Greg M. Robertson

Stents or open operation for palliation of colorectal cancer: a retrospective, cohort study of perioperative outcome and long-term survival.

PURPOSE:Expandable, metallic stents provide a new modality of palliation for patients with noncurable metastatic colorectal adenocarcinoma. This study was designed to compare the use of expandable metallic stents as a palliative measure to traditional open surgical management, with particular reference to length of stay, and survival.METHODS:Patients admitted between 1997 and 2002 with left-sided (splenic flexure and distal), colorectal adenocarcinoma and nonresectable metastatic disease (Stage 4) were treated with expandable metal stents or open surgery (resection, bypass, or stoma). The group of patients having stents inserted were compared with regard to perioperative outcome and survival to those having open surgical procedures.RESULTS:Twenty-two of 25 patients had colonic stents successfully inserted and 19 patients underwent open surgery. The two groups were comparable: stent: median age, 66 (range, 37–88) years; 13 males; and open operation: median age, 68 (range, 51–85) years; 12 males. The tumors were primary in 22 stents procedures and 18 open operations. The site of obstruction was: splenic flexure, 2 stent vs. 0 open operation; descending colon, 2 stent vs. 2 open operation; sigmoid colon, 12 stent vs. 6 open operation; rectum, 9 stent vs. 11 open operation. The American Society of Anesthesiologists (ASA) class was: ASA 1, 0 stent vs. 0 open operation; ASA 2, 6 stent vs. 9 open operation; ASA 3, 15 stent vs. 7 open operation; ASA 4, 4 stent vs. 3 open operation. The open operations were laparotomy only (n = 2), bypass (n = 1), stoma (n = 7), resection with anastomosis (n = 4), resection without anastomosis (n = 5). The complications after open operation were urinary (n = 2), stroke (n = 1), cardiac (n = 2), respiratory (n = 2), deep vein thrombosis (n = 1), anastomotic leak (n = 1). There were no stent-related complications. The mean length of stay was significantly shorter in the stent group (4 vs. 10.4 days; P < 0.0001). There was no difference in survival between the two groups (median survival: stent group, 7.5 months; open operation, 3.9 months; log-rank P value = 0.2156).CONCLUSIONS:Patients treated with stents are discharged earlier than after open surgery. Stents do not affect survival. Expandable metal stents provide an acceptable alternative and may be better than traditional open surgical techniques.

Management of Late Complications of Pelvic Radiation in the Rectum and Anus

AbstractPURPOSE: Radiotherapy has become one of the most important treatment modalities for human malignancy. Tumors affecting the organs of the pelvis are increasingly being irradiated for local treatment benefit, with the subsequent complication of anorectal injury of varying extent. The aim of this review is to determine how to manage the consequences of long-term effects of radiotherapy on the rectum and anus. METHODS: A comprehensive search of the literature with manual cross-referencing was performed using the MEDLINE, PubMed, and Cochrane Databases. RESULTS: Long-term manifestations of injury caused by pelvic radiotherapy include abscess and fistula formation, stricture, mucus discharge, urgency, tenesmus, diarrhea, increased risk of cancer, and most commonly, bleeding. Most patients present with several symptoms; however, usually one symptom dominates. CONCLUSIONS: Many of these symptoms are self-limiting, and mucosal complications may often be treated by nonsurgical methods such as topical formalin application, endoscopic argon plasma coagulation, and hyperbaric oxygen therapy. Conservative measures have not been shown to be of benefit if symptoms persist. Structural abnormalities and septic complications are likely to require surgery. Modern techniques in the delivery of radiotherapy help minimize the likelihood of rectal complications.

Management of late complications of pelvic radiation in the rectum and anus: A review

PURPOSE Radiotherapy has become one of the most important treatment modalities for human malignancy. Tumors affecting the organs of the pelvis are increasingly being irradiated for local treatment benefit, with the subsequent complication of anorectal injury of varying extent. The aim of this review is to determine how to manage the consequences of long-term effects of radiotherapy on the rectum and anus. METHODS A comprehensive search of the literature with manual cross-referencing was performed using the MEDLINE, PubMed, and Cochrane Databases. RESULTS Long-term manifestations of injury caused by pelvic radiotherapy include abscess and fistula formation, stricture, mucus discharge, urgency, tenesmus, diarrhea, increased risk of cancer, and most commonly, bleeding. Most patients present with several symptoms; however, usually one symptom dominates. CONCLUSIONS Many of these symptoms are self-limiting, and mucosal complications may often be treated by nonsurgical methods such as topical formalin application, endoscopic argon plasma coagulation, and hyperbaric oxygen therapy. Conservative measures have not been shown to be of benefit if symptoms persist. Structural abnormalities and septic complications are likely to require surgery. Modern techniques in the delivery of radiotherapy help minimize the likelihood of rectal complications.

