J. R. T. Monson

Abdominal wall metastases following laparoscopy.

Only 18 cases of recurrence at the sites of cannula insertion after laparoscopy have been reported in the literature, ten of them in the past year. The period between laparoscopic surgery and presentation of wound metastasis varies widely, from 7 days to 10 months; the lesions are typically hard, craggy and painful. The most likely mechanism is direct implantation of viable exfoliated tumour cells but three aspects specific to laparoscopy may also be important. First, there may be increased exfoliation of tumour cells following manipulation by laparoscopic instruments of an unsuspected malignancy. Second, there may be repeated close contact between tumour‐laden instruments and the port. Third, the passage of resected tissue through a small incision may coat the wound with potentially malignant cells.

Transanal endoscopic microsurgery for carcinoma of the rectum

BackgroundThe authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM).MethodsThis prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit.ResultsFor this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48–93 years). The median diameter of the lesions was 3.44 cm (range, 1.6–8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3–15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20–150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22–82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred.ConclusionsThe findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.

Transanal endoscopic microsurgery in early rectal cancer: time for a trial?

Objective  The optimal aim of oncological surgery is to balance cancer outcomes with preservation of function and quality of life. Radical resection (RR) offers the best curative procedure in colorectal cancer but at significant morbidity. Transanal endoscopic microsurgery (TEM) offers an alternative with less morbidity and better function. Its role remains unclear and needs to be established in the light of new emerging trends in rectal cancer. This review aims to evaluate the use of TEM and its limitations.

Preliminary experience with butyl-2-cyanoacrylate adhesive in tension-free inguinal hernia repair

Sir We read with interest the paper by Dr Shifrin et al. (Br J Sue 1996; 83: 1107-9) regarding carotid endarterectomy without preoperative angiography using Duplex ultrasonography as the sole investigative technique. They concluded that it was safe to omit angiography in preoperative assessment (in patients selected on surgeon’s preference) as they found no difference in postoperative complications compared with patients who had also undergone conventional angiography. We do not consider that this conclusion can be drawn from their results. Following the North American Symptomatic Carotid Endarterectomy Trial study’ a clearly defined group of patients with more than 70 per cent stenosis of the internal carotid artery were demonstrated to receive benefit from surgery compared with medical therapy. An important role of preoperative investigation in carotid disease is to assess accurately the degree of stenosis to define those patients who will benefit from surgery. The authors do not state how they assessed the stenosis found at operation and how closely it agreed with the Duplex findings. How do the authors know that they have not operated on a number of patients with a 50 per cent stenosis who did not require surgery? Such a group of patients would be exposed to the risks of surgery unnecessarily. From the data provided in this paper we would therefore still be reticent to perform endarterectomy on patients based on a single preoperative investigation such as duplex ultrasonography.

Vascular endothelial growth factor in premenopausal women - indicator of the best time for breast cancer surgery?

Timing of surgery in premenopausal patients with breast cancer remains controversial. Angiogenesis is essential for tumour growth and vascular endothelial growth factor (VEGF) is one of the most potent angiogenic cytokines. We aimed to determine whether the study of VEGF in relation to the menstrual cycle could help further the understanding of this issue of surgical intervention. Fourteen premenopausal women were recruited, along with three post-menopausal women, a woman on an oral contraceptive pill and a single male subject. Between eight and 11 samples were taken per person, over one menstrual cycle (over 1 month in the five controls) and analysed for sex hormones and VEGF165. Serum VEGF was significantly lower in the luteal phase and showed a significant negative correlation with progesterone in all 14 premenopausal women. No inter-sample variations of VEGF were noted in the controls. Serum from both phases of the cycle from one subject was added to MCF-7 breast cancer cells; VEGF expression in the supernatant was lower in the cells to which the luteal phase serum was added. The lowering of a potent angiogenic cytokine in the luteal phase suggests a possible decreased potential for micrometastasis establishment in that phase. This fall in VEGF may be an effect of progesterone and should be the focus of future studies.

