The clinical results of the Turnbull-Cutait delayed coloanal anastomosis: a systematic review.

Turnbull and Cutait described abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) in 1961. DCA could reduce anastomotic leaks, pelvic morbidity and use of stomas. Strong evidence about its clinical benefits is still lacking. This systematic review examined the clinical outcomes of DCA for the treatment of malignant or benign colorectal conditions. A systematic search of electronic medical databases was conducted. Two independent reviewers selected studies, extracted data and assessed risk of bias. The primary outcome was pelvic morbidity (anastomotic leak, pelvic abscess or sepsis, use of stoma). Fecal continence and survival data were also analyzed. From 1,251 citations, we included seven observational studies including 1,124 patients. All included studies were considered at high risk of bias. Two studies comparing DCA with immediate anastomosis reported a significant decrease in anastomotic leak, and pelvic abscess or sepsis. Low rates of pelvic morbidity were reported in the other five studies: anastomotic leak 0-7 %, pelvic abscess 0-11.8 % and pelvic sepsis 6.8-10 %. Rates of permanent stoma after DCA were low in six studies (1-6 %), with one study reporting an incidence of 25 %. Fecal continence was reported as satisfying in all studies. No differences were observed in a comparative setting. Survival data were reported in four studies. Clinical heterogeneity and methodological issues precluded meta-analysis. Based on retrospective evidence, DCA offers a low rate of anastomotic leak, pelvic morbidity and use of stoma, with reasonable fecal continence. Results are encouraging, but prospective studies are needed for comparison with standard of care.

Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the canadian colorectal DVT prophylaxis trial: a randomized, double-blind trial.

OBJECTIVE: To compare the effectiveness and safety of low-dose unfractionated heparin and a low-molecular-weight heparin as prophylaxis against venous thromboembolism after colorectal surgery. METHODS: In a multicenter, double-blind trial, patients undergoing resection of part or all of the colon or rectum were randomized to receive, by subcutaneous injection, either calcium heparin 5,000 units every 8 hours or enoxaparin 40 mg once daily (plus two additional saline injections). Deep vein thrombosis was assessed by routine bilateral contrast venography performed between postoperative day 5 and 9, or earlier if clinically suspected. RESULTS: Nine hundred thirty-six randomized patients completed the protocol and had an adequate outcome assessment. The venous thromboembolism rates were the same in both groups. There were no deaths from pulmonary embolism or bleeding complications. Although the proportion of all bleeding events in the enoxaparin group was significantly greater than in the low-dose heparin group, the rates of major bleeding and reoperation for bleeding were not significantly different. CONCLUSIONS: Both heparin 5,000 units subcutaneously every 8 hours and enoxaparin 40 mg subcutaneously once daily provide highly effective and safe prophylaxis for patients undergoing colorectal surgery. However, given the current differences in cost, prophylaxis with low-dose heparin remains the preferred method at present.

Colonic epithelial proliferation indices before and after colon cancer removal.

Rectal mucosal (epithelial) proliferation labeling indices (LI) have been widely used as a risk marker for colorectal cancer and as an intermediate end-point in chemoprevention studies. The purpose of this study was to determine whether the presence of cancer preoperatively altered the LI and whether these LI could be used over the long term as a marker for colon cancer. We studied 25 patients (18 with colorectal cancer and 7 with benign colonic diseases) who were admitted for colonic resection. Biopsies for thymidine LI were taken before, during, and 4 and 7 months after the operation. The preoperative LI of cancer patients was higher, but not significantly, than that of noncancer patients (5.22 +/- 3.54 and 4.11 +/- 1.34%, respectively, p = 0.28). The intraoperative LI was significantly higher than the preoperative LI (8.08 +/- 4.00 and 4.90 +/- 3.07%, respectively; p = 0.004). After 4 and 7 months, the LI was not significantly different from the preoperative LI (p = 0.60 and 0.89, respectively). Resection of a colonic segment did not affect the level of proliferation over time. Therefore, it is unlikely that LI can be used as a marker to predict local recurrence after curative resection of colorectal cancer.

The effect of lowering faecal pH on the rate of proliferation of the normal colonic mucosa.

Epidemiological and animal studies suggest that faecal pH may be a risk factor for colorectal cancer with low faecal pH associated with a lower incidence of the disease. The aim of this study was to determine whether faecal pH (or dietary fibre) affects the short-term risk factors for colon cancer. Sixty-nine normal volunteers were randomized into three equal groups (A-C). They provided food records, faecal specimens and submitted to rectal biopsy for thymidine labelling studies before and after a 2-week intervention. Group A received a placebo of fruit juice. Group B, approximately 3.0 g d-1 sodium sulphate in juice. Group C, 30 g d-1 supplementary dietary fibre as wheat bran in bread. Age, sex, weight, height and intake of macronutrients and minerals were similar in the groups prior to intervention. Faecal pH was similar for the three groups before and was reduced in Group B after intervention (P = 0.001) with a relative reduction of 0.5 pH units. The labelling index for the three groups was similar prior to intervention; after, it was lowest in Group B with a relative reduction of 0.5% points, although this difference was not statistically significant. The results thus do not support the hypothesis that an acidification of faecal pH leads to a reduction in risk markers for colon cancer.

