Extramural vascular invasion is an adverse prognostic indicator of survival in patients with colorectal cancer.

BACKGROUND/AIMS: Extramural vascular invasion (EVI) in colorectal cancer is reported to be a stage-independent adverse prognostic factor, and is a core item in the Royal College of Pathologists minimum data set for colorectal cancer histopathology reporting. The detection of EVI is also highly variable amongst pathologists. Our aims were to analyse both the frequency of EVI in colorectal cancer resections, and the effect of EVI on survival, in patients operated on over a 5-year period. METHOD: A retrospective analysis of patients having potentially curative surgery for colorectal cancer between January 1999 and December 2004. RESULTS: Over 5 years, 378 patients underwent a potentially curative resection. One-hundred seven (28.3%) cancers exhibited EVI, of which 104 (97%) were T3 and T4 tumours. Survival curves with and without EVI, unadjusted for nodal status and T stage, were significantly different (P = 0.0001) with 5-year survivals of 52% and 73% respectively. Survival curves for T3 and T4 tumours stratified with and without EVI also showed significantly different survival distributions (P = 0.007). A significant difference in frequency of EVI year on year was seen (P < 0.001), ranging from 8.5% to 46.7%, whereas the number of T3 and T4 tumours in each year was not significantly different (P = 0.677). CONCLUSIONS: EVI is an adverse prognostic indicator for survival in patients undergoing potentially curative resection of colorectal cancer, and the routine requirement of EVI in colorectal cancer histopathology reporting is justified. Optimal specimen preparation, meticulous histopathological analysis and regular auditing of EVI detection rates are essential for the accurate staging of colorectal cancer.

Colonic motor activity in slow-transit idiopathic constipation as identified by 24-h pancolonic ambulatory manometry.

Colorectal motor activity in slow-transit idiopathic constipation has not been fully evaluated under physiological conditions. The aim of this study was to evaluate colorectal motor activity in chronic idiopathic constipation using 24-h ambulant pancolonic manometry. Ten healthy volunteers (six females) 19-31 years of age, and eight females 25-46 years of age with slow-transit idiopathic constipation were studied. Motor activity was measured using two custom-made silicone-coated catheters, each with five solid-state pressure transducers. Bowel preparation or sedation was not used. Frequency of high-amplitude propagated contractions was reduced in chronic idiopathic constipation, median 1.9/24 h vs 6/24 h (P = 0.01). Contractile frequency of low-amplitude complexes was reduced throughout the colon in slow-transit idiopathic constipation (P < 0.0001). The interval between contractile complexes was reduced in the transverse colon and splenic flexure (P < 0.0001). This study demonstrates that colonic motor activity is abnormal in slow-transit idiopathic constipation; decreased motor activity leads to a reduction in propulsion of intraluminal contents.

Recurrent small bowel obstruction after laparoscopic surgery for gallstone ileus.

Gallstone ileus is an uncommon cause of small bowel obstruction. A patient presenting with gallstone ileus was managed in our department by laparoscopic enterolithotomy. Postoperatively, the patient developed recurrent small bowel obstruction due to the presence of a second gallstone. It is therefore important to exclude the possibility of multiple gallstones at the initial operation.

Periodic colonic motor activity identified by 24-h pancolonic ambulatory manometry in humans.

The pattern of colonic motor activity in healthy humans has not been fully elucidated to date. The aim of this study was to evaluate colorectal motor activity employing 24-h ambulant pancolonic manometry. Ten healthy volunteers (6F, 4M), aged 19-31 years were studied. Motor activity was measured using two custom-made silicone coated catheters, each with five solid-state pressure transducers. No bowel preparation or sedation was used. The study period was 24 h. A total of 232 h of recording was obtained. Sixty-three high amplitude propagated contractions were observed, median six per 24-h period. Low-amplitude colonic contractile activity showed regional and diurnal variations. Frequency of contraction was highest in the right colon [median 5.26 cpm (cycles per minute)], and transverse colon and splenic flexure (median 5.15 cpm). The interval between colonic motor complexes was shortest in the transverse colon and splenic flexure. This study introduces a new technique for the evaluation of colorectal motor activity. Subjects were studied in an ambulant setting in their own environment ensuring that this method of study is as physiological as possible. This study demonstrates that colonic motor activity has two main components: high amplitude propagated contractions and low amplitude colonic contractile activity.

A deficiency of interstitial cells of Cajal in Chagasic megacolon.

