A colorectal cancer missed by colon capsule endoscopy: a case report.

BACKGROUND: Colon capsule endoscopy (CCE) is a non-invasive alternative to colonoscopy. The reported sensitivity and specificity of CCE for the detection of clinically significant colonic neoplasia is high. To date, there have been no reported cases of colorectal cancer (CRC) missed by CCE which were located in segments adequately visualised by the capsule. CASE PRESENTATION: We present the case of a 71-year-old female, who underwent CCE for new lower gastrointestinal symptoms. The CCE reported 17 polyps (largest size 10 mm) and angiodysplasia. A 40 mm caecal pole tumour, not detected by the CCE, was identified at follow up colonoscopy. Surgical resection was performed, and the pathology sample was reported as moderately differentiated adenocarcinoma, pT2 pN0 (0/19) M0, with no evidence of EMVI. The patient made an uneventful recovery. The caecal pole tumour was not definitively identified on retrospective review of the CCE images. CONCLUSION: To date, this is the first published case of a CRC missed entirely by CCE. Further research is required to allow calculation of the post CCE interval CRC rate to allow comparison with colonoscopy and CT colonogram.

Inferior epigastric artery false aneurysm following incisional hernia repair.

INTRODUCTION: We report a case of IEA false aneurysm following a mesh repair of a large incisional hernia. We emphasize the importance to consider the diagnosis to help avoid inappropriate interventions which could increase patient morbidity. CASE REPORT: A 68-year-old male patient, who 4 weeks previously had had a mesh repair of a large incisional hernia, presented with a painful left iliac fossa swelling. This was found to be an IEA false aneurysm. This was treated successfully with percutaneous thrombin injection. CONCLUSIONS: We feel an inferior epigastric artery false aneurysm must be included in the differential diagnosis when investigating the cause of any lateral swelling following incisional hernia repair. This would help reduce the chance of a missed diagnosis and avoid any inappropriate interventions which may cause increased patient morbidity.

Stapled versus handsewn methods for ileocolic anastomoses.

BACKGROUND: Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. To our knowledge, this is the first systematic review specifically investigating ileocolic anastomosis. OBJECTIVES: To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications. SEARCH STRATEGY: MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005. Abstracts presented to the following society meetings between 1970 and 2002 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology. SELECTION CRITERIA: Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults. DATA COLLECTION AND ANALYSIS: Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 4.2 Analysis version 1.0.5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer and inflammatory bowel disease as indication for ileocolic anastomoses were performed. MAIN RESULTS: After obtaining individual data from authors for studies that include other anastomoses, six trials (including one unpublished) with 955 ileocolic participants (357 stapled, 598 handsewn) were included. The three largest trials had adequate allocation concealment. Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=5/357, HS=36/598, OR 0.34 [0.14, 0.82] p=0.02). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significant fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). There were too few Crohn's disease patients to perform sub-group analysis. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference. AUTHORS' CONCLUSIONS: Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.

Collagen promotes perianastomotic tumour growth in an experimental animal model.

Local application of growth factors promote wound healing and may find clinical application for use in high-risk intestinal anastomoses such as that following anterior resection. Since viable tumour cells are present in the bowel lumen and circulation after curative colorectal cancer surgery, it is unclear what effect such factors may have on tumour recurrence. The aim of this study was to examine the effect of epidermal growth factor (EGF) and basic fibroblast growth factor (bFGF) in a collagen suspension on perianastomotic tumour growth in an animal model. Significantly (P < 0.05) more animals in the collagen treated groups developed anastomotic tumours. The area of tumour growth at the anastomosis was also significantly greater for the collagen (median 14.7 mm2) and collagen + EGF (median 10.8 mm2) groups compared with controls (median 0.78 mm2). We were unable to demonstrate any promotion of tumour by growth factors alone. Collagen promotes perianastomotic tumour growth in this model and is not a suitable vehicle for growth factor application in colorectal cancer surgery.

Efficacy of tumoricidal agents in vitro and in vivo.

