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ABSTRACT Background Peritoneal carcinomatosis (PC) is a lethal regional progression in patients with colorectal cancer (CRC). Treatment with complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) achieves better local control than systemic palliative chemotherapy. Objectives To assess the efficacy on the prognosis of CRS and HIPEC compared with CRS only and to identify possible clinicopathological factors associated with the recurrence of PC. Methods The present retrospective study included all colorectal carcinoma cases with PC subjected to CRS with or without HIPC from January 2009 to June 2018 at the National Cancer Institute (NCI), Cairo University, Cairo, Egypt. The outcome is evaluated in terms of recurrence-free survival (RFS) and its predictors. Results Out of the 61 patients, 45 patients (73.8%) underwent CRS plus HIPEC, and 16 (26.2%) underwent CRS alone. The 1-year RFS was 55.7%, with a median of 12 months. The risk factors for recurrence identified in the univariate analysis were T4 primary tumor, high-grade, positive lymphovascular invasion (LVI), positive extracapsular nodal spread, and patients treated with CRS only, without HIPEC. In the multivariate analysis, the independent risk factors for recurrence were high grade and patients treated with CRS only. Conclusion T4 primary tumor, high grade, positive LVI, and positive extracapsular nodal spread seemed to be important predictors of recurrence following the treatment of PC. Our study also demonstrated that the addition of HIPEC to CRS improved the RFS.

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ABSTRACT Introduction Pelvic anatomy remains a challenge, and thorough knowledge of its intricate landmarks has major clinical and surgical implications in several medical specialties. The peritoneal reflection is an important landmark in intraluminal surgery, rectal trauma, impalement, and rectal adenocarcinoma. Objectives To investigate the correlation between the lengths of the middle rectal valve and of the peritoneal reflection determined with rigid sigmoidoscopy and to determine whether there are any differences in the location of the peritoneal reflection between the genders and in relation to body mass index (BMI) and parity. Design We prospectively investigated the location of the middle rectal valve and of the peritoneal reflection via intraoperative rigid sigmoidoscopy in colorectal cancer patients undergoing elective colorectal surgery. Results We evaluated 38 patients with a mean age of 55.5 years old (57.5% males) who underwent colorectal surgery at the coloproctology service of the Hospital Santa Marcelina, São Paulo, state of São Paulo, Brazil. There was substantial agreement between the lengths of the middle rectal valve and of the peritoneal reflection (Kappa = 0.66). In addition, the peritoneal reflection was significantly lower in overweight patients (p = 0.013 for women and p < 0.005 for men) and in women with > 2 vaginal deliveries (p = 0.009), but there was no significant difference in the length of the peritoneal reflection between genders (p = 0.32). Conclusion There was substantial agreement between the lengths of the peritoneal reflection and of the middle rectal valve, and the peritoneal reflection was significantly lower in overweight patients and in women with more than two vaginal deliveries.

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ABSTRACT Background Colorectal cancer (CRC) is the third most prevalent type of cancer worldwide, and is one of the major health problems in Asia, Africa, Europe, and America. The tumor antigens recently are of interesting indicators as diagnostic and prognostic tools, The aim of the present study is to detect the expression levels of carbonic anhydrase IX (CA9), the Wilms tumor gene (WT1), and the preferentially expressed antigen in melanoma (PRAME) in the peripheral blood of CRC patients in comparison with healthy controls. Methods A prospective case-control study of CRC patients was conducted. We included 25 newly-diagnosed CRC eligible patients and obtained peripheral blood samples of them as well as 10 blood samples from the control group. All samples were then submitted to deoxyribonucleic acid (DNA) extraction and a molecular study through real-time polymerase chain reaction (PCR). Results The CRC group consisted of 15 (60%) female and 10 (40%) male patients with a mean age of 50.52 ± 9.8 years, while the control group included 4 (40%) female and 6 (60%) male patients with a mean age of 47.7 ± 7.9 years. The CRC group, 24 (96%) of patient samples were CA9-positive with strong statistically significant differences (p < 0.00001; sensitivity: 96%; specificity: 90%). Regarding the WT1 gene, there were 11 (44%) positive samples in the CRC group, with no statistically significant differences (p = 0.055; sensitivity: 44%; specificity: 90%). The PRAME gene was positive in 9 (36%) samples in the CRC group, with no statistically significant differences (p = 0.357; sensitivity: 36%; specificity: 80%. Among CA9 (24 patients; 96%) of patients with CRC expressed positive results, in WT1 11(91.6%) CRC patients expressed gene, and in PRAME gene, 9 patients with CRC (81.8%) expressed positive results. Conclusion Overexpression of the CA9 gene in CRC of high sensitivity and specificity to be used as a tool to discriminate CRC from benign associate with high accuracy compare to WT1 and PRAME genes.

