Guy F Nash

Should indeterminate lung lesions reported on staging CT scans influence the management of patients with colorectal cancer

Objective  The aim of this study was to determine the significance of indeterminate lung lesions reported from staging CT scans on patients with colorectal cancer.

Intussusception in colorectal cancer.

Adult intussusception is a rare occurrence and, unlike in childhood, is usually associated with an underlying tumor. Although computed tomography (CT) imaging can identify an intussusception and point toward a cause, diagnosis is challenging if it is only intermittent. When an intussusception presents in the context of a known bowel cancer, it is possible to attribute nonspecific abdominal symptoms to the malignant process. Herein, we describe 2 cases of retrograde intussusception caused by cecal tumors that were not identified on preoperative CT scanning, only to be found during surgery. Both patients presented with intermittent severe abdominal pain and weight loss, which is not usually a feature of cecal cancer without metastases. These cases highlight the difficulty of diagnosing intermittent adult intussusception and that atypical abdominal pain might herald an otherwise occult colorectal cancer.

A diagnostic dilemma following risk-reducing surgery for BRCA1 mutation - a case report of primary papillary serous carcinoma presenting as sigmoid cancer.

BackgroundWomen that carry germ-line mutations for BRCA1 or BRCA2 genes are at an increased risk of developing breast, ovarian and peritoneal cancer. Primary peritoneal carcinoma is a rare tumour histologically identical to papillary serous ovarian carcinoma. Risk-reducing surgery in the form of mastectomy and oophorectomy in premenopausal women has been recommended to prevent breast and ovarian cancer occurrence and decrease the risk of developing primary peritoneal cancer.Case presentationWe present a case report of a woman with a strong family history of breast cancer who underwent risk-reducing surgery in the form of bilateral salpingo-oophorectomy following a mastectomy for a right-sided breast tumour. Following the finding of a BRCA1 mutation, a prophylactic left-sided mastectomy was performed. After remaining well for twenty-seven years, she presented with rectal bleeding and altered bowel habit, and was found to have a secondary cancer of the sigmoid colon. She was finally diagnosed with primary papillary serous carcinoma of the peritoneum (PSCP).ConclusionPSCP can present many years after risk-reducing surgery and be difficult to detect. Surveillance remains the best course of management for patients with known BRCA mutations.

Closure of temporary stoma after anterior resection

Dear Sir, In response to the recently published systematic review by Rai et al. [1], we were surprised to see that our previously published data on this subject were not included in their analysis. The authors stated that they conducted a search of all published abstracts from the Association of Coloproctology meetings from the last 3 years. Two abstracts presented at the 2005 Tripartite Meeting, which discussed the outcomes of a dedicated colorectal 2-week rule clinic at a large teaching hospital, were unfortunately overlooked [2,3]. This is perhaps a significant omission as the total patient cohort from this study included almost 1000 more referrals than all the other referenced studies combined. Following analysis of the staging of those colorectal cancers diagnosed via this referral route, our results strongly indicate that the fast-track system has failed to result in a greater proportion of more favourably staged tumours. Given the previous findings, which suggest that neither tumour staging [4] nor mortality [5] are associated with symptom duration in colorectal cancer, the authors’ conclusions that a re-working of the system to incorporate additional diagnostic tools would appear to be unlikely to make any meaningful contribution to improved stage migration or reduced mortality rates. Although we would not dispute that the spirit of the recommendations in striving to minimize the time interval between presentation and diagnosis has been established with the best intentions, the scientific basis on which to justify this approach, in the context of colorectal malignancy at least, appears increasingly unsound. The available evidence suggests that future resources would be more appropriately invested in a comprehensive national screening programme targeting patients aged 50 years and over.

A Simple Case of Appendicitis? An Increasingly Recognised Pitfall

Acute appendicitis is the most common presentation of the acute abdomen in the UK. Although in most cases this is an easily reached diagnosis, presentation is not always typical and there are certain other conditions which may mimic appendicitis. Diagnostic adjuncts usually provide the additional information required to make a confident diagnosis; however, in some circumstances, the safest and most reliable course of action is appropriate surgical intervention. A case report is presented of a 43-year-old woman who presented with history of peri-umbilical pain migrating to the right iliac fossa. Following further investigation, with routine blood tests, plain radiographs, ultrasound examination of the abdomen and pelvis, and CT scanning not pointing towards a definitive diagnosis, she eventually underwent a diagnostic laparoscopy which revealed primary omental torsion. An open omentectomy was performed and 2 months on she remains well.

