Spontaneous expulsion from rectum: a rare presentation of intestinal lipomas

Lipomas are rare, subserosal, usually solitary, pedunculated small lesions appearing mainly in the large intestine with a minimal malignancy potential. They usually run asymptomatic and become symptomatic when they become enlarged or complicated causing intestinal obstruction, perforation, intusucception or massive bleeding. In rare cases they can be self-detached and expulsed via the rectum as fleshy masses. This event mainly occurs in large, pendunculated lipomas which detach from their pedicle. The reason for this event remains in most of cases unclear although in some cases a predisposing factor does exist. Abdominal pain and obstructive ileus may be observed while in many cases bleeding occurs. The expulsed mass sets the diagnosis and in most of the cases all symptoms subside. Diagnosis is rarely established before surgery with the use of barium enema, computed tomography and colonoscopy which additionally provides measures of treatment and diagnosis. In atypical cases though, in cases where the malignancy can not be excluded or in complicated cases, surgery is recommended. Usually the resection of the affected intestinal part is adequate. If during surgery a lipoma is encountered simple lipomatectomy seems also to be adequate

Adrenocortical Carcinoma Presenting with Signs of Acute Abdomen

Background. Adrenocortical carcinomas represent rare malignancies. In cases of hormone-secreting tumors, the hormone in excess determines the nearly diagnostic clinical presentation. Biologically inert tumors are diagnosed either due to the mass effect or incidentally. The purpose of the present study was to present an extremely rare presentation pattern of adrenocortical carcinoma. Case Presentation. We present the case of a 35-year-old female patient that underwent emergency laparotomy due to signs of acute abdomen and concomitant cardiovascular collapse caused by a spontaneously ruptured large adrenocortical carcinoma. Conclusion. Spontaneous rupture of an adrenocortical carcinoma presenting with signs of acute abdomen is an extremely rare clinical scenario. Increased level of suspicion is essential in order to diagnose and treat timely this life-threatening complication

The revised international autoimmune hepatitis score in chronic liver diseases including autoimmune hepatitis/overlap syndromes and autoimmune hepatitis with concurrent other liver disorders

Background. We conducted a study in order to determine the usefulness and diagnostic value of International Autoimmune Hepatitis Group (IAHG) score in non-autoimmune hepatitis (AIH) hepatic disorders as well as in AIH/overlap syndromes and in cases with coexistence of AIH and other liver diseases. Methods. We applied the IAHG score in 423 patients with liver diseases excluding patients with AIH, AIH/overlap syndromes and AIH with concurrent other liver disease namely, patients with chronic hepatitis B (n = 109), chronic hepatitis C (n = 95), chronic hepatitis D (n = 4), alchoholic liver disease (n = 28), non-alcoholic fatty liver disease (n = 55), autoimmune cholestatic liver diseases (n = 77), liver disorders of undefined origin (n = 32) and with miscellaneous hepatic disorders (n = 23). 24 patients with AIH associated with any kind of liver disorder including 10 patients with AIH/overlap syndromes and 14 AIH with concurrent other liver disease were also investigated. 43 patients with AIH consisted the control group. Results. The specificity of the score was 98.1% while the sensitivity in unmasking AIH in patients with either AIH/overlap syndromes or AIH with concurrent other liver diseases was only 50% and 78.6%. In the binary logistic regression model, the presence of other autoimmune diseases (p < 0.001), the total histological score (p < 0.001) and positivity for autoantibodies (p < 0.05) were identified as independent predictors for the presnce of AIH/ovea syndromes o AI with concurren other liver diseass. Conclusion. The IAHG scoring system has very good specificity for excluding AIH in patients with chronic liver diseases but not that sensitivity in order to unmask AIH/overlap syndromes or AIH with concurrent other liver diseases. The presence of other autoimmune diseases or autoantibody markers in the absence of hepatitis viral markers should alarm physicians for the possible presence of AIH either as "pure" AIH or in association with other liver disorders (AIH/overlap syndromes or AIH with concurrent other liver diseases). Under these conditions, liver histology seems essential and it must always be included in the work up of hepatic patients. © 2007 Papamichalis et al; licensee BioMed Central Ltd

Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection:an international, multi-centre, prospective audit

Introduction: The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). Methods: A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results: Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30–0.92, P&nbsp;=&nbsp;0.02) but MBP was not (OR 0.92, 0.63–1.36, P&nbsp;=&nbsp;0.69) compared to NBP. Conclusion: This non-randomised study adds ‘real-world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Evaluating the incidence of pathological complete response in current international rectal cancer practice

The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre-operative imaging.A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post-treatment MRI restaging (yMRI) and final pathological staging.Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post-treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T-stage, N-stage, or AJCC status were each graded as 'fair' only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively).The reported pCR rate of 10% highlights the potential for non-operative management in selected cases. The limited strength of agreement between basic conventional post-chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials

Expression of Angiopoietin, GA733-1 / -2 and CEA genes in patients with colorectal genes

The colo-rectal cancer is the fourth most common type of cancer in both the male and the female population and the second cause of death from cancer in the US. In recent years, however, there is a significant reduction of disease effect. This reduction in disease mortality is a result of progress in the prevention and early detection of cancer through preventive tests and improved therapeutic agents available to physicians. Colorectal cancer is a heterogeneous disease with a different therapeutic strategy for each patient. This strategy is determined by the stage of the disease and the biology of the tumor. The evolution of the molecular study of the carcinogenesis has greatly helped in understanding the genetic nature of colorectal cancer, although there are still many to be done. This study is focused on the genetic basis of colorectal cancer by analyzing 40 patients with colorectal cancer. DNA was isolated from the peripheral blood of these patients as well as RNA from tumor cells and from cells of non-diseased intestinal mucosa from adjacent positions in order to clarify the expression of the genes in normal and in pathological tissue of the intestinal mucosa. This was followed by quantitative reaction of the Polymerase chain reaction-reverse transcription (q-RT-PCR) to determine the expression of the GA733-1, GA733-2, CEACAM5, Ang-1 and Ang-2 genes. These results were then correlated with clinicopathological features of the patients. The expression of the GA733-1gene was almost undetectable in both noncancerous mucosal tissue and cancerous tissue, while the expression of the GA733-2 gene was detectable in all samples. The mean value of GA733-2/h-PBGD mRNA was 273.31 (65.24-1,486.41) and 115.64 (11.58-1-189.14) in noncancerous and cancerous tissue, respectively (p=0.0000195). Significant correlations were found between the GA733-2 gene expression and the stage N of the disease (p=0,0343) as well as with the presence or absence of lymph node infiltration (p=0,008668). The expression of the CEACAM5 gene was detected in all samples with mean value CEACAM5/h-PBGD mRNA: 326,36 (11,97-3.3562,61) and 317,60 (3,37 to 8.896,42) in the non-cancerous