Rectal Gastrointestinal Stromal Tumor (GIST): About a Rare and Unusual Case

Rectal gastrointestinal stromal tumors (GIST) are extremely rare, accounting for approximately 0.1% of all rectal tumors. Diagnosis is based on histological and immunohistochemical confirmation. We report the case of a 38-year-old patient with a rectal GIST revealed by chronic rectal bleeding associated with rectal tenesmus, abdominal pain with painful contractions and frequent evacuations evolving in a context of altered general state. Rectoscopy was used to visualize the tumor mass and to take biopsies; their histological and immunohistochemical study revealed a rectal location of a gastrointestinal stromal tumor. The extension assessment was negative. After discussion of the case in a multidisciplinary consultation meeting, management consisted of initially putting the patient on Imatinib given the large tumor size, the degree of local invasion and the location of the mass (lower rectum), with regular follow-up in order to schedule a less invasive surgical resection later. Despite the rarity of rectal GIST, early diagnosis is necessary to avoid progression to locoregional invasion complicating some surgical resections given the anatomical constraints of the pelvic region. Hence the interest of neoadjuvant therapy with tyrosine kinase inhibitors allowing in some cases a decrease in tumor volume, a regression of the degree of local invasion and a decrease in the morbidity of the surgery in order to improve the patient's quality of life.

A Comparison of in-house and Shared Rapidplan Models for Prostate Radiation Therapy Planning

PurposeKnowledge-based planning (KBP) can increase plan quality, consistency and efficiency. In this study, we assess the success of a using a publicly available KBP model compared with developing an in-house model for prostate cancer radiotherapy using a single, commercially available treatment planning system based on the ability of the model to achieve the centre’s planning goals. Methods and MaterialsTwo radiation oncology centres each created a prostate cancer KBP model using the Eclipse RapidPlan software. These two models and a third publicly-available, shared model were tested at three centres in a retrospective planning study. Results The publicly-available model achieved lower rectum doses than the other two models. However, the planning-target-volume (PTV) doses did not meet the local planning goals and the model could not be adjusted to correct this. As a result, the plans most likely to satisfy local planning goals and requirements were created using an in-house model. For centres without an existing in-house model, a model created by another centre with similar planning goals was found to be preferred. ConclusionsVariations in local planning practices including contouring, treatment technique and planning goals can influence the relative performance of KBP. The value of publicly available KBP models could be enhanced through standardisation of planning goals and contouring guidelines, providing information related to the planning goals used to create the model and increased flexibility to allow local adaptation of the KBP model.

868 The management of acute lower gastrointestinal bleeding using a Sengstaken-Blakemore tube

Introduction Acute lower gastrointestinal haemorrhage can potentially be life-threatening. We present a case of a massive rectal bleed which was managed successfully with a balloon tamponade device designed for upper gastrointestinal haemorrhage. Presentation of case A 75-year-old gentleman, with a history of human immunodeficiency virus and cirrhosis with portal hypertension, presented with bright red rectal bleeding. Investigations showed a low haemoglobin level (74 g/L) and deranged clotting. Oesophago-gastro-duodenoscopy demonstrated no fresh or altered blood. Flexible sigmoidoscopy revealed active bleeding from a varix within the anterior rectal wall 4 cm from the anal verge. Efforts to stop the bleeding, including endoscopic clips, adrenaline injection and rectal packing, were unsuccessful and the patient became haemodynamically unstable. A Sengstaken-Blakemore tube was inserted per rectum and the gastric balloon was inflated to tamponade the lower rectum. The oesophageal balloon was then inflated to hold the gastric balloon firmly in place. A computed tomography angiogram demonstrated no evidence of haemorrhage with balloon tamponade. After 36 h, the balloon was removed with no further episodes of bleeding. Discussion The application of a balloon tamponade device should be considered in the management algorithm for acute lower gastrointestinal bleed. Advantages include its rapid insertion, immediate results and ability to measure further bleeding after the catheter has been placed. Conclusions Sengstaken-Blakemore tube per rectum may effectively control massive low rectal bleeding when alternative methods have been unsuccessful.