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ABSTRACT Study Aim The aim of the present study was to compare in real life the characteristics of treatment with infliximab according to the presence or absence of anoperineal involvement in Crohn’s disease. Methods We performed a single-center, prospective, non-interventional study, on patients with Crohn’s disease in remission who had been treated with infliximab for at least 1 year. Patients with poor treatment compliance, on antibiotics, or those with a stoma were excluded. Results We included 52 patients in this study: 34 with anoperineal lesions with or without luminal lesions, and 18 with luminal lesions only. Patients with anoperineal lesions were more likely to have undergone surgery (70.6% versus 38.9%, p = 0.027), had a shorter median time to infliximab treatment initiation (0.5 versus 5.5 years, p = 0.005), a higher mean dose of infliximab (6.6 versus 5.1 mg/kg, p = 0.015), and were more likely to receive combination treatments including infliximab (52.9% versus 11.1%, p = 0.008) than patients with luminal involvement only. Conclusions In our study, infliximab treatment was initiated more quickly, at higher doses, and more in combination therapy for anoperineal Crohn’s disease than for luminal damage alone. Additional studies are required to confirm this finding and to assess the tolerance of this treatment throughout patient management.

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ABSTRACT Background The relative rarity of synchronous para-aortic lymph node (PALN) metastasis (SPM) and metachronous PALN recurrence (MPR) in colorectal carcinoma (CRC) patients leads to a limited number of studies on patient management, and no treatment guidelines have been established to date. Objective To assess the prognostic, predictive roles, and long-term outcomes of different management strategies for isolated MPR and SPM in CRC patients to establish the best one. Materials and Methods We included 35 CRC patients with isolated MPR and 25 patients with isolated SPM who underwent curative R0 resection. We performed PALN dissection (PALND) in 15 cases in MPR group and in 10 cases in the SPM group; all remaining patients in both groups underwent chemoradiotherapy (CRT) without further surgical intervention. During the study period of about 5 years, we compared the patients who underwent PALND and those who underwent CRT. Results The overall survival and recurrence-free survival rates were significantly longer in patients who underwent PALND (p = 0.049 and 0.036 respectively).

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ABSTRACT Objective Until today, the true pathophysiology of hemorrhoidal disease (HD) has not yet been unraveled. More and more evidence guides us towards the hypothesis that reduced connective tissue stability is associated with a higher incidence of hemorrhoids. The present study aimed to compare the quantity and quality of collagen, and vessel morphometrics, in patients with symptomatic HD compared with normal controls. Methods Twenty-two samples of grade III and grade IV HD tissue from patients undergoing a hemorrhoidectomy between January 2004 and June 2015 were included in the study group. Samples of 15 individuals without symptomatic HD who donated their body to science and died a natural death served as controls. The quantity and quality of anal collagen, and anal vessel morphometrics were objectified. The quality of collagen was subdivided in young (immature) and old (mature) collagen. Results Patients with HD had an increased percentage of total anal collagen (62.1 ± 13.8 versus 18.7 ± 14.5%; p = 0.0001), a decreased percentage of young collagen (0.00009 ± 0.00008 versus 0.0008 ± 0.0008%; p = 0.001), and a smaller surface area of the anal vessels (795.1 ± 1215.9 micrometre2 versus 1219.0 ± 1976.1; p = 0.003) compared with controls. The percentage of old collagen did not differ between the control and study groups (0.588 ± 0.286% versus 0.389 ± 0.242%; p = 0.06). Conclusion The outcomes of the present study suggest that alterations in anal collagen composition may play a role in the formation of hemorrhoids.

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ABSTRACT Objective Colonoscopy is increasingly performed in octogenarians for the detection of colorectal cancer (CRC), but its benefits may be outweighed by its risks. The aim of the present study was to identify the risk factors for CRC in octogenarians presenting for colonoscopy to help stratify the need for this procedure. Methods A retrospective analysis of 434 patients aged ≥ 80 years referred for a colonoscopy between January 2018 and December 2019. Comparisons were made between those with and without CRC and advanced adenoma (AA). The primary endpoint was to identify the clinical variables predictive of CRC and AA, and the secondary endpoints were complications and death 30 days after the procedure. Results Colonoscopy was performed in 434 octogenarians, predominantly for symptoms, with CRC in 65 (15.0%) patients. Iron deficiency was associated with a higher risk of having CRC identified on colonoscopy (odds ratio [OR]: 2.33; 95% confidence interval [95%CI] = 1.36–4.00), but not symptoms such as bleeding, weight loss, or diarrhea. A colonoscopy in the last 10 years was protective, with a lower risk of CRC (OR: 0.45; 95% CI = 0.22–0.93). Patients with both normal iron stores and a colonoscopy within 10 years had a 92.5% chance of not having CRC. No variables were predictive of AA. Patients with complications, including death, were older and more likely to have underlying cardiorespiratory disease. Conclusion Iron status and colonoscopy within 10 years can be used to predict the risk of CRC in octogenarians. Those with low predicted risk, especially if older and with cardiorespiratory disease, should be considered for non-invasive tests, such as computed tomography (CT) colonography, over colonoscopy.

