Joseph Deasy

Endolaparoscopic removal of colonic polyps

A proportion of colonic polyps is not amenable to exclusively colonoscopic removal due to their location, size or tortuosity of the colon. A combined laparoscopic/colonoscopic polypectomy or endolaparoscopic polypectomy (ELP) is an alternative to formal segmental resection. We present our experience of ELP.

Colonoscopy and computerized tomography scan are not sufficient to localize right-sided colonic lesions accurately.

Aim  Accurate preoperative localization of colonic lesions is critical especially in laparoscopic colectomy where tactile localization is absent particularly in screen‐detected tumours. The study aimed to evaluate the accuracy of colonoscopy and double‐contrast computerized tomography (CT) scan to localize lesions treated by right hemicolectomy.

A Meta-analysis of Percutaneous Drainage Versus Surgery as the Initial Treatment of Crohn’s Disease-related Intra-abdominal Abscess

BACKGROUND AND AIMS Spontaneous intra-abdominal abscess formation is a common complication of Crohns disease. Percutaneous drainage [PD] may avoid surgery and preserve bowel length, although there is no consensus on its efficacy as the initial treatment and the associated outcomes if unsuccessful. This study uses meta-analytical techniques to compare the outcomes of PD alone versus primary surgery for Crohns-related intra-abdominal abscess. METHODS A comprehensive search for comparative studies examining the use of PD and surgery for spontaneous Crohns-related intra-abdominal abscess was performed. Each study was reviewed and data extracted. Random-effects methods were used to combine data. RESULTS There were six studies including a total of 333 patients that met the inclusion criteria. Surgery was performed initially in 184 patients, PD was performed in 149. Groups were similar in demographics and abscess characteristics. There was a significantly higher risk of abscess recurrence following PD (odds ratio [OR]: 6.544, 95% confidence interval [CI]: 1.783-24.010, p: 0.005]. The pooled proportion of PD patients requiring subsequent surgery was 70.7%. There was no significant difference between approaches in post-procedural complication rate [OR: 0.657, 95% CI: 0.175-2.476, p: 0.535], ultimate permanent stoma requirement [OR: 0.557, 95% CI: 0.147-2.111, p: 0.389] or length of hospital stay [difference in means: -1.006 days, 95% CI: -28.762-26.749, p: 0.943]. CONCLUSIONS PD can avoid surgery in up to 30% of patients presenting with spontaneous Crohns-related intra-abdominal abscesses. However, the suggested advantages over surgery in relation to complications and length of stay were not apparent. Further studies in this area are needed.

Global DNA methylation is altered by neoadjuvant chemoradiotherapy in rectal cancer and may predict response to treatment – A pilot study

AIM In rectal cancer, not all tumours display a response to neoadjuvant treatment. An accurate predictor of response does not exist to guide patient-specific treatment. DNA methylation is a distinctive molecular pathway in colorectal carcinogenesis. Whether DNA methylation is altered by neoadjuvant treatment and a potential response predictor is unknown. We aimed to determine whether DNA methylation is altered by neoadjuvant chemoradiotherapy (CRT) and to determine its role in predicting response to treatment. PATIENTS AND METHODS Fifty-three (n = 53) patients with locally advanced rectal cancers treated with neoadjuvant CRT followed by surgery were identified from the pathology databases of 2 tertiary referral centres over a 4-year period. Immunohistochemical staining of treatment specimens was carried out using the 5-Methylcytidine (Eurogentec, Seraing, Belgium) antibody. Quantitative analysis of staining was performed using an automated image analysis platform. The modified tumour regression grading system was used to assess tumour response to neoadjuvant therapy. RESULTS Seven (13%) patients showed complete pathological response while 46 (87%) patients were partial responders to neoadjuvant treatment. In 38 (72%) patients, significant reduction in methylation was observed in post-treatment resection specimens compared to pre-treatment specimens (171.5 vs 152.7, p = 0.01); in 15 (28%) patients, methylation was increased. Pre-treatment methylation correlated significantly with tumour regression (p < 0.001), T-stage (p = 0.005), and was able to predict complete and partial pathological responders (p = 0.01). CONCLUSION Neoadjuvant CRT appears to alter the rectal cancer epigenome. The significant correlation between pre-treatment DNA methylation with tumour response suggests a potential role for methylation as a biomarker of response.

Emergency appendicectomy in the era of laparoscopy: a one-year audit

BackgroundAppendicectomy for acute appendicitis is the commonest emergency surgical operation. With widespread acceptance of minimal access surgery most appendicectomies are now performed laparoscopically.AimsThe aim of this study was to assess whether the rate of normal appendicectomy has changed following the introduction of laparoscopic techniques in our institution.Methods A retrospective study of patients having emergency appendicectomies over a 1-year period (2005) in a large teaching hospital was undertaken.ResultsA comparison of data was made from a prior study performed at the same hospital in 1988. 196 adult patients underwent appendectomies during this period. The normal appendectomy rate was 10.2% compared to 22.8% in the previous study. This rate was twice as high in women of reproductive age as compared to men.Conclusion There has been widespread uptake of laparoscopic appendectomy in our hospital. This technique has reduced the rate of histologically normal appendicectomies due to intra-operative visualization of the appendix.