The Role of Positron Emission Tomography in the Management of Recurrent Colorectal Cancer: A Review

PurposeSurgery remains the only option for potential cure in patients with recurrent colorectal cancer. Accurate staging modalities aid in the avoidance of futile surgery, which may result in considerable morbidity in patients with incurable disease. Current imaging techniques used in disease staging often are not sensitive enough to identify low-volume metastatic disease. This study reviews the role of positron emission tomography in the assessment of patients with suspected recurrent colorectal cancer.MethodsA literature search using the PubMed, MEDLINE, and Embase database was performed, locating English language articles on positron emission tomography, positron emission tomography, recurrent colon, and/or rectal cancer. The references of these papers were searched manually for further references.ResultsPositron emission tomography is more sensitive and more specific than conventional diagnostic imaging for metastatic disease and local recurrence respectively. Studies confirm the superior ability of positron emission tomography scans compared with conventional diagnostic imaging in differentiating between scar tissue and invasive tumor. Positron emission tomography scanning is more sensitive and specific for the assessment of liver metastases (and probably in patients with lung metastasis) than conventional diagnostic imaging. Positron emission tomography is superior to conventional diagnostic imaging in the investigation of raised carcinoembryonic antigen in the postoperative patient and alters management in approximately 37 percent of patients with recurrent colorectal cancer. The limitations and cost effectiveness of positron emission tomography are discussed.ConclusionsPositron emission tomography scanning is emerging as the imaging modality of choice for patients being considered for surgery for locally recurrent colorectal cancer. Positron emission tomography has the greatest impact by detecting unresectable disease and thereby averting inappropriate surgery. Despite the high set-up costs, its use seems to be cost effective.

Parastomal hernia following minimally invasive stoma formation

Background:  Minimally invasive intestinal stoma formation using a laparoscopic approach or through a trephine, is widely described in published literature. The incidence of parastomal hernia (PH) following a stoma formed without formal laparotomy is not well reported. The present review aims to assess the current data available on minimally invasive stoma formation, with particular reference to the incidence of PH.

Enhanced recovery after surgery versus conventional care in colonic and rectal surgery

Enhanced recovery after surgery (ERAS) programmes have been shown to improve outcomes after colonic surgery. However, there is less evidence supporting ERAS in rectal surgery. The aim of this study was to compare outcomes of conventional perioperative care with those of an ERAS pathway including both colonic and rectal surgery patients.

Abdominoperineal resection or low Hartmann's procedure.

Aim:  To compare patients having low Hartmanns resection (LHP) with abdominoperineal resection (APR) by investigating postoperative complications.

The process and outcomes of a nurse‐led colorectal cancer follow‐up clinic

Aim  Evidence suggests that follow‐up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow‐up can overwhelm a service, affecting the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse‐led follow‐up service was started in 2004. We aimed to review the results of a nurse‐led colorectal cancer follow‐up clinic.

Functional Assessment of Bacterial Colonization in Patients With Ileal Pouch-Anal Anastomosis and Brooke Ileostomy

PURPOSEThis study was designed to determine whether patients with an ileal pouch-anal anastomosis have increased gastrointestinal bacterial colonization as assessed functionally compared with patients with Brooke ileostomy and to determine the effect of pouch bacterial colonization on pouch function.METHODSGastrointestinal bacterial colonization in 27 patients with an ileal pouch-anal anastomosis and 20 patients with a Brooke ileostomy was assessed using the 14C-glycocholate and glucose-hydrogen breath tests. Bacterial colonization was correlated with pouch function and pouch satisfaction.RESULTSPatients with ileal pouch-anal anastomosis had increased levels of gastrointestinal bacterial colonization as measured using the 14C-glycocholate method compared with patients with Brooke ileostomy (P = 0.03). Only three patients had a positive result on the glucose hydrogen breath test, two patients with ileal pouch-anal anastomosis, and one with ileostomy; however, the ileal pouch-anal anastomosis patients did have higher levels on this test. Pouch satisfaction and pouch symptoms of urgency were not correlated with levels of bacterial colonization, whereas there was a nonsignificant trend with continence.CONCLUSIONSWe showed increased levels of gastrointestinal bacterial colonization with ileal pouch-anal anastomosis compared with Brooke ileostomy. The increase in bacteria is not limited to the pouch but also are found in the proximal small bowel. There was no correlation between bacterial colonization and urgency, continence, and pouch satisfaction. Reasons for this are discussed.

Quality of life after rectal excision

Dear sir, We read with interest both the article by Hohenberger and Bittorf [1] and the correspondence from Mr Berry [2]. Our department until recently shared the same view as Mr Berry that a low Hartmann’s procedure would be safer in a selected group of patients, usually the elderly and infirm, by avoiding either a low anastomosis with defunctioning stoma with uncertain functional results, or a painful poorly healing perineal wound. We recently completed a review of the postoperative complications following either low Hartmann’s procedure or abdominoperineal excision [3]. Our nonrandomized, retrospective study showed a surprisingly high rate of septic complications after low Hartmann’s compared with abdominoperineal excision, specifically a high rate of pelvic abscesses. Perineal wound healing was a problem, but less trouble than the septic complications after low Hartmann’s and it seems to us on balance that abdominoperineal excision may in fact be better than a low Hartmann’s procedure.