Disordered gut motor activity is a feature of patients with Chagas' disease: colonic involvement leads to the development of megacolon and symptoms of constipation. Interstitial cells of Cajal are thought to modulate gut motility. The aim of this study was to test the hypothesis that there is an abnormality of the density of distribution of interstitial cells of Cajal in Chagasic megacolon. Interstitial cells of Cajal were identified by immunohistochemistry using an anti-c-kit antibody. Six patients with Chagasic megacolon were compared with normal controls. The density of distribution of interstitial cells of Cajal was assessed in the longitudinal and circular muscle layers, and in the intermuscular plane of the Chagasic and normal colon. Statistical analysis was performed using Fisher's exact test. The interstitial cells of Cajal density in Chagasic megacolon was much reduced in comparison to normal colonic tissue in the longitudinal muscle layer (P=0.0084), intermuscular plane (P<0.0001), and circular muscle layer (P=0.0051). The lack of interstitial cells of Cajal may play a role in the pathophysiology of the disease, leading to the development of megacolon and symptoms of constipation.

Distribution of the interstitial cells of Cajal in the human anorectum.

The interstitial cells of Cajal are proposed to have a role in the control of gut motility. The aim of this study was to establish the distribution of interstitial cells of Cajal in the wall of the normal human anorectum. Interstitial cells of Cajal express the proto-oncogene c-kit. Interstitial cells of Cajal were identified in the colon by immunohistochemical staining, using a rabbit polyclonal anti-c-kit antibody. Anorectal tissue was obtained at surgical resection for carcinoma of the colorectum. Density of interstitial cells of Cajal was graded. Statistical analysis was performed using chi2 tests. In the longitudinal and circular muscle layers of the rectum interstitial cells of Cajal were seen in the bulk of the muscle layer. In the intermuscular plane interstitial cells of Cajal encased the myenteric plexus. Interstitial cells of Cajal were found at the inner margin of the circular muscle and in association with neural elements of the submuscular plexus. Within the internal anal sphincter interstitial cells of Cajal were infrequently scattered among the muscle fibres. The density of interstitial cells of Cajal in the internal anal sphincter was significantly lower than that observed in the circular muscle layer of the rectum (P = 0.014). In conclusion, interstitial cells of Cajal are evenly distributed in the layers of the muscularis propria of the rectum, but have a lower density in the internal anal sphincter.

Regional and transmural density of interstitial cells of Cajal in human colon and rectum.

The interstitial cells of Cajal (ICC) are thought to play an important role in the control of gut motility. The regional and transmural pattern of distribution of ICC in the normal human colon and rectum was evaluated with immunohistochemistry using an anti-c-kit antibody. The transmural distribution of ICC was constant throughout the whole colon, the density of ICC was significantly greater at the myenteric plexus than at either the longitudinal or circular muscle layers, and in the rectum the transmural distribution was more even. Regionally, at the myenteric plexus, the transverse colon had a significantly greater density of ICC compared with the right colon (P = 0.038), left colon (P = 0.006), and rectum (P = 0.008). The pattern of distribution of ICC identified in this study is consistent with the proposed roles of ICC as colorectal pacemakers, intermediaries of the neural control of muscle activity, and coordinators of colorectal muscle activity. The highest density of ICC was at the myenteric plexus of the transverse colon, which is the proposed region of pacemaking activity.

Role of the interstitial cells of Cajal in the control of gut motility.

BACKGROUND: The interstitial cells of Cajal (ICCs) are a population of cells in the gastrointestinal tract which have a role in the control of gut motility. METHOD: A comprehensive review of the scientific literature was undertaken to assess current understanding of the morphology, structure, identification, distribution, development and function of these cells. RESULTS AND CONCLUSIONS: ICCs have an important role in the control of gut motility. Experimental evidence from animal studies suggests roles as pacemakers and coordinators of gut motor activity, and as intermediaries in the neural control of motility. With an increasing understanding of the distribution and behaviour of these cells in the healthy or diseased human gastrointestinal tract, there is the potential to develop novel therapeutic approaches to diseases that have gut dysmotility as a contributory factor.

The problem family and community medicine.

The characteristics of problem families are described and especially their dependency upon the social services. They are of increasing importance to community medicine since as shown by the literature their members form 5--10% of the total population and use from 50--80% of the total social and corrective services. The social pathology of 16 root and 110 sub-families was investigated; enquiries have also been made into the family dynamics and especially child rearing, learning problems and ill health. Infections, injuries and childhood disorders are particularly frequent. There are administrative advantages in regarding these families as socially handicapped.

Multiproblem families and their psychiatric significance.

The characteristics of multiproblem families are described, and the investigations in a research project are reported. A note is made of their epidemiological significance. Reasons are suggested as to why they have received little psychiatric attention. In particular their child upbringing practices, including child rearing and learning disorders, are described. The psychiatry of inadequacy is considered and the validity of the various diagnoses used. Finally it is suggested that the place of psychiatry in their care should be reconsidered and that a better knowledge of social handicap should be acquired.