A New Approach for Pelvic Tumors Invading the Rectum

Objective: Sometimes pelvic tumors invade the rectal wall, needing removal Design: An alternative technique of radical/conservative surgery (trying to preserve as much as possible the muscular complex) is presented, inspired by De La Torre treatment of Hirschprung’s disease. The lower rectum is only partially resected on the non-involved side, where only mucosa is removed, followed by a lower end to end rectal anastomosis Results: Normal defecation Conclusion: A good surgical alternative

Comparison of Endoscopic Brush And Net Catheters As Sampling Tools To Analyze Lower Rectum Intestinal Mucus Samples of Patients With Ulcerative Colitis

Background and aims: The pathophysiology of ulcerative colitis remains unclear, but early lesions on the colorectal mucosal surface may play an important role in its etiology. Intestinal mucus samples, including inner and outer layers, are collected by net or brush catheters, but the quality of the samples obtained by each method has not been fully investigated. The aim of this study was to compare the microbiome and protein content of Intestinal mucus collected by net and brush catheters during colonoscopy.Methods: Intestinal mucus samples from the lower rectum of four patients with ulcerative colitis were collected using a net catheter, a brush catheter, and intestinal fluid suction. Microbiome and protein content were analyzed using 16S rRNA gene sequencing and mass spectrometry.Results: The patients demonstrated significant differences in microbiome alpha diversity (p <0.05), but this difference was not observed between the sampling methods. Net catheter samples demonstrated higher total protein concentrations than brush catheter samples. Mucus-associated proteins (Mucin-2, Mucin-5B, Mucin-13, and IgGFc-binding protein) were more abundantly collected by nets in three patients with active ulcerative colitis, but more abundant by brushes in patients with inactive ulcerative colitis. Bifidobacterium and some oral bacteria were similarly associated with ulcerative colitis activity.Conclusions: Brush catheters are more likely to collect the intestinal mucus of inner layer, whereas net catheters are more likely to collect larger samples that include the outer mucus layer, as well as intestinal fluid. Two sampling methods with different types of work on the mucosa may lead different results among patients with mucosal vulnerabilities.

Debulking Operation, Radiation Therapy, and Sphincter-Sparing Local Wide Excision for The Lower Rectal Melanoma: A Case Report

Background Rectal melanoma is a rare disease that accounts for about 1% of rectal cancers. Abdominoperineal resection was the standard surgical intervention for local control. However, it can lead to complications and reduce the quality of life due to colostomy. Debulking surgery, radiotherapy (RT), and sphincter-sparing wide local excision (WLE) were performed on a patient with rectal melanoma.Case presentationA case of a 79-year-old woman with anal pain and bloody stool for 1 month was reported in this study. The digital examination of the rectum revealed a big polypoid mass over the lower rectum. Stage II rectal melanoma was diagnosed by colonoscopy, biopsy, magnetic resonance imaging, and positron emission tomography. The patient initially received debulking surgery to relieve the symptoms of active bleeding followed by radiotherapy for the residual tumor with partial response. Finally, a sphincter-sparing WLE was performed for the residual tumor to preserve the anal function. The postoperative course went smoothly. No local recurrence and anal symptoms were observed during the 2-years follow-up period.Conclusions: Combining debulking surgery, RT, and WLE may be a viable alternative for rectal melanoma that cannot be completely resected at the beginning and accompanied by bleeding symptoms.

Evaluation of the Efficacy of Sapta Winsati Guggulu in the Management of Shushkarsha: A Comparative Clinical Study

Introduction: Hemorrhoids, also called piles, co-related with Arsha in Ayurveda, are swollen veins in the anus and the lower rectum, similar to varicose veins. Hemorrhoids can develop inside the rectum known as internal hemorrhoids or under the skin around the anus known as external hemorrhoids. Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4% in the general population. Objectives: This is a clinical study was conducted to evaluate the efficacy of the Sapta Winshati Guggulu in the management of Shushkarsha. Methodology: 40 patients diagnosed with Shushkarsha were randomly selected to this study and they were randomly divided into two groups and was named as the Group-A (Tested group) and the Group-B (Control group). All the patients (both A and B groups) were treated by Abhayarishta, Chirabilwa Kwatha and Sukumara Churna. Only Group-A (testing group) was additionally treated with Sapta Winshati Guggulu. Data collection: Subjective parameters such as pain and Objective parameters such as circumference of the pile and distance of the prolapse were collected. Data analysis: All the subjective and objective parameters were entered by using reputed methods and were analyzed by using graphs and figures and SPSS Statistical Software. Results: p-value and t-value of Group-A and Group-B were statistically significant. But, Significant level of Group-A was higher than Group-B. Conclusion: According to the findings, finally it can be concluded that the Sapta Winshati Guggulu has remarkable effect in the management of the Shushkarsha. Key words: Hemorrhoids, Piles, Shushkarsha, Chirabilwa Kwatha, Sapta Winshati Guggulu.

