Management of enterovaginal fistulae in a colorectal unit.
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Diagnostic Imaging↗
Biomedical subjects
J M P Hyland
Publications and source records attributed to J M P Hyland.
Pathological response following long-course neoadjuvant chemoradiotherapy for locally advanced rectal cancer.
AIMS: To standardize the pathological analysis of total mesorectal excision specimens of rectal cancer following neoadjuvant chemoradiotherapy for locally advanced disease (T3/T4), including tumour regression. METHODS AND RESULTS: Standardized dissection and reporting was used for 60 patients who underwent total mesorectal excision following long-course chemoradiotherapy. Tumour regression was scored by two pathologists (K.S., D.G.) using both an established 5-point tumour regression grade (TRG), and a novel 3-point grade. Both scores were evaluated for interobserver variability. A complete or near-complete pathological response (3-point TRG 1) was found in 10 patients (17%). Using the 5-point TRG, there was good agreement between both pathologists (kappa = 0.64). Using the 3-point grade, agreement was excellent (kappa = 0.84). No disease recurrence has been reported in patients with a complete, or near complete pathological response (3-point TRG 1), after a mean follow-up of 22 months. CONCLUSION: Tumour regression grade is a useful method of scoring tumour response to chemoradiotherapy in rectal cancer. TRG 1 and 2 can be regarded as a complete pathological response (ypT0). A modified 3-point grade has the advantage of better reproducibility, with similar prognostic significance.
Adult↗
Diagnosis and treatment of enterovesical fistulae.
OBJECTIVE: Enterovesical fistulae are a recognized complication of a variety of inflammatory and neoplastic conditions. Despite advances in imaging and treatment the diagnosis may be delayed and the management remains diverse. We describe our experience with their diagnosis and management. PATIENTS AND METHODS: This retrospective study encompassed all patients referred over a 10-year period with clinical suspicion of or confirmed enterovesical fistula. Demographics, clinical presentation, aetiology and clinical outcome were evaluated. Mean follow-up was 18 months (range 6-50 months). RESULTS: Thirty patients were studied. The mean age was 63.5 years (range 23-92 years). Fifteen (50%) patients presented with classical urinary symptoms (pneumaturia, faecaluria and recurrent urinary tract infections). The commonest investigations (n, % positive) included CT (15, 80), cystoscopy (16, 87.5), endoscopy (11, 54.5) and barium enema (8, 50). There were 20 inflammatory and 10 neoplastic aetiologies. Five patients were treated conservatively and 25 patients underwent surgery. Surgery resulted in symptomatic cure in the majority of cases (22/25). CONCLUSION: Classical urinary symptoms were only evident in 50% of patients with confirmed fistulae. We advocate CT scanning as the optimum imaging modality before surgical intervention. Surgical treatment in a specialized unit remains the most effective treatment of enterovesical fistulae.
Adult↗
Expression of Cathepsin B and L antigen and activity is associated with early colorectal cancer progression.
Cathepsin B and Cathepsin L are cysteine proteases important in the process of invasion and metastasis. The aim of our study was to assay antigen and activity levels of these enzymes and to correlate these with established clinical and pathological prognostic parameters including patient survival. 99 patients undergoing operations for colorectal cancer were included in this study. We quantitated cathepsin B and L levels in matched normal mucosa and cancer samples using an enzyme-linked immunosorbent assay (ELISA) and specific activity assays and expressed the results as tumour/normal ratios. Significant correlations were found between tumour/normal cathepsin B and L antigen and activity ratios. Cathepsin B and L tumour/normal activity ratios were greater than 1 in early stage disease and there were gradual reductions in cathepsin B (P = 0.02) and L (P = 0.03) activity ratios with advancing tumour stage. Survival of patients with potentially curative disease was inversely related to both cathepsin B (P = 0.007) and L (P = 0.001) activity ratio, in addition to cathepsin L antigen ratio (P = 0.008). Our findings suggest that cysteine proteases play an important role in colorectal cancer progression.
