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In colorectal cancer (CRC), surgical outcomes in the young (

Although continuous wound infusion (CWI) with local anaesthetic has been used as an adjunct for pain relief following laparotomy, its use as the main modality has not been studied. This approach negates side effects related to intravenous opioid administration, therefore promoting enhanced recovery from surgery. We conducted this study to investigate the feasibility and efficacy of CWI following laparotomy. Consecutive patients who underwent laparotomy from June 2016 to December 2019 were analysed. All patients were given CWI with only oral supplementation. Pain was assessed based on the numeric rating scale (NRS). One hundred and three patients were analysed. Mean age was 61.1 (standard deviation 16.7). 47.6% of patients were operated for intestinal obstruction. Large bowel resection was the most common operation performed (49.5%). 69.9% of patients underwent emergency surgery, whilst 51.5% of patients had surgery for cancer. On postoperative day 0, NRS was 3.2 (standard deviation (sd) 2.6) which decreased to 1.5 (sd 1.9) on day 3, and 1.1 (sd 1.8) on day 5. Mean time to flatus was 2.3 (sd 1.4) days, whilst mean time to first bowel movement was 3.1 (sd 1.7) days. Patients were able to commence ambulation by 2.5 (sd 1.8) days. Patients could tolerate a normal diet on day 3.9 (sd 3.3), and IV drip was removed on day 3.5 (sd 3.0). Mean length of stay was 9.1 (sd 6.9) days. Only two patients suffered from respiratory depression (1.9%) whilst five patients suffered from hypotension (4.9%). No patients had pruritus. 23.3% of patients had nausea or vomiting. Only one patient had a catheter-related complication which was easily addressed. CWI provides adequate pain relief as the principle modality of analgesia after surgery, without opioid side effects.

Anastomotic leakage after a colorectal resection results in devastating consequences for patients. Indocyanine green fluorescence angiography is a modality to visualize vascular perfusion at the anastomotic site and can help surgeons decide the viability of the anastomosis. We performed this systematic review and meta-analysis to evaluate the efficacy of indocyanine green fluorescence angiography in decreasing anastomotic leakage.PubMed, Web of Science, Embase, and the Cochrane Library were searched to identify studies comparing the use of indocyanine green fluorescence angiography versus standard care on rates of anastomotic leakage. Data were pooled with the Mantel-Haenszel method and analyzed based on a random-effects model to estimate the pooled odds ratio and 95% confidence interval. The heterogeneity of studies was evaluated using ITwenty studies were included in this meta-analysis of 5,498 patients. The pooled estimate of the odds ratio was 0.46 (95% confidence interval 0.34-0.62; P.00001) favoring indocyanine green fluorescence angiography. The overall anastomotic leak rate was 3.7% (n = 82) in the intervention group and 8.6% (n = 282) in the control group. Indocyanine green fluorescence angiography led to a change in the anastomotic site in 216 (9.7%) patients. Subgroup analyses of anastomotic leakage requiring intervention, patients requiring a low colorectal anastomosis, and prospective studies had a pooled estimate of odds ratio 0.55 (95% confidence interval 0.35-0.89), odds ratio 0.38 (95% confidence interval 0.27-0.54; P.0001), and odds ratio 0.49 (95% confidence interval 0.30-0.81; P = .005) respectively.The use of indocyanine green fluorescence angiography is associated with a decrease in anastomotic leakage. This association is present in patients with severe anastomotic leakage requiring intervention as well as low colorectal anastomoses.

Current enhanced recovery after surgery (ERAS) protocols are designed for all patients without tailored programmes for at-risk groups. A risk score to determine elective colorectal cancer patients at risk for prolonged length of stay (LOS) would help to identify this group for preoperative intervention. Multivariate analysis of demographic and preoperative variables was performed to identify independent risk factors for prolonged LOS, defined as 7 days or more. A stepwise variable selection approach using logistic regression was then used to build a risk prediction model. Among 172 patients in our population, 41.9% of patients had prolonged LOS. Five variables were included in our risk prediction model. These were age ≥ 65 years (OR 13.9 5.09–38.0; p