and cancerous tissue. A significant correlation was detected between the expression of CEACAM5 gene and the degree of tumor cell differentiation (p=0.0465). The levels of carcino embryonic antigen in human serum were assessed in more than 50% of the samples. The mean value of CEA levels in peripheral serum was 6,5715 (0,86-24,95), while a correlation of CEACAM5 gene and their levels in the peripheral blood was not detected in cancerous cells. Finally, Ang-1 and Ang-2 genes are expressed in all analyzed samples. The mean value of Ang-1/h-PBGD mRNA was 3,6248 (0,0530-16,5433) and 0,9373 (0,0002-11,2039) in the non-cancerous and cancerous tissue, respectively. Concerning the expression of Ang-2, the mean value of Ang-2/h-PBGD gene was 0,7492 (0,0012-5,3992) in noncancerous tissue and 1,4122 (0,0020-0,9665) in cancerous tissue. Significant correlations were observed between the expression of Ang-1 gene and the T stage of the tumor (p=0.04536) as well as Ang-2 gene expression and the tumor cell differentiation grade (p=0.0049). Moreover, the expression level of Ang-1/Ang-2 genes was correlated with the T phase of the tumor (p=0.0364) and the presence of lymph node (N) according to the TNM staging system (p=0.0363).In conclusion, the extremely low levels of the GA733-1 gene detected in our samples was in accordance with the knowledge for the expression of this gene only in colorectal cancer with liver metastasis; the levels of GA733-2 mRNA transcripts were significantly correlated with the N stage of disease as well as with the presence or absence of lymph node infiltration. The increased expression of CEACAM5 gene might be related to the tumor cell differentiation grade, while it was not detected any correlation between the expression of CEACAM5 in cancer cells and its level in peripheral blood. Concerning the expression of Ang-1 and Ang-2 genes, it is evident that as the T phase of the tumor is increased the expression of Ang-1 is reduced, while the low levels of Ang-2 gene were observed in low-grade tumor cells differentiation. Finally, the diversification of the expression of the two angiopoietins in the tumor tissue was correlated with the T stage of the tumor as well as with the presence of lymph node metastasis (N). These results suggest that a better understanding of colorectal cancer biology will significantly contribute to a more rational and effective treatment of the disease.Ο κολο-ορθικός καρκίνος αποτελεί τον τέταρτο πιο συχνό τύπο καρκίνου τόσο στον αντρικό όσο και στο γυναικείο πληθυσμό και τη δεύτερη αιτία θανάτου από καρκίνο στις ΗΠΑ. Τα τελευταία χρόνια όμως παρατηρείται σημαντική μείωση της επίπτωσης της νόσου. Η μείωση αυτή της θνητότητας της νόσου είναι απόρροια της προόδου στην πρόληψη και στην έγκαιρη διάγνωση του καρκίνου μέσω των προληπτικών ελέγχων, της καλύτερης διάγνωσης και της βελτίωσης των θεραπευτικών μέσων που διατίθενται. Ο κολο-ορθικός καρκίνος είναι μία ετερογενής νόσος με διαφορετική θεραπευτική στρατηγική για τον κάθε ασθενή που καθορίζεται από το στάδιο της νόσου και τη βιολογία του όγκου. Η εξέλιξη της μελέτης της μοριακής βάσης της καρκινογένεσης έχει βοηθήσει σημαντικά την κατανόηση της γενετικής φύσης του κολο-ορθικού καρκίνου, αν και υπάρχουν ακόμα πολλά προς διερεύνηση.