Endoscopic transanal resection of rectal tumours using a urological resectoscope--still has a role in selected patients.

INTRODUCTION: Transanal resection of rectal villous adenomas or adenocarcinomas can be carried out using various modalities such as operative excision, fulguration, laser coagulation or cryotherapy. Transanal endoscopic microsurgery is currently not widely available. Transanal resection can provide effective palliation for locally advanced rectal tumours in patients unfit for abdomino-perineal excision of rectum. A urological resectoscope can be safely and repeatedly used to resect advanced primary or locally recurrent rectal tumours by colorectal surgeons with urological expertise. This study reports our experience of treating rectal lesions with endoscopic transanal resection (ETAR) using the urological resectoscope. METHODS: Patients were identified from one surgeons' prospectively collected operating data. Charts were retrieved and reviewed. RESULTS: Over a 13-year period a total of 43 ETAR procedures were carried out in 20 patients (11 males; mean age 74 years; range 54-92 years) using the urological resectoscope. Twelve (60%) patients had a single resection; 8 (40%) patients required more than one resection; the mean number of procedures per patient was 2.2 (range 1-8). The median interval between resections for recurrent disease (excluding planned repeat resections) was 340 days (range 168-2337 days). Histopathology revealed rectal adenoma (with varying degrees of dysplasia) in 11 (55%) patients and adenocarcinoma in 9 (45%). The majority (30; 70%) of resections were carried out in patients with benign disease, with 13 (30%) in patients with rectal adenocarcinoma. Mean operating time per resection was 25 min. Thirteen (30%) resections were carried out under spinal anaesthetic. There was no procedure related mortality. There were no cases of haemorrhage, rectal perforation, 'TUR syndrome' or pelvic sepsis. No patients with benign disease subsequently developed an invasive carcinoma. CONCLUSIONS: Accepting that this technique provides limited histopathological information regarding extent of resection and tumour clearance, our experience demonstrates that ETAR of rectal tumours using the urological resectoscope can provide a minimally invasive, effective and safe means of treating and palliating patients with benign and malignant rectal disease. There remains a place for this technique in selected patients.

Laparoscopic cholecystectomy: experience with 303 patients over the initial four years.

A total of 303 patients underwent attempted laparoscopic cholecystectomy (LC) over a four-year period by two consultant surgeons or a senior trainee under their supervision. The procedure was completed in 291 with a conversion rate to open cholecystectomy of 3.9% and a median postoperative length of stay of two days, range zero to nine days. In eighteen patients the indication for LC was failure of symptoms to settle, two of whom required conversion (11.1%). Diathermy dissection was avoided in Calot's triangle and dissection started at the junction of Hartmann's pouch and cystic duct with full mobilisation of this area prior to clip application. Pre-operative endoscopic retrograde cholangiopancreatography ERCP was performed in patients suspected of having common bile duct stones without routine intra-operative cholangiography. There was one death in this series (0.3%) and an overall complication rate of 6.3 %. There was no incidence of either bile duct injury or leak. LC can be performed with a low complication rate with attention to careful dissection technique in the region of Calot's triangle.

Carcinoma in Crohn's disease of the colon.

Two cases of carcinoma in Crohn's disease of the colon are reported. One patient was a 30-year-old man who had asymptomatic Crohn's ileocolitis resulting in an acute presentation due to toxic dilatation of the colon. This was preceded by a short prodromal period of four weeks, characterized by intermittent diarrhea on the basis of a coloileal tumor fistula. A mucus-secreting adenocarcinoma was present in the sigmoid colon associated with both adjacent and one nearby focus of high-grade mucosal dysplasia. Pelvic wall and abdominal metastases were present, and the patient died two months later. The other patient was a 60-year-old woman who had a nine-year history of biopsy-proven Crohn's proctocolitis. A stricture of the sigmoid colon due to Crohn's disease also harbored an invasive adenocarcinoma. The carcinoma was not evident preoperatively or on initial gross pathologic examination. The presentation and pathology of large intestinal carcinoma in Crohn's colitis are discussed and illustrated.

Two histologically different, synchronous carcinomas in a single male breast. A case report.

A rare case of male breast carcinoma is reported. The operative specimen revealed two histologically distinct tumours, a papillary carcinoma and a colloid carcinoma. Features may support the theory of multicentric origin of breast cancer.