Reversal of Hartmann's procedure: experience in an Asian population.

INTRODUCTION: With improvements in surgical techniques, instrumentation and perioperative care, Hartmann's procedure is now less frequently performed. Restoration of intestinal continuity after Hartmann's procedure has traditionally been viewed to be technically demanding and associated with significant morbidity and mortality. This is a study of outcomes after the reversal of Hartmann's procedure in an Asian population. METHODS: A prospectively collected database showed that 255 patients had undergone Hartmann's procedure from October 1989 to October 2005. Patients who subsequently underwent Hartmann's reversal were identified and their records reviewed retrospectively. RESULTS: Hartmann's reversal was attempted in 49 patients. The most common indication for Hartmann's procedure was colorectal carcinoma (49.0%). The median interval between resection and reversal was 23 weeks. Reversal was successful in 46 (93.9%) patients, with 79.6% experiencing no intraoperative complications. Failure of reversal was significantly associated with prior radiotherapy to the pelvis (p-value = 0.007). Anastomotic leak rates and re-bleeding rates were both 0.0%. 79.6% of patients made an uneventful recovery with no postoperative complications. There was no significant increase in the complication rate in older patients or patients with higher American Society of Anesthesiologists status. The overall incidence of 30-day morbidity and mortality was 20.4% and 0.0%, respectively. CONCLUSION: In our population, Hartmann's procedure is more commonly performed for colorectal cancer rather than for diverticular disease, resulting in lower rates of stoma reversal. Hartmann's reversal could be performed with acceptable morbidity and minimal mortality, although prior radiotherapy and shorter rectal stump may pose challenges during reversal surgery.

Twenty years of familial adenomatosis polyposis syndromes in the Singapore Polyposis Registry: an analysis of outcomes.

INTRODUCTION: The Singapore Polyposis Registry (SPR) was established in 1989 at the Singapore General Hospital. This initiative was aimed at providing a central registry service to facilitate identification, surveillance and management of families and individuals at high risk of colorectal cancer. The aim of the present study was to provide a comprehensive review of all patients with familial adenomatous polyposis (FAP) syndrome in the SPR. METHODS: All patients diagnosed with FAP in 1989-2009 were analysed. Data was extracted from a prospectively collected database. RESULTS: 122 patients from 88 families were analysed. The median age of this cohort was 29 (range 10-68) years. 97 percent of the cases were FAP and 3 percent were attenuated FAP. 92 patients tested positive for adenomatous polyposis coli gene. 42 percent of patients were diagnosed with colorectal cancer, of which 78 percent were diagnosed at an advanced stage. 73 percent of patients underwent restorative proctocolectomy and 21 percent had total colectomy. The median age at operation was 30 years. At median follow-up of 98 months, ten-year overall survival was 75.6 percent (95 percent confidence interval 67.0-84.2) and the median age at death was 40 years. For cancer cases, the overall recurrence was 13.5 percent. Recurrence and disease-free survival were not significant for the type of surgery performed (p-value is 0.486). CONCLUSION: The SPR plays an important and integral part in counselling patients and families with FAP. Improved surveillance programmes may be required to detect the development of cancers in these patients at an earlier stage.

Anal canal malignancies: a review in an Asian population.

INTRODUCTION: Anal canal malignancies are rare tumours of the gastrointestinal tract that represent less than five percent of anorectal malignancies. METHODS: We retrospectively reviewed patients with anal canal malignancies who were treated from April 1989 to December 2008. Patients were identified from a prospective database and records were analysed for age, gender, presenting symptoms, duration of symptoms, mode of diagnosis, histological subtypes, stage of disease, treatment received, duration of follow-up, recurrence rates and survival. RESULTS: A total of 61 patients were treated for anal canal malignancies, comprising 2.1 percent of all anorectal malignancies treated during the same period. There were 31 male and 30 female patients, with a median age at diagnosis of 61 (range 38-83) years. The commonest presenting symptoms were per rectal bleeding (69.4 percent) and pain (33.9 percent). The commonest histology was adenocarcinoma (50.8 percent) and squamous cell carcinoma (SCC) (40.3 percent). Patients underwent either surgery, radiotherapy, chemoradiation or a combination of modalities. The median duration of follow-up was 28 (range 1-120) months. Five patients developed recurrences after a median of 23 (range 2-36) months. The five-year overall survival and disease-free survival was 65.5 percent and 63.7 percent, respectively, with SCC showing a trend toward a better prognosis. CONCLUSION: Anal canal tumours are a rare clinical entity. They are usually present in the elderly with per rectal bleeding. They are usually treated using a multimodality approach, after the accurate establishment of histological diagnosis, which can yield reasonable survival rates.