Haemorrhoidal artery ligation operation for the treatment of symptomatic anorectal varices

1 Coffin CM, Dehner LP, Meis – Kindblom JM. Inflammatory myofibloblastic tumor, inflammatory fibrosarcoma, and related lesions: a historical rewiev with different diagnostic considerations. Semin Diagn Pathol 1998; 15: 102–10. 2 Ramachandra S, Houlowood K, Bisceglia M, Fletcher CDM. Inflammatory pseudotumor of soft tissue: a clinicopathological and immunohistochemical analysis of 18 cases. Histopathology 1995; 27: 313–23. 3 Symmers D. Primary hemangiolymphoma of the haemal nodes: an unusual variety of malignant tumors. Arch Int Med 1921; 38: 467–74. 4 Weiss SW, Sobin L. (1994) WHO Classification of Soft Tissue Tumors. Spinger Verlag, Berlin. 5 Jones EC, Clement PB, Young RH. Inflammatory pseudotumors of the urinary bladder. A clinicopathological, immunohistochemical, ultrastructural and flow cytometric study of 13 cases. Am J Surg Pathol 1993; 17: 267–74.

Therapeutic use of the Heald Silastic Anal Stent

An 85-year-old man underwent a laparoscopic-assisted subtotal colectomy for widespread high-grade dysplasic changes caused by ulcerative colitis. A water-soluble contrast enema was performed on the post-operative day 8 to investigate a persistent ileus associated with a lowgrade temperature but no anastomotic leak was demonstrated. He remained clinically stable without evidence of peritonitis and started opening his bowels. However, ongoing signs of grumbling sepsis and diarrhoea prompted abdominopelvic computerized tomography (CT) on day 11. This showed a substantial gas/fluid collection in the left side of the abdomen originating from an anastomotic leak at the ileorectal anastomosis. A drain was inserted radiologically, which failed to improve the situation. Subsequent CT scanning demonstrated little resolution of the collection in comparison with previous films and a persistently dilated rectum was also noted. The risks of further major surgery in this now frail man were felt to be too great and a highly conservative surgical approach was therefore taken from basic surgical principals. First, the (relative) obstruction distal to the anastomosis caused by the ballooned rectum was relieved using a Heald Silastic Stent (Fig. 1) placed in the anal canal (Fig. 2). Secondly, the fine tube drain was replaced with a corrugated drain inserted into the residual collection via a 5 cm incision (under general anaesthesia). Concurrent treatment with parenteral nutrition and broad-spectrum antibiotics was also given. Four weeks after this manage-

Hollow seton for magnetic resonance imaging fistula visualization

Magnetic resonance imaging (MRI) in conjunction with examination under anaesthetic is generally agreed to be the ‘gold standard’ investigation for complex fistulae-inano [1,2]. Setons are not normally demonstrated and indeed may make a primary track hard to distinguish on MRI. We have found that the use of a hollow 3-mm diameter silastic tube seton allows the clear visualization of drained fistula tracks with MRI (Fig. 1). These setons are well tolerated by patients and are useful in the setting of ongoing perianal sepsis, particularly when planning further surgery. References

GTN headaches and reduction of natural banding

resulted in a diagnosis of Crohn’s disease. The stricture in the barium enema had been attributed to inflammation and the cobblestone appearance of the caecum to luminal ulceration interspersed with islets of normal mucosa. The stricture was due to the presence of pharmacobezoar, whilst tablets indurating into the bowel wall were responsible for the cobblestone appearance. The supposed fistula joining the sigmoid colon to caecum reported on the CT, was shown to be a large caecal diverticulum extending inferiorly towards the rectum. Medications that have been reported as responsible for pharmacobezoar include: aluminium hydroxide gel, enteric-coated aspirin, sucralfate, guar gum, cholestyramine, enteral feeding formulae, Psyllium preparations, Nifedipine XL and Meprobamate [2]. Nifedipine preparations have been reported as upper gastro-intestinal concretions in several published case reports. However this case is especially interesting due to the caecal location of the pharmacobezoar and also the ‘cobblestoned’ nature of the indurated caecum [4].

Minimally invasive treatment of radiation proctitis and piles - a video vignette.

1 Hahnloser D, Cantero R, Salgado G, Dindo D, Rega D, Delrio P. Transanal minimal invasive surgery (TAMIS) for rectal lesions: should the defect be closed? Colorectal Dis 2015; 17: 397–402. 2 Food and Drug Administration. Guidance for Industry. E6 Good Clinical Practice: Consolidated Guidance. pp. 37–42. http://www.fda.gov/cder/guidance/959fnI.pdf (accessed May 12, 2015). 3 Dekkers OM, Egger M, Altman DG, Vandenbroucke JP. Distinguishing case series from cohort studies. Ann Intern Med 2012; 3: 37–40.