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The incidence of esophageal cancer (EC) is on the rise. With the distinct subtypes of adenocarcinoma and squamous cell carcinoma comes specific risk factors, and as a result, people of certain regions of the world can be more prone to a subtype. For example, squamous cell carcinoma of the esophagus has the highest incidence in eastern Africa and eastern Asia, with smoking being a major risk factor, whereas adenocarcinoma is more prevalent in North America and western Europe, with gastroesophageal reflux disease being a leading risk factor. With that being said, adenocarcinoma and squamous cell carcinoma have similar and unfortunately poor survival rates, partly because EC is prone to early metastasis given that the esophagus does not have a serosa, as well as the superficial nature of its lymphatics compared with the rest of the gastrointestinal tract. This makes early detection of the utmost importance, and certain patients have been shown to have the benefit of screening/surveillance endoscopies, including those with Barrett's esophagus, lye-induced/caustic strictures, tylosis, and Peutz-Jeghers syndrome. Until treatments significantly improve, identifying EC at the earliest stage will have the best success for patient outcomes, and further elucidation of its pathogenesis and risk factors may lead to identifying other high-risk groups that should be screened.

Aberrant crypt foci (ACF) are the earliest morphologically identifiable lesions in the colon that can be detected by high-definition chromoendoscopy with contrast dye spray. Although frequently associated with synchronous adenomas, their role in colorectal tumor development, particularly in the proximal colon, is still not clear. The goal of this study was to evaluate the profile of colon-adherent bacteria associated with proximal ACF and to investigate their relationship to the presence and subtype of synchronous polyps present throughout the colon. Forty-five subjects undergoing a screening or surveillance colonoscopy were included in this retrospective study. Bacterial cells adherent to the epithelia of ACF and normal mucosal biopsies were visualized by in situ hybridization within confocal tissue sections. ACF showed significantly greater heterogeneity in their bacterial microbiome profiles compared with normal mucosa. One of the bacterial community structures we characterized was strongly correlated with the presence of synchronous polyps. Finally, using DNA mass spectrometry to evaluate a panel of colorectal cancer hotspot mutations present in the ACF, we found that three APC gene mutations were positively associated with the presence of Instestinibacter sp., whereas KRAS mutations were positively correlated with Ruminococcus gnavus. This result indicates a potential relationship between specific colon-associated bacterial species and somatically acquired CRC-related mutations. Overall, our findings suggest that perturbations to the normal adherent mucosal flora may constitute a risk factor for early neoplasia, demonstrating the potential impact of mucosal dysbiosis on the tissue microenvironment and behavior of ACF that may facilitate their progression towards more advanced forms of neoplasia.

Aberrant crypt foci (ACF) are the earliest morphologically identifiable lesion in the colon that can be detected by high-definition chromoendoscopy with contrast dye-spray. Although frequently associated with synchronous adenomas, their role in colorectal tumor development, particularly in the proximal colon, is still not clear. The goal of this study was to evaluate the profile of colon-associated bacteria associated with proximal ACF and to investigate their relationship to the presence and subtype of synchronous polyps present throughout the colon. Forty-five subjects undergoing a screening or surveillance colonoscopy were included in this retrospective study. Our study cohort included a total of 16 subjects with no identifiable proximal lesions (either ACF or polyp), 14 subjects with at least 1 ACF but no polyp(s), and 15 subjects with both at least 1 ACF and a synchronous proximal polyp(s) detected at colonoscopy. Bacterial cells adherent to the epithelia of ACF and normal mucosa were visualized by in situ hybridization within confocal sections. Bacterial DNA isolated from biopsies was used to construct PCR amplicon libraries targeting the V4 hypervariable region of the 16S rRNA gene, which were then sequenced on the Illumina platform. ACF showed significantly greater heterogeneity in their bacterial profiles compared to normal mucosa. Interestingly, one of the bacterial community structures we characterized was strongly correlated with the presence of synchronous polyps. The observed dysbiosis is more prominent within the colonic epithelium that also harbors synchronous polyps. Finally using DNA-mass spectrometry to evaluate a panel of colorectal cancer hot-spot mutations present in the ACF, we found that several APC gene mutations (R1450*, R876*, S1465fs*3) were positively associated with the presence of Instestinibacter sp., whereas KRAS mutations (G12V, G12D) were positively correlated with Ruminococcus gnavus. This result indicates a potential relationship between specific colon-associated bacterial species and somatically acquired CRC-related mutations. Overall, our findings suggest that perturbations to the normal adherent mucosal flora may constitute a risk factor for early neoplasia, demonstrating the potential impact of mucosal dysbiosis on the tissue microenvironment and behavior of ACF that may facilitate (or impede) their progression towards more advanced forms of neoplasia.