Implantation of exfoliated tumour cells can give rise to local recurrence of colorectal cancer and it has been recommended that the bowel lumen be lavaged with a tumoricidal agent. This study identified which tumoricidal agents are currently used in Scotland and investigated their efficacy in vitro and in vivo. Cytotoxic efficacy was tested in vitro by a clonogenic assay and in vivo by a rat model with viable intraluminal tumour cells. Overall 70 per cent of surgeons used a tumoricidal agent during colorectal cancer surgery. Povidone-iodine, sodium hypochlorite and chlorhexidine-cetrimide were all effective at killing tumour cells in vitro but were all inactivated by the presence of 25 per cent whole blood in vitro. With 10(5) cells in vivo povidone-iodine and sodium hypochlorite significantly (P < 0.02) reduced the incidence of tumour growth while chlorhexidine-cetrimide had no significant effect. With 10(6) cells povidone-iodine had no effect on the incidence of tumour growth. Tumoricidal agents have effective cytotoxicity in vitro but are only weakly cytotoxic in vivo.

Comparison of manually constructed and stapled anastomoses in colorectal surgery. West of Scotland and Highland Anastomosis Study Group.

OBJECTIVE: The authors compared both the initial and the long-term outcomes of patients undergoing stapled and sutured colorectal anastomoses. SUMMARY BACKGROUND DATA: Sutured and stapled large bowel anastomoses are perceived to be equally safe, but concern has been raised about increased rates of tumor recurrence with the use of stapling instruments. METHODS: The outcome of patients with sutured and stapled colorectal anastomoses were compared in a prospective, multicenter, randomized study. Factors affecting long-term outcomes were assessed by both univariate and multivariate analysis. RESULTS: Seven hundred thirty-two patients were recruited. There was a significant increase in radiologic leakage in the sutured group (14.4% vs. 5.2%, p < 0.05), but there was no difference in clinical anastomotic leak rates, morbidity, or postoperative mortality. Tumor recurrence and cancer-specific mortality were higher in the sutured patients (7.5% and 6.7%, respectively) and in patients with anastomotic leaks. CONCLUSIONS: This study shows that suturing or stapling are equally safe in large bowel surgery. However, it also shows a long-term benefit of stapling in colorectal cancer patients.

Relative effect of surgery and radiotherapy on the internal jugular vein following functional neck dissection.

We examined the internal jugular veins in three groups of patients who had undergone (1) a functional neck dissection and radiotherapy, (2) a functional neck dissection alone, or (3) radiotherapy alone, using a noninvasive color Doppler ultrasound scan. The internal jugular veins were ultrasonically bilaterally normal in 18% of patients who had undergone a functional neck dissection and radiotherapy, in 88% of patients who had undergone a functional neck dissection alone, and in 57% of patients who had undergone radiotherapy alone. The combination of a functional neck dissection and radiotherapy significantly affected the internal jugular vein when compared with a functional neck dissection alone.

Use of the appendix to provide urinary continence.

We describe a technique used to provide urinary continence to a group of teenagers with neuropathic bladders. The technique gives continence to a urinary reservoir by utilising the appendix as a continent catheterisable conduit. Of the first five patients to have this procedure performed in this institute, four became fully continent. We feel that this procedure can be of great benefit to both children and adults with urinary incontinence.

Meconium ileus: a review 1972-1990.

This article reviews the management and mortality of 53 neonates with meconium ileus and cystic fibrosis treated in one paediatric surgical centre from 1972 to 1990. Forty-four patients (83 per cent) presented with simple meconium ileus and 26 of 40 patients in this group were successfully treated with Gastrografin enemas. Four patients suffered a perforation as a result of the enema (perforation rate 5 per cent). The 1-year survival rate for simple meconium ileus was 81 per cent and for complicated meconium ileus 75 per cent.

Encephaloceles: a review 1971-1990.

Fifty-two patients with an occipital encephalocele were managed at our institution between 1971-1990 inclusive. The case notes of fifty-one patients were available for review. Thirty-four of the patients presented in the first decade of the study. Fifty-seven per cent (29) developed hydrocephalus and 18 of these required shunting. The overall one year mortality was 23% (12) but only one patient died within the last decade. Of 23 patients followed up by postal questionnaire to general practitioners; 14 had no obvious deficit and 9 had a combination of deficits. Only one death occurred after one year of life in a child with a very severe handicap.

Bilateral rectus sheath haematoma complicating alcoholic liver disease.

Rectus sheath haematoma has been well documented with over 500 cases reported. The main interest is in their ability to mimic severe intra-abdominal pathology with a resultant low rate of pre-operative diagnosis. We report a case of a bilateral rectus sheath haematoma complicating severe alcoholic liver disease and review the modes of diagnosis and management.