International guidelines recommend colonoscopy following hospitalisation for acute diverticulitis. There is a paucity of evidence supporting the efficacy of colonoscopy in this context, particularly for patients with CT-diagnosed uncomplicated left-sided diverticulitis. This study aims to investigate the frequency that colorectal cancer (CRC) and advanced adenomas (AA) are identified during follow-up colonoscopy after hospitalisation with CT-proven left-sided diverticulitis for the first time in a UK population. In this single-centre retrospective-cohort study all patients presenting with CT-diagnosed uncomplicated left-sided diverticulitis between 2014 and 2017 were identified. The incidence of histologically confirmed CRC and AA identified at follow-up colonoscopy 4–6 weeks following discharge was assessed. 204 patients with CT proven uncomplicated left-sided diverticulitis underwent follow-up colonoscopy. 72% were female and the median age was 63 years. There were no major complications. 22% of patients were found to have incidental hyperplastic polyps or adenomas with low-grade dysplasia. No CRC or AA were found. Routine colonoscopy following acute diverticulitis in this cohort did not identify a single CRC or AA and could arguably have been omitted. This would significantly reduce cost and pressure on endoscopy departments, in addition to the pain and discomfort that is commonly associated with colonoscopy.
Background Pancreatic ductal adenocarcinoma (PDAC) is associated with a historically poor long-term survival of 5-10%, despite surgical resection. Borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) is reported as potentially resectable disease with a degree of vascular involvement, increasing the risk of a positive surgical margin. This cohort of patients have the worst survival despite curative resection and adjuvant chemotherapy. Emerging evidence suggests that neo-adjuvant chemoradiation (NCR) improves R0 resection rates in BR-PDAC patients. We evaluated the R0 resection rate, disease free survival (DFS) and overall survival (OS) in our patients, who had undergone NCR for BR-PDAC at our institution. Methods Data was collected retrospectively for all patients undergoing NCR for BR-PDAC between Jan 2010 to Mar 2020 for this study. Surgical management was ratified by clinical assessment and cross-sectional imaging in a pancreatic multidisciplinary team meeting (MDM). Patients underwent NCR by a number of standardised regimens. Patients with proven regressive or stable disease on imaging underwent a pancreatic resection. All BR-PDAC patients underwent resection in the form of classical Whipple’s or pylorus preserving pancreaticoduodenectomy (PPPD) depending on intra-operative findings. Patient morbidity, R0 resection rate, histological parameters, DFS and OS were evaluated. Results 29 patients were included in the study (16 men and 13 women), with a median age of 65 years (range, 46-74 years). 17 patients received FOLFIRINOX and 12 patients received gemcitabine (GEM) based NCR regimens. All patients received chemoradiation at the end of chemotherapy (range 45-56Gy). 75% had an R0 resection, with a greater proportion in the FOLFIRINOX group. Whole cohort median DFS was 35 months, survival was superior in the FOLFIRINOX group (42 months). Median OS was 30 months for the whole group, with a greater median OS in the FOLFIRINOX versus the GEM cohort (42 versus 29 months). Conclusions We present a single centre retrospective study utilising NCR for BR-PDAC, we reiterate the strong association of an R0 resection with superior patient overall survival following surgery in this cohort. We show that in patients with BR-PDAC, NCR results in superior R0 resection rates with an associated increase in patient survival. Our results show that survival advantage is greatest in BR-PDAC patients who received neo-adjuvant FOLFIRINOX. Our findings affirm the advantage of NCR prior to surgery, particularly FOLFIRINOX based treatment, in this cohort of patients.
Background Duodenal adenocarcinoma (DA) is a rare gastrointestinal malignancy. Due to the low incidence of DA there is limited data reporting patient outcomes following radical pancreatic resection. Large retrospective single and multi-centre studies suggest that lymph node metastasis is an important factor for long-term patient survival following resection. The management of DA has tended to favour aggressive surgical resection with pancreaticoduodenectomy (PD), although a morbidity of up to 50% has been reported, mostly related to post-operative pancreatic fistulas. We assessed the disease-free (DFS) and overall survival (OS) in patients undergoing pancreaticoduodenectomy for DA in our institution. Methods We retrospectively analysed all patients undergoing pancreatic resection for DA at our institution between January 2009 – March 2020 inclusive. All DAs were cytologically or histologically proven prior to surgical resection following imaging review in a Hepato-pancreaticobiliary multidisciplinary team meeting. Patients underwent a Whipple’s with distal gastrectomy or pylorus preserving pancreaticoduodenectomy (PPPD) based on tumour size and location. Statistical analysis was performed by a Mann-Whitney U test using a p-value significance of 0.05 (SPSS, IBM, USA). DFS and OS curves were presented by Kaplan- Meier survival curves. Results 19 patients underwent pancreatic resection at our institution for DA during the study period. 12 patients underwent Whipple’s with distal gastrectomy and 9 patients underwent PPPD. The overall postoperative morbidity and mortality was 37% and 5% respectively. R0 resection was achieved in 18 patients (95%). 9 patients (47%) had no nodal involvement. Median follow up was 31 months (range 1-108 months). Median DFS was 17 months but was significantly higher in patients with no nodal metastasis [p < 0.001]. Median OS was 9.5 months for the whole cohort but was significantly higher in the patients with no nodal vs nodal metastasis (60 vs 17.5 months respectively) p < 0.003]. Conclusions DA can be resected by PD or segmental resection. PD is favoured due to improved resection margins and overall increased patient survival, despite an increased morbidity. Our series reports comparable morbidity and mortality to the published literature for DA resected by PD. This study reports a 95% R0 resection rate for DA with a 3- and 5-year survival of 50% and 30% respectively. DFS was found to be significantly higher in patients with no nodal disease, despite predominant T4 disease. This series has identified that lymph node metastasis is one of the most important prognostic determinants of long-term patient survival. Program permission yes
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