Do Clinicopathological Features of the Cancer Patient Relate with Nipple Areolar Complex Necrosis in Nipple-Sparing Mastectomy?

Background

The selections of nipple-sparing mastectomy (NSM) are principally depending on oncologic indication and oncologic safety. The main complication of NSM is nipple areolar complex (NAC) necrosis, and it is usually related to surgical technique. However, the patients’ clinicopathological factors should be also considered.

Method

We retrospectively reviewed 934 consecutive NSM patients during 2002–2007 at the European Institute of Oncology, Milan, Italy. We identified a group of patient who had NAC excision because of NAC necrosis and compared this group with those who had successful NAC conservation. We analyzed the association between the risk of NAC necrosis and the clinicopathological features of the patients.

Results

Among 934 NSM, 772 were invasive cancers and 162 were in situ cancers. Of the 934, 40 NAC (4.2 %) were removed during the postoperative period because of necrosis. When we considered age, BMI, menopausal status, smoking status, tumor size, axillary lymph node status, in situ or invasive cancer histology, presence of extensive situ component, grading, estrogen receptor, progesterone receptor, HER2/neu overexpression, Ki-67 proliferative index, and peritumoral vascular invasion, no association was observed between patients’ clinicopathological features and NAC necrosis incidence.

Conclusions

In our study, clinicopathological features have no significant impact on necrosis complication in therapeutic NSMs. Positive retroareolar margin is the risk of necrosis. Further studies are required to avoid bias due to the different cancer treatments such as different reconstruction techniques and intraoperative radiation protocols. The correlation between breast morphology and NAC necrosis should also be investigated in the future.     

Approach to Hemorrhoids

Hemorrhoids are a very common anorectal disorder defined as the symptomatic enlargement and abnormally downward displacement of anal cushions. The current pathophysiologies of hemorrhoids include the degenerative change of supportive tissue within the anal cushions, vascular hyperplasia, and hyperperfusion of hemorrhoidal plexus. Low-grade hemorrhoids are easily and effectively treated with dietary and lifestyle modification, medical intervention, and some office-based procedures. An operation is usually indicated in symptomatic high-grade and/or complicated hemorrhoids. Whilst hemorrhoidectomy has been the mainstay of surgical treatment, more recently other approaches have been employed including Ligasure hemorrhoidectomy, stapled hemorrhoidopexy, and doppler-guided hemorrhoidal artery ligation. Post-procedural pain and disease recurrence remain the most challenging problems in the treatment of hemorrhoids. This article deals with modern approaches to hemorrhoids based on the latest evidence and reviews of the literature. The management of hemorrhoids in complicated situations is also discussed.     

Enhanced recovery after surgery vs conventional care in emergency colorectal surgery

AIM: To investigate the feasibility and beneficial effects of enhanced recovery after surgery (ERAS) programme in the setting of emergency colorectal surgery.METHODS: Between January 2011 and October 2013, patients undergoing emergency resection for obstructing colorectal cancer at the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand using ERAS programme were compared with those using conventional care (1:2 ratio). They were matched for their age, gender, ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score, and type of surgery. Primary outcomes were length of hospital stay and postoperative morbidity. Secondary outcomes included gastrointestinal recovery, 30-d readmission, and time interval from surgery to chemotherapy.RESULTS: Twenty patients treated with ERAS programme were compared with 40 patients receiving conventional postoperative care. Median of hospital stay was shorter in the ERAS group: 5.5 d (range: 3-16) vs 7.5 d (range: 5-25), P = 0.009. The ERAS group had a non-significant reduction in the incidence of postoperative complication (25% vs 48%, P = 0.094). No 30-d mortality and readmission occurred. Patients with ERAS programme had a shorter time to first flatus (1.6 d vs 2.8 d, P < 0.001) and time to resumption of normal diet (3.5 d vs 5.5 d, P = 0.002). Time interval between operation and initiation of adjuvant chemotherapy was significantly shorter in the ERAS group (37 d vs 49 d, P = 0.009).CONCLUSION: The ERAS programme in the setting of emergency colorectal surgery was safe and feasible. It achieved significantly shorter hospitalisation and faster recovery of bowel function.     

