Role of CT colonography and virtual colonoscopy in preoperative evaluation and diagnosis of colorectal cancer compared with colonoscopy

Virtual colonoscony is a potentially powerful tool for noninvasive colorectal evaluation. In the past 20 years, the radiology of colorectal cancer has evolved from the barium enema to advanced imaging modalities like magnetic resonance imaging [MRI], virtual colonoscopy and positron emission tomography [PET]. Virtual colonoscopy is rapidly evolving and might considerably change the imaging of colorectal cancer in the near future. The use of virtual colonoscopy for screening purposes and imaging of the colon in occlusive cancer or incomplete colonoscopies is currently under evaluation [Pijl et al., 2002]. CT colonography has been proposed as an alternative procedure for the examination of colorectal cancer patients because it is not limited to endo-luminal exploration of the colon [Royster et al., 1997], it reaches the cecum, even in cases of obstructive lesions; and combines study of the colon with evaluation of target organs for metastases, in particular the liver [Neri et al, 2002, Horton et al., 2000, Morrin et al., 2000, Fenlon et al., 1999, Macari et al., 1999, and Morrin et al., 1999]. The aim of our study was to evaluate CT colonography in patients with a clinical suspicion of colorectal cancer in comparison with colonoscopy and histopathological findings after surgery. This study included a total of 15 patients [9 men, 6 women; mean age, 53 years; age range [35-67 years] with clinical suspicion of colorectal cancer. The study was conducted from September 2000 through May 2004 in Al Jedani Group of Hospitals and Riyadh Care Hospitals in Saudi Arabia. For all patients the followings were done. o History taking and clinical examination. o Routine investigations. o Colonoscopy with biopsy if possible. o CT colonography. o Operative resection of the tumor when indicated. o Histopathological examination of the operative specimen: CT Colonographic Technique: Before CT scanning, room air was insufflated through a rectal enema tube from a bag containing room air and had a 2,000-mL maximum capacity. The abdominal CT study was performed before and after intravenous injection of iodinated contrast agent, iodixanol [Visipaque 320; Nycomed Amersham, Oslo, Norway]; 140 mL of contrast agent was administered at 3 mL/sec. CT colonographic analysis was performed by a radiologist. Evaluation included that of the endoluminal and extracolonic compartments. Colonic evaluation included that for the presence of wall thickening, cancers, polyps, and wall discontinuity. The liver was evaluated in an attempt to detect metastases. Acquired CT data were transferred to a computer system which permits obtaining multiplanar three-dimensional reformations of the air-distended colon, as well as an endoluminal perspective through the distended colonic lumen. Our 15 patients included 12 cases of colorectal cancer and 3 non malignant cases [one normal case, one case of ulcerative colitis and one case of diverticular disease]. The conventional colonoscopy diagnosed all the 12 cases of colorectal cancer. It was completed in only 7 patients [58.3%]. It could not be completed in 5 patients [41.7%]; 3 cases [25%] with distal occlusive carcinoma with inability to proceed proximally and 2 cases [16.7%] with patient's in tolerance to complete the colonoscopy. A distal occlusion [located in the rectum, sigmoid colon, or descending colon] was found, and colonoscopy failed to enable exploration of the colon segments proximal to the site of occlusion. In the other 2 patients, colonoscopy enabled exploration of the colon lumen up to the sigmoid [one case] and splenic flexure [one case]. Furthermore, 3 of these 5 cases had synchronous cancer missed due to incomplete colonoscopy. Also, colonoscopy showed 2 false positive cases [13.3%] for cancer which proved to be normal by histopathology. CT colonography diagnosed all the 12 cases of colorectal carcinoma. It could visualize the entire colon in 115 of the 120 colonic segments [95.8%]. It had one false positive case and ruled out malignant lesion in 2 cases [13.3%] supposed to be malignant by colonoscopy. Also, it diagnosed 3 cases [25%] of synchronous cancer missed by colonoscopy and 3 cases [25%] of concomitant liver metastasis. All the 12 cases proved to be malignant were subjected to operative management with histopathological examination which confirmed malignancy. The operative findings revealed synchronous lesions in 3 cases [25%] which were diagnosed by CT colonography and not by colonoscopy. CT colonography revealed the presence of three hepatic lesions [diameter range, 2-5 cm] suspicious for metastases. These 3 cases of liver metastasis were confirmed intraoperatively. One liver hemangioma [diameter 2 cm] was detected with CT. CT colonography has good patient compliance and is a useful diagnostic modality in detecting colorectal neoplasms. Its main advantage is its ability to detect extracolonic pathology. CT colonography can be considered an important diagnostic technique to evaluate preoperatively the proximal colon in patients with distal occlusive carcinomas, as it gives better results than conventional colonoscopy, as well as being well tolerated and less invasive. Its' advantages over conventional colonoscopy included the ability to detect abnormalities proximal to obstructing carcinomas, accurate localization of abnormalities within the colon, and good patient tolerance. It may play an important role in future diagnosis of colorectal cancer and for screening patients at risk