Nicorandil related anal ulcer.

BackgroundAnal ulceration is uncommon. Patients are typically referred because of severe anal pain, bleeding, discharge, and ulceration. It is important to exclude anal carcinoma, and to consider more unusual causes.MethodsA 74-year-old lady presented with severe anal pain and ulceration. This was subsequently noted to be related to nicorandil, a potassium channel activator used in the treatment of angina. Discontinuation of nicorandil and faecal diversion allowed symptom relief and ulcer healing.ConclusionKnowledge of the association between nicorandil and anal ulceration is essential in order to appropriately diagnose and manage this condition.

C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer

Anastomotic leak (AL) after anterior resection results in increased morbidity, mortality and local recurrence. The aim of this study was to assess the ability of C‐reactive protein (CRP) to predict AL in the first week after anterior resection for rectal cancer.

Fast-Track for the Modern Colorectal Department

In recent years, fast-track or enhanced recovery after surgery (ERAS) colorectal pathways have been utilized to achieve faster recovery and discharge from hospital with swift resumption of normal activities of daily living without an increase in complications or readmissions. Despite the large body of evidence available, however, adoption of the fast-track methodology in current surgical practice has been slow and sporadic. As outlined by a recent Cochrane review, practice uptake has mostly focused on individual component uptake. Therefore, instead of repeating what already has been established in the literature pertaining to colorectal fast-track surgery, the aim of this article is to interrogate the evidence concerning the individual components of ERAS pathways as they relate to a contemporary surgical department to determine the most relevant critical components for patients undergoing colorectal surgery in modern surgical practice.

Adenocarcinoma arising in a retrorectal teratoma: case report and review of the literature.

A 46-year-old woman, para 3, presented with a 3-month history of difficulty passing urine. Bimanual pelvic and digital rectal examination revealed a large retrorectal mass. The patient had no significant medical history. Pelvic magnetic resonance imaging (MRI) demonstrated a large, 12-cm septated cystic structure occupying the pelvis, anterior to the sacrum with solid components posteriorly. Appearances on MRI were suggestive of a teratoma (Fig. 1). There was no radiological evidence of sacral invasion. At laparotomy, the rectum and the uterus were grossly normal but displaced anteriorly by a large cystic mass in the pelvis. Dense adhesions were encountered between the presacral fascia and the cyst. The cyst was drained to facilitate dissection. A postanal semicircular incision allowed mobilization from below, protecting the rectum and sphincter complex. The specimen was resected and sent for histopathological analysis. Gross examination of the specimen revealed a large cystic structure of 60 · 80 · 30 mm. Microscopic examination showed foci of skin with mature skin appendigeal structures, areas of keratinizing squamous epithelium, respiratory epithelium and smooth muscle. Additionally, tissue showing moderately differentiated adenocarcinoma was identified, measuring 30 · 15 · 11 mm. However, benign colonic epithelium was not identified in the wall of the mass lesion. Immunohistochemical staining showed the malignant cells to be CK20and CDX2-positive, with focal positivity for CK7. Inhibin and WT1 were negative. This profile was in keeping with adenocarcinoma of colonic origin (Fig. 1).

Meta-analysis of the clinicopathological characteristics and peri-operative outcomes of colorectal cancer in obese patients

BACKGROUND The effect of obesity on the clinicopathological characteristics of colorectal cancer (CRC) has not been clearly characterized. This meta-analysis assesses the pathological and perioperative outcomes of obese patients undergoing surgical resection for CRC. METHODS Meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were searched for studies reporting outcomes for obese and non-obese patients undergoing primary CRC resection, based on body-mass index measurement. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS A total of 2183 citations were reviewed; 29 studies comprising 56,293 patients were ultimately included in the analysis, with an obesity rate of 19.3%. Obese patients with colorectal cancer were more often female (OR 1.2, 95% CI 1.1-1.2, p<0.001) but there was no difference in the proportion of rectal cancers, T4 tumours, tumour differentiation or margin positivity. Obese patients were significantly more likely to have lymph node metastases (OR 1.2, 95% CI 1.1-1.2, p<0.001), have a lower nodal yield, were associated with a longer duration of surgery, more blood loss and conversions to open surgery (OR 2.6, 95% CI 1.6-4.0, p<0.001) but with no difference in length of stay or post-operative mortality. CONCLUSION This meta-analysis demonstrates that obese patients undergoing resection for CRC are more likely to have node positive disease, longer surgery and higher failure rates of minimally invasive approaches. The challenges of colorectal cancer resection in obese patients are emphasized.