Stapled transanal rectal resection for obstructed defecation: a cautionary tale.

PURPOSE: This prospective study was designed to assess the efficacy and safety of a novel technique in treating outlet obstruction syndrome using a transanal double-stapling procedure. METHODS: Two hundred thirty patients (187 female) with obstructed defecation underwent stapled transanal rectal resection over a six-year period with follow-up at 2, 6, and 12 months, then yearly; median follow-up was 24 (range, 12-68) months. All failed conservative measures. Patients with slow transit constipation and puborectalis dyssynergia were excluded. RESULTS: Operating time was short (median, 35 (range, 20-95) minutes), with 159 (69%) performed as day cases (outpatient). Major complications were seen in 16 (7%); there were no deaths. Twelve (5%) patients reported severe postoperative pain. Immediate postoperative fecal urgency was reported by 107 (46%) patients, but persisted at six months in only 26 (11%). Three (1%) developed recurrent rectal prolapse. Nearly all incontinent patients (98%) reported an improvement, with a median Wexner score reduction of 5 points (P < 0.0001). Constipation improved in 77% of patients. Seventy-seven percent of patients were "very glad" they had the operation, and 86% "recommended" stapled transanal rectal resection to a friend. CONCLUSION: Stapled transanal rectal resection can be performed on a day-case basis with high levels of patient satisfaction. Incontinence and constipation are improved. However, significant morbidity occurs in 7% of patients, and urgency of defecation persists beyond six months in 11%.

Is routine magnetic resonance imaging justified for the early detection of resectable liver metastases from colorectal cancer?

PURPOSE: This study was designed to determine whether routine follow-up by magnetic resonance imaging improves the detection of resectable liver metastases from colorectal cancer and patients' survival. METHODS: Patients who underwent curative surgery for colorectal cancer were included in a program of liver surveillance by routine magnetic resonance imaging, in addition to the standard follow-up protocol consisting of clinical examination and biochemical tests. The median follow-up was 41 (interquartile range, 30-53) months, with a median magnetic resonance imaging surveillance period of 20 (interquartile range, 12-27) months. Cases were analyzed for mode of diagnosis, resectability, and overall survival. RESULTS: Liver metastases were found in 37 (13 percent) of 293 patients studied. Magnetic resonance imaging diagnosed hepatic metastases with 84 percent sensitivity and 90 percent specificity. In 28 (76 percent) patients, carcinoembryonic antigen and/or liver function tests were abnormally elevated and 5 patients (14 percent) were symptomatic. Hepatic resection was possible in only nine patients (24 percent). Magnetic resonance imaging detected all resectable cases, whereas traditional follow-up would have missed three (33 percent) cases suitable for surgery. CONCLUSIONS: Although magnetic resonance imaging surveillance increased the number of patients suitable for liver resection by 50 percent, these represented only 1 percent of the patients included in the study. Whether these results are enough to justify the allocation of expensive resources is controversial.

Routine follow-up by magnetic resonance imaging does not improve detection of resectable local recurrences from colorectal cancer.

OBJECTIVE: To determine if routine follow-up by magnetic resonance imaging (MRI) improves the detection of resectable local recurrences from colorectal cancer. SUMMARY BACKGROUND DATA: Surgical treatment offers the best prospect of survival for patients with recurrent colorectal cancer. Unfortunately, most cases are often diagnosed at an unresectable stage when traditional follow-up methods are used. The impact of MRI surveillance on the early diagnosis of local recurrences has yet to be ascertained. METHODS: Patients who underwent curative surgery for rectal and left-sided colon tumors were included in a program of pelvic surveillance by routine MRI, in addition to the standard follow-up protocol. Cases were then analyzed for mode of diagnosis, resectability, and overall survival. RESULTS: Pelvic recurrence was found in 30 (13%) of the 226 patients studied. MRI detected 26 of 30 (87%) and missed 4 of 30 (13%) cases with local recurrence. Of the latter, 3 were anastomotic recurrences. In 28 (14%) patients, local recurrence was suspected by an initial MR scan but cleared by subsequent MRI or CT-guided biopsy. Recurrent pelvic cancer was diagnosed by MRI with 87% sensitivity and 86% specificity. In 19 (63%) cases, CEA was abnormally elevated, and 9 patients (30%) were symptomatic. Surgical resection was possible in only 6 patients (20%). There was no difference between MRI and conventional follow-up tests in their ability to detect cases suitable for surgery. CONCLUSIONS: Pelvic surveillance by MRI is not justified as part of the routine follow-up after a curative resection for colorectal cancer and should be reserved for selectively imaging patients with clinical, colonoscopic, and/or biochemical suspicion of recurrent disease.

A case-control study of laparoscopic right hemicolectomy vs. open right hemicolectomy.

PURPOSE: The purpose of our study was to examine all laparoscopic right hemicolectomies performed for cancer in our unit and to compare them with a case-control series of open right hemicolectomies, with emphasis on long-term survival. METHODS: In a retrospective case-control series of right hemicolectomies, those done laparoscopically were compared with an age-matched and stage-matched series of patients who underwent open surgery. Survival was analyzed with the Kaplan-Meier method. RESULTS: Ninety-nine patients were included in the study, 33 laparoscopic and 66 open. Mean age 69.7 years. Dukes staging was the same between the two groups and mean follow-up period was 65.7 months. There were six laparoscopic conversions. The number of days patients were kept nil by mouth was significantly less in the laparoscopic cohort, with a mean of 2.4 days vs. a mean of 3.65 days (P = 0.005, Mann-Whitney U test). The number of days during which patients required parenteral opiates was significantly less in the laparoscopic cohort, with a mean number of days of 2.5, in contrast to 4.5 days in the open group (P = 0.008, Mann-Whitney U test). When overall survival was compared between the open and laparoscopic groups, no difference was found, with a mean overall survival of 40 months in the laparoscopic cohort and 39.4 months in the open cohort (P = 0.348, log-rank test). CONCLUSION: Laparoscopic right hemicolectomy for cancer does not compromise long-term survival and affords the advantage of a shorter period of postoperative ileus and decreased analgesia requirements.

