Total mesorectal excision is optimal surgery for rectal cancer: a Scandinavian consensus.
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Colorectal Surgery↗
Biomedical subjects
E L Bokey
Publications and source records attributed to E L Bokey.
Morbidity and mortality following laparoscopic-assisted right hemicolectomy for cancer.
PURPOSE: This study was undertaken to compare morbidity, mortality, and pathology after laparoscopically assisted right hemicolectomy (LARHC) or open right hemicolectomy (ORHC) for cancer of the right colon. METHODS: Patients undergoing either LARHC or ORHC for invasive carcinoma of the right colon during a 30-month period were studied. Data were collected from two sources. All morbidity, mortality, and pathology data were collected prospectively in a form suitable for computer storage and analysis as part of the ongoing Concord Hospital Colorectal Cancer Registry. Data concerning in hospital course were obtained by casenote review. RESULTS: Twenty-eight patients underwent LARHC, and 33 had an ORHC during the study period. The two groups were well matched with respect to age, sex, weight, associated comorbidities, and tumor stage. Mean operating room use time was significantly higher for LARHC (LARHC = 261 minutes; ORHC = 203 minutes; P < 0.001). Mean hospital stay from date of resection was the same in both groups (LARHC = 12 days; ORHC = 12.2 days). There was no significant difference between procedures with respect to postoperative complications, return of gastrointestinal function, or narcotic analgesic requirements. There was a significant shorter distal margin of resection in the LARHC group (ORHC = 13.4 cm; LARHC = 10 cm; P = 0.03). Total cost was significantly greater for LARHC ($9,064 vs. $7,881 (Australian); P < 0.001). Median follow-up was 23.4 months for the LARHC group and 23.9 months for the ORHC group. To date, there have been no local or port site recurrences. CONCLUSION: Although there is no difference in morbidity and mortality following LARHC or ORHC, there is no apparent benefit for LARHC.
Aged↗
Case report: gastrointestinal tuberculosis simulating Crohn's disease.
A male Caucasian presented with abdominal pain and a right iliac fossa mass. There were no risk factors for Mycobacterium tuberculosis infection. He was investigated by upper and lower gastrointestinal endoscopy, chest and small bowel radiology. The latter showed stricturing of the third and fourth parts of the duodenum, mid-jejunum and terminal ileum. Biopsies were non-specific and he was thought to have Crohn's disease. Subsequent treatment with corticosteroids resulted in improved well being and weight gain; however, the patient demonstrated disease progression with the development of complex fistulae and Escherichia coli septicaemia. At surgery the patient was found to have an ileal inflammatory mass with fistulae to the sigmoid colon. The terminal ileum, fistulae and a segment of colon were resected. Treatment with anti-tuberculous drugs ensued and the patient is now asymptomatic after 15 months of follow-up. This case serves to highlight the difficulty in making the diagnosis of gastrointestinal tuberculosis, a disease that may mimic Crohn's disease, and the need for caution in the use of corticosteroids in any disease in which tuberculosis enters into the differential diagnosis. The role of surgery in making the diagnosis and managing the complications, in conjunction with anti-tuberculous drugs, and the prospect of cure are exemplified by this case.
Adult↗
Best practice parameters for management of rectal cancer: recommendations of the Colorectal Surgical Society of Australia.
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Female↗
Lymphovascular clearance in laparoscopically assisted right hemicolectomy is similar to open surgery.
BACKGROUND: The application of laparoscopic techniques to malignant colorectal disease has led to concerns regarding the adequacy of excision achieved. This study was performed to compare specimen histopathology following laparoscopically assisted right hemicolectomy (LARHC) with that following open right hemicolectomy (ORHC). METHODS: Data regarding patient details and tumour pathology were obtained by case-note review and from the Concord Hospital Colorectal Cancer Database. Thirty-two patients had LARHC for neoplastic lesions and 34 had ORHC for similar lesions over the same period. The two groups were well matched with respect to age, sex, weight and tumour characteristics. Early stage disease was more common in the LARHC group. RESULTS: There was no clinically significant difference between the groups in terms of margins of clearance or number of lymph nodes harvested. CONCLUSIONS: LARHC allows lymphovascular clearance indistinguishable from that afforded by open surgery. Long term outcome and survival data are required to confirm its role in the treatment of malignant colorectal disease.
