Per-anal excision of large, rectal, villous adenomas.

PURPOSE: Considering the malignant potential of villous adenoma of the rectum, complete resection at the first intervention is desirable and yet many series suggest that a high recurrence rate must be expected. The experience of one colorectal surgeon in the management of this condition is described. METHODS: Between 1993 and 2000, 50 patients underwent per-anal resection of villous adenoma. The procedure was conducted in the prone jackknife position unless contraindicated, with dissection performed using a diathermy blade, with particular attention to circumferential and deep margins of excision. RESULTS: The mean distance of the proximal margin of the tumor from the dentate line was 5.6 (range, 0.5-11) cm. The mean length of the tumor was 5.2 (range, 0.5-9) cm. Mean anesthetic time was 27 (range, 10-110) minutes, and median hospital stay was two (range, 1-14) days. There was no significant perioperative morbidity and no mortality. On histology of ten patients, there were foci of adenocarcinoma. Excision was complete histologically in 49 patients. The median follow-up was 30 (range, 6-91) months. The patient with incomplete excision developed a probable recurrence after six months, which was ablated with diathermy (residual tumor rate, 2.1 percent). Two patients have subsequently developed villous adenoma at different sites within the rectum (metachronous tumor rate, 4.3 percent). CONCLUSIONS: Many series of this procedure report recurrence in up to 36 percent and significant complication in up to 19 percent of patients. Transanal endoscopic microsurgery has achieved recurrence rates of 2.8 percent and low complication rates but for economic reasons has failed to find a widespread role. This article demonstrates that large, villous tumors of the low and mid rectum can be simply and effectively treated by per-anal resection with recurrence rates equivalent to transanal endoscopic microsurgery.

Spotlight on a distant mirror - colorectal cancer surgery in a 20-year period at a general hospital.

BACKGROUND: A published audit of the management of colorectal cancer at a general hospital in the 1970s was available for comparison with a later audit at the same hospital in the 1990s. METHODS: Case note analysis. RESULTS: In the later audit, more cases were treated annually by an unchanged surgical team. The incidence of synchronous combined excision of the rectum, for rectal cancers suitable for resection, was halved, and that of anterior resection of the rectum (sphincter sparing, without a permanent stoma) increased almost threefold. The incidence of local recurrence in cases suitable for rectal surgery dropped from 17% to 9%, in spite of the change in the principal operation undertaken for this population. Outcomes associated with critical care improved as resources in this discipline became available. Overall survival figures were only improved by 6% in the20-year period, reflecting a diagnosis of Dukes C tumours or worse in at least 45% of the stable population studied in both audits. CONCLUSION: More resources are necessary in Great Britain to increase survival figures in this common cancer. Earlier diagnosis and more specialist management of the disease may allow us to emulate American and Swedish survival figures.

A case for the removal of the 'normal' appendix at laparoscopy for suspected acute appendicitis.

This study suggests that appendicectomy should be routinely performed at laparoscopy for suspected acute appendicitis and that this can be achieved with minimal morbidity.

Defunctioning colostomy for low anterior resection: a selective approach.

Seventy-seven consecutive low anterior resections of the rectum were performed with a selective approach to the use of a defunctioning colostomy. A defunctioning colostomy was performed in seven patients (9 per cent) where there was concern about the anastomosis due to difficult dissection (three), incomplete doughnuts (three) and tension on the anastomosis (one). The mean level of the tumour in the defunctioned group was 7.6 cm. Clinical anastomotic leakage occurred in two patients (3 per cent) in the non-defunctioned group, both of which were controlled with subsequent transverse colostomies. There were no perioperative deaths. Selective defunctioning of low colorectal anastomoses can produce low rates of anastomotic dehiscence while reducing the morbidity associated with a temporary stoma.