A. M. Cuthbertson

Evaluation of new occult blood tests for detection of colorectal neoplasia

BACKGROUND Hemoccult II, the guaiac-based fecal occult blood test used in most colorectal cancer screening programs, has an unsatisfactory sensitivity for asymptomatic colorectal neoplasms. We evaluated the relative performance of four fecal occult blood tests, directed against various components of the hemoglobin molecule. METHODS All tests, Hemoccult II, HemoccultSENSA (a more sensitive guaiac test), HemeSelect (an immunochemical test specific for human hemoglobin), and HemoQuant (the heme-porphyrin assay), were performed by 107 patients with symptomatic colorectal cancer and 81 patients with predominantly asymptomatic adenoma. Hemoccult-SENSA and HemeSelect were performed by 1,355 screenees. RESULTS HemeSelect and Hemoccult-SENSA had significantly higher sensitivity for colorectal cancer (97% and 94%, respectively) than the other tests. HemeSelect had the highest sensitivity for adenomas; in 45 patients with large (> or = 10 mm) adenomas, sensitivity was 76% for HemeSelect, 60% for HemoccultSENSA, and 42% for both Hemoccult and HemoQuant. In the screenees, estimated specificity was 97.8% for HemeSelect and 96.1% for Hemoccult-SENSA. CONCLUSIONS HemeSelect and Hemoccult-SENSA have the highest levels of sensitivity for detection of colorectal neoplasia, but the immunochemical test HemeSelect provides the best combination of specificity and sensitivity.

Megacolon in adults.

SummaryIn a series of 17 adult patients with megacolon, six seemed to have Hirschsprung’s disease. All were said to have had the disease in childhood and all had normal rectums, but biopsies were done in only two cases. One of the patients was treated conservatively, but he died of pneumonia two years later, and collapse of the lungs secondary to the distention of the colon appeared to be an important factor.Three patients had excellent results after sigmoidal colectomy. Pull-through excision (one case) may have been unnecessarily radical.Patients with idiopathic or acquired Hirschsprung’s disease have had less satisfactory results after surgery, and after sigmoidal colectomy in particular. If intensive medical treatment fails, total colectomy and ileorectal anastomosis may be the best procedure.

A comparison between single and double dose intravenous timentin for the prophylaxis of wound infection in elective colorectal surgery

A prospective, randomized, single-blind, controlled clinical trial was undertaken to determine whether two doses of systemic Timentin provided superior prophylaxis against postoperative sepsis in elective colorectal surgery compared with a single dose of the same antibiotic. Timentin, a combination of ticarcillin and clavulanic acid was administered intravenously (3.1 g) at the commencement of operation to all patients, and this was repeated after 2 hours in those patients randomized to receive a second dose. The wound infection rate was 11 percent in the 143 patients completing follow-up and receiving a single dose, and 13 percent in the 128 patients receiving two doses of Timentin (P>0.05). The rates of postoperative septicemia 3vs.4 percent and intra-abdominal abscess 5vs.8 percent were similar. Multivariate analysis of the factors likely to affect postoperative wound infection rate demonstrated an association with the type of hospital, public or private, wound infection rate 16 and 6 percent, respectively (P<0.01), and the surgeon group defined by the number of patients contributed greater than 25 or less than 25, wound infection rate 6 and 18 percent, respectively (P<0.05). We concluded that a single dose of intravenous Timentin was as effective as two doses for prophylaxis against surgical infection and that the surgeon group and the hospital in which the operation took place were statistically significant predictors of postoperative wound infection.

Suture-line neoplastic recurrence following large-bowel resection.

Nineteen patients who had a suture-line recurrence of a bowel neoplasm are reviewed. This sequela to colonic or rectal resection and anastomosis is most common distally, and following segmental or anterior resections. It was absent after small-to-large bowel anastomosis, and following pull-through resection. Three types of suture-line recurrence were observed at exploration, and the times of development fell into early and late groups. Prognosis was best where there was mucosal recurrence only and when this developed late.

Angiosarcoma of the colon

A case of angiosarcoma of the large bowel is presented. The tumor occurred in a 16-year-old girl who presented with lower abdominal pain and rectal bleeding. A sigmoid colectomy was performed. Although macroscopic omental and pelvic peritoneal metastases were noted at operation, she did not receive adjuvant therapy and was alive and well more than three years after surgery. The literature on colonic angiosarcoma is also reviewed.

Squamous Cell Carcinoma of the Anal Canal and Anal Margin

This is a study of 41 patients with squamous carcinoma of the anus. There were 23 with a carcinoma situated above the dentate line, the five-year survival rate being 27%, and 18 with a carcinoma below the dentate line, with a five-year survival rate of 30%. Advanced local and lymphatic spread at the initial examination was a prominent feature of the series. SUMMARY The records of 41 patients with squamous cell carcinoma of the anal canal and anal margin are reviewed. An exact follow-up study was possible in every instance. There were 23 individuals with carcinoma of the anal canal and 18 with carcinoma of the anal margin. Spread to local structures or lymph nodes was observed in nearly half of the patients with anal canal carcinoma, and less frequently in anal margin carcinoma. The preferred method of treatment for anal canal carcinoma was a Miles abdominoperineal resection, and for anal margin carcinoma wide local excision. The combined five-year survival was 28.6%, being 27% for anal canal carcinoma, and 30.5% for anal margin carcinoma.

Subtotal colectomy for obstructing carcinoma of the upper left colon

Summary and ConclusionsApplication of the principle of immediate resection and ileocolostomy to tumors of the right portion of the colon and to tumors of the upper left portion of the colon, in suitable cases, provides an easy and safe convalescence.Twelve patients with obstructing lesions of the upper left portion of the colon were treated by immediate subtotal colectomy and ileocolostomy. there was one postoperative death, due to an anastomotic leak which caused a tension pneumoperitoneum. This complication is so rare that it was considered worthy of a separate report which appeared in 1964.1 During the period under review, two obstructing carcinomas of the sigmoid flexure were treated in a similar fashion by immediate subtotal colectomy and ileocolostomy. Both these patients have had a good result, but it is believed that with tumors situated so far distally as the sigmoid flexure, some of the advantages of this form of treatment are lost.It remains to be seen whether the long-term period of survival has been improved by this method.