Rectovaginal fistula after low anterior resection: Prevention and management

Rectovaginal fistula after low anterior resection for rectal malignancy is one of the most challenging postoperative complications because it is difficult to treat and may complicate plans of adjuvant therapy. This problematic complication could lead to multiple operations, stoma formation, sexual dysfunction, fecal incontinence and psychosocial ramifications. This review comprehensively covers an overview of its incidence, risk factors, presentation and evaluation, management (ranging from conservative measures, endoscopic treatment and local tissue repair to radical resection and redo anastomosis) and treatment outcomes of rectovaginal fistula after low anterior resection. Notably, these therapeutic options and outcomes are influenced by several factors, including the size and location of the fistula, tumor clearance, cancer staging, quality of colorectal anastomosis and surrounding tissue, presence of diverting stoma, previous attempted repair, and the surgeon’s experience. Also, strategies to prevent rectovaginal fistula after low anterior resection are presented with illustrations. Finally, a decision-making algorithm for managing this complication is proposed.     

Colorectal cancer screening by double contrast barium enema in Thai people

Purpose: The incidence of colorectal cancer (CRC) has been increasing in Asian countries including Thailand.Double contrast barium enema (DCBE) is one of the investigation tools used in CRC screening. This study aimedto determine the incidence of colorectal neoplasm detected at screening by DCBE in Thai people. Methods:The computerized radiology database of screening DCBE in Thai adults between June 2009 and October 2011at the Faculty of Medicine, Siriraj Hospital, was reviewed. DCBE examination performed in a surveillanceprogram after curative CRC resection or the removal of colorectal polyps was also considered as a screeningDCBE. Results: A total of 819 screening DCBEs performed during this 28-month period were analyzed. Themean age of patients was 59.8 ± 13.6 years. Of the total, 467 (57%) were male. A family history of CRC and aprevious history of curative CRC resection or polyp removal were noted in 34 patients (4%) and 124 patients(15%), respectively. A total of 31 patients (3.8%; 95%CI = 2.7%-5.3%) were reported to have colorectal polypor mass demonstrated on DCBE. Of these, follow-up endoscopy was performed in 20 cases (65%). Accordingto pathological results, the incidence of advanced adenoma and CRC detected at screening DCBE was 0.7%(95%CI = 0.3%-1.6%; n=6) and 0.4% (95%CI = 0.1%-1.1%; n=3), respectively. Conclusions: The screeningDCBE performed in Thai adults had a diagnostic yield of 0.7% for advanced adenoma and 0.4% for CRC.     

Persistent perineal sinus: Incidence,pathogenesis, risk factors,and management

This review discusses the incidence, pathogenesis, risk factors, diagnosis, and therapeutic options for persistent perineal sinus (PPS), defined as a perineal wound that remains unhealed more than 6 months after surgery. The incidence of PPS after surgery for inflammatory bowel disease (IBD) ranges from 3% to 70% and after abdominoperineal resection (APR) for low rectal cancer, it can be up to 30%. These unhealed wounds are frequently related to perioperative pelvic or perineal sepsis. Crohn’s disease (CD) and neoadjuvant radiation therapy are also important risk factors. The management of PPS is based on an understanding of pathogenesis and clinical grounds. The advantages and disadvantages of the current therapeutic approaches, including the topical administration of various drugs, vacuum-assisted closure, and perineal reconstruction with a muscle flap or a myocutaneous flap are also discussed.     

What are the risk factors of colonoscopic perforation?

Background  

Knowledge of the factors influencing colonoscopic perforation (CP) is of decisive importance, especially with regard to the avoidance or minimization of the perforations. The aim of this study was to determine the incidence and risk factors of CP in one of the endoscopic training centers accredited by the World Gastroenterology Organization.