The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI.

OBJECTIVE: The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland. METHOD: A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide. RESULTS: Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48-60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding. CONCLUSION: Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.

Curative resection for low rectal adenocarcinoma: abdomino-perineal vs anterior resection.

OBJECTIVE: Local recurrence after abdomino-perineal excision of the rectum for tumours has been reported to occur in up to a third of patients in contrast to 4% after restorative anterior resection. METHOD: Low rectal tumours were defined as tumours within 8 cm of the anal verge and were treated by either stapled low anterior resection (SLAR) or abdomino-perineal excision of the rectum (APER). One hundred and seventy-eight patients with tumours in the lower third of the rectum (30% of 591 rectal cancers) underwent surgical resection between 1980 and 2001. Data were collected prospectively; 68 (38%) had SLAR and 110 (62%) had APER with median follow up of approximately 12 years; 54 SLAR (79%) and 76 APER (69%) had curative procedures on clinical and pathological criteria. RESULTS: Local and distant recurrence occurred in seven (13%) and eight (15%) patients in the SLAR group and six (8%) and 14 (18%) patients in the APER group, respectively. Overall 5-year survival was 63% and 60% in the SLAR and APER groups, respectively CONCLUSION: For rectal cancers within 8 cm of the anal verge, both procedures achieved equivalent results measured by low local recurrence rates and overall survival.

Hepatic resection for colorectal metastases - a national perspective.

BACKGROUND: Many consultant surgeons are uncertain about peri-operative assessment and postoperative follow-up of patients for colorectal liver metastases, and indications for referral for hepatic resection. The aim of this study was to assess the views the consultant surgeons who manage these patients. METHODS: A postal questionnaire was sent to all consultant members of the Association of Coloproctology of Great Britain and Ireland and of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The questionnaire assessed current practice for preoperative assessment and follow-up of patients with colorectal malignancy and timing of and criteria for hepatic resection of metastases. Number of referrals/resections were also assessed. RESULTS: The response rate was 47%. Half of the consultants held joint clinics with an oncologist and 89% assessed the liver for secondaries prior to colorectal resection. Ultrasound was used by 75%. Whilst 99% would consider referring a patient with a solitary liver metastasis for resection, only 62% would consider resection for more than 3 unilobar metastases. The majority (83%) thought resections should be performed within the 6 months following colorectal resection. During follow-up, 52% requested blood CEA levels and 72% liver ultrasound. Half would consider chemotherapy prior to liver resection and 76% performed at least one hepatic resection per year with a median number of 2 resections each year. CONCLUSIONS: A substantial proportion of patients are assessed for colorectal liver metastases preoperatively and during follow-up though there is spectrum of frequency of assessment and modality for imaging. Virtually all patients with solitary hepatic metastases are considered for liver resection. Patients with more than one metastasis are likely to be not considered for resection. Many surgeons are carrying out less than 3 resections each year.

Surveillance of individuals at intermediate risk of colorectal cancer--the impact of new guidelines.

OBJECTIVE: Individuals with two first degree relatives, or one diagnosed at age < 45 years, with colorectal cancer are at sufficient risk to merit surveillance. Most undergo colonoscopy four to five yearly, starting 10 years before the youngest case. The aim of this study was to assess the impact of a proposed new surveillance protocol. SUBJECTS AND METHODS: We identified individuals with these risk criteria seen in our clinic from 1989 to 2001 and reviewed their notes with respect to colonoscopy. RESULTS: Colonoscopy (n = 295) was performed on 186 patients in accordance with current recommendations. Cancer was detected in three and adenoma in 21 individuals. Applying the proposed protocol, 123 (42%) fewer colonoscopies would have been performed. No cancers would have been missed, but in five cases a small adenoma would not have been detected. CONCLUSIONS: Proposed new guidelines for surveillance of those at intermediate risk reduce the burden of colonoscopy without compromising identification of significant neoplasia.

Multiple microaneurysms of the superior hemorrhoidal artery: unusual recurrent massive rectal bleeding: report of a case.

A case of massive rectal bleeding in a 38-year-old male patient from a previously unreported source is presented. Multiple microaneurysms affecting the rectum were demonstrated on an inferior mesenteric artery angiogram. The importance of angiography both for diagnosis and potential therapy in patients with continuous active lower gastrointestinal bleeding is emphasized.

Diagnostic lessons learnt from a series of enterovesical fistulae.

