Joseph W. Nunoo-Mensah

Adenocarcinoma Arising in the Middle of Ileoanal Pouches : Report of Five Cases

Restorative proctocolectomy with ileal pouch-anal anastomosis with or without mucosectomy has become the procedure of choice in patients with long-standing ulcerative colitis complicated by malignancy or medically refractory disease and for familial polyposis syndrome. Some reports have demonstrated the development of malignancy at the ileoanal anastomosis. We present a recent series of five patients who developed adenocarcinoma in the middle of their ileal pouch including the first case of pouch carcinoma in a patient who underwent pouch formation for ulcerative colitis. We discuss their presentation and management. Development of ileal pouch cancers, while rare, has been seen with increasing frequency in our practice. Patients with long-standing ileal pouches may benefit from routine surveillance of the pouch as often as every six months, which can be performed quickly and easily in the office using flexible endoscopy.

Fistula-in-ano: do antibiotics make a difference?

BackgroundThe objective of this study was to evaluate the hypothesis that antibiotics in conjunction with drainage of anorectal abscesses will reduce the incidence of fistulae formation. The impact of age and associated comorbidity on the formation of fistulae were also evaluated.MethodsPatients with a diagnosis of anorectal abscesses were identified from the database of a single colorectal practice. Demographic data, comorbidity, antibiotic usage, and fistulae formation were collected from review of patients charts and phone contact. Statistical analysis was performed with the two-sided Fishers exact and Walds chi-square tests.ResultsFifty-six patients with complete data were analyzed. The overall fistulae formation rate was 32%. Of all patients, 45% received a course of broad-spectrum antibiotics at the time of drainage and 48% of patients had associated comorbidity. Although trends were evident, there were no statistical significant associations between fistulae formation and age, comorbidity, and antibiotics.ConclusionAlthough not statistically significant, there was a trend that antibiotics and age >45 years may be protective against the formation of fistulae. Similarly, the data suggest that the presence of comorbidity may increase the risk of fistula formation. We are encouraged by this result and propose to conduct a larger randomized prospective study.

Prevalence of intra-abdominal surgery: what is an individual's lifetime risk?

Background: The lifetime risk of intra-abdominal surgery is unknown. The objectives of this study were to derive this information from our local population, and to consider the role of incidental surgery. Methods: Over an 8-year period, 2648 autopsy and clinical records from a public and private hospital were reviewed for evidence of intra-abdominal surgery. Results: 2262 (85%) cases were from the public hospital and 386 (15%) from the private hospital. The adjusted intra-abdominal surgical rate was 43.8% in those over the age of 60. With the exception of the age group 21–40, there were no statistical significant differences in operative rates between hospitals. The intra-abdominal surgical rate over the age of 60 was used as an estimate of the lifetime risk of intra-abdominal surgery. Conclusions: The lifetime risk of intra-abdominal surgery can be used to assess the utilization of healthcare among ethnic groups and in considering the role of incidental surgery.

Is there a role for neoadjuvant treatment with gleevec for large rectal gastrointestinal stromal tumors

Dear Editor: Gastrointestinal stromal tumors (GISTs) are the most common type of mesenchymal malignancy in the gastrointestinal tract. Because GISTs are resistant to conventional chemotherapy and radiotherapy, surgical resection is the mainstay treatment for resectable diseases. Based on their expression of c-kit (CD117), a transmembrane growth factor receptor, GISTs can be distinguished from leiomyomas and schwanomas. Imatinib mesylate (Gleevec, Novartis Pharma AG, Basel, Switzerland), a tyrosine kinase inhibitor targets this receptor. By downregulating tyrosine kinase activity, this drug reduces cell proliferation and induces apoptosis. Systemic therapy with Gleevec is currently approved for the treatment of c-kit-positive unresectable and metastatic GIST. Its role in the neoadjuvant setting has, however, not been clearly established. We report of a case of a large rectosigmoid GIST that was effectively downstaged with Gleevec, facilitating a limited resection and avoidance of a pelvic exenteration, which would have otherwise been required. A 67-year-old male Asian presented with a 10-day history of low abdominal and pelvic pain, frequent bowel movement, and dysuria. He has no history of rectal bleeding. Digital rectal examination revealed a large extramucosal mass in the mid, right, and anterior wall of the rectum. Rigid proctoscopy and colonoscopy demonstrated an extraluminal lesion starting at 3 cm above the puborectalis muscle and ascending up to the rectosigmoid junction. Cystoscopy revealed normal bladder mucosa but with an impression of an extrinsic mass compressing the bladder. Computer tomography (CT) scan confirmed an 8.5-cm pelvic mass arising from the wall of the rectum. Although there was no evidence of distant metastasis, the CT could not exclude invasion of the bladder by tumor. Transanal core biopsy revealed a spindle cell tumor with high mitotic activity (>5/50 high power field) and positive staining for CD-117. These features were consistent with the diagnosis of a c-kit-positive GIST. Because of the size of the tumor and the extent of surgery required to excise it, preoperative treatment with 600 mg of Gleevec daily for 10 weeks was initiated. The treatment was tolerated well by the patient with the exception of a skin rash that affected the patient’s back, abdomen, and upper and lower limbs. The rash resolved after Gleevec was discontinued. N. Wasserberg (*) . J. W. Nunoo-Mensah . R. W. Beart Jr . T. S. Ker Department of Colorectal Surgery, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA 90033, USA e-mail: nwasserberg@surgery.usc.edu Tel.: +1-323-8653690 Fax: +1-323-8653671 (2007) 22: 981–982

Re: Surgical Volume and Long-Term Survival Following Surgery for Colorectal Cancer in the Veterans Affairs Health-Care System

Re: Surgical Volume and Long-Term Survival Following Surgery for Colorectal Cancer in the Veterans Affairs Health-Care System