Intraoperative contrast colonography as a method to assess colonic and colorectal anastomosis

Anastomotic leakage is a major problem in colorectal surgery, and previous studies have suggested that intraoperative identification of leaks allows repair at the time of surgery. This will decrease the incidence of postoperative leakage [Wheeler and Gilbert 1999]. It is important to prevent leakage after colonic and colorectal anastomoses because of the high incidence of leakage and high mortality associated with it. Some studies had high anastomotic leakage rate from 9.8% to 18% [Karanjia et al., 1994, Benoist et al., 1997, Law et al., 2000, Nesbakken et al., 2001, and Eckmann et al., 2004] while others had lower rate from 2.9% to 7.3% [Vignali et al., 1997, Luna-Perez et al., 1999, Isbister 2001, and Sutton et al., 2004]. Methods to detect leakage are all concerned for postoperative detection. Intraoperative methods to assess colonic anastomosis has been developed and used. These include doppler flowmetry [Boyle et al., 2000] and transanal injection of air [Vignali et al., 1997] or saline [Wheeler and Gilbert 1999]. In this study, we will assess the liability of leakage of colonic and colorectal anastomosis intraoperatively by using a new technique by transanal injection of radiological contrast material at the completion of the anastomosis and taking X-rays to ensure that there is no leakage of the anastomosis. Also, a coloring agent was added for direct visualization of any anastomotic defects. If leakage is present, it has to be secured intraoperatively before closure of the abdomen. This study included 10 patients who were subjected to intraoperative radiological contrast testing after colonic or colorectal anastomosis. The study was conducted in Al Jedani Group of Hospitals in Saudi Arabia between January 2001 and November 2004; There were 7 males and 3 females. Mean age was 49.3 years [range 23-65 years]. The anastomosis performed was either handsewn or stapled anastomosis. We used the non-ionic water-soluble contrast material lohexol [Omnipaque, Amersham Health Inc.] 350 mg1/ml. We used 50 ml lohexol + 50 ml Normal saline 0.9% + 5 ml Methylene blue as a coloring agent. After completion of the anastomosis, its integrity was tested intraoperatively. Transanal injection of the contrast using Foley's catheter No. 22 French. Injection using a manometer to a maximum distending pressure of 25-30 cm. of water. Using the screen to detect leaking anastomosis during injection. Visualization of the coloring agent [Methylene blue] at leaking anastomotic site. Any leaks were repaired and the anastomosis retested until it was free of leakage. Postoperative gastrografin enema was performed at 10th postoperative day. Comparison of data between intraoperative colonography, leaking coloring agent and postoperative study. Indication of resection and anastomosis included colorectal cancer [7 cases], diverticular disease [2 cases] and volvulous with gangrene of sigmoid colon [1 case]. Types and levels of anastomosis included right hemicolectomy [2 cases], left hemicolectomy [1 cases], sigmoidectomy [4 cases], and anterior resection of the rectum [3 cases]. Number of leakage of anastomosis detected by our technique was 3 cases [2 of stapled anastomosis and one of handsewn anastomosis]. These 3 cases were detected by leaking of contrast material under screen and visualization of coloring agent [Methylene blue] at the leaked suture line. There was one case after sigmoidectomy for volvulous with gangrene. The other two cases were after anterior resection for rectal and rectosigmoid carcinoma. There was only one postoperative leakage after anterior resection for cancer rectum. Comparison between in traoperalive colonography and 10th day postoperative study: There were 3 cases of anastomotic leakage detected by intraoperative colonography. The defects were repaired intraoperatively. All the 3 cases were not leaking by the 10th postoperative gastrografin enema. Only one case of postoperative leakage was detected by 10th postoperative gastrografin enema which was different from the 3 cases detected and corrected intraoperatively. A total of 2 complications occurred out of 10 patients [20%]. One case of anastomotic leak occurred after low stapling and one case of wound infection. There was no postoperative mortality. A high leak rate has been identified in patients with very low anastomoses. This high leak rate can be avoided by routine use of intraoperative contrast testing of colorectal anastomosis. This is the secret of having a low leak rate. This technique is simple, safe and effective. Although it has the disadvantage of inability to assess the blood supply of the colonic ends, it avoided potential leaks in 3 cases, detected anastomotic defects which can be repaired intraoperatively specially in low anastomosis which can not be directly visualized because of its depth in the pelvis. We recommend routine use of one of modalities for intraoperative assessment of colorectal anastomosis and intraoperative correction of defects detected. We recommend use of intraoperative colonography for larger number of cases to ensure validity of comparison between it and other modalities of intraoperative assessment