OBJECTIVE: An enterovesical fistula (EVF) is an uncommon condition requiring careful and sometimes extensive preoperative investigation. Our experience over a 10-year period has been reviewed with emphasis on the diagnostic investigations performed. PATIENTS AND METHOD: Forty-two patients (30 male) have been studied. Presenting symptoms, diagnostic investigations, and subsequent treatment have been reviewed. RESULTS: The site of the fistulae were; 37 colonic, 2 rectal, and 3 ileal. The commonest presenting symptoms were; pneumaturia 75%, faecaluria 63% and urinary tract infections 57%. The positivity rate of the investigations performed were; cystoscopy 89%, urine cytology 86%, barium enema 65%, computerized tomography (CT) scanning 55%, IVP 35%, and cystography 27.5%. The causes of the fistula were; diverticular disease 71%, carcinoma 20%, Crohn's disease 7%, and radiotherapy 2%. CONCLUSIONS: We recommend cystoscopy and urine cytology for faecal material as the first-line investigations in all patients with a suspected enterovesical fistulae. CT scanning and barium enema should not be first line investigations but may be performed subsequently to help determine the aetiology and planning of surgery.

Effect of faecal occult blood testing on colorectal cancer mortality in the surveillance of subjects at moderate risk of colorectal neoplasia: a case-control study.

Colonoscopy is the established method of surveillance of subjects at high risk of developing colorectal neoplasia. Its role in the surveillance of a population at moderate risk is less clear, however, as the procedure is expensive, time consuming and occasionally hazardous. The aim of this study was to estimate by case-control methods the effect of faecal occult blood (FOB) screening on colorectal cancer (CRC) mortality in a population at moderate risk of developing CRC. Screening by FOB testing prior to diagnosis in patients over the age of 45 years who died of CRC diagnosed in 1989-1998 was compared with screening in controls matched with the case for age and sex. Information about episodes of FOB testing and potential confounders was obtained from the data collection system of the screening programme. Cases were less likely than controls to have ever been screened, with an odds ratio of 0.64 (95% confidence interval 0.34-1.15) for exposure to at least one FOB testing. There was no significant difference between the sub-groups according to gender, age at diagnosis or location of the cancer. The inverse association between screening for faecal occult blood and fatal colorectal cancer suggests that screening in a population at moderate risk of CRC can reduce mortality from CRC in this group.

The role of colonoscopy in coloproctological practice.

Colonoscopy has completely changed the practice of colorectal surgery. It has both diagnostic and therapeutic roles. In diagnosis, it allows direct visualization of the colon and taking of tissue biopsies for histology. The commonest therapeutic manoeuvre is polypectomy for bleeding. Colonoscopy is safe and, where facilities exist, it should be used as first-line investigation of colorectal disorders.

Outcome after multiple colorectal tumours.

BACKGROUND: Patients with primary colorectal cancers have a higher risk of development of second tumours synchronously or metachronously. This special group of patients raise a particular interest in their characteristics and outcome. METHODS: The records of 1009 patients with colorectal cancer were scrutinized. A group with multiple cancers was identified. Perioperative investigations, patterns of follow-up, pathological variables and outcome were noted. RESULTS: There were 22 patients with metachronous tumours and 39 with synchronous tumours following 'curative' operations in 20 and 28 respectively. There was no difference in Dukes classification between the two groups: Polyps were associated with metachronous lesions in ten of 22 patients and synchronous lesions in 17 of 39 patients. Five-year survival was 75 per cent for patients with metachronous tumours and only 18 per cent for those with synchronous tumours. CONCLUSION: In this study patients with metachronous tumours seemed to do very well while those with synchronous lesions did very badly. There were no identifiable demographic or clinical characteristics to account for this. There is a need to study this group of patients and identify factors like tumour biology or host resistance which prevent spread of tumour.

Stapled anastomoses in colorectal surgery: a prospective study.

