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Background The impact of RAS/BRAF mutation on primary response rates after total neoadjuvant therapy (TNT) in patients with advanced rectal cancer is unclear. The aim of this study was to assess complete response rates after TNT according to RAS/BRAF mutation status. Methods A prospective observational study was performed in patients with rectal cancer who underwent TNT with curative intent at three South Australian hospitals between 2019 and 2023. Patients were classified according to their mutation status: mutant RAS/BRAF (mutRAS) or wild-type RAS/BRAF (wtRAS). The primary endpoint was overall complete response (oCR) rate, defined as the proportion of patients who achieved clinical complete response (cCR) and/or pathological complete response (pCR). Results Of the 150 patients eligible for inclusion, 80 patients with RAS/BRAF status available were identified. Of these, 43 (53.8%) patients were classified as mutRAS and 37 (46.3%) patients as wtRAS. Patients with mutRAS had significantly lower cCR and oCR rates after TNT than patients with wtRAS (14% vs. 37.8%, p  = 0.014; 11.6% vs. 43.2%, p  = 0.001, respectively). There was no significant difference in pCR rate between the groups. Of the 80 rectal cancer patients tested, 35 (43.8%) had metastatic disease (M1). There was no significant difference in complete M1 response rates between the groups (17.6% vs. 38.9%, p  = 0.254). Conclusion RAS/BRAF mutations negatively impact primary tumor response rates after TNT in patients with advanced rectal cancer. Large-scale national studies are needed to determine whether RAS/BRAF status could be used to select optimal oncologic therapy in rectal cancer patients.

Abstract Intrabiliary colorectal metastases are rare. We present a case of an 84-year-old man who developed obstructive jaundice secondary to intrabiliary growth of colorectal metastases. The patient presented with three weeks of jaundice and significant weight loss in the preceding months. The patient’s background included metastatic colorectal carcinoma, with a previous right hemicolectomy and left hepatectomy for liver metastases. A MRCP showed an obstruction of the biliary tract transitioning at the ampulla. Histology confirmed a malignant adenocarcinoma. When compared to the patient’s previous resected colorectal liver metastases, morphology and immunohistochemistry was consistent with colorectal metastases. This case highlights the importance of differentiating a new intraductal papillary neoplasm from a colorectal metastasis. Correctly identifying these lesions requires the use of MRCP and ERCP, as well as immunohistochemistry. This is a priority for clinicians to ensure appropriate therapy.

Purpose Sarcopenia is a prognostic factor for poor outcomes in colorectal cancer, but data are scarce in colorectal surgery for benign conditions where patients could benefit from a deferral of surgery to enter a prehabilitation programme. We assessed the incidence of sarcopenia and complications in patients with benign colorectal disease. Methods Patients who underwent elective non-malignant colorectal surgery during 2018–2022 were retrospectively identified. The cross-sectional psoas area was calculated using computed tomography (CT) imaging mid-3 rd lumbar vertebrae. Sarcopenia was determined using gender-specific cut-offs. The primary outcome was complications measured by the comprehensive complication index (CCI). Results Of 188 patients identified, 39 (20.7%) were sarcopenic. Patients diagnosed with sarcopenia were older (63 vs. 58 years, p  = 0.047) and had a reduced BMI (24.7 vs. 27.38 kg/m 2 , p  = 0.001). Sarcopenic patients had more complications (82.1 vs. 64.4%, p  = 0.036), and CCI was statistically but not clinically higher (20.9 vs. 20.9, p  = 0.047). On univariate linear regression analysis, age ≥ 65 years old, ASA grade ≥ 3, active smokers, sarcopenia, and preoperative anaemia were predictive of CCI. Propensity score-matched analysis was performed, matching 78 cases to remove selection bias, which demonstrated sarcopenia had no impact on postoperative complications. On multivariate analysis, age ( p  = 0.022), smoking ( p  = 0.005), and preoperative anaemia ( p  = 0.008) remained predictive of CCI. Conclusion Sarcopenia is prevalent in one-fifth of patients undergoing benign colorectal surgery. Taking advantage of the longer preoperative waiting periods, sarcopenia could be explored as a target for prehabilitation programmes to improve outcomes.

PurposePelvic exenteration (PE) involves radical surgical resection of pelvic organs and is associated with considerable morbidity. Sarcopenia is recognised as a predictor of poor surgical outcomes. This study aimed to determine if preoperative sarcopenia is associated with postoperative complications after PE surgery.MethodsThis retrospective study included patients who underwent PE with an available preoperative CT scan between May 2008 and November 2022 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia. Total Psoas Area Index (TPAI) was estimated by measuring the cross-sectional area of the psoas muscles at the level of the third lumbar vertebra on abdominal CT, normalised for patient height. Sarcopenia was diagnosed based on gender-specific TPAI cut-off values. Logistic regression analyses were performed to identify risk factors for major postoperative complications with a Clavien-Dindo (CD) grade ≥ 3.ResultsIn total, 128 patients who underwent PE were included, 90 of whom formed the non-sarcopenic group (NSG) and 38 the sarcopenic group (SG). Major postoperative complications (CD grade ≥ 3) occurred in 26 (20.3%) patients. There was no detectable association with sarcopenia and an increased risk of major postoperative complications. Preoperative hypoalbuminemia (P = 0.01) and a prolonged operative time (P = 0.002) were significantly associated with a major postoperative complication on multivariate analysis.ConclusionSarcopenia is not a predictor of major postoperative complications in patients undergoing PE surgery. Further efforts aimed specifically at optimising preoperative nutrition may be warranted.

We describe the case of a gall bladder torsion in an elderly female patient, which was discovered during laparoscopic exploration for presumed acute cholecystitis. The rising incidence of this relatively uncommon process can be attributed to increasing life expectancy. Gall bladder torsion typically manifests in septuagenarians and octogenarians of the female gender, as seen in the presented case. It is thought that local mesenteric redundancy predisposes to the development of mechanical organoaxial torsion along the gall bladder’s longitudinal axis involving the cystic duct and artery. Clinicians must have a high index of suspicion for gall bladder torsion, as a mimicker of acute cholecystitis, in the described patient demographic. Preoperative diagnosis is challenging with the vast majority of reported cases being diagnosed intraoperatively, and only five cases preoperatively. Prompt surgical intervention results in an overall mortality rate of approximately 5%, while a delay in diagnosis can lead to catastrophic patient outcomes.