Cytotoxic T-cell immunity against telomerase reverse transcriptase in colorectal cancer patients.

The catalytic subunit of telomerase (hTERT) has recently been proposed as a potential tumour-associated antigen capable of inducing T-cell mediated immunity in cancer patients. Before any attempts at vaccination with hTERT antigens can be made, one should establish if cancer patients possess cytotoxic T-lymphocytes (CTL) that can recognise hTERT epitopes. The T-cell response against two HLA-A2-specific epitopes of hTERT in 37 colorectal cancer patients and 12 normal controls was analysed using an interferon gamma (IFN-gamma) ELISPOT assay. For comparison the response to HLA-A2-restricted epitopes of CEA and influenza A matrix protein was also measured. CTL that recognised either of the two hTERT epitopes studied were found in 7 (19%) of colorectal cancer patients, with 2 (5%) possessing T-cells that recognised both these peptides. Four (11%) colorectal cancer patients had CTL that reacted to the CEA epitope. No relationship between cancer stage and the presence of specific CTL against hTERT or CEA was observed. None of the normal controls possessed T-cells capable of recognising either the hTERT or the CEA epitopes. However, a similar proportion of patients and normal controls had CTL reactive with the influenza A peptide. The results of this study demonstrate that CTL active against hTERT are present in approximately 20% of colorectal cancer patients irrespective of disease stage. Moreover, these cells are functional, able to secrete IFN-gamma when stimulated with the relevant peptide.

Gastric barotrauma in a scuba diver: report of a case.

Stomach rupture can occur as a consequence of the expansion of compressed air during rapid ascent after diving. We present the case of a middle-aged woman who suffered a gastric tear from surfacing too quickly after diving, and discuss the diagnosis and management of such patients by reviewing previously reported similar events. Gastric barotrauma should be suspected in divers who complain of abdominal pain, even in the absence of frank signs of peritoneal irritation. Although pneumoperitoneum is always present in these patients, it can also occur as a consequence of pulmonary barotrauma, making gastroscopy or radiological contrast studies, or both, essential for a definitive diagnosis. Surgical repair represents the treatment of choice for an active full-thickness tear and, if associated with arterial gas embolism or decompression sickness, should ideally be performed in a center where a category I (intensive care-capable) hyperbaric unit is available.

Does laparoscopic abdominoperineal resection of the rectum compromise long-term survival?

PURPOSE: Laparoscopic techniques for bowel resection have not enjoyed widespread popularity. Of concern is that long-term follow-up data of cancer specific outcomes is not yet available. The aim of our study was to examine the long-term outcome of abdominoperineal resection for cancer done laparoscopically compared with a similar cohort who underwent open surgery. METHODS: A retrospective review was performed of all abdominoperineal resections done in our center between 1992 and 2000, comparing the cancer-specific outcomes of the laparoscopic cohort with the open cohort. The analysis was performed on an intention-to-treat basis and survival analysis was calculated by the techniques of Kaplan-Meier. RESULTS: Eighty-nine patients were reviewed. Twenty-eight operations were done laparoscopically, and 61 were open. The two groups were matched for age and stage of disease. There was no difference in mean length of overall survival (open = 30.3 months; laparoscopic = 40.8 months; P = 0.355 log rank). No difference in overall recurrence rate, isolated recurrence rate, or distant recurrence rates was seen nor was there any difference in the disease-free period. There was no difference in the number of lymph nodes harvested from the resected specimens, and the distance to the lateral margins or involvement of tumor in the lateral margins between the two groups was the same. The laparoscopic cohort did have a significantly shorter length of stay (mean, 13 days) compared with the open cohort (mean, 18 days), P = 0.008 Mann-Whitney U test. CONCLUSIONS: Laparoscopic abdominoperineal resection of the rectum for cancer does not compromise cancer-specific survival outcomes. The patients avoid a large abdominal wound, which improves cosmesis and presumably is responsible for the significantly shorter length of stay.

The role of CD8(+) T cells in immune responses to colorectal cancer.

Cytotoxic T lymphocytes (CTL) are essential effectors of the cell-mediated immune response. The ability of CTL to specifically recognise and lyse malignant cells expressing the relevant surface antigens under optimal in vitro conditions justifies attempts to boost their number and activity through various forms of immunotherapy. Considering the high prevalence of colorectal cancer and poor survival rates for patients with advanced-stage disease, the development of new protocols based on CTL stimulation represents a genuine and promising treatment option. Significant advances in recombinant DNA technology and molecular biology have led to the identification of a number of tumour-associated antigens (TAA). These have served as vaccine constituents and/or stimuli for obtaining CTL used for adoptive immunotherapy after in vitro stimulation and expansion. The present review describes the properties and functions of CTL as effectors of the immune response against tumours, and summarises the known TAA recognised by CTL and the current status of CTL-related immunotherapeutic interventions in colorectal cancer patients.