Elderly patients with colorectal cancer are high-risk surgical candidates. ERAS protocols have been developed to mitigate against these risks. We performed this study to quantify the risks which elderly patients face and then to determine independent risk factors for short-term ERAS-specific outcomes. An analysis of a prospectively collected audit database of all patients who underwent elective colorectal cancer resection within an ERAS framework from January 2018 to December 2018 was performed. Elderly was defined in our study as age ≥ 65 years. There were 172 elective colorectal cancer resections performed. Ninety-seven (56.4%) were elderly. Elderly patients were at increased risk of developing post-operative complications (33.0% vs 16.0%, p = 0.011), longer time to diet (3.4 vs 2.2 days, p = 0.001), and longer hospital stay (10.9 vs 6.7 days, p = 0.007). Independent risk factors were determined for the abovementioned three outcomes. Elderly status was the only risk factor for increased complications (OR 2.61 95% CI (1.05–6.51), p = 0.040). For delayed time to soft diet, male gender (OR 6.67(1.92–20.0), p = 0.002), open approach (OR 9.06(2.26–36.30), p = 0.002), and increased operative time (OR 1.01(1.00–1.01) p = 0.014) were risk factors. Finally, elderly age (OR 5.53(1.82–16.84), p = 0.003), leucocyte count (OR 1.39(0.76–2.57), p = 0.038), open approach (OR 5.26(1.41–19.62), p = 0.013), operative time (OR 1.01(1.00–1.01), p = 0.021), and Clavien-Dindo classification (OR 7.97(1.27–49.88), p = 0.027) were risk factors for prolonged length of stay. Elderly patients are intrinsically at risk for increased complications, longer time to soft diet and longer hospital stay. ERAS protocols may need to be specifically tailored for elderly patients.

Obstructed colorectal cancers (CRCs) continue to be challenging to manage. Apart from surgical resection, the use of self-expanding metallic stents (SEMS) has become increasingly popular. SEMS could potentially allow for the conversion of an emergency operation into a semi-elective procedure, allow for the optimization of the patient’s physiology, avoid the requirement for a stoma, as well as allow for a minimally-invasive approach to be adopted. This review article therefore highlights the evidence available in the literature pertaining to the use of SEMS in obstructed CRCs.

Enhanced recovery after surgery (ERAS) programs for patients undergoing colorectal surgery has yielded promising results. However, there remains controversy regarding the application of ERAS protocols in an elderly population. The aim of this review is to compare the clinical outcomes between ERAS versus conventional peri-operative care (Non-ERAS) for colorectal surgery in patients aged ≥ 65 years old. The PRISMA guidelines were adhered to. A comprehensive search was performed using Medline, Embase and the Cochrane Library electronic databases and relevant articles were identified. Indications for the colorectal resections included both benign and malignant diseases, while emergency surgeries were excluded. Primary outcomes include post-operative morbidity, length of stay and re-admission rates. Data analysis was performed using Revman 5.3. A total of six studies were included, which involved a total of 1174 patients. ERAS was associated with a lower incidence of post-operative morbidity compared to Non-ERAS (OR 0.38, 95% CI 0.25–0.59), p

The mechanism underlying improved survival in non-metastatic colon cancer with higher lymph node (LN) yield is unknown. This study aimed to identify whether molecular features in the primary tumour were predictive of LN yield.Clinical, genomic, transcriptomic, proteomic and methylation data of non-metastatic, colon cancers studied in The Cancer Genome Atlas were interrogated for associations with LN yield. Based on maximal survival effects, patients were segregated into high (15) and low (≤15) LN yield. Gene set enrichment analysis was performed on transcriptomic changes to identify biological processes associated with LN yield. Correlations were validated in an independent set of Stage II colon cancers.High LN yield was found predictive of overall and disease-free survival. There was no association of higher LN yield and increasing nodal positivity. High LN yield was strongly linked with gene expression changes associated with the adaptive and dendritic cell immune response. This association was most prominent in node-negative cancers. Analogous findings were reproduced in the validation dataset.The study shows a strong association of an activated immune response in tumours with a high LN yield. Immunogenic tumours have a better prognosis, likely explaining the survival benefit with higher LN yields.

Our study seeks to describe our surgical technique of the use of a tissue expander and a pelvic sling in order to perform high-dose pelvic irradiation without incurring radiation toxicity to the small bowel. High-dose radiation therapy for pelvic tumours comes at a risk of radiation toxicity to the small bowel. Our study discusses our novel surgical technique of compartmentalising the abdomen and the pelvis through the use of a tissue expander and pelvic sling to avoid small bowel radiation toxicity. We present a patient with an unresectable sacral chordoma. We describe our surgical technique incorporating both a tissue expander and an absorbable pelvic mesh sling to successfully compartmentalise the abdomen from the pelvis. The patient underwent an uneventful surgical procedure to place the tissue expander within the pelvis and deploy the pelvic mesh sling. Following surgery, a separation of at least 8 cm was achieved between bowel loops and the tumour. A dose of 70 Gy delivered over 35 fractions using intensity modulated radiotherapy (IMRT) was administered to the sacral chordoma, whilst managing to constrain the maximum bowel dose to 35.7 Gy. Surgery to remove the tissue expander was uneventful. The patient has not suffered any small bowel irradiation toxicity. Our technique to exclude small bowel from the pelvis is effective and safe. This technique not only can be applied in the setting of unresectable sacral chordomas but also may be applicable to other pelvic cancers which require radiation therapy.