Adult↗
Perianal Crohn's disease and infliximab therapy.
INTRODUCTION: Perianal manifestations occur in almost half of patients with Crohn's disease and often respond poorly to conventional therapies. The introduction of anti-tumour necrosis factor alpha agents (e.g. infliximab) has altered the management of patients who fail first and second line medical and surgical therapies. METHODS: We performed a literature search of the PubMed database using the Medical Search Headings infliximab, perianal Crohn's disease, fistulae, cost and safety. We also performed a manual search using references from these articles, review articles and proceedings from major gastroenterology meetings. RESULTS: Use of infliximab, at a dose of 5mg/kg at intervals of 0, 2 and 6 weeks, results in significant improvement in disease in approximately 70% of patients with fistulae. Prior examination under anaesthesia with placement of non-cutting seton sutures in fistula tracks is a useful adjunct in many patients. Preliminary results show a benefit from maintenance infliximab therapy and from concomitant use of immunosuppressants such as azathioprine. No clinical or biochemical markers have been identified which predict non-response to infliximab, although its use is contraindicated in patients with strictures. Acute infusion reactions are the most common side-effect of infliximab therapy and they are usually mild. Despite initial fears, the incidence of opportunistic infection is low. There is inadequate information, at present, regarding a possible increase in incidence of lymphoma with infliximab therapy. Infliximab is expensive compared with established therapies and its use will increase the lifetime cost of treating Crohn's disease. CONCLUSION: While infliximab is a useful adjunct in selected patients, the cornerstones of management of perianal Crohn's are essentially unchanged.
Antibodies, Monoclonal↗
Peritoneal involvement in stage II colon cancer.
A pathologist (K.S.) reviewed histologic slides for peritoneal involvement by tumor cells for 118 patients with stage II colon cancer. Patients were followed up for a median of 6 years. Tumor cells were found free in the peritoneal space in 16 cases (13.6%). The presence of cancer cells free in the peritoneal space was associated with lymphovascular invasion (P = .001) and neural invasion (P < .001). The overall 5-year survival was 80% in the patient population, but was 39% and 86% for those with and without tumor cells free in the peritoneal space, respectively (P < .0001). Multivariate analysis confirmed that free tumor cells within the peritoneal space (P < .0001) and lymphovascular invasion (P = .007) were related independently to outcome. Peritoneal involvement with tumor cells free in the peritoneal space in stage II colon cancer is a powerful indicator of outcome; patients have a survival similar to that for patients with stage III disease.
Adult↗
Sigmoid volvulus: a 10-year-audit.
BACKGROUND: Chronic constipation in elderly, institutionalised patients is the leading cause of sigmoid volvulus in the developed world. Endoscopic deflation is associated with a 90% recurrence rate and a 35% mortality rate. AIMS: To review a 10-year experience of sigmoid volvulus and encourage more aggressive primary treatment. METHODS: A retrospective study was performed on 16 patients with sigmoid volvulus from 1992 to 1999. Patients were identified using the hospital inpatient enquiry (HIPE) data system. Demographics, clinical course, intervention, complications and outcome were recorded. RESULTS: The male:female ratio was 5:3 and mean age was 78 years (range 39-92). Fifty per cent had at least one risk factor: Parkinson's disease (n=3); multiple sclerosis (n=1); Alzheimer's disease (n=1); and hypokalaemia (n=3). Thirty-seven per cent were managed conservatively and 63% required surgical intervention. Mean time to surgery was 2.4 days. Operations performed were sigmoid colectomy (45%), Hartmann's procedure (33%) and total colectomy (22%). There was one post-operative death from myocardial ischaemia. Mean duration of admission was 21 days. CONCLUSIONS: Endoscopic deflation of a sigmoid volvulus facilitates optimisation of cardiopulmonary co-morbidity in a high-risk group of patients. It converts an emergent to an elective procedure and minimises operative morbidity as a result.
Aged↗