Adenocarcinoma, Mucinous↗
Peritoneal involvement by rectal cancer.
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Humans↗
Postoperative morbidity and mortality following resection of the colon and rectum for cancer.
PURPOSE: The aim of this study was to report the prevalence of postoperative complications and mortality of patients with colorectal cancer when treated by conventional surgery. METHODS: Morbidity and mortality following open resection for colorectal cancer were analyzed in 1,846 patients whose clinical, operative, and pathology data were prospectively documented over a 20-year period. RESULTS: Mortality following elective resection of the left and right colon was low, whereas overall morbidity was high (37.2 percent). Respiratory and cardiac complications were especially common. Incidence of clinically significant leakage was similar following right (0.5 percent) or left (1.1 percent) hemicolectomy. Incidence of anastomotic leakage was significantly higher after emergency right hemicolectomy (4.3 percent). Overall morbidity following excision of the rectum was high (40.2 percent). Respiratory and cardiac complications predominated. Incidence of clinically significant anastomotic leakage following anterior resection was low (2.9 percent). Over the years, there has been a decline in the number of patients with tumor demonstrated histologically in a line of resection, suggesting an improved local surgical clearance. CONCLUSIONS: These results following conventional surgery may be useful when evaluating new techniques.
Adenocarcinoma↗
Transfusion does not influence patient survival after resection of colorectal cancer.
Two recent reviews reached opposing conclusions regarding the apparent detrimental effect of peri-operative blood transfusion on patient survival after resection of colorectal cancer. However, both sides agree that the influence of confounding variables has not been controlled adequately in most studies. The present study is based on 433 patients who had a curative resection for colorectal cancer between 1984 and 1989 and whose details and follow-up information were recorded in the Concord Hospital Colorectal Cancer Registry, Sydney. The association between peri-operative transfusion and patient survival after resection of colorectal cancer was examined taking into account 20 other prognostic variables. A proportional hazards regression model showed that transfusion did not have a statistically significant independent effect on survival after controlling for the patient's poor general condition, the complexity of the surgery and the occurrence of postoperative complications.
Blood Transfusion↗
Ureteric ischaemia following major colorectal resection.
An ischaemic injury of the ureter following major colorectal surgery is reported. The aetiology and incidence of this unusual complication is reviewed. Surgical techniques for prevention of such an injury are discussed.
Aged↗
Pathologic determinants of survival associated with colorectal cancer with lymph node metastases. A multivariate analysis of 579 patients.
BACKGROUND: Patients with colorectal carcinoma found to have regional lymph node metastases after curative resection form a large and prognostically diverse group. This study aims to determine which pathology variables have independent prognostic effects. METHODS: The data from the 579 patients used in this analysis were collected prospectively during a period of 21.5 years. The patients were from one institution, and the pathologic documentation was standardized. Patient follow-up ranged between 6 months and 21.5 years. Survival analysis was by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. RESULTS: On univariate analysis, eight pathology variables had a significant association with survival. Six of these variables showed significant independent effects on survival on multivariate analysis. In diminishing potency, these variables were: apical lymph node involvement; spread involving a free serosal surface; invasion beyond the muscularis propria; location in the rectum; venous invasion; high tumor grade. Significant independent effects also were shown for patient age and gender. The number of involved lymph nodes added no significant independent prognostic information. CONCLUSION: Six pathology variables have been identified that act independently in determining the survival of patients with colorectal carcinoma and lymph node metastases. The most potent of these variables, apical lymph node involvement, was used by Dukes to subclassify Stage C tumors. Another variable, direct spread beyond the muscularis propria, defines the Astler-Coller subclassification. It is recommended that all six independent variables be included in any future protocol for stratifying this prognostically diverse group of patients.
