A rare case of jejuno-ileal intussusception secondary to a gastrointestinal stromal tumour.

Gastrointestinal stromal tumours (GISTs) are rare tumours, making up 0.2-1% of gastrointestinal malignancies [Zakaria and Daradkeh (Jejunojejunal intussusception induced by a gastrointestinal stromal tumour. Case Rep Surg 2012; 2022: :173680)]. Their relative rarity combined with non-specific presentation results in tumours often remaining undiagnosed until surgery or histological examination [Martis et al. (A rare case of jejunojejunal intussusception in an adult. Indian J Surg 2013; 75: (Suppl 1):18-20)]. Presentation as a lead point for intussusception is particularly rare. We present the first case of GIST leading to intussusception at the jejuno-ileal junction in an otherwise well patient prior to presentation. Provisional diagnosis was made during emergency laparotomy, and confirmed through histological analysis. A typical immunohistochemical profile was identified, after which the patient was commenced on adjuvant imatinib therapy. We discuss classical presentation of intussusception and GIST. Further considerations of the investigation and treatment options of GISTs are also presented.

Metachronous colorectal cancer: a competing risks analysis with consideration for a stratified approach to surveillance colonoscopy.

BACKGROUND: The incidence of metachronous cancer will become an important clinical consideration as the life expectancy of the population increases and as rates of curative resection improve. OBJECTIVE: To assess the pattern of metachronous cancer development following curative resection of colorectal cancer in an unselected patient population offered postoperative colonoscopic surveillance. METHOD: Prospective clinical follow-up after curative colorectal cancer resection and surveillance colonoscopy with or without polypectomy in accordance with the national guidelines. Actuarial analysis and competing risk analysis were performed to account for death and recurrence and to stratify for age, gender, stage, and tumor site. RESULTS: Five hundred thirty-eight patients with median follow-up 4 years 2 month (0-16) years. Fifteen patients (3%) developed metachronous cancer, at a median time interval of 90 months from primary resection. Thirteen metachronous cancer patients (87%, 13/15) underwent one to five surveillance colonoscopies: nine patients were asymptomatic at time of diagnosis of metachronous cancer. Competing risks analysis suggests that the adjusted cumulative incidence in males aged 55 is 4% at 10 years compared with 1% in females aged 85 years old. CONCLUSIONS: A patient aged under 65 at the time of the primary curative resection carries a 2% 5-year risk of metachronous cancer, implying that 3 year surveillance colonoscopy is justified. Whereas patients aged over 75 carry less than a 2% 10-year risk, implying that it is seldom warranted to repeat the colonoscopy more frequently than every 5 years. A stratified approach to the frequency of surveillance colonoscopy requires further consideration.

Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS).

BACKGROUND: Postoperative nausea and vomiting is one of the most common complications affecting patients after surgery and causes significant morbidity and increased length of hospital stay. It is accepted that patients undergoing surgery on the bowel are at a higher risk. In the current era of minimally invasive colorectal surgery combined with enhanced recovery, reducing the incidence and severity of postoperative nausea and vomiting is particularly important. Dexamethasone is widely, but not universally used. It is known to improve appetite and gastric emptying, thus reduce vomiting. However, this benefit is not established in patients undergoing bowel surgery, and dexamethasone has possible side effects such as increased risk of wound infection and anastomotic leak that could adversely affect recovery. DESIGN: DREAMS is a phase III, double-blind, multicenter, randomized controlled trial with the primary objective of determining if preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing elective gastrointestinal resections. DREAMS aims to randomize 1,350 patients over 2.5 years.Patients undergoing laparoscopic or open colorectal resections for malignant or benign pathology are randomized between 8 mg intravenous dexamethasone and control (no dexamethasone). All patients are given one additional antiemetic at the time of induction, prior to randomization. Both the patient and their surgeon are blinded as to the treatment arm.Secondary objectives of the DREAMS trial are to determine whether there are other measurable benefits during recovery from surgery with the use of dexamethasone, including quicker return to oral diet and reduced length of stay. Health-related quality of life, fatigue and risks of infections will be investigated. TRIAL REGISTRATION: ISRCTN21973627.

Clostridium septicum sepsis and colorectal cancer - a reminder.

BACKGROUND: Spontaneous clostridium septicum infections are rare and are associated with a high mortality. Association of clostridium infection with colorectal malignancies have been previously reported and most cases are described in tumours of the ascending colon. We report our experience of clostridium septicum infection in the presence of tumour perforation in a series of two patients as a reminder of its association with sepsis in the presence of colorectal malignancy. CASE PRESENTATION: We isolated clostridium septicum infection in a series of two patients admitted as emergencies. One patient was found to have a perforated caecal tumour intraoperatively whilst the other had a perforated rectal tumour. The clinical outcome and management of each case are reported and underlying reasons for variations in outcome are discussed. CONCLUSION: Although uncommon, the possibility of clostridium septicum sepsis should be borne in mind in patients who present with underlying malignancy and have sepsis. The cumulative effect of sepsis and malignant perforation is associated with a high morbidity and mortality. Awareness and early diagnosis of clostridium septicum may improve the prognosis of what is usually regarded as a fatal infection.