Comparison of magnetic resonance imaging-fluorodeoxy- glucose positron emission tomography fusion with pathological staging in rectal cancer.

BACKGROUND: : This study represents an initial experience with combined magnetic resonance imaging (MRI) and [(18)F]fluorodeoxyglucose positron emission tomography (FDG PET) (MRI-PET fusion) in the primary staging of rectal carcinoma. METHODS: : A retrospective analysis of data recorded on patients with rectal cancer was undertaken. Patients requiring long-course radiotherapy were excluded. Chest radiography, abdominal computed tomography and endorectal ultrasonography were performed. In addition, MRI of the pelvis, whole-body FDG PET and MRI-PET fusion were carried out. All patients subsequently underwent anterior resection. RESULTS: : Twenty-three patients with rectal carcinoma (15 men), of median age 60 (range 46-75) years, were enrolled. In tumour (T) assessment, MRI correctly staged 14 of 22 T2/T3 tumours. In lymph node assessment, MRI-PET fusion had a sensitivity of 44 per cent, with a specificity and positive predictive value of 100 per cent. No additional information was acquired from MRI-PET fusion over MRI plus abdominal computed tomography and chest radiography. CONCLUSION: : MRI-PET fusion adds little to conventional investigations for staging rectal carcinoma.

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.

Screening for colorectal cancer using a quantitative immunochemical faecal occult blood test: a feasibility study in an Asian population.

BACKGROUND: The quantitative immunochemical faecal occult blood test (qFOBT) has been shown to be an accurate method of identifying significant colorectal neoplasia including cancer and advanced adenomas. This study reports the results of a Singapore population-based colorectal cancer screening event using the qFOBT. METHODS: This event was held as part of a colorectal cancer awareness exhibition. All asymptomatic individuals above the age of 40 years with no previous colorectal cancer screening in the last 1 year were invited to participate. Eligible participants were screened using two consecutive qFOBTs with a positive faecal haemoglobin threshold taken at 100 ng/mL. Participants with at least one positive qFOBT result were recalled and advised to undergo colonoscopy. Endoscopic polypectomy or surgery was performed according to colonoscopic findings. RESULTS: A total of 751 (55% male, 45% female) participants with a median age of 53 years (range, 40-85 years) took part in the screening event. Five hundred and forty (72%) participants returned the qFOBT samples, of which 57 (11%) tested positive. Fifty-two of these participants proceeded to colonoscopy. Three participants had sigmoid cancer and 12 had advanced polyps, all of which were located distally in the sigmoid colon or rectum. Five of the participants required surgery for colorectal neoplasia and all recovered well without complications. CONCLUSION: The qFOBT at a positive faecal haemoglobin threshold of 100 ng/ml has a high positive predictive value and is an effective screening tool for colorectal cancer in an Asian population.

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.

Correlation of histology with anorectal function following stapled hemorrhoidectomy.

INTRODUCTION: The inadvertent removal of smooth muscle during the use of stapled hemorrhoidectomy had raised concerns about its effects on postoperative anorectal function. We correlated the amount of smooth muscle removed with anorectal function in the early postoperative period. METHODS: Patients were assessed preoperatively with an Eypasch quality-of-life questionnaire and underwent anorectal manometry and physiology testing. This was followed by a similar examination at three months postoperatively. Patients were operated on by a single surgeon and the excised anorectal mucosa was sent for histologic examination. The amount of smooth muscle excised was expressed semiquantitatively as a percentage of the total tissue removed. RESULTS: Sixty-eight patients (33 males) were recruited prospectively, with median age of 44 years. Six patients were lost to follow-up. Removal of anal transitional zone did not increase the incidence of incontinence. Both median preoperative and postoperative continence scores were good. Only one patient had incontinence to gas as a result of the operation. Median preoperative and postoperative quality-of-life scores were 114 and 131, respectively, out of a total of 144, the higher postoperative scores showing an improvement. Correlation of quality-of-life scores and mean resting anal pressures with percentage of smooth muscle removed did not show any statistical significance. CONCLUSIONS: Some smooth muscle will invariably be excised in stapled hemorrhoidectomy but the amount of smooth muscle removed did not significantly affect the continence score, quality of life, or mean anal resting pressure after stapled hemorrhoidectomy. It remains a safe and preferred procedure for the treatment of hemorrhoids.

Minilaparotomy left iliac fossa skin crease incision vs. midline incision for left-sided colorectal cancer.

BACKGROUND: Midline laparotomies offer excellent exposure but are associated with increased postoperative pain and longer recovery. A minilaparotomy resection of leftsided colorectal cancers was studied as an alternative approach. PATIENTS AND METHODS: We performed a case-control retrospective review of 280 randomly selected patients (140 midline incisions; 140 left skin crease incisions) who underwent elective, curative resection of left-sided colorectal cancers. RESULTS: Patients in both groups were of comparable age and sex. The left skin crease incision was shorter (median length, 13.5 cm) than the midline incision (median length, 20.0 cm). Median operation time was less in the left skin crease group (75 min) than in the midline incision group (105 min). Similar types of operations were performed, including left hemicolectomies, sigmoid colectomies, anterior resections and ultra-low anterior resections. Adequacy of resection was confirmed by histological analysis, with no involvement of margins. The median numbers of lymph nodes removed were comparable: 10 for the skin crease incision group and 12 for the midline incision group. Postoperative parameters for the skin crease incision group showed that feeding, ambulation, narcotic use and hospital stay were significantly better than the parameters in the midline group. Complications of intestinal obstruction were also reduced in the skin crease incision group. CONCLUSIONS: The limited left skin crease incision provides adequate margins of clearance in colorectal cancers when compared to the midline incision, but has advantages of shorter operation time, earlier feeding and ambulation, and earlier discharge from hospital.

