Rectum versus colon: should malignant polyps be treated differently?

BACKGROUND: The management of malignant colorectal polyps removed at endoscopy remains controversial with patients either undergoing surgical resection or regular endoscopic surveillance. Lymph node (LN) metastases occur in 6-16% of patients with malignant polyps. This study assessed the rate of LN metastases in patients undergoing surgical resection for malignant polyps removed endoscopically to determine if there is a difference in the rate of LN metastases between colonic and rectal polyps. METHODS: A retrospective review of a prospectively maintained database was performed from 2010 to 2018. All patients who underwent surgical resection following endoscopic removal of a malignant colorectal polyp were reviewed. Clinical data including patient demographics and tumour characteristics were examined. RESULTS: A total of 177 patients underwent surgical resection in the study period. The median age at diagnosis was 65 years (range 22-88 years) with females comprising 52% of the patient cohort (n = 92/177). Polyps were located in the colon in 60.5% of cases with the remainder located in the rectum. The median number of LN harvested was 14 (range 0-44) with malignant LN (including a mesenteric tumour deposit) identified in 8.5% of resection specimens (n = 15/177). Malignant LNs were retrieved in 5.5% of right-sided tumours, 5.6% of left-sided tumours and 12.9% of rectal tumours (P = 0.090). CONCLUSION: A small proportion of patients with malignant polyps removed endoscopically will have LN metastases. The results of this study suggest that the tumour location might be a useful predictive marker; however, a further study with increased patient numbers is required to properly establish this finding.

Transanal endoscopic microsurgery colorectal anastomosis: a critical step to natural orifice colorectal surgery in humans.

BACKGROUND: Transanal endoscopic microsurgery is used in the surgical management of advanced rectal polyps and early rectal cancers. There are case reports of transanal endoscopic microsurgery colorectal anastomoses being performed with laparoscopic assistance in humans. METHODS: The concept of a transanal endoscopic microsurgery colorectal anastomosis without laparoscopic assistance has been discussed and trialed on animal and cadaveric specimens; however, to date, there have been no technical reports of this particular procedure in the literature. RESULTS: We present a technical note describing a transanal endoscopic microsurgery intraperitoneal colorectal anastomosis in a live human without laparoscopic assistance.

Quality of life valuations of HPV-associated cancer health states by the general population.

OBJECTIVES: To obtain health-related quality of life valuations (ie, utilities) for human papillomavirus (HPV)-related cancer health states of vulval, vaginal, penile, anal and oropharyngeal cancers for use in modelling cost-effectiveness of prophylactic HPV vaccination. METHODS: Written case descriptions of each HPV-associated cancer describing the 'average' patient surviving after the initial cancer diagnosis and treatment were developed in consultation with oncology clinicians. A general overview, standard gamble questionnaire for each health state and a quiz was conducted in 120 participants recruited from the general population. RESULTS: In the included population sample (n=99), the average age was 43 years (range = 18-70 years) with 54% men, 44% never married/43% married, 76% education beyond year 12 and 39% employed full-time. The utility values for the five health states were 0.57 (95% CI 0.52 to 0.62) for anal cancer, 0.58 (0.53 to 0.63) for oropharyngeal cancer, 0.59 (0.54 to 0.64) for vaginal cancer, 0.65 (0.60 to 0.70) for vulval cancer and 0.79 (0.74 to 0.84) for penile cancer. Participants demonstrated a very good understanding of the symptoms, diagnosis and treatment of these cancers with a mean score of 9 (SD=1.1) on a 10-item quiz. CONCLUSIONS: This study provides utility estimates for the specific HPV-related cancers of vulval, vaginal, penile, anal and oropharyngeal cancers valued by a general population sample using standard gamble. The results demonstrate considerable quality of life impact associated with surviving these cancers that will be important to incorporate into modelling cost-effectiveness of prophylactic HPV vaccination in different populations.

Implantation of ethylene vinyl alcohol copolymer for faecal incontinence management.

