treatment for obstructive colorectal cancer: A systematic review and meta-analysis.

Previous meta-analyses on palliative treatment of malignant colorectal obstruction with Self-Expandable Metal Stent (SEMS) or emergency surgery reported contradictory results for morbidity, and frequently included extracolonic obstruction. Therefore, the current meta-analysis aimed to exclusively analyze palliative treatment for primary obstructive colorectal cancer, with early complication rate as a primary outcome. A systematic literature search was performed on studies comparing palliative SEMS and emergency surgery. Corresponding authors were contacted for additional data. Eighteen studies were selected (1518 patients). Early complication rate was 13.6 % for SEMS and 25.5 % for emergency surgery (Odds Ratio (OR) 0.46, 95 % confidence interval (CI) 0.29-0.74). Mortality was 3.9 % and 9.4 % (OR 0.44, 0.28-0.69). Stomas were present in 14.3 % and 51.4 % of patients (OR 0.17, 0.09-0.31). More late complications occurred after SEMS (23.2 % versus 9.8 %, OR 2.55, 1.70-3.83), mostly due to SEMS obstruction. In conclusion, SEMS placement seems the preferred treatment of obstructing colorectal cancer in the palliative setting.

The factors that lead to a delay between general practitioner referral of symptomatic patients and specialist diagnosis of colorectal cancer: an audit in the Bay of Plenty District Health Board.

AIM: To determine factors leading to delay between referral by the GP of symptomatic patients and subsequent specialist diagnosis of colon or rectum cancer (CRC). METHOD: A retrospective audit of patients with new CRC referred by their GP over a 30-month period to the specialist services. Analysis of referral letters, specialist grading and subsequent results of investigations. We focused on the High Index of Suspicion (HIS) criteria for suspected CRC. RESULTS: Only 65 out of 181 patients fulfilled the HIS criteria and of these only half were correctly identified in the referral letter. Only 48 who fulfilled HIS criteria were graded as urgent by the specialist and had their fast-track diagnostic test within a median of 21 days (5-114). The remaining 133 waited a median of 67 days (10-387) (p<0.001). The diagnosis was reached faster if the patient went straight to colonoscopy rather than initial outpatient assessment: median 32 versus 81 days (p=0.008). CONCLUSION: The HIS Urgent pathway only identified a third of patients and so the criteria should be reviewed. GPs frequently failed to recognise and refer those who met the criteria. A standardised referral form prompting the inclusion of all required information would improve this.

Effects of polyphyllin D, a steroidal saponin in Paris polyphylla, in growth inhibition of human breast cancer cells and in xenograft.

Paris polyphylla is a traditional Chinese Medical herb that has been used in treating cancer for thousands of year. Without studies on the anticancer effects of Paris polyphylla being initiated before, we have first studied the component of Paris polyphylla and have spotted out a steroidal saponin, polyphyllin D. As long as the chemical structure and the improved synthesis of polyphyllin D were ascertained, both in vitro to in vivo studies were performed. It was found that treatment of MCF-7 and MDA-MB-231 cells with polyphyllin D resulted in the inhibition of viability and induction of apoptosis in a dose-dependent manner, with an IC50 of 5 microM and 2.5 microM, respectively, after 48 hours of incubations. Apoptosis of MCF-7 and MDA-MB-231 cells by polyphyllin D was evidenced by the occurrence of DNA fragmentation, formation of a hypodiploid peak in the cell cycle analysis, phosphatidyl-serine externalization and a late loss of membrane integrity. Mechanistically, polyphyllin D dissipates the mitochondrial membrane potential, induces a downregulation of anti-apoptotic Bcl-2 expression and an up-regulation of pro-apoptotic Bax expression, and activates caspase-9. These results suggest that polyphyllin D elicits apoptosis through mitochondria dysfunction. In vivo study demonstrated that daily administration of polyphyllin D (2.73 mg/kg body weight) through intravenous injection for ten days in nude mice bearing MCF-7 cells effectively reduced tumor growth for 50% in terms of tumor weight and size, given no significant toxicity in heart and liver to the host. All these findings provide novel insights that polyphyllin D could serve as a candidate in breast cancer treatment.