OBJECTIVE: To evaluate the safety and efficacy of stapled anastomosis in left sided colorectal reconstructions. DESIGN: Prospective study. SETTING: District hospital, UK. SUBJECTS: 218 Consecutive patients who underwent elective colorectal reconstructions with stapled anastomoses between July 1980 and July 1994. INTERVENTIONS: 154 Anterior resections of the rectum using single or double stapled anastomoses, 37 rejoining after Hartmann's operations, and 28 restorative proctocolectomies with formation of J pouch ileoanal anastomoses. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: There were 5/154 clinical anastomotic leaks after anterior resection of the rectum and 1/28 after stapled J pouch ileoanal anastomoses. There were no leaks after rejoining of Hartmann's. The overall clinical leak rate was therefore 3%. 11/154 tumours recurred locally after anterior resection of the rectum (7%) during a mean follow up of 18 months, and 8 (73%) developed within 2 years of operation. All but one recurrence developed after single stapled anastomosis. Dukes' staging remains the most reliable prognostic indicator of the local recurrence of the tumour. There were five postoperative deaths after anterior resection but none after Hartmann's procedure or J pouch ileoanal anastomosis, giving an overall postoperative mortality of 2.3%. CONCLUSION: The use of stapling instruments in left sided colorectal anastomosis is safe and technically easy, with a low clinical anastomotic leak rate and an acceptable rate of local recurrence after anterior resection of the rectum.

Screening for colorectal cancer with an immunological faecal occult blood test: 2-year follow-up.

This study is a 2-year follow-up of an average-risk population offered screening with both Haemoccult and Hemeselect tests to determine the interval cancer rate, and thus sensitivity. The effect on compliance with Hemeselect of testing over 1 day rather than 3 days was investigated in a separate cohort. In the first study, 3948 subjects received tests; 1489 (37.7 per cent) completed both tests and 148 had a positive result, 17 (1.1 per cent) were Haemoccult positive and 145 (9.7 per cent) were Hemeselect positive. Investigation of 142 patients revealed ten with cancer (Dukes stage A, seven; B, one; C, two). All were detected by Hemeselect but only one was Haemoccult positive. After a median follow-up of 35 (range 26-43) months, seven further patients developed colorectal cancer (stage A, one; B, three; C, three) but none followed a negative Hemeselect test (100 per cent sensitivity). In the second study 2703 subjects were offered Hemeselect tests. Compliance for testing over 1 day (48.6 per cent) was significantly better than that over 3 days (43.1 per cent) (chi 2 = 8.1, 1 d.f., P < 0.01). Hemeselect is a promising screening test for the early detection of colorectal cancer.

An unusual presentation of intestinal duplication with a literature review.

A 52-year-old male presented with urinary symptoms of frequency and hesitation. X-rays, ultrasound, and computerized tomography investigations were performed that indicated the diagnosis and position of an enteric duplication cyst. Elective surgery was performed to completely remove the duplication cyst. Histological examination showed that the cyst was lined by stratified squamous, ciliated, and gastric-type epithelium, with a muscularis mucosae and a muscularis Propria. No malignancy or dysplasia was seen. Duplications of the alimentary tract are uncommon congenital abnormalities. They may be multiple and arise at any level from the mouth to the anus. Usually observed early in life, a minority may remain unsuspected until adulthood. The clinical presentations may be vague and diverse depending on their location. These include pain, distention, dysphagia, dyspepsia, and complications involve bleeding, perforation, malignancy, and obstruction of the alimentary tract and vessels. Plain x-rays are of limited use in the diagnosis of duplications but ultrasound findings may be diagnostic, with computerized tomography useful in delineating surrounding structures. Once the diagnosis is established, surgical correction is the treatment of choice, preferably with complete removal.

Lymphocyte subset infiltration patterns and HLA antigen status in colorectal carcinomas and adenomas.

Fifty eight large bowel adenocarcinomas and 20 adenomas were studied immunohistochemically, using fresh frozen tissue sections, with regard to lymphocyte subpopulations (CD3, CD4, CD8, CD19, and CD20) in the inflammatory infiltrate and to expression of human leucocyte antigens (HLA-ABC, HLA-A2, and HLA-DR). The findings were related to differentiation and Duke's stage of carcinoma. The inflammatory infiltrate was found to have a phenotype that remained constant irrespective of the intensity of the inflammation. CD4 and CD3 positive cells predominated with fewer CD8 positive cells and a scanty diffuse CD19/20 positive cell population. CD19/20 follicular aggregates were common at the advancing margin of the carcinomas. There was no significant association with Duke's stage, differentiation or HLA status. HLA changes (ABC loss, A2 loss, and DR gain) were associated with differentiation, being more common and more extensive in poorly differentiated carcinomas. HLA-A2 loss was also associated with stage of progression of carcinoma. Inflammation associated with adenomas was found to have a similar phenotype to that associated with carcinomas. HLA changes in adenomas were uncommon, being seen in only one of our 20 cases.

