The management of colorectal liver metastases: Expanding the role of hepatic resection in the age of multimodal therapy.

Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.

Colorectal cancer audit: a comparative study before and after establishing a specialty colorectal surgery unit.

OBJECTIVE: A prospective audit was kept for colorectal cancer after the establishment of a special-interest colorectal unit at a Melbourne metropolitan teaching hospital. METHODS: These data were compared with data collected retrospectively on surgical management of colorectal cancer by general surgeons in the hospital. RESULTS: The groups were well matched with respect to age, sex, pathological staging and elective vs urgent surgery. Differences were found in postoperative length of stay (9 vs 12 days, P = 0.01) in favour of the colorectal special interest group. Differences were found in the permanent stoma rate with regard to rectal cancer with the colorectal special interest group having a lower permanent stoma rate. CONCLUSION: Specialisation improved the results of treatment.

Long-term clinical outcome of surgery for solitary rectal ulcer syndrome.

BACKGROUND: When severe symptoms of solitary rectal ulcer syndrome persist despite medical management, surgery may be necessary. METHODS: A retrospective review was carried out of 81 patients undergoing surgery for solitary rectal ulcer syndrome in the 10-year period from 1984 to 1993 to determine the long-term outcome at a minimum follow-up of 12 months. Of the 81 patients, 15 were excluded from further analysis (11 were followed up for less than 12 months, two died and two were lost to follow-up). Sixty-six patients were studied (median age 38 (range 15-77) years; 53 female). Of these, 49 underwent rectopexy, nine Delorme's operation, two anterior resection and four creation of a stoma as the initial operation. RESULTS: At a median follow-up of 90 (range 12-177) months, the rectopexy had failed in 22 of 49 patients; 19 of these patients underwent further surgery, including rectal resection with coloanal anastomosis (four with three failures), colostomy (11) and other procedures (four). Ultimately, 14 required a stoma. Constipation was the indication for a stoma in nine of the 11 patients who had colostomy as the first procedure after failure of rectopexy. Nine patients had Delorme's operation as the first procedure. At median follow-up of 38 (range 19-107) months, there were four failures. Two of these ultimately required a stoma. Of the seven patients who underwent anterior resection as the initial or subsequent procedure, a stoma was finally necessary in four. Anterior resection used as a salvage procedure was not successful. The overall stoma rate was 30 per cent (20 patients). Of 11 symptoms assessed before operation only incontinence and incomplete evacuation were related to a poor outcome following surgery. CONCLUSION: Antiprolapse operations result in a satisfactory long-term outcome in about 55-60 per cent of patients having surgery for solitary rectal ulcer syndrome. Results of anterior resection are disappointing.

On-table colonic lavage: an alternative.

A new technique of on-table colonic lavage is described. This technique has been used in those patients with inadequate bowel preparation at the time of elective or semi-elective surgery. The main difference in this technique compared with others previously described is that the lavage is performed after the resection and anastomosis of the colon is completed. Experience of this technique with four patients is described.

Lymph node involvement and tumor depth in rectal cancers: an analysis of 805 patients.

BACKGROUND: Superficial rectal tumors are said to involve regional lymph nodes rarely. This presumption must be proven beyond any doubt if less radical surgery is to be offered for such patients. PATIENTS AND METHODS: Eight hundred five cases (467 males; median age, 64 (range, 19-97) years) of rectal cancer were reviewed. RESULTS: Lymph node positivity, number of lymph nodes involved, lymphatic vessel, and venous and perineural invasion were significantly increased with increasing depth of invasion of tumor through the bowel wall in univariate analysis. The percentage of lymph node involvement at each tumor depth was as follows: T1, 5.7 percent; T2, 19.6 percent; T3, 65.7 percent; T4, 78.8 percent. Overall lymph node involvement was 59 percent. For patients younger than 45 years of age, the percentage of lymph node involvement was 33.3, 30, 69.3, and 83.3 percent compared with 3.1, 8.4, 64.2, and 78.8 percent for patients aged 45 years or above for T1, T2, T3, and T4, respectively. CONCLUSION: Increased depths of tumor penetration beyond T1 and age less than 45 years have an excessive incidence of lymph node positivity. The finding of lymphatic vessel invasion on biopsy is highly indicative of lymph node metastasis.

Overlap repair of damaged anal sphincter. A single surgeon's series.

PURPOSE: This study was undertaken to review consecutive cases of anal sphincter repair performed by a single surgeon with respect to outcome as measured by continence grade using the Parks-Browning scale. Other parameters such as manometry, pudendal nerve function, and morbidity are also reviewed with respect to outcome. METHODS: Thirty-one of 52 patients identified by computer were available for analysis. Case notes were retrieved, and information was transferred into a standard proforma. Minimum follow-up was one month, and continence grade was documented from clinical notes recorded at follow-up. Statistical analysis was performed using Instat computer package. RESULTS: Four patients were male, 27 were female. Average age was 41.9 years. There was no postoperative mortality; postoperative morbidity was 32 percent in total, but morbidity per procedure was 19.6 percent. Most (20 of 31) patients had a clear obstetric-related cause of their anal sphincter injury. Successful outcome was achieved in 74.2 percent of patients. Postoperative anal manometry was not discriminatory between successful and failed groups. Anal ultrasound appeared accurate in documenting residual anal sphincter defects in the poor outcome group in the small number of patients in whom it was done. Use of a stoma in covering the anal wound while it healed was associated with less infection of the wound, but there was no statistical difference in success rate between those covered by a stoma and those not covered. CONCLUSIONS: Overlap repair of the damaged anal sphincter continues to give good results. Routine use of covering stomas is not supported in this small study; however, it should still be considered in difficult cases. Endoanal ultrasound may have the ability to identify those patients with poor results from an initial repair who may benefit from repeat repair.