Recommendations for a Combined Laparoscopic and Transanal Approach in Treating Deep Endometriosis of the Lower Rectum—The Rouen Technique

The complete excision of low rectovaginal deep endometriosis is a demanding surgery associated with an increased risk of intra- and postoperative complications, which can impact the quality of life. Given the choices of optimal surgery procedures available, we would like to emphasize that a minimally invasive approach with plasma medicine and a transanal disc excision could significantly improve surgery for deep endometriosis, avoiding the lateral thermal damage of vascular and parasympathetic fibers of roots S2–S5 in the pelvic plexus. The management of low rectal deep endometriosis is distinct from other gastrointestinal-tract endometriosis nodules. Suggestions and explanations are presented for this minimal approach. These contribute to individualized medical care for deep endometriosis. In brief, a laparoscopic transanal disc excision (LTADE; Rouen technique) was performed through a laparoscopic deep rectal dissection, combined with plasma energy shaving, and followed by a transanal disc excision of the low and mid-rectal deep endometriotic nodules, with the use of a semi-circular stapler. LTADE is indicated as the first-line surgical treatment for low and mid-rectal deep endometriotic nodule excisions, because it can preserve rectal length and innervation. This technique requires a multidisciplinary team with surgical colorectal training.

P135 Proximal Extension of lower rectal Ulcerative Proctitis

Background Previous studies have shown proximal extension (PE) rate of ulcerative proctitis (UP) is approximately 50%. This rate teach us the importance of treating UP adequately. Basically, we have to treat them with topical 5-ASA. But in clinical practice, we sometimes experience the case whose inflammation remain endoscopically, even though the symptoms have been relieved. Should we strengthen our treatment at this situation, especially inflammation at lower rectum? We aimed to know PE rate of lower rectal UP and optimize the treatment. Methods We retrospectively investigated the medical charts of patients with UP from 2010 to 2020 at Kenseikai Nara Coloproctology Center. We excluded the patients with UP shrinking from left-sided or pancolitis as a result of the treatment. The cases with missing value were excluded too. Variables of interest included gender, onset age, disease location, initial mayo endoscopic subscore (MES) and treatment, and the time to PE. To compare the cohorts we used Fisher’s exact test and Mann-Whitney test. Proximal extension free survival (PEFS) was calculated using the Kaplan-Meier method. Results Sixty-five patients were recruited. Mean age was 42 years old, the ratio of males to females was 1.17. The number of lower rectal UP patients at first examination was 24. We observed MES 1 inflammation for 30 patients, and MES 2 for 35. Median follow-up duration was 73.5 months. PE occurred in 34 patients: 28 patients had left-sided colitis and 6 had pancolitis. Fifty-four patients were medicated and other 11 patients were just observed. Among the patients medicated, 23 patients were took only topical drugs, 18 were took only oral drugs and other 13 were took both. We couldn’t find any relationships between initial medication and PE rate. The multivariate analysis revealed that having peri-appendiceal red patch and lower rectal UP were reduce the risk of PE. MES was not related to PE (table 1). PEFS at 1 year, 2 year are 81%, 81% for lower rectal UP (Rb group), and 66%, 61% for the patients having the disease beyond middle Houston’s valve (Not-Rb group), though we couldn’t find significant difference (Fig.1). Among 34 patients having PE, we used biologics for only five patients and got their inflammation under control. Conclusion Patients with lower rectal UP is less likely to extent their disease location. There’s no difference between the route of treatment and PE rate, but it’s important to carefully check PE within first one year.