Colorectal cancer in Nigeria: 40 years on. A review.

This paper is a review of work done on colorectal cancer in Nigeria over the last 40 years showing geographic spread, age and sex ratios, predominant histopathology and paucity of polyposis coli syndromes. The male/female ratio is averagely equal, the peak age remains around 44 years, there is a significant subgroup of the under-30s and there are more rectal cancer cases than colon cancer cases. Of the colon cancer cases, the caecum seems to be the more favoured site. There seems to be quite a significant incidence of mucin-secreting adenocarcinoma subgroups which are said to carry a worse prognosis. Almost all the authors have stated the rarity of polyposis coli syndromes; a few have looked into the possibility of mismatch repair mutations as an aetiological factor.

Porcine dermal collagen graft in abdominal-wall reconstruction.

We describe the use of a porcine dermal collagen graft in the reconstruction of a large abdominal-wall defect in a woman. The graft was not rejected and, after 1 year, was not associated with incisional hernia. This graft may become an alternative to synthetic-mesh and flap reconstructions because, despite being of a similar tensile strength, it promotes less adhesion, is incorporated into the host tissue and is less prone to infection.

Outcome of argon beam and LASER ablation of large rectal adenomas.

OBJECTIVE: Endoscopic ablation of large rectal adenomas is being increasingly used as primary treatment. Despite the avoidance of general anaesthesia and the prevention of more major procedures, patients undergoing endoscopic ablation have the disadvantage of multiple treatment sessions and the lack of adequate tissue sample for complete histological study. The aim of this study was to analyse the outcome of all patients with large rectal polyps treated with endoscopic ablation. PATIENTS AND METHODS: Between 1993 and 1998, 29 patients who underwent endoscopic ablation of large rectal adenoma were identified. All their case notes were analysed and information was collected on recurrence, treatment episodes, complications, the incidence of carcinoma and the necessity for further procedures. RESULTS: At a median 40 (range 4-67) months follow-up, 41% of patients had recurrence of their adenoma and 14% had been diagnosed with adenocarcinoma. Only 24% of patients had been discharged while 21% were clear but were still under surveillance. Seven (24%) patients had complications, 6 stenosis and one severe bleeding. All stenosis occurred in patients who had more than 10 treatment sessions. In all, 31% of patients needed further endoanal or abdominal surgery and the median time to making this decision was 28 (range 4-66) months. There were no deaths. CONCLUSION: Laser and argon ablation of large rectal adenomas has proved very disappointing. It should be reserved for patients who are unfit to undergo general anaesthesia.

The trauma team--a system of initial trauma care.

Trauma remains the leading cause of death under the age of 35 years. England and Wales lost 252,000 working years from accidental deaths, including poison, in 1992. In this country, preventable deaths from trauma are inappropriately high. In many hospitals there are not enough personnel; in the majority, there are no recognisable trauma care systems, which can reduce preventable deaths to a minimum. The appropriateness of trauma centres for this country is being assessed in Stoke-on-Trent, and a report is due out later this year. Even if the recommendation is made to establish such centres, it is unlikely that many will be set up. Consequently most hospitals will have to rely on their own resources to set up and run a trauma team. This type of trauma care system is the subject of this article.

Murphy's sign, acute cholecystitis and elderly people.

The presentation of acute abdomen in elderly people differs from that in younger patients. We retrospectively assessed how the presence or absence of Murphy's sign affected initial diagnosis of acute cholecystitis in elderly patients. In the presence of Murphy's sign, diagnostic accuracy for acute cholecystitis was 80% dropping to 34% when the sign was negative. The positive predictive value of the test in elderly people was 0.58, with a sensitivity of 0.48 and a specificity of 0.79. In elderly patients, a positive Murphy's sign is useful, but a negative sign should be treated with caution and other diagnostic tests and promptly. There should be cautious interpretation of classical signs in elderly patients.

Primary duodenal carcinoma.

Eight cases of primary duodenal carcinoma in a district general hospital are presented. The cases highlight the advanced state of the disease at presentation, the difficulty in diagnosis, and its poor prognosis. Duodenal carcinoma occurs in both sexes worldwide with no predisposing factors in the majority of cases. There is an increased risk in patients with familial adenomatous polyposis and adenomas of the duodenum. Duodenal carcinoma occurs about 22 years from the diagnosis of familial adenomatous polyposis in about 2% of patients, forming over 50% of upper gastrointestinal cancers occurring in these patients. Carcinomatous changes occur in 30 to 60% of duodenal villous adenomas and much less in tubulo-villous and tubular adenomas. These categories of patients should be screened and adequately followed up. Aggressive and radical surgery, even in the presence of locally advanced disease and lymph node involvement, gives a better outcome. When curative surgery is not possible, chemotherapy must accompany palliation with or without radiotherapy. Pre-operative chemotherapy may facilitate a curative radical resection. The general five-year survival is 17-33% but some centres have achieved a five-year survival of 40-60% with aggressive management of these patients.

Small bowel obstruction due to encapsulation and abnormal artery.

A case of peritoneal encapsulation is reported. Of fourteen reported and two anecdotal cases, this is the third case with small bowel obstruction. Bowel malrotation is associated with the condition and in our case an abnormal artery was the cause of obstruction. We support previous authors' suggestions that, if the condition is found incidentally at laparatomy, it should be treated surgically by excision of the peritoneal sac and division of any tight band.