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ABSTRACT Objectives Sometimes, severe adhesion occurs between the rectus abdominis muscle and the ileal intestinal limbs after temporary diverting ileostomy. This can make ileostomy reversal difficult. The aim of the present study is to assess whether absorbable adhesion barrier made of oxidized regenerated cellulose (INTERCEED) could contribute to improved surgical outcomes in stoma reversal. Methods This was a single-institutional retrospective study. A total of 36 consecutive patients who underwent ileostomy reversal by a single surgeon were retrospectively reviewed. INTERCEED was inserted between the ileal limbs and the rectus abdominis muscle at the time of ileostomy creation in 12 patients. Surgical outcomes of the ileostomy reversal were compared between patients treated with and without INTERCEED. Results The degree of adhesion formation between the ileal limbs and the rectus abdominis muscles, operating time, and estimated blood loss were significantly reduced in patients treated with INTERCEED compared with those treated by the conventional approach. None of the patients in the INTERCEED group had postoperative complications after the initial surgery and ileostomy reversal. Conclusions INTERCEED is suitable for insertion between the ileal limbs and the rectus abdominis muscles because of its softness and flexibility. The use of INTERCEED for diverting ileostomy contributes to reduced adhesion formation, operative time, and blood loss in patients, and further research is needed to confirm our results.

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ABSTRACT Introduction The optimal rectal cancer care is achieved by a multidisciplinary approach, with a high-quality surgical resection, with complete mesorectal excision and adequate margins. New approaches like the transanal total mesorectal excision (TaTME) aim to achieve these goals, maximizing the sphincter preservation ratio, with good oncologic and functional results. This report describes a way to implement TaTME without a proctor, presents the first case series of this approach in a center experienced in rectal cancer, and compares the results with those of the international literature. Methods We performed a retrospective study of the first 10 consecutive patients submitted to TaTME for rectal cancer at our institution. The primary outcomes were postoperative complications, pathological specimen quality and local recurrence rate. The results and performance were compared with the outcomes of a known structured program with proctorship and with the largest meta-analysis on this topic. Results All patients had locally advanced cancer; therefore, all underwent neoadjuvant therapy. A total of 30% had postoperative complications, without mortality or re-admissions. In comparison with the structured training program referred, no differences were found in postoperative complications and reintervention rates, resulting in a similar quality of resection. Comparing these results with those of the largest meta-analysis on the subject, no differences in the postoperative complication rates were found, and very similar outcomes regarding anastomotic leaks and oncological quality of resection were registered. Conclusion The results of this study validate the safety and effectiveness of our pathway regarding the implementation of the TaTME approach, highlighting the fact that it should be done in a center with proficiency in minimally invasive rectal surgery.

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ABSTRACT Background Anal fissure is a common surgical disease that is usually treated conservatively. The golden surgical treatment for anal fissure is lateral internal sphincterotomy, but it may result in multiple complications. Therefore, other treatment methods have recently been introduced, and one of them is the injection of botulinum toxin A (BTA) and fissurectomy. In the present study, we aim to evaluate the effectiveness of the combination of fissurectomy and BTA injection in the treatment of chronic anal fissure by single surgeon. Materials and Methods The present is a non-randomized prospective cohort study conducted by a single surgeon in Saudi Arabia. Our sample was composed of 116 female patients, with mean age of 36.57 ± 11.52 years, who presented to our Surgical Outpatient Clinic with chronic anal fissure between October 2015 and July 2020, and were treated with BTA injection combined with fissurectomy. They were followed up for 1, 2, 3, 4, and 8 weeks, and after one year to evaluate the efficacy and safety of the treatment. The main outcomes analyzed were symptomatic relief, complications, recurrence, and the need for further surgical intervention. Results The treatment with BTA injection combined with fissurectomy was effective and safe in 115 patients (99.1%) at 1 year of follow-up. A total of 5 patients experienced recurrence at 8 weeks, which resolved completely with pharmacological sphincterotomy, and 12 patients experienced minor incontinence, which disappeared later. Conclusion In total, 70 units of BTA injection combined with fissurectomy is a suitable second-line treatment of choice for chronic anal fissure, with a high degree of success and a low rate of major morbidity.

