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A 26-year-old man presented to emergency department with respiratory distress. The initial diagnosis after chest X-ray was massive haemothorax, after insertion of a chest drain and further investigations, it turned up to be a rare case of a delay presentation of traumatic diaphragmatic rupture (DR) (after 1 year of the initial trauma). After excessive resuscitation of the patient in the emergency department, the patient underwent an emergency laparotomy which revealed ischaemic transverse colon herniated into the chest through a 7 cm diaphragmatic defect. Resection of the ischaemic bowel had been done, and the patient admitted to Intensive Therapy Unit (ITU) postoperatively. The patient had an uneventful recovery and discharged home on postoperative day 9. As DR after thoracoabdominal trauma is a rare condition that can be missed at initial presentation, we would like to highlight the main challenges in diagnosing and managing similar cases after reviewing related cases in the literature.

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BACKGROUND: Neoadjuvant chemoradiotherapy (CRT) is considered the standard approach before any surgical intervention for locally advanced rectal tumors and has been proven to significantly improve the local recurrence rates of rectal cancer. However, the optimal timing of surgical resection after neoadjuvant CRT remains debatable. OBJECTIVE AND METHODS: We conducted a retrospective review of 65 consecutive patients with locally advanced rectal cancer who underwent preoperative CRT followed by surgical resection in order to evaluate the optimal time for surgical treatment. We used two alternative groups for analysis: patients who underwent surgery up to 6 weeks after CRT (n = 28) and those who underwent surgery 6 weeks or more after CRT (n = 27). Also, we compared patients who were operated on within 3 months (n = 39) with those who underwent surgical resection after more than 3 months (n = 16). Nonresponders to CRT were excluded from the analysis. RESULTS: There was no statistically significant association between waiting period post CRT and radiological downstaging for any group (p > 0.05 for any association). Also, there was no association between recurrence of disease, cancer-related deaths, perineural invasion, or positive lymph node ratio and any waiting period up to 3 months (p > 0.05 for all associations). CONCLUSION: In this small exploratory study there was no evident difference in outcome according to timing of surgery, which suggests that further research in larger cohorts is warranted.

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Colorectal cancer (CRC) places a considerable burden on individuals and society in Europe, being the second most common cause of cancer-related death in the region. While earlier diagnosis and advances in treatment have considerably improved survival in recent years, further progress is needed. One of the greatest challenges associated with the treatment of CRC is the fact that current therapies for advanced disease are not curative, necessitating treatment for many years and placing a significant healthcare burden on society. To reduce the burden of CRC, care delivery must be more efficient and cost-effective. In particular, development of adequate screening programmes is needed, along with chemo-preventative strategies and newer, more active therapies. Further challenges include the lack of optimal selection of patients for adjuvant therapy, identification of the most appropriate target populations for current treatments and the optimum sequence for new molecular targeted agents. This article outlines current developments and unmet needs in CRC, and provides a detailed vision for improvements in the management of the disease. Implementation of some of these strategies will go some way to improving outcomes for patients with CRC.

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Surgical robotics is, at present, one of the most dynamically developing areas of biomedical engineering that has been proven to increase the stability and robustness of surgery. Robotics can integrate, assist, control and extend the human capabilities, correcting for manual errors, or record the spatial points-of-interest and motions. This is of importance as an adjunct to many laparoscopic subspecialty procedures, from cardiac to pelvic surgery. Evidence-based medicine is now demonstrating that robotized equipment can greatly add to the preoperative simulation, the ergonomics of the procedure, the preoperative simulation and the risk-free training of the surgeon with precision surgery and less trauma to the patient. This article discusses the robots that are clinically available at present and their importance to the surgeon and patient.

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BACKGROUND & AIMS: Kruppel-like factor 6 (KLF6) is a ubiquitous zinc finger tumor suppressor that is often mutated in prostate cancer. Our aims were to establish the frequency of KLF6 inactivation in sporadic and inflammatory bowel disease (IBD)-associated colorectal cancers (CRC); to correlate these abnormalities with mutation and/or loss of TP53, APC, and K-RAS; and to characterize the behavior of mutant KLF6 in colon-derived cell lines. METHODS: We analyzed DNA isolated from 50 microdissected CRC cases, including 35 sporadic and 15 IBD-associated tumors. Microsatellite analysis and direct sequencing were used to establish the incidence of microsatellite instability, KLF6 and TP53 allelic imbalance, and KLF6, K-RAS, TP53, and APC mutation. Loss of growth suppressive function of the CRC-derived KLF6 mutants was characterized by in vitro thymidine incorporation assays and Western blotting. RESULTS: KLF6 was inactivated by loss and/or mutation in most sporadic and IBD-related CRCs. The KLF6 locus was deleted in at least 55% of tumors, and mutations were identified in 44%. Rates of KLF6 loss and mutation were similar to those of TP53 and K-RAS in the same samples. KLF6 mutations were present in tumors with either microsatellite or chromosomal instability and were more common, particularly in the IBD-related cancers, in the presence of wild-type APC. Unlike wild-type KLF6, cancer-derived KLF6 mutants neither suppressed growth nor induced p21 following transfection into cultured cells. CONCLUSIONS: Deregulation of KLF6 by a combination of allelic imbalance and mutation may play a role in the development of CRC.

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