Background
Diverting ileostomy (DI) is utilised in rectal cancer surgery to mitigate the effects of anastomotic leak. The aim of this study was to assess the clinical risk factors associated with post‐operative complications of DI reversal.
Methods
A single‐centre retrospective analysis of patients who underwent surgical resection for rectal cancer and subsequent DI reversal between January 2012 and December 2020 was undertaken. Medical records were reviewed to extract clinical, operative and pathologic details and post‐operative complications according to the Clavien‐Dindo classification. Univariate and multivariable analyses were undertaken to assess risk factors associated with post‐operative complications of DI reversal.
Results
One hundred and twenty‐six adult patients who underwent DI reversal were included of which 49 had a post‐operative complication (39%). The most common complication was prolonged post‐operative ileus, which occurred in 24 patients (19%). On multivariable analysis smoking was significantly associated with overall complications (odds ratio [OR] = 5.60, 95% confidence interval [CI] 1.90–16.52, p = 0.0018), and high Clavien‐Dindo (2–5) category complications (OR = 4.60, 95% CI 1.81–11.68, p = 0.0013). In addition, patients who received adjuvant chemotherapy were less likely to have a reversal of DI complication (OR = 0.43, 95% CI 0.19–0.94, p = 0.0342) and less likely to have a high Clavien‐Dindo (2–5) category complication (OR = 0.44, 95% CI 0.20–0.93, p = 0.0311).
Conclusion
Smokers who have undergone surgical resection of rectal cancer have a significantly increased risk of post‐operative complications after DI reversal. In these patients, the importance of smoking cessation must be emphasised. The decreased complication rate observed in patients who received adjuvant chemotherapy was an unexpected finding.
Breast cancer most commonly metastasizes to the bone, lung, liver, and brain. The colon is an uncommon site for metastases and its symptoms are variable. A 60-year-old female with a history of breast cancer was referred for colonoscopy following a positive fecal occult blood test (FOBT); there were no discrete lesions concerning for primary colonic cancers or metastasis; however, a random biopsy revealed metastatic breast cancer. The possibility of colonic metastases must be considered when assessing positive FOBT in a patient with previous breast cancer.
synchronous NRAS genetic mutation confirmed the ultimate diagnosis of metastatic de-differentiated melanoma. The authors' experience here reinforces the importance of seeking the correct diagnosis through meticulous clinical and pathological investigation and highlights the benefits of discussion at a multidisciplinary meeting. This ensures that patients do not receive misguided treatment. Our case also serves to reinforce the longstanding adage in medicine that common things occur commonly and the principle of 'Occam's Razor' in seeking a single unifying diagnosis for the patient's presentation. Specifically, for this patient, it was far more likely for the popliteal mass in the draining distribution of a previously excised heel melanoma to correspond with a metastatic deposit rather than a new primary sarcoma (despite the apparent findings of the initial pathology). Through clinician scepticism and experience as well as further considered investigation, the correct diagnosis was ultimately clinched. In conclusion, this is a rare case highlighting the diagnostic difficulties associated with the increasingly recognized clinical entity of de-differentiated melanoma and the critical role of genetic testing in confirming this diagnosis. Of interest in this case was that the standard melanoma markers were lost from the primary melanoma to its metastasis; however, the same somatic genetic aberration persisted. Notably, this genetic mutation was not the more commonly identified BRAF V600E mutation but a more rarely reported NRAS p.Q61R mutation. Surgeons and pathologists involved in the treatment of patients with melanoma and sarcoma must be aware of dedifferentiated melanoma when formulating their differential diagnosis, as otherwise it will frequently be missed which may result in incorrect diagnosis and inappropriate treatment.
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