Solitary caecal ulcer syndrome: our experience with this benign condition.

AIM: Solitary caecal ulcer syndrome is rare. We describe our experience of 10 patients with the condition. METHOD: A prospectively collected database of patients undergoing colonoscopy or surgery with histology reporting a solitary caecal ulcer was reviewed from 1999 to 2008. Patients with known carcinoma of the colon, cytomegalovirus infection, amoebiasis, inflammatory bowel disease, immunosuppression and history of nonsteroidal anti-inflammatory drug use were excluded. RESULTS: Ten patients were found to have a solitary caecal ulcer. All were of Chinese ethnicity, of median age 61 years. The most common presenting symptoms were haematochezia and right-sided abdominal pain. Histological findings included ulceration sharing some features of solitary rectal ulcer syndrome, but with differences to suggest a different aetiology. CONCLUSION: Solitary caecal ulcer syndrome should be included in the differential diagnosis of lower gastrointestinal haemorrhage, right iliac fossa pain or when computed tomography imaging demonstrates caecal wall thickening. The diagnosis can only be made on histopathological examination.

The fourth branch of the superior rectal artery and its significance in transanal haemorrhoidal dearterialisation.

INTRODUCTION: Transanal haemorrhoidal dearterialisation is a non-excisional surgical method for the treatment of haemorrhoidal disease. It uses a Doppler ultrasound probe to accurately identify the site to suture-ligate the piles, resulting in a decrease in the arterial inflow to the piles and their subsequent regression. METHODS: A total of 140 consecutive patients who underwent transanal haemorrhoidal dearterialisation were studied. The number and locations of the haemorrhoidal arteries were documented. The presenting symptoms and their subsequent resolution were noted. RESULTS: The median number of haemorrhoidal arteries ligated was four. Seventy-five patients (53.6%) had four haemorrhoidal arteries ligated. A total of 82 patients (58.6%) had a 'fourth' haemorrhoidal artery in the left anterior one o'clock position. Symptoms of bleeding, prolapse, pain and itching resolved in 92, 65, 68 and 60% of patients who presented with the respective symptoms preoperatively. CONCLUSION: There is a fourth haemorrhoidal artery consistently found in the left anterior one o'clock position. Adequate treatment of this artery minimises the recurrence of haemorrhoidal symptoms.

418 cases of laparoscopic colorectal resections: a single-institution experience and literature review.

INTRODUCTION: Evidence from randomised controlled trials has shown that laparoscopic colon and rectal cancer resection not only confers short-term benefits but also does not differ considerably in terms of its long-term oncological outcomes, as compared with open surgery. METHODS: All laparoscopic colon and rectal resections performed between January 2005 and December 2007 were included. Patient records were reviewed from a prospective database and the relevant clinical data was obtained, with a subgroup analysis of cancer procedures performed. RESULTS: 418 patients (247 male), median age 63 years (range 24 to 88), underwent laparoscopic resection of the colon and rectum. The median Body Mass Index (BMI) was 22.5 (range 13.5 to 39.3). The majority of the procedures were performed for malignant disease (81.3 percent) and the most common procedure was anterior resection (79.4 percent). The median duration of surgery was 135 minutes (range 65 to 330), with conversions to open surgery in 44 patients (10.5 percent). Complications occurred in 78 patients (18.7 percent), including anastomotic leaks in five (1.20 percent). The median length of hospital stay was five days (range 3 to 90) and the median follow-up was 19 months (range 1 to 46). In the 340 patients with malignant disease, the median number of lymph nodes harvested was 13 (range 5 to 48), and at the latest review, 230 patients (67.6 percent) were disease-free, with locoregional recurrence in 2.9 percent and systemic recurrence in 10 percent. CONCLUSION: To date, this is the largest series of laparoscopic colorectal resections reported locally, and our results show that it is safe, feasible and produces favourable results.