Background: Surveillance guidelines following excision of colonic tubular adenomas are well established. However, adherence to the guidelines are rarely audited. The aim of our study was to evaluate the rate of compliance to the recommended guidelines following polyp removal. Methods: A review of a prospectively collected colonoscopy database in a single tertiary institution was conducted for all patients who underwent polypectomy in 2008. We excluded patients who were diagnosed with or had prior history of colorectal malignancy. The frequency of subsequent colonoscopic were evaluated against the recommended guidelines based on the clinico-histological characteristics of the removed polyps. Results: There were 419 colonoscopies with polypectomies performed in 2008. The patient cohort had a median age of 60 years (range, 26–95 years), with the most common diagnosis being tubular adenoma with low grade dysplasia (n=291, 69.5%). Adherence to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) post-polypectomy surveillance guidelines, based on the factors such as the characteristics of the colonic polyps and bowel preparation at initial colonoscopy, was only 13.8% (n=58). There were 107 (25.5%) patients who had their surveillance endoscopy performed earlier than recommended. None of them were diagnosed with malignancy. The majority of patients (n=192, 45.8%), had surveillance scopes later than recommended or were lost to follow-up. Amongst these patients, two actually were diagnosed to have malignancy 3 and 5 years after their recommended surveillance scope date, respectively. Conclusions: There is a very low compliance to post-polypectomy surveillance guidelines. More needs to be done to improve compliance to guidelines.

Although continuous wound infusion (CWI) with local anaesthetic has been used as an adjunct for pain relief following laparotomy, its use as the main modality has not been studied. This approach negates side effects related to intravenous opioid administration, therefore promoting enhanced recovery from surgery. We conducted this study to investigate the feasibility and efficacy of CWI following laparotomy.Consecutive patients who underwent laparotomy from June 2016 to December 2019 were analysed. All patients were given CWI with only oral supplementation. Pain was assessed based on the numeric rating scale (NRS).One hundred and three patients were analysed. Mean age was 61.1 (standard deviation 16.7). 47.6% of patients were operated for intestinal obstruction. Large bowel resection was the most common operation performed (49.5%). 69.9% of patients underwent emergency surgery, whilst 51.5% of patients had surgery for cancer. On postoperative day 0, NRS was 3.2 (standard deviation (sd) 2.6) which decreased to 1.5 (sd 1.9) on day 3, and 1.1 (sd 1.8) on day 5. Mean time to flatus was 2.3 (sd 1.4) days, whilst mean time to first bowel movement was 3.1 (sd 1.7) days. Patients were able to commence ambulation by 2.5 (sd 1.8) days. Patients could tolerate a normal diet on day 3.9 (sd 3.3), and IV drip was removed on day 3.5 (sd 3.0). Mean length of stay was 9.1 (sd 6.9) days. Only two patients suffered from respiratory depression (1.9%) whilst five patients suffered from hypotension (4.9%). No patients had pruritus. 23.3% of patients had nausea or vomiting. Only one patient had a catheter-related complication which was easily addressed.CWI provides adequate pain relief as the principle modality of analgesia after surgery, without opioid side effects.

Placement of self-expanding metal stents has been increasingly adopted as a bridge to surgery in patients presenting with obstructed left-sided colorectal cancers. The optimal bridging time has yet to be widely established, hence this retrospective study aims to determine the optimal bridging time to elective surgery post endoluminal stenting. All patients who underwent colorectal stenting for large bowel obstruction in a single, tertiary hospital in Singapore between January 2003 and December 2017 were retrospectively identified. Patients’ baseline demographics, tumour characteristics, stent-related complications, intra-operative details, post-operative complications and oncological outcomes were analysed. Of the 53 patients who successfully underwent colonic stenting for malignant left sided obstruction, 33.96% of patients underwent surgery within two weeks of stent placement while 66.04% of patients underwent surgery after 2 weeks of stent placement. Univariate analysis between both groups did not demonstrate significant differences in postoperative complications and stoma formation. Significant differences were observed between both groups for stent complications (38.89% vs 8.57%, p = 0.022), on-table decompression (38.89% vs 2.86%, p = 0.001) and systemic recurrence (11.11% vs 40.00%, p = 0.030). Increased bridging interval to surgery (OR 13.16, CI 1.37–126.96, p = 0.026) was a significant risk factor for systemic recurrence on multivariate analysis. Patients undergoing definitive surgery within 2 weeks of colonic stenting may have better oncological outcomes without compromising on postoperative outcomes. Further prospective studies are required to compare outcomes between emergency surgery and different bridging intervals.

