K.I. Deen

Quality of life of stoma patients: temporary ileostomy versus colostomy

Ileostomy for proximal diversion as a preferred option over colostomy has been a recent topic of interest. Our study evaluated the quality of life (QOL) of patients with a temporary ileostomy and compared it with that of patients with a temporary colostomy. The QOL of 25 patients with an ileostomy (median age 42 years, range 22–76 years) was compared with that for 25 patients with a colostomy (median age 44 years, range 18–70 years). Indications for a stoma were rectal carcinoma, trauma, inflammatory bowel disease, anastomotic leak, or incontinence following an operative procedure for rectal prolapse. The study was conducted at a median of 8 weeks (range 6–16 weeks) for ileostomy patients and of 9 weeks (range 5–17 weeks) for colostomy patients following stoma creation. A self-administered structured questionnaire was used, with responses obtained for 10 QOL questions on a visual analog rating scale (0–100 mm); they were graded good (71–100), satisfactory (31–70), or poor (0–30). Altogether, 22 (88%) patients with an ileostomy, compared with 16 (64%) patients with a colostomy, were able to purchase their stomal appliances (p = 0.09, χ2: NS). Effluent was tolerable in 18 (72%) patients with an ileostomy compared with 7 (28%) patients with a colostomy (p = 0.002, χ2). Appetite was not affected in any of the patients with an ileostomy (100%), compared with 64% of patients with a colostomy (p = 0.002, χ2), travel by public transport 32% compared to 28% with colostomy (NS), dress in 20% compared to 24% with colostomy (NS), and daily activities 28% compared to 24% with colostomy (NS). Moreover, 68% with an ileostomy did not have a problem with hygiene compared with 40% with a colostomy (NS); 95% with an ileostomy abstained from sexual activity compared with 81% with a colostomy (p = 0.21, χ2: NS). Both ileostomy and colostomy resulted in significant QOL impairment. However, with ileostomy, the effluent was more tolerable, had less of an impact on personal hygiene, and preserved the appetite compared with colostomy. There were no differences in travel, dress, daily chores, or sexual activity between the two groups.

Neoadjuvant therapy for rectal cancer down-stages the tumor but reduces lymph node harvest significantly.

PurposeThe impact of neoadjuvant therapy (NAT) for rectal cancer on lymph node yield is not well known. This study evaluates the impact of NAT on tumor regression and lymph node harvest.MethodsThe subjects were 40 patients with rectal cancer; 20 receiving high-dose, long-course neoadjuvant therapy, and 20 age- and sex-matched controls who did not receive neoadjuvant therapy. Tumor regression (TRG) was graded from 1 to 5 as: TRG1, no residual tumor cells; TRG2, occasional residual tumor cells with marked fibrosis; TRG3, marked fibrosis with scattered tumor cells or groups; TRG4, abundant cancer cells with little fibrosis; TRG5, no tumor regression. We also evaluated the number of lymph nodes retrieved from excised specimens, the size of the largest node, and the extent of lymph node involvement by the tumor.ResultTumor regression was seen in all patients; as TRG1 in 6 (30%), TRG2 in 2 (10%), TRG3 in 3 (15%), and TRG4 in 9 (45%). The median nodal harvest was 4 (range (0–12) in the NAT group vs 9 (range 1–19) in the control (P = 0.001). The median size of the largest lymph node was 5 mm (range 2–12 mm) in the NAT group vs 9 mm (range 4–15 mm) in the control group (P = 0.004). Tumor-positive nodes were identified in 4 of 17 of the NAT group patients and in 9 of the 20 controls (P = 0.308).ConclusionAlthough NAT down-stages rectal cancer, it results in a significantly low yield of lymph nodes, which are also significantly smaller than those in nonirradiated controls. Therefore, surgeons and histopathologists must ensure adequate sampling and accurate staging is done for patients with irradiated rectal cancer.

Comparison of hydrogen peroxide instillation with Goodsall's rule for fistula-in-ano.

Background: Identification of the internal opening is an essential step in the management of fistula‐in‐ano. The predictive accuracy of Goodsall’s rule is compared with instillation of hydrogen peroxide for fistulas‐in‐ano.