Adult↗
Should relatives of patients with colorectal cancer be screened? A critical review of the literature.
PURPOSE: The objective of our investigation was to attempt to address the controversial issue concerning index screening and surveillance of relatives of patients with colorectal cancer and to identify those areas of research that should be considered in future studies. METHODS: Relevant literature was reviewed concerning the screening of asymptomatic first-degree relatives of patients with colorectal cancer not associated with the rare autosomal dominant inherited colorectal cancer syndromes. RESULTS: The data reviewed suggest that there is an increased risk of colorectal neoplasia in this population and a significantly higher yield of adenomas and carcinomas when colonoscopy is used for index screening. However, significant variability in study design and screening protocols and inconsistencies in data presentation make clinical interpretation and data analysis confusing and difficult. CONCLUSIONS: There is a critical need for standardization in future studies. Furthermore, as there are no studies that document decreased overall mortality from colorectal cancer in first-degree relatives as a result of screening, the decision as to whether to screen this population needs to be based on future prospective controlled trials.
Adenoma↗
Clinicopathologically diagnosed residual tumor after resection for colorectal cancer. A 20-year prospective study.
BACKGROUND: A lack of comprehensive information exists on the nature, incidence, and prognostic significance of known residual tumor in colorectal cancer patients treated by bowel resection. This study aims to provide this information. METHODS: A prospective series of 1766 consecutive patients from the Concord Hospital Colorectal Cancer Registry (Concord, Australia) was used for the analysis. Residual tumor was defined as distant metastases diagnosed clinically or pathologically or tumor demonstrated histologically in a line of resection. The pathologic study was highly standardized. Patient follow-up ranged from 6 months to 20.5 years. Survival analysis was by the Kaplan-Meier method. Multivariate models were examined using Cox proportional hazards regression. RESULTS: The prevalence of residual tumor was 20.9% and the median survival was 11.6 months. In 4.5%, tumor transection alone occurred, 14.5% had distant metastases alone, and 1.9% had both. The difference in survival between the first two groups was at marginal statistical significance (P = 0.076). When each of these two groups was compared with the third group, significant differences were noticed (P = 0.001 and P = 0.004, respectively). Five of 14 pathology variables examined had a significant effect on survival using univariate analysis. On multivariate analysis only tumor transection and distant metastases had significant independent effects. CONCLUSIONS: Known residual tumor was common in this series: one in five resections. Survival studies show that tumor transection, as defined, is a valid criterion for residual tumor. Survival is significantly reduced when tumor transection and distant metastases both are present. These findings should be heeded when staging colorectal cancer and when stratifying patients for postoperative adjuvant therapy.
Adult↗
Assessment of human colorectal biopsies by 1H MRS: correlation with histopathology.
Samples (3 mm3) of histopathologically normal (n = 15) and carcinomatous tissue (n = 15) were obtained from colectomy specimens and examined by 1H MRS. A combination of one- and two-dimensional spectra, obtained with appropriate acquisition and processing parameters, provide multiple diagnostic parameters allowing the distinction between normal and carcinomatous tissue. The diagnostic parameters include resonances from choline, choline-based, and other metabolites, cell surface fucosylation, and altered lipid profiles. Tissues histopathologically classified as normal, while remaining distinct from the malignant spectral profile, were found to fit into two categories, one of which had some of the spectral characteristics of malignancy. These results indicate that 1H MRS identifies abnormal colorectal mucosa, which is not morphologically manifest. Such abnormalities have been reported previously to exist in premalignant colorectal tissue by monoclonal antibody studies. Collectively, these results suggest that a clinical study of colorectal biopsies by 1H MRS could provide support for the use of MRS as an adjunct to current pathological procedures.