Η παρούσα διδακτορική διατριβή εστιάστηκε στη μελέτη της γενετικής βάσης του κολο-ορθικού καρκίνου μελετώντας 40 ασθενείς με κολο-ορθικό καρκίνο, από τους οποίους απομονώθηκε γενετικό υλικό τόσο από τα καρκινικά κύτταρα του όγκου όσο και από κύτταρα του μη νοσούντος εντερικού βλεννογόνου από παρακείμενες θέσεις προκειμένου να παρατηρήσουμε την έκφραση γονιδίων στο φυσιολογικό και παθολογικό ιστό του εντερικού βλεννογόνου. Στη συνέχεια ακολούθησε ποσοτική αντίδραση αλυσιδωτής αντίδρασης Πολυμεράσης-αντίστροφης μεταγραφής (q-RT-PCR) για τον προσδιορισμό της ποσοτικής έκφρασης των γονιδίων GA733-1, GΑ733-2, CEACAM5, Ang-1 και Ang-2. Τα αποτελέσματα αυτά συσχετίστηκαν στη συνέχεια με τα κλινικοπαθολογικά χαρακτηριστικά των ασθενών. Η έκφραση του γονιδίου GA733-1 ήταν πολύ χαμηλή έως μη ανιχνεύσιμη τόσο στο μη καρκινικό βλεννογονικό ιστό όσο και στον καρκινικό. Η έκφραση του γονιδίου GA733-2 ήταν ανιχνεύσιμη σε όλα τα δείγματα και η μέση τιμή GA733-2/h-PBGD ήταν 273,31 (65.24-1,486.41) και 115,64 (11.58-1-189.14???) στο μη καρκινικό και καρκινικό ιστό, αντιστοίχως (p = 0.0000195). Στατιστικώς σημαντικές συσχετίσεις εντοπίστηκαν μεταξύ της έκφρασης του γονιδίου GA733-2 και το στάδιο Ν της νόσου (p = 0,0343) και με την παρουσία ή μη λεμφαδενικής διήθησης (p=0,008668). Η έκφραση του CEACAM5 γονιδίου στον ιστό ήταν ανιχνεύσιμη σε όλα τα δείγματα με μέση τιμή CEACAM5/h-PBGD mRNA: 326,36 (11,97-3.3562,61) στο μη καρκινικό ιστό, ενώ στον καρκινικό ιστό η μέση τιμή CEACAM5/h-PBGD mRNA ήταν 317,60 (3.37 έως 8896.42). Σημαντική συσχέτιση εντοπίστηκε μεταξύ της έκφρασης του CEACAM5 γονιδίου και του βαθμού διαφοροποίησης των καρκινικών κυττάρων (p=0.0465). Τα επίπεδα του καρκινο-εμβρυϊκού αντιγόνου στον ανθρώπινο ορό αξιολογήθηκε σε περισσότερους από το 50% των δειγμάτων. Η μέση τιμή των επιπέδων του CEA στο περιφερικό ορό ήταν 6,5715 (0,86-24,95), ενώ δεν εντοπίστηκε κάποια συσχέτιση της έκφρασης του CEACAM5 στα καρκινικά κύτταρα και των επιπέδων τους στο περιφερικό αίμα. Τέλος, τα γονίδια Ang-1 και Ang-2 εκφράζονται σε όλα τα υπό μελέτη δείγματα. Η μέση τιμή έκφρασης Ang-1/h-PBGD ήταν 3,6248 (0,0530-16,5433) και 0,9373 (0,0002-11,2039) στο μη καρκινικό και καρκινικό ιστό, αντιστοίχως. Ως προς την έκφραση του γονιδίου Ang-2, η μέση τιμή Ang-2/h-PBGD ήταν 0,7492 (0,0012-5,3992) στο μη καρκινικό ιστό και 1,4122 (0,0020-10,9665) στον καρκινικό ιστό. Παρατηρήθηκαν σημαντικές συσχετίσεις μεταξύ της έκφρασης του γονιδίου Ang-1 και του σταδίου Τ του όγκου (p=0.04536) καθώς και του γονιδίου Ang-2 και του βαθμού διαφοροποίησης των καρκινικών κυττάρων (p=0.0049). Αναλύοντας τα αποτελέσματά μας προέκυψε συσχέτιση μεταξύ των επιπέδων έκφρασης των γονιδίων Ang-1/Ang-2 και του σταδίου Τ του όγκου (p= 0.0364) καθώς και με την παρουσία λεμφαδενικών μεταστάσεων (Ν) σύμφωνα με το σύστημα σταδιοποίησης κατά ΤΝΜ (p= 0.0363).Συμπερασματικά, η έκφραση του γονιδίου GA733-1 συσχετίστηκε με την ανάπτυξη ηπατικών μεταστάσεων και του GA733-2 γονιδίου με το στάδιο Ν της νόσου. Η αυξημένη έκφραση του CEACAM5 γονιδίου πιθανόν να εμπλέκεται στο βαθμό διαφοροποίησης των καρκινικών κυττάρων, ενώ δεν εντοπίστηκε κάποια συσχέτιση μεταξύ της έκφρασης του CEACAM5 στα καρκινικά κύτταρα και των επιπέδων του στο περιφερικό αίμα. Ως προς την έκφραση των γονιδίων Ang-1 και Ang-2 προέκυψε ότι όσο αυξάνεται το στάδιο Τ του όγκου τόσο μειώνεται η έκφραση της Ang-1, ενώ η μειωμένη έκφραση της Ang-2 παρατηρήθηκε στα χαμηλού βαθμού διαφοροποίησης καρκινικά κύτταρα. Τέλος, η διαφοροποίηση της έκφρασης των δύο αγγειοποιητινών στον καρκινικό ιστό συσχετίστηκε με το στάδιο Τ του όγκου (p= 0.0364) καθώς επίσης και με την παρουσία λεμφαδενικών μεταστάσεων (Ν). Τα αποτελέσματα αυτά υποδεικνύουν ότι η καλύτερη κατανόηση της βιολογίας του κολο-ορθικό καρκίνου θα συμβάλει σημαντικά στην ορθολογικότερη και αποτελεσματικότερη θεραπεία της ασθένειας