Long-term effects of dietary calcium on risk markers for colon cancer in patients with familial polyposis.

There is conflicting evidence regarding the benefit of calcium in prevention of colon cancer. Patients who have undergone ileorectal operations for familial polyposis can be useful to study hypotheses on prevention of colon cancer. In this study we evaluated the effect of long-term calcium supplementation on risk markers of colon cancer. Thirty-one patients with familial polyposis, after subtotal colectomy, were randomized to group A, which received placebo, and group B, which received 1200 mg of calcium daily. Intervention lasted 9 months, in which they underwent four 3-monthly evaluations that included food records, fecal pH, calcium and bile acids, and rectal biopsy for thymidine labeling. Age, height, weight, macronutrients, and dietary fiber were comparable in both groups. More women were in the group that received placebo. Fecal pH, weight, and bile acid levels were similar before intervention and remained unchanged. Fecal calcium levels were similar before intervention and increased in the calcium group throughout the study (p less than 0.05). Labeling index of placebo and calcium groups was similar before intervention (4.8 and 6.1, respectively). After 3 months it was reduced in both groups (3.1 and 4.4, respectively; p less than 0.05). After 6 months it was reduced only in the calcium group (3.4; p less than 0.05). After 9 months it did not differ from the starting point (3.4 and 4.0, respectively). In a long-term intervention study with a homogenous group of patients with familial polyposis, supplemental dietary calcium did not affect mucosal risk factors for colon cancer.

Effects of sodium sulfate on fecal pH and proliferation of colonic mucosa in patients at high risk for colon cancer.

High fecal pH level has been suggested as a risk factor for colorectal cancer. We previously demonstrated that, although sodium sulfate did not affect the proliferation rate of colonic mucosa, as indicated by thymidine-labeling index, it did lower fecal pH in subjects at average risk for colon cancer. In the current study, we evaluated the effects of sodium sulfate on fecal pH and proliferation of colonic mucosa in subjects at high risk for colon cancer. Fifty-seven patients who had had colonic polyps removed were randomly assigned to two groups to receive either sodium sulfate (27 patients) or a placebo (25 patients) at a mean dose of 4 g/day for 14 days. Age, sex, height, and weight were comparable in both groups. Before intervention, levels of fecal pH were similar in the two groups, but after intervention, fecal pH was reduced only in the sodium sulfate group (mean decrease, 0.3 U; P less than .01). Thymidine-labeling index (number of labeled cells per number of cells counted) was similar in the two groups prior to intervention and did not change significantly after intervention (mean increase, 0.9%; P = .35). Regression analysis revealed no correlation between the change in labeling index and the change in fecal pH. We conclude that high fecal pH level is only indirectly associated with the development of colon cancer and, therefore, may be a secondary, rather than a primary, measure of cancer risk.

Effect of calcium supplementation on mucosal cell proliferation in high risk patients for colon cancer.

Recent findings suggest that supplemental calcium could lower the abnormally high proliferation rate found in the colonic mucosa of subjects at high risk for colon cancer. In this double blind controlled study, this effect in volunteers previously operated upon for a colorectal adenocarcinoma was tested. Thirty subjects were randomised to receive either elemental calcium 1200 mg/day or a placebo. Mucosal proliferation was measured with tritiated thymidine labelling before and after the 30 day intervention period. Diets, faecal pH and the concentration of calcium and bile acids in the aqueous phase of feaces were also measured. Labelling index did not differ significantly in the two groups before intervention (placebo 4.0(2.4) v calcium 4.9(2.9), but the difference approached significance afterwards (4.4(2.4) v 6.5(3.4), p = 0.06). Individual changes occurring with intervention were tabulated and comparison of the means for the groups was not significant (delta = 0.3 vs delta = 1.8, p = 0.11). Calcium concentration, faecal pH and deoxycholic acid concentration increased in the calcium group (p = 0.02, 0.005 and 0.004 respectively). Calcium does not show any effect in decreasing colonic mucosal proliferation in this high risk group for colon cancer; it may increase faecal pH and the production of deoxycholic acid in the colon.

Percutaneous endoscopic gastrostomy made easier.

The use of a Fogarty catheter instead of a silk suture in performing an endoscopic gastrostomy offers several advantages. It avoids the problems of stomach deflation, the stomach slipping off the intravenous cannula, the troublesome passage of a soft suture through a small caliber tube and grasping a soft mobile object in the stomach.