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The presence of Lewis blood group antigens (Lewis(a), Lewis(b)) was determined immunohistochemically in 75 carcinomas and 58 adenomas of the sigmoid colon and rectum. 1. The rate of positive Lewis(b) staining of adult normal mucosa was 100% in the ascending colon, 100% in the transverse colon, 25% in the sigmoid colon and 30% in the rectum, respectively. The incidence of Lewis(b) was high in the proximal colon but low in the sigmoid colon and rectum. 2. The rate of positive Lewis(b) staining was 97% in cancer, 57% in adenoma and 26% in normal mucosa, respectively. The difference between the incidence of positive Lewis(b) staining in normal mucosa, and those in cancer and adenoma was significant (p less than 0.01). 3. The rate of positive Lewis(b) staining was 42% in mild and moderate dysplastic adenoma and 68% in severe dysplastic adenoma. There was a significant difference between the percentage of Lewis(b) staining in mild or moderate dysplastic adenoma and that of severe dysplastic adenoma (p less than 0.05). The expression of Lewis(b) antigen correlated with the size of adenoma. These results suggest that Lewis(b) antigen has a cancer-associated nature and Lewis(b) staining might be useful as an indicator of malignant potential of adenoma of the sigmoid colon and rectum.
Over a decade (1978-88), 180 cases of colorectal carcinoma were diagnosed. Twenty of the patients had shown no "precancerous" colonic conditions whereas screening had revealed various pathologies indicating risk in the remaining 160. The percentage distribution of the tumour in the large bowel was as follows: sigmoid colon 38%, rectum 25%, descending colon 21%, caecum 12%, transverse colon 4%. Dukes-type surgical staging of the screened patients revealed 42% in stage A, 48% stage B and 10% stage C. The sensitivity and specificity of the haemoccult test was 86% and 98% respectively while the diagnostic accuracy of double-contrast opaque enema was 79% compared to 84% for coloscopy alone and 98% for combined coloscopy and biopsy.
Rectosigmoid motility, anal manometry, and radiopaque marker studies have suggested the presence of several patterns of altered colonic transit in patients with chronic idiopathic constipation. Colonic transit scintigraphy was used to evaluate 23 constipated patients. After oral passage of a tube to the cecum, 50 microCi of 111In-diethylenetriaminepentaaceticacid (111In-DTPA) were instilled, and abdominal images were obtained for 48 h with a gamma camera. The 95% confidence limit for the geometric center in normals at 24 h was used as a criterion to differentiate patients with colonic inertia from those with functional rectosigmoid obstruction. In patients with functional rectosigmoid obstruction, colonic transit was essentially normal. In colonic inertia, transit was delayed in the cecum and ascending colon, hepatic flexure, and transverse colon. These two distinct patterns of colonic transit may have different pathogenetic and therapeutic implications.
During 11 years, 14 cases of tuberculosis of the colon are radiographied. The clinical findings are not specific and the association with evolutive pulmonary tuberculosis is infrequent (28%). The radiological features are described: ulcerations (4 cases), ulcerations and hypertrophic features (3 cases) and hypertrophic features (7 cases). The involving sites are caecum and ileocecum in 6 cases, ascending colon in 3 cases, transverse colon in 2 cases, descending colon in 2 cases and recto-sigmoid in 2 cases. The differential diagnosis are segmental Crohn colitis and colonic carcinoma. Endoscopic examination with biopsy is a help to the diagnosis, but in 5 cases, it will be deficient. The diagnosis of colonic tuberculosis is setting only by surgical resections in 6 cases (43%) and 4 patients have been treated by medical treatment with success. No relapse appears in operated patients.
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Esophageal replacement using transverse colon with left colic pedicle is reviewed. 18 were done for caustic stenosis with one death, 4 for atresia without mortality. For caustic stenosis the authors advocate early transplant since the third month if dilatations failed. Improvement of technique using staplers prevented any complication in the last 8 patients. These good results allowed the authors to switch to isoperistaltic gastric tube. In esophageal atresias, the authors did not find any indication of replacement in the 12 last years.
A case of an ileal carcinoma involving the entire midgut treated with a massive enterectomy of the small bowel distal to the ligament of Treitz, the right colon, and part of the transverse colon is discussed. After 1 year on home hyperalimentation, hepatic nodules were seen on CT scans; metastases could not be proven. At 3 years a hepatic wedge resection was performed, multiple areas of necrosis and fibrosis were found, but no carcinoma. This case is presented as an example of an alternative in treatment for this type of carcinoma and to illustrate the problems of differential diagnosis of liver defects on the CT scan in patients on longterm hyperalimentation.