BACKGROUND: Obtaining 12 lymph nodes following resection for rectal cancer is an important prognostic marker. However, patients who have received neoadjuvant therapy are known to have a lower lymph node yield. We conducted this study to determine the clinical significance of evaluating

Background: Patients with positive lymph nodal involvement in colon cancer have always been deemed to fare worse than those without. However, questions have been increasingly raised on the true prognosis of T4N0 disease. We conducted this study to investigate how T4N0 disease would compare with T3N1 disease. Methods: All patients with colon cancer treated from 2008 to 2014 was collected. Preoperative, intraoperative and histological information was compared between patients with T4N0 and T3N1 disease. Variables which significantly differed were included in multivariate analysis for recurrence and survival. Kaplan-Meier curves and cox regression analysis for time to recurrence and survival were evaluated. Results: Seventy-eight patients had T4N0 colon cancer, while 160 had T3N1 disease. Vascular invasion, lymphatic invasion, total lymph node yield, and the administration of adjuvant chemotherapy were identified as variables for evaluation. Over a median follow-up of 41.4 (range, 21.6–65.0) months for T4N0 patients and 42.4 (range, 21.1–63.8) months for T3N1 patients, there was no statistically significant difference in the association of stage of cancer with survival [overall survival (OS): 0.97 (95% CI, 0.38–2.45), P=0.94]. Kaplan-Meier curves also showed no difference in time to death (P=0.867). There was no statistically significant difference in the time to death [hazard ratio (HR): 0.56 (95% CI, 0.20–1.55), P=0.26]. Conclusions: T4N0 colon cancers have similar outcomes to T3N1 disease and should be considered as stage III disease in future classification. Patients diagnosed with T4N0 disease should receive similar treatment as those with T3N1 disease and counselled accordingly.

First degree relatives (FDR) of colorectal cancer (CRC) patients are at increased risk of CRC compared to the general population. However, screening colonoscopy rates amongst the FDRs remain dismal. The aim of the study was to explore the various issues amongst the patients and their FDR precluding their adoption of screening colonoscopy. A qualitative study of CRC patients and their FDRs was performed. Semi-structured interviews were conducted with participants using open-ended questions until data saturation was achieved. These qualitative data were then thematically analysed. Fifty CRC patients and thirty-one FDRs were recruited between June 2015 and December 2015. For the patients, three main themes emerged, which include (i) poor understanding of the CRC screening guidelines for their FDRs, (ii) recommendations are lacking amongst medical professionals and (iii) numerous barriers are hindering patients from being advocates for screening colonoscopy for their FDRs. For the FDRs, three main themes emerged. These include (i) poor understanding of the exact CRC screening guidelines amongst the FDRs, (ii) the lack of health promotion efforts amongst medical professionals and (iii) barriers to the uptake of screening colonoscopy such as fear of colonoscopy, high cost of the procedure, its associated inconvenience and perceived invulnerability of the individual. Patients and FDRs are not aware of the increased risks of developing CRC amongst the family members. Guidelines regarding screening are also not clearly understood. The numerous barriers that are present amongst the CRC patients and their FDRs can be addressed.

Patients with low rectal cancer who have enlarged lateral pelvic lymph nodes are known to have a worse prognosis. There is however uncertainty over what constitutes a lateral pelvic lymph node of clinical significance. As the main modality for the detection of such lymph nodes is magnetic resonance imaging (MRI), characteristics of these lateral lymph nodes identified may have prognostic value and assist with guiding treatment. Options to manage such lateral lymph nodes includes neoadjuvant chemoradiotherapy as well as lateral lymph node dissection. Surgery is extensive and may lead to significant morbidity to the patient. This review article evaluates diagnostic and management strategies in patients with lateral pelvic lymph nodes in low rectal cancer.

There is an increasing incidence of elderly patients requiring emergency laparotomy. Our study compares the outcomes of elderly patients undergoing emergency laparotomy against the outcomes of non-elderly patients. Patients who underwent emergency laparotomy between 2015 and 2017 from the National University Hospital, Singapore, were included. Apart from demographic data, indication of surgery and surgical procedure performed were collected. Prospectively collected nutritional scores were evaluated. Outcome measures included duration of surgery, length of ICU and total hospital stay, post-operative complications, and mortality indices. We performed multivariate Cox regression analysis to determine the contribution of various risk factors towards overall survival following emergency laparotomy. A total of 170 emergency laparotomies were performed. Compared to non-elderly patients, elderly patients had a significantly longer mean stay in hospital (31.5 vs. 18.6 days, p = 0.006) and mean stay in ICU (13.1 vs. 5.3 days, p = 0.003). More elderly patients suffered from post-laparotomy complications compared with non-elderly patients (65.8% vs. 37.4%, p

An ileostomy is usually created to avert systemic sepsis in a patient with a tenuous anastomosis. However, what is often not reported are the numerous issues facing these patients subsequently, ranging from readmissions, non-reversal of the stoma, and complications from the closure. This study was performed to identify these issues among patients following creation of an ileostomy. We conducted a retrospective analysis of consecutive patients who had an ileostomy created from January 2011 to December 2016 at two institutions. Statistical analysis was performed to identify risk factors associated with readmissions and ileostomy non-reversal. In total, 193 patients had an ileostomy created during the study period. Twenty-six (13.5%) patients developed stoma-related complications requiring readmission. The most common cause of readmission (9.3%) was due to dehydration and acute kidney injury secondary to high stoma output. One hundred thirty (67.4%) patients had their ileostomy reversed. On multivariate analysis, only stomas created during an ultra-low anterior resection were associated with reversal (OR 2.88 [95% CI, 1.24–6.68]; p = 0.014). Among the patients who underwent ileostomy reversal, seven (3.6%) patients developed complications from their ileostomy reversal. Four patients (2.1%) suffered from an anastomotic leak which required repeat surgical intervention with one mortality from the ensuing sepsis. Almost half of the patients who had an Ileostomy had an undesirable outcome, including readmissions, non-reversal, and post-operative complications following closure. Patients need to be properly counselled about the risks involved prior to the index operation.