Liver abscess, modalities of treatment: percutaneous, laparoscopic, and open drainage

Liver abscesses, although relatively rare in the Western World [Cushieri and Giles 1995 and Johnson and Taylor 1992] are commonly encountered in tropical regions Traditionally, surgical treatment for such abscesses involved open drainage of the abscess through a hepatotomy via a transperitoneal or retroperitoneal approach [Greenstein et at, 1984]. Other modalities of treatment of liver abscess include percutaneous and laparoscopic drainage. This paper presents our experience in the treatment of 12 patients of liver abscess using different modalities of drainage with comparison between them. Twelve patients suffering from hepatic abscess were managed interventionally between July 2001 and June 2004 in Al Jedani and Al Riyadh Care hospitals in Saudi Arabia. Eight patients were treated with percutaneous drainage and 7 patients were judged to require surgical drainage, 6 of them selected for laparoscopic drainage of the abscess. Only one patient was openly drained early in our series. The patients were followed prospectively and factors studied included clinical presentation, investigations, surgical indications, surgical technique and outcome. We divided the patients into two groups: Group I: with percutaneous drainage of liver abscess [8 patients]. Group II: with laparoscopic or open drainage of liver abscess [7 patients] including 3 patients with failed percutaneous drainage. We compared between the two groups in different aspects. There were eight men and four women with a mean age of 45 [range 36-65] years. All patients presented with fever and upper abdominal pain. All patients had preoperative ultrasonographic confirmation of the abscess and 10 also underwent CT for preoperative localization of the abscess. Nine patients had right lobe and three had left lobe abscesses. The diameter of the abscesses ranged from 4.5 to 15 [mean 8.5] cm, as measured by ultrasonography and CT. In seven patients etiological factors for the liver abscess could be identified. For group I [percutaneous drainage], 3 cases failed [2 with persistent fever and pain and one case with recurrence of abscess after catheter removal]. For group II [laparoscopic drainage], initial success was achieved in 6 out of the 7 patients. There was no wound infection or death. Repeat ultrasonography or CT gave normal findings in all patients at the end of follow up period. Comparison between percutaneous and laparoscopic drainage: The duration of the procedure was 25 [20-60] min. in group I [percutaneous group] and 35 [25-120] min. in group II [laparoscopic group] with statistical significant difference. The mean amount of pus drained was 80cc in group I and 150 cc in group II with statistical significant difference. The duration of drainage was 5 days in group I and 4 days in group Il [no statistical significant difference]. Resolution of symptoms was 5 cases out of 8 [62.5%] in group I and 6 cases out of 7 [85.7%] in group II with statistical significant difference. Adequacy of drainage with decrease in size of abscess cavity was 5 cases out of 8[62.5%] in group I and 6 cases out of 7 [85.7%] in group II with statistical significant difference. Three cases were converted in group 1[37.5%] and one case with blocked drain in group II [14.3%]. Recurrence rate was [12.5%] in group I and 0% in group II. There were no complications nor deaths in both group I and group II. Although each modality of drainage has its indication. laparoscopic drainage had several advantages over other modalities. Laparoscopic drainage was more effective than other modalities of drainage perhaps because of larger drainage tube as revealed by greater mean amount of pus drained in group II [laparoscopic] with statistical significant difference. Also, the better adequacy of drainage in the laparoscopic group was shown by resolution of symptoms in [85.7%] in group 11 [laparoscopic] compared to [62.5%] in group I [percutaneous]. Adequacy of drainage with decrease in size of abscess cavity was 5 cases out of 8[62.5%] in group I and 6 cases out of 7 [85.7%] in group II with statistical significant difference. The failure rate was lower in laparoscopic group. There are also other advantages over percutaneous drainage, including the opportunity to explore the abdomen adequately [Tay et al., 1998]