Changes in T cell subsets, interleukin-6 and C-reactive protein after laparoscopic and open colorectal resection for malignancy

Background: Attenuation of the immune response to surgery, as demonstrated with the laparoscopic approach to cholecystectomy, has potential benefits in patients undergoing laparoscopic colonic resection for malignancy. We aimed to study the perioperative immune response in patients undergoing laparoscopically assisted and open surgery for colorectal cancer. Methods: This study involved 23 patients undergoing laparoscopically assisted (n = 13) and open surgery (n = 10). Interleukin-6 (IL-6) C-reactive protein (CRP), the total lymphocyte count, and the CD3, CD4, CD8, CD16, and CD19 lymphocyte subpopulations were assayed preoperatively and at 4, 8, 10, 24, 48, and 168 h postoperatively. Results: Significant rises in IL-6 and CRP were demonstrated within 4 and 24 h, respectively (p < 0.001) in both groups. However, no significant difference between the groups was seen. Significant decreases in total lymphocyte count and all T cell subsets were demonstrated in both groups, beginning at 4 h (p < 0.01). However, no significant difference between the groups was seen. All parameters, excluding CRP, had returned to baseline by 7 days postoperatively in both groups. Conclusions: Patients with malignancy exhibit significant perioperative immune disturbance with laparoscopically assisted and open surgery. The current data do not provide justification for the laparoscopically assisted approach on grounds of immune preservation.

Vaginography—Investigation of choice for clinically suspected vaginal fistulas

PURPOSE: Vaginal fistulas are rare but can cause extremely distressing symptoms for patients and prove difficult to define anatomically. Barium studies have been reported as having a maximum sensitivity of only 34 percent for detection of vaginal fistulas. Vaginography is an alternative method for diagnosis and evaluation of suspected vaginal fistulas, which has been reported to have a sensitivity of 100 percent. We reviewed our total experience of vaginography to fully assess its capabilities. METHODS: Twenty-seven patients with clinically suspected vaginal fistulas were investigated with vaginography during a six-year period. Results of vaginograms were compared with final operative or clinical diagnosis and with results of other radiologic investigations. RESULTS: Vaginography successfully identified 19 of 24 fistulas, giving a sensitivity of 79 percent. In our series, barium enema was only able to identify 9 percent of fistulas arising from the colon. CONCLUSIONS: In this, the largest series of vaginograms, apparent reduction in sensitivity from the 100 percent quoted in earlier series to 79 percent probably represents a more accurate assessment of vaginography as a diagnostic investigation. Even allowing for this reduction, vaginography is still the most sensitive, economic, and informative investigation for identification and delineation of vaginal fistulas. We recommend that vaginography be the initial investigation of choice in patients with clinically suspected vaginal fistulas.

Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists

Aim  Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction.

Alterations in the immune system and tumor growth in laparoscopy.

BackgroundThe explosion in the use of therapeutic laparoscopy during the past decade has focused much research interest on finding a basic scientific support for the clinically apparent attenuation of the stress response to surgery. In particular, the potential impact that attenuation of the immune response to surgery may have on laparoscopy for the cure of malignancy has attracted much attention.MethodsA review of the published literature on the stress response to laparoscopic surgery and the impact of laparoscopy on tumor growth was performed.ResultsEvidence favors an attenuation of the immune response to surgery with laparoscopic cholecystectomy. Whether this is true also of more major procedures such as laparoscopically assisted colectomy for malignancy is currently unclear. In animal models, tumor growth after laparoscopic surgery is less than after laparotomy and depends on the insufflation agent used.ConclusionsLaparoscopic cholecystectomy appears to be associated with attenuation of the immune response to surgery. The implications of these findings for the future use of laparoscopic surgical techniques for malignant disease remain unclear.

Staged delivery of Nd:Yag laser therapy for palliation of advanced rectal carcinoma

PURPOSE: This study was designed to assess the degree of symptom relief, complication rate, and survival time of patients who undergo palliation with the neodymiumyttrium aluminum garnet (Nd:YAG) laser for advanced rectal cancer. METHODS: Charts of 41 consecutive patients with advanced rectal cancer treated by this method were reviewed. RESULTS: Thirty-three patients received laser treatment for a primary tumor, and eight received laser palliation for local recurrence following previous surgery. Mean number of treatments delivered was 2 (range, 1–6) for patients with a primary lesion and 2 (range, 1–4) for those patients with local recurrence. In patients in whom more than one delivery was required, subsequent procedures were deferred for more than six weeks. Morbidity rate was 2 percent, with no procedure-related mortality. Median survival time was 19 (range, 1–60) months for patients with a primary tumor and 7 (range, 3–38) months for patients with local recurrence. Four patients subsequently elected to undergo palliative surgery, and five other patients had a loop colostomy formed because of large-bowel obstruction after a mean of 24 (range, 18–41) months. Nd:YAG laser treatment offered adequate laser palliation for 78 percent of patients in this series. However, patients who survive for more than 24 months after their first laser treatment are more likely to require palliative surgery. CONCLUSIONS: The majority of patients undergoing laser ablation for palliation do not require large numbers of treatment sessions. By delaying the interval between treatments, morbidity and mortality rates are negligible. Most patients avoid a stoma or defer the date of requiring one before their death with this therapy.