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ABSTRACT Introduction Giant colonic diverticulum (GCD) is rare phenomenon, with less than 200 cases described in the literature. One of the complications of GCD is diverticulitis. To date, there is paucity of data addressing the diagnosis and management of GCD complicated by acute diverticulitis. Objective To better understand the diagnostic tools, the initial management, and the long-term follow-up for this group of patients as well as to recommend a proper multidisciplinary approach to this infrequent disease. Method A systematic literature search was performed using the PubMed, Embase, and Cochrane databases to identify all the published studies on GCD complicated by diverticulitis. Two of the authors assessed the relevance of the included full-text papers. The articles were assessed independently. Results In total, 12 cases were identified. Our results show that 10/11 (91%) of the patients who had computed tomography (CT) scans during the initial evaluation had a correct diagnosis. There was no case of failure to non-operative approach (7/7). The patients who had an emergency operation were treated so due to diffuse peritonitis (two patients), acute hemorrhage arising from ulcers within the diverticula (one patient), and misdiagnosis (one patient). Conclusion Giant colonic diverticulitis is a very rare disease. Computed tomography scan is a valuable tool for the initial diagnosis as well as for treatment strategy planning. Non-operative management is a viable option for patients without diffuse peritonitis. Interval endoscopy is recommended if no contraindication exists.

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ABSTRACT Background and Aims The present systematic review and meta-analysis was designed to estimate the safety and effectiveness of ustekinumab in the treatment of Crohn disease (CD) in clinical trials and observational studies. Methods We retrieved all the related publications from the PubMed, Cochrane, EBSCO, Google Scholar and EMBASE databases using a systematic search strategy. We only included clinical trials and observational studies that were published in English. Results Only 31 studies that met the eligibility criteria out of the 733 identified studies were included. The overall clinical response rate in the cohort studies was of 0.539 (95% confidence interval [95%CI]: 0.419–0.659), and in the clinical trials it was of 0.428 (95%CI: 0.356–0.501). The pooled clinical remission rate was of 0.399 (95%CI: 0.295–0.503) in randomized control trials (RCTs,) and of 0.440 (95%CI: 0.339–0.542) in cohort studies. The rate of adverse effects was of 0.158 (95%CI: 0.109–0.207) in cohort studies and of 0.690 (95%CI: 0.633–0.748) in RCTs. Conclusion Ustekinumab is effective in the treatment of CD. However, more research is required on the safety profiles because there was considerable variation among the included studies.

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ABSTRACT Introduction McKittrick-Wheelock syndrome is a rare condition that arises from a hypersecretory state secondary to large colorectal tumors, mainly villous adenomas, leading to an electrolytic disorder associated with chronic diarrhea that usually persists for years. It is a relatively unknown disease that can lead to severe complications such as acute kidney injury, severe hyponatremia, and hypokalemia. In fact, it causes death in most untreated cases. Surgical removal of the tumor is the most successful treatment, and symptoms tend to disappear after proper management. Case Report A 62-year-old man with a 2-year history of mucoid diarrhea preceded by abdominal pain presented with acute kidney injury, hyponatremia, and hypokalemia. A digital rectal examination and sigmoidoscopy were performed, and revealed a large laterally-spreading tumor in the rectum. Further investigation showed a rectal tubulovillous adenoma with secondary McKittrick-Wheelock syndrome. An anterior resection of the rectum with a colonic J-pouch and a diverting ileostomy were performed, and the patient improved with the resolution of the renal failure and electrolyte disturbances. The histopathological analysis revealed an invasive rectal adenocarcinoma. Discussion McKittrick-Wheelock syndrome is a condition with a low incidence that needs early intervention and proper diagnosis. It is of extreme importance that this disease is included in the differential diagnoses for chronic diarrhea associated with an electrolytic disorder.

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ABSTRACT Retrorectal hamartoma, also called tailgut cyst, is a congenital lesion resulting from the non-regression of embryo remnants of the hindgut. We describe in this work the case report of a 68-year-old man, previously healthy, complaining of rectal bulging for 4 months, which was diagnosed by nuclear magnetic resonance imaging as a multi-loculated and mucinous lesion, suggestive of tailgut cyst. In view of the finding, the lesion was surgically resected, due to the potential for future complications, and, through the anatomopathological analysis, there were no findings of malignancy in the specimen.