Single-incision laparoscopic surgery for right hemicolectomy: our initial experience with 10 cases.

BACKGROUND: Published data has confirmed the oncological safety and efficacy of laparoscopic colorectal surgery. Continued surgical innovation has seen the recent resurgence of single-port laparoscopic surgery. We present a series of 10 cases of single-incision laparoscopic surgery (SILS) for right hemicolectomy, with the aim of reaffirming the feasibility and favourable short-term results of this technique. METHODS: Ten patients underwent SILS for right hemicolectomy using the SILS port, between June 2009 and August 2009. A longitudinal periumbilical incision was used as the access point for all cases. Data analysed included age, gender, American Society of Anaesthesiology score, body mass index (BMI), location of disease, duration of surgery, length of incision and duration of hospital stay. Inclusion criteria were no prior abdominal surgery, no intra-abdominal sepsis, no distant metastases and a BMI of <30. RESULTS: All 10 cases of right hemicolectomy were successfully performed using the SILS port through a single periumbilical incision. The median age of patients was 64 years (range 48-83 years), with a median body mass index of 21.5 kg/m(2) (range 18.9-25.6 kg/m(2)). The median duration of surgery and hospital stay was 83 min (range 60-125 min) and 6 days (range 5-11 days), respectively. No morbidity or mortality was associated with this technique, and all patients recovered uneventfully. CONCLUSION: This case series illustrates that SILS for right hemicolectomy is feasible and safe. However, the routine use of this innovative technique in malignant disease cannot be recommended without further large-scale prospective trials.

Radiation proctitis: a decade's experience.

INTRODUCTION: Pelvic radiotherapy is an essential component of potentially curative therapy for many pelvic malignancies; however, the rectum consequently often sustains collateral injury. METHODS: The researchers retrieved patient data that was prospectively gathered over a ten-year period between January 1995 and December 2004. The relevant details, including gender, age, pelvic pathology for which radiotherapy was administered, the presenting symptoms, the interval between radiotherapy and the onset of symptoms, the mode of diagnosis, treatments received, length of hospital stay and duration of follow-up, were analysed. RESULTS: During the period under review, 77 patients were admitted for the treatment of radiation proctitis, with a median follow-up period of 14 (range 1-61) months. There were 23 male and 54 female patients, with a median age of 63.9 (range 37-89) years. The most common underlying cancers were gynaecological (63.6 percent), prostate (18.2 percent) and colorectal (15.6 percent) cancer. The most common presenting symptom was bleeding per rectum (89.6 percent), with a change in bowel habits a distant second (10.4 percent). The median latent period between the completion of radiotherapy and the onset of symptoms was 24 (range 3-68) months. The majority of the patients (72.5 percent) received non-surgical treatment, most commonly using topical 4 percent formalin solution to arrest the bleeding, with more than half the patients requiring repeat treatments. 14 (18.2 percent) patients required colorectal resections for intractable bleeding, intestinal obstruction or intra-abdominal sepsis. CONCLUSION: Radiation proctitis can be a therapeutic challenge, even in the most experienced hands. The majority of patients who present with per rectal bleeding can be treated using topical modalities, while surgery may offer the only chance of relief from life-threatening symptoms.

Genome-wide scan identifies a copy number variable region at 3q26 that regulates PPM1L in APC mutation-negative familial colorectal cancer patients.

Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited form of colorectal cancer (CRC) caused by mutation in the adenomatous polyposis coli (APC) gene. However, APC mutations are not detected in 10-50% of FAP patients. We searched for a new cancer gene by performing genome-wide genotyping on members of an APC mutation-negative FAP variant family and ethnicity-matched healthy controls. No common copy number change was found in all affected members using the unaffected members and healthy controls as baseline. A 111 kb copy number variable (CNV) region at 3q26.1 was shown to have copy number loss in all eight polyps compared to matched lymphocytes of two affected members. A common region of loss in all polyps, which are precursors to CRC, is likely to harbor disease-causing gene in accordance to Knudsen's "two-hit" hypothesis. There is, however, no gene within the deleted region. A 2-Mb scan of the genomic region encompassing the deleted region identified PPM1L, coding for a novel serine-threonine phosphatase in the TGF-beta and BMP signaling pathways. Real-time PCR analyses indicate that the 3'UTR of PPM1L transcript was down-regulated more than two-folds in all six polyps and tumors compared to matched mucosa of the affected member. This down-regulation was not observed in APC mutation-positive FAP patients. Our results suggest that the CNV region at 3q26 harbors an element that regulates the expression of an upstream candidate tumor suppressor, PPM1L, thus providing a novel mechanism for colorectal tumorigenesis in APC mutation-negative familial CRC patients.

LARG at chromosome 11q23 has functional characteristics of a tumor suppressor in human breast and colorectal cancer.

Deletion of 11q23-q24 is frequent in a diverse variety of malignancies, including breast and colorectal carcinoma, implicating the presence of a tumor suppressor gene at that chromosomal region. We examined a 6-Mb region on 11q23 by high-resolution deletion mapping, using both loss of heterozygosity analysis and customized microarray comparative genomic hybridization. LARG (leukemia-associated Rho guanine-nucleotide exchange factor) (also called ARHGEF12), identified from the analysed region, is frequently underexpressed in breast and colorectal carcinomas with a reduced expression observed in all breast cancer cell lines (n=11), in 12 of 38 (32%) primary breast cancers, 5 of 10 (50%) colorectal cell lines and in 20 of 37 (54%) primary colorectal cancers. Underexpression of the LARG transcript was significantly associated with genomic loss (P=0.00334). Hypermethylation of the LARG promoter was not detected in either breast or colorectal cancer, and treatment of four breast and four colorectal cancer cell lines with 5-aza-2'-deoxycytidine and/or trichostatin A did not result in a reactivation of LARG. Enforced expression of LARG in breast and colorectal cancer cells by stable transfection resulted in reduced cell proliferation and colony formation, as well as in a markedly slower cell migration rate in colorectal cancer cells, providing functional evidence for LARG as a candidate tumor suppressor gene.

Carcinoembryonic antigen screening: how far should we go?

INTRODUCTION: The role of carcinoembryonic antigen (CEA) in screening has been previously investigated and found to be inefficient because of its low sensitivity and specificity. Nevertheless, it is still used as a tumour marker in health screening packages, often for asymptomatic patients. We aimed to review all asymptomatic patients who were referred to our department for raised CEA, to determine if this was indeed associated with significant pathology, and to what extent the asymptomatic patients should be investigated. METHODS: All patients with no gastrointestinal symptoms, and whose only indication for endoscopy was a raised CEA level, were entered into the study group. All the investigations were retrospectively reviewed and any pathology was noted. RESULTS: There were 217 asymptomatic patients who presented for endoscopy and further evaluation due to raised CEA, from December 1998 to August 2004. After the initial investigations, a total of 20 primary and eight metastatic cancers were found. The malignancies detected included 11 colorectal cancers, two stomach cancers, five lung cancers, one periampullary carcinoma and one ovarian teratoma. There were two cases of metastasis in the lungs and six with liver metastasis. In the subsequent median follow-up period of 13 (range 6-97) months, an additional 16 (7.4 percent) primary cancers were detected. CONCLUSION: Asymptomatic average-risk patients who present with raised CEA should be investigated endoscopically and radiologically for commonly-associated cancers, and thereafter followed up for at least two years, as up to 7.4 percent present with a subsequent malignancy.

Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb.