The use of fecal immunochemical test (FIT) in the screening for colorectal cancer is long established. However, more than 50 % of patients with positive FITs have a negative colonoscopy. The role of a subsequent oesophago-gastro-duodenoscopy (OGD) is debatable. The aim of this study is to evaluate the yield of OGD in patients with positive FITs. A retrospective review of patients who underwent colonoscopy for a positive FIT between Jan. 2008 and Dec. 2012 was identified from a prospectively collected endoscopy database at the National University Hospital, Singapore. Patients who underwent concurrent or subsequent OGDs for positive FIT formed the study group. We considered any new cancer or significant upper gastrointestinal pathology such as peptic ulcer disease or gastritis requiring treatment as a positive examination. A total of 202 patients underwent both a colonoscopy and an OGD for a positive FIT and formed the study group. One hundred and six (52.5 %) of them had a positive examination with gastritis and duodenitis representing the most common UGI pathology in 89 (44.1 %) patients. Twenty-nine (14.4 %) patients tested positive for helicobacter pylori infection and another 16 (7.9 %) patients had peptic ulcer disease. There were no UGI cancers detected. One patient had an esophageal leiomyoma that was treated conservatively. Routine gastroscopy for FIT positivity has a high diagnostic yield for benign upper gastrointestinal pathology. Well-designed prospective studies to further evaluate the cost-effectiveness of routine gastroscopy in the work up of FIT positivity are warranted to make better clinical practice guidelines.

Summary Dendritic cells (DCs) are professional antigen-presenting cells that hold great therapeutic potential. Multiple DC subsets have been described, and it remains challenging to align them across tissues and species to analyze their function in the absence of macrophage contamination. Here, we provide and validate a universal toolbox for the automated identification of DCs through unsupervised analysis of conventional flow cytometry and mass cytometry data obtained from multiple mouse, macaque, and human tissues. The use of a minimal set of lineage-imprinted markers was sufficient to subdivide DCs into conventional type 1 (cDC1s), conventional type 2 (cDC2s), and plasmacytoid DCs (pDCs) across tissues and species. This way, a large number of additional markers can still be used to further characterize the heterogeneity of DCs across tissues and during inflammation. This framework represents the way forward to a universal, high-throughput, and standardized analysis of DC populations from mutant mice and human patients., Graphical Abstract Image 1, Highlights • A conserved gating strategy aligns dendritic cells (DCs) in mouse and human tissues • Unsupervised computational analysis of flow cytometry data outperforms manual analysis • Mass cytometry reveals heterogeneity of DC subsets across mouse and human tissues • DC activation upon inflammation tracked by automated analysis of mass cytometry, Using unsupervised analysis of flow cytometry and mass cytometry data obtained from multiple mouse, macaque, and human tissues, Guilliams et al. provide a universal toolbox for the automated identification of dendritic cells. This framework represents the way forward to high-throughput and standardized analysis of dendritic cells from mutant mice and patients.

Background: It remains contentious whether endoscopic stenting or upfront surgery is more optimal in patients with metastatic colorectal cancers presenting with large bowel obstruction. Methods: A retrospective review of all patients with metastatic colorectal cancer who underwent either endoscopic stenting or emergency surgery for acute large bowel obstruction was performed. Results: Between January 2007 and June 2014, 66 patients, median age, 64 (range, 25–96) years, presented with acute large bowel obstruction from metastatic colorectal cancer. Forty (60.6%) patients underwent endoscopic stenting whilst the rest received immediate upfront surgical intervention. Of the 40 patients, 29 (72.5%) were successfully stented. The remaining 11 (27.5%) patients who failed endoscopic stenting required immediate emergency surgery to relieve the obstruction. Patients who failed endoscopic stenting had worse complications than those patients who had their stents successfully inserted [odds ratio (OR), 23.3; 95% confidence interval (CI), 2.29–250.00, P=0.004]. Patients who underwent emergency surgery had a longer median length of stay than patients who had successful endoscopic stenting (P=0.003). The patients that underwent successful stenting had earlier commencement of chemotherapy compared to those who had upfront surgery (P=0.02). There was no difference in stoma creation rates between patients who had emergency surgery versus those who were successfully stented. Conclusions: Stenting is a safe option in patients with stage IV colorectal cancer presenting with acute large bowel obstruction. Earlier commencement of chemotherapy occurs in patients who were successfully stented. Patients who failed stenting have equivalent outcomes to those who undergone upfront emergency surgery.