Colorectal cancer in the young: a 12-year review of patients 30 years or less.

OBJECTIVES: As the incidence of young colorectal cancer is rising, a review of the characteristics of such malignancy in those under 30 years of age is timely at this stage. PATIENTS AND METHODS: Thirty-nine patients (21 M, 18 F) were operated upon over a 12-year period in a single centre. The mean age was 25 years and median follow-up was 20 months. RESULTS: Rectal bleeding, change in bowel habit and abdominal pain were the commonest symptoms. Six patients had a positive family history, while four others were diagnosed as index cases of familial adenomatous polyposis. Rectal tumours made up 43% of all colorectal cancers diagnosed. Seventy percent of patients presented at an advanced stage, but curative resection was attempted for 29 patients. Eight underwent palliative resections, 1 had an ileostomy while another underwent a bypass procedure. Eleven patients have died, 14 had no evidence of recurrent disease while 3 were still alive with recurrent disease. CONCLUSION: Age does not affect survival, and early endoscopy is recommended for all with persistent symptoms. Early diagnosis, radical resection and adjuvant therapy still form the cornerstone in management of colorectal cancer in this age group.

Small bowel malignancies: a review of 29 patients at a single centre.

OBJECTIVE: We analysed the incidence, clinical presentation and outcome of small bowel malignancies treated in the department. PATIENTS AND METHODS: From July 1993 to December 2001, 29 patients with small bowel malignancies were operated upon. The median age was 60 years (30-87 years), and there were 11 males and 18 females. The more frequently used diagnostic investigations included barium contrast studies, and CT scanning. RESULTS: The most frequent complaint was abdominal pain, though other symptoms like abdominal mass, weight loss and change in bowel habit may also be present. Intestinal obstruction necessitated emergency operation in some cases. One case was treated as Crohn's stricture and two others, as irritable bowel syndrome for nearly 6 months before referral was made for surgery. Fifteen cases were secondaries to the small bowel, and fourteen were primary small bowel malignancies. The secondaries were metastases from colorectal cancers (8), gynaecological cancers (5), breast (1) and transitional cell carcinomas (1). Of the 14 primary small bowel malignancies, there were 8 lymphomas, 4 adenocarcinomas and 2 neuroendocrine tumours. Eleven of these patients were alive at mean follow-up of 25 months (1-97 months) and 2 were lost to follow-up. Only one of the secondary small bowel malignancies was alive at the time of review. CONCLUSION: Small bowel malignancy is a rate entity with pre-operative diagnosis remaining difficult. Early surgical intervention with a high index of suspicion is required to improve survival.

A 12-year experience in the surgical management of vesicovaginal fistulae.

INTRODUCTION: Vesicovaginal fistulae are largely iatrogenic and represent therapeutic dilemmas in surgical approach and timing of repairs. AIM: We have reviewed our surgical management of vesicovaginal fistulae over a 12-year period to determine whether the outcome is dependent on surgical approach and timing of repair. PATIENTS AND METHODS: From January 1990 to September 2001, 23 patients were referred to our department of whom 20 have retrievable records. Fourteen of these 20 patients had gynaecological operations as the primary cause for their fistulas whilst the remaining six had varied causes ranging from forceps delivery to recurrent pelvic malignancies. RESULTS: Of 20 patients, four underwent transvaginal repair, seven transvesical repair, eight supravesical repair and one required an ileal conduit diversion. There was an 85% success after first repair with only three fistula recurrences, two of whom underwent a successful second repair and one was treated conservatively and successfully with urethral catheterisation. There were no further recurrences at mean follow-up of 23 months for our cohort. Earlier repair seemed to be associated with a higher recurrence rate (33% of six patients within six weeks) compared with delayed operations (7% of remaining 14 operated after six weeks). CONCLUSION: Vesicovaginal fistulae can be successfully managed surgically. Although the type of approach did not affect outcome, the timing of the repair may affect the success of the operation.

Results of long saphenous vein stripping.

OBJECTIVE: To audit retrospectively all long saphenous vein stripping performed or supervised intra-operatively by a single surgeon over a seven-year period. PATIENTS: One hundred and twenty-four patients (156 limbs) operated primarily in standard surgeon-supervised operations, were audited. METHODS: All patients were questioned via telephone interviews, and those with symptoms or recurrent varicosities were recalled for clinical review and investigations by the surgeon. RESULTS: Eighty-seven cases presented with lower limb pain, 36 with eczema and 27 with ulcer. Eighty-one percent of operations were performed for symptomatic varicose veins and 19% were done for cosmesis. There were 153 limbs with varicosities, 121 of these had documented long saphenous vein reflux preoperatively. One hundred and sixteen limbs resolved post-operatively, five did not resolve, and four recurred. Incompetent perforators and short saphenous veins were the commonest causes of non-resolution and recurrence. Complications, including five cases of saphenous nerve paraesthesias, were temporary and met with full resolution eventually. CONCLUSION: A 96% success rate is possible after high tie, stripping of the long saphenous vein with multiple avulsions of varicosities. Recurrence is 3% over the period of follow-up.