Our understanding of diverticular disease has evolved significantly during the last 25 years, and as such, a reexamination is in order. We performed a literature search for the years 1960-2017 of PubMed, Medline, and Google Scholar for updates regarding the epidemiology, risk factors, and therapies for traditional diverticulitis as well as the recently described subtypes of diverticular disease, segmental colitis associated with diverticulosis, and symptomatic uncomplicated diverticular disease. Although the prevalence of diverticulosis is still extremely common in the general population, the literature suggests that the incidence of diverticulitis is much less than previously believed and occurrences do not necessarily increase with age. In addition, the commonly held beliefs that low-fiber diets alone contribute to the development of diverticulosis and diverticulitis have not been verified; however, the combination of a low-fiber diet and a high red meat/high-fat diet is a risk factor for diverticulitis. Surgery continues to be the treatment for severe complications of diverticulitis, but new literature suggests that it has a poor utility in preventing a recurrence of diverticulitis in the long term; therefore, elective surgery after two episodes of diverticulitis is no longer the standard.

Background: Chronic postoperative pain has been reported in as many as 62.9% of patients after inguinal herniorrhaphy. Moderate to severe neuropathic pain requiring intervention develops in 2.2% to 11.9% of patients as a result of ileoinguinal and genitofemoral nerve entrapment. Cryoanalgesic ablation has been successful in treating chronic pain from craniofacial neuralgia, facet joint syndrome, and malignant pain syndromes. We report our experience using cryoanalgesic ablation for chronic ileoinguinal and genitofemoral neuralgia after inguinal herniorrhaphy. Methods: Ten patients with ileoinguinal, genitofemoral, or combined neuralgia underwent 12 cryoanalgesic ablations between April 1996 and June 2001. These patients were referred from a multidisciplinary pain clinic, and focused low-volume nerve blocks were used to map nerve involvement preoperatively. After surgical exposure, nerves and surrounding tissues were cooled to ?70°C for 3 min using the Lloyd Neurostat. Patients were seen 2 weeks postoperatively and offered monthly follow-up assessments. Results: Nine men and one woman, ages 20 to 54 (mean, 42.6 years) were treated during 58 months, with a mean follow-up period of 8.2 months, for ileoinguinal (n = 4), genitofemoral (n = 1), and combined (n = 5) neuralgia. Patients reported one to five prior herniorrhaphies (mean, 1.8), experienced neuropathic pain 0 to 14 years (mean, 6.3 years), and underwent up to 3 (mean, 1.3) ablative pain procedures before referral. After cryotherapy, patients reported overall pain reduction of 0% to 100% (mean, 77.5%; median, 100%); 80% reported decreased analgesic use, and 90% reported increased physical capacity. Two patients underwent additional cryotherapy, one for incomplete relief and one for recurrent pain, both with 100% efficacy. Wound infection (n = 1) was the only complication. Conclusions: Cryoanalgesic ablation successfully eliminates ileoinguinal and genitofemoral neuralgia in most patients, and should be considered early in the treatment of patients with postherniorrhaphy neuropathic pain.

A 34-year-old woman with a history of asthma and oral contraceptive use died suddenly. Autopsy examination showed chronic pulmonary emboli with an acute pulmonary saddle embolus. An underlying congenital thrombophilic disorder was considered. Molecular studies on DNA isolated from blood using polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analysis revealed coagulation factor V Leiden mutation. The incidence of venous thromboembolism in patients with factor V Leiden mutation and associated activated protein C (APC) resistance is discussed.This article presents a case report of a 34-year-old woman with a known medical history of asthma and oral contraceptive use who died suddenly from a massive pulmonary embolus. This woman had no underlying malignancy, trauma, recent surgery, or other predisposing factors putting her at risk of venous thromboembolism except for her use of oral contraceptives. Upon autopsy, a large saddle embolus was found occluding the main pulmonary arteries with bilateral extension into the smaller arteries. An acute pulmonary embolus obliterating the lumen of the main pulmonary artery was found during the microscopic examination. Molecular studies of blood DNA using polymerase chain reaction and restriction fragment length polymorphism revealed a coagulation factor V Leiden mutation. Female carriers of factor V Leiden mutation who take oral contraceptives have a more than 30-fold increased risk of developing deep venous thrombosis. This case demonstrates that the woman had an underlying predisposition that was further potentiated by oral contraceptive use. The incidence of venous thromboembolism in patients with factor V Leiden mutation and associated activated protein C resistance is discussed.