During gestation the developing human fetus is exposed to a diverse range of potentially immune-stimulatory molecules including semi-allogeneic antigens from maternal cells, substances from ingested amniotic fluid, food antigens, and microbes. Yet the capacity of the fetal immune system, including antigen-presenting cells, to detect and respond to such stimuli remains unclear. In particular, dendritic cells, which are crucial for effective immunity and tolerance, remain poorly characterized in the developing fetus. Here we show that subsets of antigen-presenting cells can be identified in fetal tissues and are related to adult populations of antigen-presenting cells. Similar to adult dendritic cells, fetal dendritic cells migrate to lymph nodes and respond to toll-like receptor ligation; however, they differ markedly in their response to allogeneic antigens, strongly promoting regulatory T-cell induction and inhibiting T-cell tumour-necrosis factor-α production through arginase-2 activity. Our results reveal a previously unappreciated role of dendritic cells within the developing fetus and indicate that they mediate homeostatic immune-suppressive responses during gestation.

Although The Bethesda System for Reporting Thyroid Cytopathology has provided clinicians with a standardized classification scheme for the diagnosis of thyroid fine-needle aspiration cytology (FNAC) specimens, the indeterminate categories of Bethesda III (B3)-atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS)-and Bethesda IV (B4)-follicular neoplasm/suspicious for follicular neoplasm (FN/SFN)-continue to pose challenges with regards to ideal diagnostic and therapeutic management. Having previously demonstrated the presence of nuclear atypia as a high-risk subgroup in B3, the objective of this study was to evaluate the malignancy rates in the B4 subgroup with nuclear atypia.A retrospective review of all thyroid FNACs diagnosed as B4 (FN/SFN) between 2008 and 2015 was conducted at a tertiary referral center in Singapore. Data on patient demographics, sonographic features, and final histological diagnosis were collected. This was compared to data from a previous analysis on all nodules diagnosed as B3 (AUS/FLUS) over a similar period.A total of 137/309 (44.3%) and 88/111 (79.3%) FNACs diagnosed as B3 and B4, respectively, underwent surgical excision yielding final histopathological diagnoses. The malignancy rate of B4 was 31/88 (35.2%) compared to B3, which was 37/137 (27.0%). Subclassification based on the presence of architectural versus nuclear atypia showed significantly higher malignancy rates in B4 nodules with nuclear atypia (21.8% vs. 57.6%; p 0.01). These findings corroborate previous results within the B3 category (malignancy rate of 14.7% vs. 36.8%; p 0.01). The only sonographic features predictive of malignancy were the presence of macrocalcifications in B4 compared to irregularity of margins in B3.The presence of nuclear atypia identifies subgroups with significant differential malignancy risks within both the B3 and B4 categories. This supports the notion that subclassification is a useful risk stratification tool that can guide diagnostic and therapeutic management of indeterminate thyroid nodules with heterogenous risk profiles.

Background: Liposarcoma of the spermatic cord is a rare condition presenting as an inguinal or scrotal mass. We describe our experience in the management of five patients diagnosed with this disease. Methods: We conducted a retrospective analysis of patients who underwent treatment for the condition between 2011 and 2014. Demographic data collected included the patient’s age, presentation, site of tumour, tumour size and grade and World Health Organisation (WHO) histotypes. Adequacy of tumour resection and the use of adjuvant chemotherapy or radiotherapy were also recorded. The study end points included duration of disease-free survival (DFS) as well as overall survival (OS). Results: During the study period we identified five patients with a diagnosis of liposarcoma of the cord with a median age of 67 (range 33–72) years. Three patients presented with primary disease and two were diagnosed post-resection and required re-excision to obtain R0 resection margins. Three patients had well-differentiated and two patients had dedifferentiated liposarcoma. None of the patients required adjuvant chemotherapy or radiotherapy following achievement of R0 resection margins and developed loco-regional recurrence or distant metastases. Median DFS was 30 (range 10–45) months. Conclusion: Liposarcomas of the cord are rare soft-tissue sarcomas with a high incidence of recurrence. Treatment of choice is radical orchidectomy, wide excision of the tumour and high ligation of the spermatic cord. Long-term follow-up is necessary.