PURPOSE: The primary objectives of this trial were to evaluate the safety and feasibility of treatment and to gain a preliminary indication of the effectiveness of ethylene vinyl alcohol injections into the anal sphincters of faecally incontinent patients. METHODS: Between April 2004 and February 2006, we conducted a prospective, single-arm, procedure optimization study of ethylene vinyl alcohol injections in 21 subjects with well-characterized faecal incontinence and an intact external anal sphincter at two Australian hospitals. RESULTS: There was a significant decrease in the Cleveland Clinic Florida Faecal Incontinence Score (CCFFIS) (P= 0.0005) and the Faecal Incontinence Severity Index score (P= 0.005) after treatment. At 12 months post-treatment, the mean CCFFIS had decreased by 37% (P= 0.0021), and 47% of subjects had a > or =50% improvement in CCFFIS. There were significant improvements in embarrassment (P= 0.0455) and coping/behaviour (P= 0.0056) domains of the Faecal Incontinence Quality of Life. At 12 months, the mean anal canal length had increased by 29% (P= 0.066), with 40% of patients demonstrating increases of 50% or more. There were no further improvements following retreatment. CONCLUSIONS: Ethylene vinyl alcohol injection into the anal intersphincteric plane is feasible and well tolerated. Improvement in faecal incontinence compared with baseline was seen. Retreating initial non-responders was not successful.

Giant villous adenoma presenting as McKittrick-Wheelock syndrome and pseudo-obstruction.

McKittrick-Wheelock syndrome is a rare but recognised complication of hypersecretory rectosigmoid villous adenoma. Fluid and electrolyte imbalances require close monitoring because of large-volume losses of water, sodium and potassium. We report an unusual presentation of the syndrome associated with the development of acute pseudo-obstruction of the colon, presumably due to electrolyte dysfunction and acute renal failure.

Transanal endoscopic microsurgery: the first 50 cases.

BACKGROUND: Transanal endoscopic microsurgery is a form of minimally invasive rectal surgery first used at Cabrini Hospital in April 1997. This paper presents a prospective analysis of the first 50 cases with a median follow up of 33 months (range 20-48 months). METHODS: Prospective data was obtained from all cases between April 1997 and June 2000. RESULTS: Forty-nine patients (30 men and 19 women) underwent 50 procedures. Thirty-six had benign lesions and 14 malignant. The mean distance of the lower edge of the lesion from the anal verge was 8.7 cm. Three cases were converted to traditional transanal or transabdominal operations. Full-thickness excision was performed on 26 patients and the rectal wound was closed in 13 cases. The mean duration of transanal endoscopic microsurgery was 67 min (range 20-175), with a mean blood loss of 24 mL (0-300). The mean diameter and area of the fixed specimen was 3.7 cm (1.5-9.8) and 11.4 cm2 (0.8-18.9), respectively. Complications included postoperative fever (3), urinary retention (1) and per rectum bleeding (1). There was one death. The mean length of stay was 4 days. Histology confirmed complete excision in 39 (78%) cases and there have been two instances of local recurrence of adenoma (5%). CONCLUSIONS: Transanal endoscopic microsurgery is an effective, safe and cost-beneficial procedure for local excision of selected lesions in the middle and upper thirds of the rectum.

Rectal cancer in Victoria in 1994: patterns of reported management.

BACKGROUND: A retrospective survey of medical practitioners was conducted to describe the management of patients newly diagnosed with rectal cancer in 1994, prior to the publication of best practice guidelines. METHODS: A sample of 908 patients with rectal cancer diagnosed between 1 January and 31 December 1994 was identified from the Victorian Cancer Registry. Questionnaires were then sent to the treating doctor(s) for completion. The topics covered by the questionnaires included: reported management by method of diagnosis; staging investigations; and treatment by surgery, chemotherapy and radiotherapy. RESULTS: Seven hundred and twenty-six (80%) of 908 eligible patients were surveyed. Surgery was the primary treatment in 681 (93.8%) with curative intent in 483 (70.9%) of these cases. One- third (163; 33.7%) of curative cases were pathologically staged as Dukes' C. Almost all patients (96%) were symptomatic, and three-quarters were referred by general practitioners to 166 surgeons. One-third (221; 32.5%) underwent liver computed tomography or ultrasound, and only three cases had transrectal ultrasound. Restorative anterior resection was the most common surgical procedure (431; 63.3%) with 160 (23.5%) and 34 (5.0%) patients being managed with abdominoperineal resections and local excision, respectively. Chemotherapy and radiotherapy were administered as part of the initial management to 216 (31.7%) and 171 (25.1%) patients, respectively. In five of the 171 cases, radiotherapy was given preoperatively. CONCLUSIONS: There was considerable variation in preoperative assessment. Staging was less complete than expected by today's standards. The diversity of surgical techniques observed may reflect both the lack of clinical trials and disparity in surgical training and experience. Referral to stomal therapists, and medical and radiation oncologists was lower than would now be expected, as was the use and timing of adjuvant therapies. These findings will be useful as a baseline for comparison with subsequent surveys conducted since the introduction of evidence-based guidelines.