Necrotising fasciitis is a life-threatening soft tissue infection that is associated with high mortality and morbidity. It has been described in the form of Fournier's gangrene following rectal perforations related to colorectal cancer. In these rare instances, spontaneous perforation of locally-advanced rectal carcinoma provides an entry point for bacterial seeding to the surrounding soft tissues, resulting in Gram-negative sepsis of the perineum. To our knowledge, necrotising fasciitis extending beyond the perineum due to rectal perforation has not been previously described. We report an unusual self-induced traumatic rectal perforation presenting with severe necrotising fasciitis of the lower limb in a 73-year-old Chinese man. Our patient was successfully treated with a multidisciplinary approach that involved a defunctioning colostomy as well as prompt and rigorous debridement of the affected limb. We also review the literature on the management of retroperitoneal rectal perforations and their sequela, as well as discuss the various surgical options commonly applied and their outcomes.

Robotic-assisted surgery for low rectal dissection: from better views to better outcome.

INTRODUCTION: The use of robotics in colorectal surgery is relatively new. The first few cases of colonic surgery using da Vinci Surgical System were reported in 2002. Since then, several centres had reported on their experience, with favourable outcomes. Our department started to embark on robotics in colorectal surgery in December 2007. The aim of our paper was to share our early experience with robotics in colorectal surgery and provide an update on the current status of robotics. METHODS: Preparations included formal training with the da Vinci Surgical System, certification of the surgeons, and obtaining Hospital Ethics committee approval. We used a hybrid technique of laparoscopic and robotic assistance in the resection of mid- to low-rectal cancer (total mesorectal excision). Laparoscopic approach was used to isolate the inferior mesenteric artery and for mobilisation of the left colon. The da Vinci robot was used in the dissection of the rectum down to the pelvic floor. We reviewed the outcomes of our early experience with emphasis on feasibility and safety. RESULTS: Over a period of three months, we performed eight cases of robotic-assisted colorectal surgery for cancer. The median age of the patients was 55 (range 42-80) years. The median operating time was 192.5 (range 145-250) minutes. There were no intraoperative or postoperative complications related to the use of robotics. The median length of hospital stay was five (range 4-30) days. CONCLUSION: Robotic-assisted laparoscopic colorectal surgery is a safe and feasible procedure.

Colorectal cancer mass screening event utilising quantitative faecal occult blood test.

INTRODUCTION: Colorectal cancer (CRC) is a leading cause of morbidity and mortality with human and financial costs. Screening by faecal occult blood test (FOBT) has proven to be effective in decreasing mortality from CRC in both randomised trials and case-control studies. We report on the results of a CRC screening event using quantitative FOBT (QFOBT) held in Singapore. METHODS: The mass screening event was held over two days, and participants 40 years or older without prior screening performed in the preceding year were eligible. Those with significant symptoms or medical comorbidities were excluded. Stool sampling was done with two issued immunochemical QFOBT kits, and participants with positive stool samples with equal or greater than 100 ng haemoglobin/ml sample solution in any two samples were advised to have a colonoscopy screening conducted. RESULTS: A total of 1,048 participants took part in the screening event. 222 (21 percent) of the participants claimed to have some abdominal symptoms prior to screening. 49 participants (26 males, 23 females) tested positive for QFOBT and 47 were evaluated. 10 (21 percent) had polyps and one case of colorectal cancer was detected. Seven of these cases had significant neoplasia (lesions 1 cm or larger) and were treated. Two patients required surgery. CONCLUSION: Our study demonstrates wide variation in the attitudes of participants who turned up for screening. In addition, the number of significant colorectal neoplasia patients (14 percent) in those with positive QFOBT provides further evidence of the importance of screening with a potential reduction in CRC mortality. Continuous education of the public in events such as this, is essential to improving attitudes towards screening.

Systematic review of intraoperative colonic irrigation vs. manual decompression in obstructed left-sided colorectal emergencies.