Patient: Male, 68 Final Diagnosis: Intestinal perforation Symptoms: Abdominal pain Medication: — Clinical Procedure: Exploratory laparotomy and bowel resection Specialty: Surgery Objective: Unusual clinical course Background: Intestinal tuberculosis can mimic many conditions. The incidence of intestinal tuberculosis in developed countries has risen in tandem with the increase in patients with immunocompromised states. This is a condition which needs to be considered in patients who present with symptoms and signs of bowel perforation on a background of immunosuppression in order to obtain the correct diagnosis and, consequently, the correct treatment. Case Report: We report a patient with a background of sarcoidosis who had been on mycophenolate mofetil, tacrolimus, and high-dose prednisolone. He presented with abdominal pain without overt peritonitis. Initial imaging showed small locules of free air in the abdominal cavity. The patient was managed with intravenous antibiotics as up-front surgery was deemed to be high risk. However, on a repeat imaging scan 3 days later, larger locules of gas were seen within the abdominal cavity, indicating progression and non-resolution of his acute condition. The patient was brought to the operating theatre and a perforation at the ileum was found. A segment of small bowel containing the perforation was resected. Histology showed the presence of acid-fast bacilli (AFB) on Ziehl-Neelsen stain, leading to a diagnosis of intestinal tuberculosis. Conclusions: A high index of suspicion for intestinal tuberculosis is needed in patients who are on immunosuppression. Intestinal tuberculosis presenting with perforation is unlikely to lead to spontaneous resolution without operative management, and patients should be brought to the operating theatre for immediate surgery.

Anal adenocarcinoma is a rare condition and can arise in chronic inflammatory states such as in Crohn's disease, or in a chronic fistula-in-ano. We report our diagnosis and management of a patient who presented with a large perineal lump with a long-standing history of perianal fistulous disease. This was initially evaluated with a Magnetic Resonance Imaging, and the diagnosis was confirmed with biopsy. Multimodality treatment with chemoradiotherapy and surgery should be offered to achieve the best outcomes., Highlights • Although anal adenocarcinoma is rare, it can arise from chronic inflammatory states such as long standing perianal fistulae. • MRI can be helpful in delineating the underlying aetiology, but histology is ultimately required for definitive diagnosis. • Radical surgery with either neoadjuvant or adjuvant chemoradiotherapy appears to be most effective.

Background/Aims: While colonoscopy is indicated in patients >50 years old presenting with hematochezia, its role in those ≤50 remains debatable. This study aims to evaluate the role of colonoscopy in patients presenting with hematochezia who are ≤50 years old. Methods: A retrospective review of all patients aged ≤50 years who underwent colonoscopy for hematochezia in 2012 was conducted. Patient demographics, endoscopic details, and histological results were analyzed. Patients were stratified by age to compare differences in outcome. Results: A total of 361 patients with a median age of 44 (range, 18-50) years were reviewed. Hemorrhoid (n = 183, 69.6%) was the most common etiology. Seventy-two neoplastic polyps were identified in 48 (13.3%) patients. There was a significantly larger proportion of patients aged 41-50 years who had neoplastic polyps compared to those aged ≤40 (18.8 vs. 3.8%, p ≤ 0.001); 43.8% (n = 28) of the neoplastic polyps found in those aged 41-50 were proximal to the splenic flexure. The only 2 (0.5%) patients with malignancy were aged 41-50 years. Conclusion: Performing colonoscopy in patients presenting with hematochezia should be strongly considered for those aged 41-50 years in view of the significant likelihood of underlying neoplastic polyps compared to those aged ≤40 years.

Purpose Perianal adenocarcinoma arising from a chronic anorectal fistula is a rare condition for which the natural history and optimal management are not well established. For that reason, we conducted a retrospective analysis of 5 consecutive patients with a perianal adenocarcinoma arising from a chronic anorectal fistula managed at our institution from January 2014 to December 2015. Methods The patients were identified from a prospectively collected colorectal cancer database that included all patients managed for colorectal cancer at our institution. Results The median age at diagnosis was 64 years (range, 55-72 years). Magnetic resonance imaging (MRI) was the initial investigation for all patients and showed a hyperintense T2-weighted image. One patient underwent an abdominoperineal resection following neoadjuvant chemoradiotherapy and remained disease free during the 12-month follow-up. Three patients received neoadjuvant therapy with intent for surgery, but did not undergo surgery due to either worsening health or metastatic spread. One patient declined intervention. The median overall survival was 10.5 months (range, 2-19 months). Conclusion A high index of suspicion is required to make a clinical diagnosis of an anal adenocarcinoma arising from a chronic fistula. Histologic diagnosis must be achieved to confirm the diagnosis. Multimodal therapy with neoadjuvant chemoradiotherapy followed by abdominoperineal resection is the treatment of choice.

Endoscopy remains a critical component of General Surgery and Gastroenterology training. Whilst residents need to gain experience, the quality of endoscopy which patients receive cannot be compromised. We conducted this study to compare quality indicators between consultants and residents with regards to colonoscopy. A review of colonoscopies from a prospectively collected database was performed from September 2011 to February 2016. Quality indicators such as caecum intubation rate, adenoma detection rate, adherence to a 6-min withdrawal rule, mean number of polyps detected per colonoscope, and complications were collected and compared between the two groups. In total, out of 25,749 colonoscopies that were performed, 14,168 (55.0%) were performed by Consultants. Consultants achieved a better caecum intubation rate compared with residents (96.0% vs 94.9%, p