Young patients with colorectal cancer have poor survival in the first twenty months after operation and predictable survival in the medium and long-term: Analysis of survival and prognostic markers

ObjectivesThis study compares clinico-pathological features in young (<40 years) and older patients (>50 years) with colorectal cancer, survival in the young and the influence of pre-operative clinical and histological factors on survival.Materials and methodsA twelve year prospective database of colorectal cancer was analysed. Fifty-three young patients were compared with forty seven consecutive older patients over fifty years old. An analysis of survival was undertaken in young patients using Kaplan Meier graphs, non parametric methods, Coxs Proportional Hazard Ratios and Weibull Hazard models.ResultsYoung patients comprised 13.4 percent of 397 with colorectal cancer. Duration of symptoms and presentation in the young was similar to older patients (median, range; young patients; 6 months, 2 weeks to 2 years, older patients; 4 months, 4 weeks to 3 years, p > 0.05). In both groups, the majority presented without bowel obstruction (young - 81%, older - 94%). Cancer proximal to the splenic flexure was present more in young than in older patients. Synchronous cancers were found exclusively in the young. Mucinous tumours were seen in 16% of young and 4% of older patients (p < 0.05). Ninety four percent of young cancer deaths were within 20 months of operation. At median follow up of 50 months in the young, overall survival was 70% and disease free survival 66%. American Joint Committee on Cancer (AJCC) stage 4 and use of pre-operative chemoradiation in rectal cancer was associated with poor survival in the young.ConclusionIf patients, who are less than 40 years old with colorectal cancer, survive twenty months after operation, the prognosis improves and their survival becomes predictable.

Colorectal cancer in the young, many questions, few answers

At a time where the incidence of colorectal cancer, a disease predominantly of developed nations, is showing a decline in those 50 years of age and older, data from the West is showing a rising incidence of this cancer in young individuals. Central to this has been the 75% increase in rectal cancer incidence in the last four decades. Furthermore, predictive data based on mathematical modelling indicates a 124 percent rise in the incidence of rectal cancer by the year 2030 - a statistic that calls for collective global thought and action. While predominance of colorectal cancer (CRC) is likely to be in that part of the large bowel distal to the splenic flexure, which makes flexible sigmoidoscopic examination an ideal screening tool, the cost and benefit of mass screening in young people remain unknown. In countries where the incidence of young CRC is as high as 35% to 50%, the available data do not seem to indicate that the disease in young people is one of high red meat consuming nations only. Improvement in our understanding of genetic pathways in the aetiology of CRC, chiefly of the MSI, CIN and CIMP pathway, supports the notion that up to 30% of CRC is genetic, and may reflect a familial trait or environmentally induced changes. However, a number of other germline and somatic mutations, some of which remain unidentified, may play a role in the genesis of this cancer and stand in the way of a clear understanding of CRC in the young. Clinically, a proportion of young persons with CRC die early after curative surgery, presumably from aggressive tumour biology, compared with the majority in whom survival after operation will remain unchanged for five years or greater. The challenge in the future will be to determine, by genetic fingerprinting or otherwise, those at risk of developing CRC and the determinants of survival in those who develop CRC. Ultimately, prevention and early detection, just like for those over 50 years with CRC, will determine the outcome of CRC in young persons. At present, aside from those with an established familial tendency, there is no consensus on screening young persons who may be at risk. However, increasing awareness of this cancer in the young and the established benefit of prevention in older persons, must be a message that should be communicated with medical students, primary health care personnel and first contact doctors. The latter constitutes a formidable challenge.

Histopathology reporting in colorectal cancer: a proforma improves quality.

Aim  The histopathology report is vital to determine the need for adjuvant therapy and prognosis in colorectal cancer (CRC). Completeness of those in text format is inadequate. This study evaluated the improvement of quality of histopathology reports following the introduction of a template proforma, based on standards set by the Royal College of Pathologists (RCP), UK.