Management of bile duct injuries

The incidence of bile duct injuries increased with the wide spread shift from open to laparoscopic cholecystectomy. The estimated incidence of major bile duct injuries, which was 0.1% to 0.3% [Strasberg et al, 1995 and Roslyn et al, 1993] during the open cholecystectomy era, has risen to an estimated 0.4% to 0.6% [Fletcher et al, 1999, Adamsen et al, 1997, and Wherry et al, 1996] for laparoscopic cholecystectomy. This increase has led to substantial patient morbidity and major financial implications [Misra et al, 2004 and Savader et al, 1997]. Proper management of iatrogenic bile duct injury is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery [Tsalis et al, 2002]. A review of our experience with bile duct injuries was performed to determine the optimal management and outcomes of patients presented with biliary tract injuries. The present study included 11 patients with cystic and/or bile duct injuries. They were collected from inpatients of Ain Shams University and Specialized Hospitals in Egypt and Al Jedani Hospitals in Saudi Arabia, between August 1999 and January 2004. They were 7 females and 4 males whose age ranged from 25 to 68 years [mean 40.5]. All patients were subjected to the following: History, Clinical Examination, Laboratory investigations, Radiological investigations [Abdominal U/S. ERCP, MRCP], Preoperative Preparation, and Operative and / or nonoperative management according to the case and type of injury. A total of II patients were treated for a bile duct injury. Eight patients presented after laparoscopic cholecystectomy [72.7%] and 3 patients after open cholecystectomy [27.3%]. The majority of patients were operated on for chronic cholecystitis [72.7%]. An intra operative diagnosis of a biliary injury was determined in 4 patients [36.4%]. Two different groups of patients can be identified according to the clinical presentation and this is mainly dependent on the time interval between the procedure, the start of the first symptoms and the detection of injury. Injury detected during laparoscopic cholecystectomy [intraoperatively]: An intra operative diagnosis of a biliary injury was determined in 4 patients [36.4%]. One patient had avulsed cystic duct and three had injury of CBD. The four patients diagnosed intra operatively with bile duct injury were treated by: Roux-en-Y choledechojejunostomy in 2 cases with CBD injuries. Direct CBD repair in one patient with CBD injury, Stitching of avulsed cystic duct in one patient. Delayed identification of a bile duct injury in the postoperative period: Seven patients [63.6%] presented with jaundice, fever, biliary peritonitis, biliary fistula, vomiting, and abdominal pain. Four of them were diagnosed as ligated common bile duct and managed surgically by Roux-en-Y hepatico-jejunostomy [36.4%]. While 3 patients [27.3%] were managed by endoscopic stenting, 2 with cystic duct leakage and 1 with lacerated right hepatic duct. Morbidity occurred in 1 patient [9.1%] in the form of wound infection. And there was one mortality case [9.1%] from biliary peritonitis. Bile duct injury represents a serious life threatening problem that represents a challenge even to the experienced biliary surgeon. Early referral to specialist center gives the best chance of long term success. Patients with bile duct injury should be investigated very thoroughly by laboratory tests radiological investigations and must be managed very carefully preoperatively by correction of the anemia and hypoalbuminemia and the clotting abnormalities. The results of this study showed that surgical exploration and hepaticojejunostomy played the main role in management of patients with ligated common bile duct. Also choledechojejunostomy or direct repair of CBD injuries was the main surgical strategy for cases diagnosed intraoperatively. Meanwhile, ERCP sphincterotomy and/or stenting played a role in management of patients with cystic duct leakage

Modified shoelace technique for repair of large midline incisional hernia

Operations for large and recurrent abdominal hernia have a high associated recurrence rate although it is lower when prosthetic material is used. Many techniques were prescribed for repair of such hernia with varying degree of success. We present in this study a modification of the old shoelace technique used for repair of large midline incisional hernia discussing the results and the complications associated with such modification especially infection, respiratory complications and recurrence. We concluded that modified shoelace technique is a good method for repair of large midline incisional hernia as it is associated with low incidence of respiratory complications and recurrence

Selective versus routine intra-operative cholangiography during cholecystectomy

This study aimed to examine the selective criteria for intraoperative cholangiography by measuring their sensitivity, specificity, positive predictive value and negative predictive value. The ability of these indicators to predict CBD stones at cholecystectomy was measured, so the role of selective intraoperative cholangiography can be evaluated. The study included 70 patients with gall bladder stones with no prove of concomitant CBD stones by clinical and ultrasonographic examination. Patients were subjected to cholecystectomy with routine intraoperative cholangiography. Out of them, eight had positive cholangiograms and common bile duct [CBD] stones. So, many unnecessary cholangiograms were performed with loss of money and time with associated morbidity. The clinical, laboratory, radiological and operative data of all cases were reviewed compared with cholangiograms. Certain parameters or criteria were common in patients with positive cholangiograms. The study also tried to determine certain criteria to select patients at high risk to perform selective intraoperative cholangiography