The long-term outcomes of selective organ preservation in operable, locally advanced head and neck cancers in two sequential chemoradiotherapy (CRT) protocols (HN-53, HN-67) are reported. A total of 65 patients were treated with CRT consisting of carboplatin (AUC = 1/week) and paclitaxel (60 or 40 mg/m2/week) with radiation (1.8 Gy/day). After 5 weeks of CRT, if primary site biopsies were pathologically negative, then completion CRT to 67–72 Gy was done with neck dissection in node-positive cases. Alternatively, a positive rebiopsy required primary site resection and neck dissection followed by radiotherapy boost as deemed necessary. Pathologic complete responses occurred in 71% patients who then completed CRT; the remaining 29% patients underwent primary site surgery. The 5-year and median overall survival were 47% and 57 months with no statistically significant differences between the two groups. Overall long-term failure rates were: 6% local, 6% regional, and 32% distant. This strategy of selective organ preservation was effective in 71% patients with CRT, whereas salvage surgery was required in the remainder. Long-term survival was equivalent in both treatment groups.

Previously irradiated recurrent rectal cancer is a formidable patient threat with limited treatment options. Isolated pelvic perfusion (IPP) by the balloon-occlusion technique provides high-dose regional chemotherapy that may facilitate resection if appropriate or palliate pain and fungating tumor mass in the symptomatic patient. We currently report our results in 49 recurrent rectal cancer patients (26 had neoadjuvant IPP with intent to resect and 23 had IPP for palliation).IPP was done for 1 hour with paclitaxel 30 mg/m(2), 5 fluorouracil 1500 mg/m(2), cisplatin/oxaliplatin 60-130 mg/m(2), and mitomycin C 10 to 15 mg/m(2) (the latter three achieving pelvic-to-systemic drug ratios of 6-9:1).Neoadjuvant perfusion in 26 patients achieved a response in 14 patients (made resectable). Seven had R0 resections (clear margins), six by abdominal sacral resection (ABSR), and one by an extended APR. Of seven other patients, one had a complete pathologic response negating planned resection, one had50% tumor regression in pelvis (but developed distant metastases), and three refused ABSR. Planned ABSR in two patients was aborted because of complicating cardiovascular issues. A variety of medical and cancer issues precluded resection in the remaining 12 of these 26 neoadjuvant patients. Within the neoadjuvant group, median survival was 24 months in the responding (made resectable) group (14 patients) and it was 8 months in the non-resectable group (12 patients), p = 0.0001. In the responding (made resectable) group, seven patients had R0 resections (median survival 26 months) and seven patients were not resected (median survival 18 months), p = 0.0198. In the IPP group for palliation, 17 of 23 patients (74%) had significant relief of pain, and other tumor-related symptoms (mean survival 11 months).Isolated pelvic perfusion using a simplified balloon-occlusion technique has promise in palliation of or augmenting resectability of advanced rectal malignancy in patients not amenable to treatment with conventional modalities.

Background: Circumferential mucosectomy with stapled proctopexy (CMSP) was first introduced in 1993 as a less painful and highly effective alternative to traditional operative hemorrhoidectomy. Although CMSP has many advantages over traditional hemorrhoidectomy, some authorities and insurers continue to regard it as an inpatient procedure and others have been slow to adopt this progressive technique. This study documents the safe and effective outpatient nature of this procedure. Methods: From December 2001 through August 2002, 33 patients with mucosal prolapse and prolapsing internal hemorrhoids were treated using circumferential mucosectomy with stapled proctopexy as outpatients at an ambulatory surgery center. Fourteen (42%) patients were treated using local anesthesia with intravenous sedation, 18 (55%) chose spinal anesthesia, and general anesthesia was used in one patient. Patients were evaluated postoperatively by telephone at 1 and 2 weeks, and seen in clinic at 4 weeks. Results: One patient (3%) required an emergency department visit for minor postoperative bleeding. None of our elderly patients required emergency department evaluation and none reported significant complications. Four patients (13%) required urinary catheter placement prior to discharge from the surgery center due to urinary retention. One patient (3%) developed an uncomplicated urinary tract infection, which resolved with antibiotic treatment. Two patients were seen earlier than 4 weeks at the surgeon’s request; one was immunocompromised from chemotherapy for metastatic carcinoid, and one reported persistent pain during initial telephone follow-up. No complications were identified in either patient, and no additional complications have been noted to date. Conclusions: CMSP is a safe, effective, time-efficient procedure for patients with mucosal prolapse and prolapsing hemorrhoids that can be performed safely in the ambulatory surgery center setting. Age is not a limiting factor in selecting patients for this safe outpatient procedure.

3759 Background: Recurrence after initial resection of rectal cancer often presents with local regional disease and distant metastases. Aggressive monitoring and surgical intervention is controvers...