AIMS: A systematic review was conducted to determine if manual decompression is a safe alternative to intraoperative colonic irrigation prior to primary anastomosis in obstructed left-sided colorectal emergencies. METHODS: Search for relevant articles from 1980 to 2007 was conducted on Medline, Embase and the Cochrane Controlled Trials Register using the keywords "colonic lavage, irrigation, decompression, washout, obstructed and bowel preparation", either singularly or in combination. Trials in English publications with similar patient characteristics, inclusion criteria and outcome measures were selected for analysis. Thirty-day mortality, anastomotic leak rates and post-operative wound infection were studied as outcome variables. Analysis was performed with RevMan 4.2 software. RESULTS: Seven trials were identified for systematic review, with a total of 449 patients. Data from the single randomised controlled trial and one prospective comparative trial were analysed separately. Results from the remaining five studies were pooled into two arms of a composite series, one with colonic irrigation and one without. Results showed no significant difference in the anastomotic leak rates and mortality rates between the colonic irrigation and manual decompression arms in the randomised and comparative trials. The composite series, however, showed significantly better results with manual decompression (RR 6.18, 95% CI 1.67-22.86). The post-operative infection rate was similar in both groups. CONCLUSION: Manual decompression was comparable to colonic irrigation for primary anastomosis in obstructed left-sided colorectal emergencies, with no significant increase in mortality, leak or infection rates.

Meta-analysis of defunctioning stomas in low anterior resection for rectal cancer.

BACKGROUND: A defunctioning stoma is frequently created to minimize the impact of any subsequent anastomotic leak after a low rectal anastomosis. This review evaluates the need for routine stoma formation. METHODS: A meta-analysis was performed of randomized controlled trials (RCTs) and non-randomized studies with an interventional group evaluating the need for a defunctioning stoma after low anterior resection for rectal cancer. Primary outcomes analysed included clinical anastomotic leak rate, reoperation rate and mortality related to leak. RESULTS: Four RCTs and 21 non-randomized studies, with 11,429 patients in total, were analysed. Meta-analysis of the RCTs showed a lower clinical anastomotic leak rate (risk ratio (RR) 0.39 (95 per cent c.i. 0.23 to 0.66); P < 0.001) and a lower reoperation rate (RR 0.29 (0.16 to 0.53); P < 0.001) in the stoma group. Meta-analysis of the non-randomized studies showed a lower clinical anastomotic leak rate (RR 0.74 (0.67 to 0.83); P < 0.001), lower reoperation rate (RR 0.28 (0.23 to 0.35); P < 0.001) and lower mortality rate (RR 0.42 (0.28 to 0.61); P < 0.001) in the stoma group. CONCLUSION: A defunctioning stoma decreases clinical anastomotic leak rate and reoperation rate. It is recommended after low anterior resection for rectal cancer.

Laparoscopic high anterior resection with natural orifice specimen extraction (NOSE) for early rectal cancer.

Laparoscopic surgery for colorectal cancer requires an abdominal incision to extract the resected specimen. We describe a technique for laparoscopic resection of an early-stage upper rectal cancer in a 51-year-old man followed by transanal specimen delivery, hence avoiding the need for making any additional abdominal incisions for retrieval of the specimen. Pneumoperitoneum was created, followed by medial-tolateral mobilization of the sigmoid colon, and take down of the splenic flexure and division of the inferior mesenteric vessels laparoscopically. The upper rectum distal to the tumour and proximal colon was transected with a laparoscopic stapler. The specimen was retrieved transanally via an opening in the rectal stump. The proximal colon was then delivered transanally and the anvil of the circular stapler inserted before returning it to the pelvic cavity. The rectal stump was transected again just below the opening to close off the stump, and the colorectal anastomosis was then completed intracorporeally. The patient, a 51-year-old male (BMI 18.6 kg/m(2)) with a 2.5-cm, early-stage posterior rectal cancer 12 cm from the anal verge, underwent the above-described procedure. Postoperative recovery was uneventful. He resumed normal daily activities 1 week after surgery. Histology confirmed a T1N0 upper rectal cancer. In the effort to minimize surgical trauma and postoperative pain, natural orifice specimen extraction techniques have been attempted. This procedure may be applicable to benign tumours and early colorectal cancer, and serves as an intermediate step between laparoscopic and natural orifice surgery.