Pre-operative hypoalbuminaemia predicts poor overall survival in rectal cancer: a retrospective cohort analysis

BackgroundSerum albumin is a marker of nutrition and inflammation. It has recently emerged as a predictor of outcome after surgery for rectal cancer. Our aim was to evaluate if pre-operative serum albumin would predict survival after resection for rectal cancer.Method226 Patients with rectal cancer of all stages undergoing resection with curative intent were studied. Kaplan-Meier curves analysed survival based on a pre-operative albumin level of <35 g/L vs. >35 g/L. We sought for significant associations of survival with age, sex, stage, tumour site, use of neoadjuvant chemoradiation, microscopic positive resection margins, differentiation, angio, peri-neural, and lymphovascular invasion using individual variable analysis. Multifactorial analysis was performed using type III analysis with Weibull hazard model and Cox-proportional hazard model. Significance was assigned to a P value <0.05.ResultsOf 226 patients (median age- 59 years; range 19 – 88, Male - 54%), forty five (20%) had an albumin level < 35 g/L and was associated with a poor overall survival (P = 0.02). Mean survival in months for <35 g/L vs. >35 g/L was 64.7 (SE - 9.3) vs. 95.8 (SE – 7.0) and 5 year overall survival rates were 49% and 69%. Individual variable analysis revealed age, circumferential margin, stage, perineural, lympho-vascular and angio invasion to be also significant. With multifactorial analysis hypoalbuminaemia (HR = 0.58; 95% CI: 0.35 - 0.95, P = 0.03), advanced stage (HR = 2.0; 95% CI: 1.26 - 3.23, P < 0.01) and positive circumferential margin (HR = 2.2; 95% CI: 1.26 - 3.89, P < 0.01) remained significant.ConclusionPreoperative hypoalbuminaemia is an independent risk factor for poor overall survival in rectal cancer. Advanced tumour stage and circumferential margin positivity were the other associations with poor survival.

Anorectal physiology and transit in patients with disorders of thyroid metabolism

Background: Data on anorectal physiology in patients with disordered thyroid metabolism are lacking. This prospective study was performed to evaluate anorectal physiology in patients with either hyperthyroidism and diarrhoea, or hypothyroidism and constipation in order to assess slow transit in hypothyroid patients.

The recto-anal inhibitory reflex: abnormal response in diabetics suggests an intrinsic neuroenteropathy

As electrical stimulation of the rectum has been shown to result in reflex internal sphincter inhibition mediated by intrinsic nerves, we aimed to evaluate the integrity of these nerves in the rectum of diabetic patients. Anal canal pressure, recto‐anal inhibitory reflex (RAIR) and continence were evaluated in 30 diabetic patients (male: female 13: 17, median age 57 years, range 37–70) and these data were compared with similar data obtained from 22 age‐ and sex‐matched healthy controls (male: female 9: 13, median age 51 years, range 19–65 years). Median duration of diabetes was 8 years (range 3–30). Twelve (40%) of the 30 diabetics had impaired continence for gas (n= 12) and liquid faeces (n= 3). None of the controls had incontinence. Median maximum resting anal canal pressure (MRP) was: patients 30 mmHg (range 20–75 mmHg) versus controls 40 mmHg (range 20–105 mmHg, P= 0.61). Median maximum squeeze pressure (MSP) was 65 mmHg (range 30–150 mmHg) in patients versus 84mmHg (range 35–230 mmHg) in controls (P= 0.59). Median threshold rectal mucosal electrosensation (RMES‐T) was 27 mA (5–40 mA) in patients versus 13 mA (5–28 mA) in controls (P = 0.03). Maximum tolerable rectal mucosal electrosensation was 40 mA (20–60) in patients versus 20 mA (10–30), in controls (P= 0.042, all comparisons using the Wilcoxon rank test). Recto‐anal inhibitory reflex was present in eight, abnormal in five (one incontinent) and absent in 17 (11 incontinent) diabetics, while it was present in 18 and abnormal in four controls (test of proportion, P= 0.031). Blood glucose in diabetics on the day of the procedure was 98 mg/dL (70–165 mg/dL). Rectal mucosal electrosensitivity and RAIR were impaired in significantly more patients with diabetes than controls, implying impairment of intrinsic neuronal function. The recto‐anal inhibitory reflex was either impaired or absent in all diabetic patients with incontinence.

Sexual and urinary dysfunction following rectal dissection compared with segmental colectomy.

Introduction The aim of this study was to assess the impact of nerve sparing surgery and major abdominal surgery on sexual and urinary function in men and women with colorectal cancer undergoing rectal dissection and segmental colectomy.