Adenocarcinoma↗
Heredity, molecular genetics and colorectal cancer: a review.
It is estimated that the hereditary polyposis and non-polyposis colorectal cancer (CRC) syndromes, which have an autosomal dominant pattern of inheritance, represent less than 10% of the total CRC burden. Thus, more than 90% of all cases of CRC have previously been considered to arise 'sporadically', with no identifiable genetic link. However, recent clinical evidence now suggests that a significant proportion of CRC seen in the general population may involve an inherited genetic susceptibility. Therefore, constructing an accurate family tree on all patients with a family history of CRC is an essential part of identifying families with an increased risk for CRC who could then be offered screening. Also, molecular genetic study of colorectal adenomas and carcinomas has led to a proposed genetic model of colorectal tumorigenesis which involves interactions between oncogenes and tumour suppressor genes. This information has important potential implications for screening, determining prognosis and for providing multiple targets for altering the sequence of malignant transformation.
Colorectal Neoplasms↗
Patient characteristics and pathology in colorectal adenomas removed by colonoscopic polypectomy.
Between September 1981 and August 1987 420 patients with 565 adenomas underwent colonoscopic polypectomy to produce a 'clean colon'. Data from these patients were analysed to identify associations between patient characteristics (age and sex), polyp characteristics (site, size, shape, multiplicity and villous content) and the degree of dysplasia in the index adenoma. In univariate analysis, severe dysplasia in the index adenoma was significantly but weakly associated with size (> or = 10 mm), peduncular shape and villous architecture. Logistic regression confirmed an independent effect only from villous architecture. These findings suggest that it is unlikely that strong predictors of a patient developing a metachronous adenoma or colorectal cancer can be identified on the basis of an index adenoma found at initial colonoscopy. These patients will continue to be followed to investigate this question.
Adenomatous Polyps↗
Intra-operative ultrasound for the detection of hepatic metastases from colorectal cancer.
The aim of this study was to compare the accuracy of intra-operative ultrasound (IOUS) with other imaging modalities and with surgical palpation in detecting liver metastases from colorectal cancer (CRC). Intra-operative ultrasound was performed in 100 patients undergoing surgery for CRC. All patients had pre-operative liver function tests, transcutaneous ultrasound and computerized tomography (CT) scan of the liver. The liver was palpated intra-operatively by a surgeon who was unaware of the pre-operative findings. The liver was then assessed by IOUS. Intra-operative ultrasound detected more patients with metastases than either CT scan, transcutaneous ultrasound or surgical palpation. It also detected a greater number of smaller metastases in these patients and allowed better anatomical definition compared with pre-operative investigations.
Adult↗
Hartmann's procedure for carcinoma of the rectum and sigmoid colon.
A review of the Hartmann's operation for patients with rectal and sigmoid cancer over an 18 year period is presented. There were 1063 patients who had a resection for carcinoma of the rectum or sigmoid colon and 4.4% of these had a Hartmann's procedure. This operation was particularly useful in the management of patients who presented with a proximal obstruction or perforation at the tumour site. It was also effective in the elective treatment of elderly unfit patients who had locally advanced tumours or those with distant metastases. Re-anastomosis is recommended in those patients who are relatively fit and have had a potentially curative resection.
Age Factors↗
Complications following closure of loop ileostomy.
The morbidity and mortality of 50 patients undergoing closure of loop ileostomy was reviewed. The patients had a mean age of 57.9 years and significant intercurrent disease. There were no in-hospital deaths or anastomotic leakage at the site of closure. Small bowel obstruction occurred in 12% of patients, all of whom responded to conservative treatment. The wound infection rate was 14%, but the development of a wound infection did not result in a significantly longer hospital stay. We conclude that, when a careful technique of sharp dissection is used, closure of a loop ileostomy is associated with an acceptably low incidence of complications even in elderly and often unwell patients.
Adolescent↗