Relation between stage, grade, proliferation, and expression of p53 and CD44 in adenomas and carcinomas of the colorectum.

AIMS: To investigate the changes in and relations among p53, CD44 and MIB-1 expression in adenocarcinomas of the colorectum and to determine whether these changes are progressive across the adenoma-carcinoma sequence. METHODS: Expression of p53 protein, CD44 adhesion molecule and MIB-1 proliferation antigen was detected using immunohistochemistry in 68 colorectal carcinomas and 32 colorectal adenoma. The staining characteristics were compared with degree of dysplasia in adenomas, and differentiation and Dukes' stage in carcinomas. Results were analysed and assessed using Spearman's rank correlation and independent t tests. RESULTS: p53 staining was present in som adenomas and correlated with the degree of dysplasia. There was significantly more staining in carcinomas than adenomas and significant correlation between staining and Dukes' stage. CD44 staining was maximal in adenomas, diminished in carcinomas and was minimal in metastasising carcinomas. There was inverse correlation between p53 and CD44 expression across the adenoma-carcinoma-metastasising carcinoma sequence. MIB-1 expression was highest in carcinomas but did not correlate with either p53 or CD44 expression. CONCLUSIONS: There are progressive changes in p53, CD44 and MIB-1 expression in adenomas and carcinomas. A combination of these tests may prove useful in assessing which patients with adenomas are at greatest risk of progressing to carcinoma.

A 10-year prospective audit of outcome of surgical treatment for colorectal carcinoma.

The outcome of 555 patients who underwent surgery under the care of a surgeon with an interest in colorectal disease was examined prospectively over a 10-year period with no exclusions. There was a 4.7 percent incidence of clinical leaks (10 percent for anterior resection) and an overall corrected 10-year survival rate after curative surgery of 58, 59 and 48 percent for right colonic, left colonic and rectal tumours respectively. The incidence of isolated local recurrence was 8 percent after curative surgery for carcinoma of the rectum. Twenty-five percent of patients with rectal tumours required abdominoperineal excision. Patients who underwent curative abdominoperineal excision of the rectum had corrected 5- and 10-year survival rates of 48 and 36 percent, compared with 60 and 58 percent respectively for curative anterior resection. The perioperative mortality rate of those undergoing palliative surgery was 8 percent, and 75 percent died within 2 years from distant and not local disease. A policy of always attempting resection was validated by the fact that 99 percent of primary tumours were removed with a low perioperative mortality rate (4 percent overall), a high curative resection rate and a low morbidity rate.

Is an immunological faecal occult blood test better than Haemoccult? A cost-benefit study.

Immunological faecal occult blood (FOB) tests have theoretical advantages over their guaiac counterparts in that they are specific for human haemoglobin. HemeSelect is a semi-quantitative immunological FOB text. Faecal material is eluted into test diluent and serial dilutions are performed. The manufacturers recommend that erythrocyte agglutination at 1:8 dilution is considered a positive reaction. However, further serial dilutions can be carried out and the highest dilution at which the test remains positive determined. At 1:8 dilution, the test has been shown to be more sensitive for symptomatic colorectal cancer than Haemoccult. The aim of this study is to compare the positive rates, neoplastic yield and costs of Haemoccult with HemeSelect at various dilutions in asymptomatic average risk subjects aged 50-74. 1489 subjects satisfactorily completed both tests, 145 (9.7%) returned positive Hemeselect tests (read at 1:8 dilution, 38 patients with neoplasms > or = 1 cm) and 17 positive Haemoccult tests (1.1%). All positive Hemeselect tests were further serially diluted. As the Hemeselect dilution increased to 1:16, 1:32, 1:64 and 1:128 so the positive rate and yields of neoplasms > or = 1 cm progressively fell to 6.8% & 35, 3.6% & 20, 2.7% & 18 and 1.5% & 12, compared with 1.1% and eight neoplasms > or = 1 cm for Haemoccult. In spite of the unit cost of the Hemeselect test being greater than Haemoccult, the cost per neoplasm > or = 1 cm was lower for Hemeselect at 1:8 and 1:16 dilutions than Haemoccult. However, for an equivalent neoplastic yield, Haemoccult was cheaper. Hemeselect is a versatile test whose positive rate can be tailored according to the risk of the group being screened.