Background The optimal management of bleeding from the lower gastrointestinal tract (LGIB) remains controversial. We aim to evaluate the efficacy of mesenteric embolization for LGIB and to identify predictors for re-bleeding after the procedure. Methods We conducted a retrospective review of all patients who underwent mesenteric embolizations for LGIB in our institution over a 6-year period (from August 2007 to August 2013). Technical success was defined as the absence of contrast extravasation on post-embolization angiogram. Clinical success was defined as the absence of overt LGIB (clinical bleeding with >1 g/dL decrease in haemoglobin) within 30 days post-embolization. Results Mesenteric embolization was performed in 26 patients with LGIB. Technical success rate was 100%, with no occurrence of post-embolization ischaemia. Clinical success rate was 65.4%, with nine patients re-bleeding within 30 days post-embolization. Three underwent surgery, one underwent re-embolization and five were treated conservatively. Mortality rate was 19.3% (five patients), with two bleeding-associated mortalities. Site and aetiology of LGIB, platelet count and coagulation status prior to embolization, number of packed red blood cells and fresh frozen plasma transfusion were found to be predictors of clinical failure. After Bonferroni's correction (P < 0.005), platelet count of ≤140 × 109/L prior to embolization was the only statistically significant factor associated with re-bleeding (odds ratio = 17.5, 95% confidence interval: 2.364–129.57; P = 0.004). Conclusion Mesenteric embolization was found to be safe and effective in treating LGIB (100% technical success, no post-embolization ischaemia), with 65.4% of cases not requiring further intervention. Low platelet count prior to embolization appears to be associated with clinical failure.

Reported outcomes of patients followed failed endoscopic stenting for acute left-sided malignant colonic obstruction remained lacking. This study aims to compare the outcomes between endoscopic stenting and emergency surgery in patients with acute left-sided malignant colonic obstruction and to identify factors that predict failed stenting. A retrospective review of all patients with acute left-sided malignant colonic obstruction in the National University Hospital, Singapore was performed. From January 2007 to October 2013, 165 patients, with a median age of 68 years (range, 25–96), formed the study group. Sixty-nine (41.8 %) patients underwent immediate surgery. Endoscopic stenting was attempted in 96 (58.2 %) patients and was successful in 76 (79.2 %). The remaining 20 (20.8 %) failed the procedure and were operated immediately. Three of the patients who were successfully stented but did not improve clinically also required emergency surgery. Patients that failed stenting were 13.3 (95 % confidence interval (CI), 3.61–48.8; p

Stenting has been increasingly adopted in colorectal cancer patients presenting with acute large bowel obstruction. However, long-term outcomes of stenting are lacking in the literature. Our study attempts to compare the long-term outcomes of colonic stenting and emergency surgery amongst left-sided colorectal cancer patients presenting with acute large bowel obstruction. A retrospective review of all patients who presented with nonmetastatic colorectal cancer who underwent either endoscopic stenting or emergency surgery for acute large bowel obstruction was performed from January 2007 to April 2016. Patients were analysed in an intention-to-treat analysis. Forty-seven (46.1%) patients underwent emergency surgery, whereas 55 (53.9%) underwent colonic stenting with a technical success rate of 71.0%. Patients who underwent emergency surgery were more likely to develop severe complications compared with patients who underwent successful colonic stenting, but the difference was not statistically significant (odds ratio [OR] 2.84; 95% confidence interval [CI] 0.71–11.3, p = 0.139). Patients were followed up for a median of 48.3 months (3.1–111) in the stenting group and 51.2 months (1.2–117.1) in the emergency surgery group. Recurrence rates between colonic stenting and emergency surgery were similar (25.6% vs. 21.3%, p = 0.500), with more anastomotic and peritoneal recurrences were noted in the emergency surgery group. 5 year disease free survival (77% vs. 73%, p = 0.708) and overall survival (86% vs. 62%, p = 0.064) also were similar. Patients who underwent endoscopic stenting for large bowel obstruction have comparable long-term outcomes as those who undergo emergency surgery. The role of endoscopic stenting in obstructed colorectal cancers merits further evaluation.

Background: Colonoscopy is advocated following acute diverticulitis to ensure that malignancy is not missed. In an Asian population, diverticulitis is more common in the right colon and in younger patients. The purpose of this study is to examine the utility of colonoscopy amongst Asian patients Methods: A retrospective review of all patients aged 50 years and under who were treated for colonic diverticulitis between 2012 and 2014 was performed. All patients were advised to undergo a colonoscopy when the diverticulitis had settled, and findings at colonoscopy were recorded. Results: Fifty-five patients aged Conclusion: Right-sided diverticulitis is more common in the young Asian population. Most patients can be conservatively treated. Follow-up colonoscopy may not be required in these patients.

We describe the diagnosis of an adult who presented with hematochezia. This was investigated and found to be from a bleeding Meckel's diverticulum. As this condition is rare in adults, there is no consensus regarding the optimal mode of management. We propose the use of angioembolisation in the diagnostic and therapeutic management of this condition. Our case showed that this strategy is indeed feasible and can achieve good short-term control, allowing for definitive surgery in an elective setting.