We studied 347 patients with primary colorectal carcinoma treated by surgery during 1973-1983: 64 (18.2%) with right colon carcinoma, 158 (45.7%) with left colon carcinoma, 14 (4.2%) with transverse colon carcinoma, and 110 (31.9%) with rectal carcinoma. We compared the right-sided carcinoma (RSC) and left-sided carcinoma (LSC) groups. Obstruction was found in 17.2% of RSC compared with 20.3% LSC patients (P greater than 0.05). Advanced disease (Dukes stages C and D) was found in 34.4% on the right and 47.8% on the left side (P = 0.01). Crude 5-year survival rate, by life table method, was 71% on the right and 66% on the left side (P greater than 0.05); this difference became significant (P = 0.03) when Dukes stage B patients were compared. We conclude that patients with RSC are not diagnosed, as is commonly believed, at advanced stages of the disease. We found that the 5-year survival rate of RSC patients was the same or, occasionally, better than that of LSC patients.
The results of performing laparoscopic-assisted colectomy in 20 patients with invasive carcinoma of the colon were analyzed in this study. The site of the lesion was the right colon in 5 patients, the transverse colon in 1, the left colon in 13, and the rectosigmoid in 1. In 2 patients, the laparoscopic procedure needed to be converted to an open laparotomy. Limited lymph node dissection (R1+, R2) was carried out in 10 patients and extensive node dissection (R3) was carried out in 9 patients. The histological depth of invasion in the 18 patients who underwent laparoscopic-assisted colectomy was the submucosa in 9, the muscularis propria in 2, and the extramuscular layer in 7. There were 3 patients who developed postoperative complications, 1 of whom underwent reoperation due to perforation of the colon. The postoperative course of the patients who underwent laparoscopic surgery was compared with that of a retrospectively selected control group of patients who had undergone open laparotomy. The postoperative recovery of the patients who underwent laparoscopic surgery was significantly faster than that of those who had undergone open laparotomy. Thus, we consider that laparoscopic-assisted colectomy with lymph node dissection is technically feasible provided that patients are properly selected. This procedure may be indicated not only for colonic carcinoma in the early stage, but also for that with invasion of the muscularis propria or the extramuscular layer.
A 58-year-old female with a history of portal vein thrombosis was referred to our hospital with abdominal pain and distention. Colon fiber and enema of the colon showed stenosis at the transverse colon and the ascending colon, with edematous mucosa. Laparotomy revealed no abnormal findings other than chronic ischemia of the colon. To our knowledge, this is the first reported case of colon stenosis caused by portal vein thrombosis.
BACKGROUND: In recent years, stent placement for malignant colorectal obstruction has become an accepted alternative to surgery. The purpose of this study was to evaluate the usefulness of self-expandable metallic stents (SEMS) as palliative management for patients with unresectable malignant colorectal obstruction. METHODS: Twelve patients with unresectable malignant colorectal obstruction were treated with SEMS as palliative therapy. The sites of obstruction were located in the rectum (n = 9), the descending colon (n = 1), and the transverse colon (n = 2). All procedures were performed with combined endoscopic and fluoroscopic guidance. We analyzed the technical and clinical success rates of stent placement and the complications associated with the procedure. RESULTS: The stents were successfully implanted and bowel obstruction was relieved in all cases; the technical and clinical success rates were 100%. Two complications occurred, including stent migration. There was no case requiring reintervention. All patients died of initial disease or another coexisting disease between 9 and 534 days (mean 133 +/- 148 days) after stent placement. None of the patients with stent in position at death had clinical or radiologic signs of bowel obstruction. CONCLUSIONS: SEMS placement in patients with malignant colorectal obstruction is technically feasible and safe, making it useful as a palliative treatment.
Between 1979 and 1989, 169 patients had a curative operation for right sided colonic cancer. A retrospective analysis of the incidence and degree of lymph node metastasis was performed in all and survival rate was determined in 144 patients who could be followed over a period of 5 years or more. In all patients, dissection involved the removal of right colon (i.e., caecum, ascending colon, and right side of transverse colon). Dissection of regional lymph nodes in 84 patients (group 1) involved the removal of mesocolic lymph nodes related to the segment of the removed intestine. In 60 patients (group 2) dissection was extended to the nodes situated anterior to mesenteric and retropancreatic vessels. Morbidity and mortality rates were similar in the two procedures. The number of lymph nodes and the level of apical node examined were significantly different in the two groups. The 5-year survival rates showed no statistically significant difference, but in group 2 three of the nine patients with metastasis to N4 nodes are free of disease, surviving at 7, 12 and 14 years, respectively. The principle of extensive lymph node dissection is proposed as a procedure that supplies more accurate staging and might reduce the incidence of loco-regional recurrence.
The effects of endogenous and exogenous opioid substances on feline colonic transit were evaluated using colonic transit scintigraphy. Naloxone (0.3 mg/kg, i.m.) accelerated emptying of the cecum and ascending colon, and filling of the transverse colon. Endogenous opioid peptides thus appear to play a significant role in the regulation of colonic transit. At a moderate dose of morphine (0.1 mg/kg, i.m.), cecum and ascending colon transit was accelerated, while at a larger dose (1.0 mg/kg, i.m.) morphine had no effect. Since naloxone, a relatively nonspecific opioid antagonist, and morphine, a principally mu opioid receptor agonist, both accelerate proximal colonic transit, a decelerating role for at least one of the other opioid receptors is inferred.
BACKGROUND: Acute colonic pseudo-obstruction is often treated by colonoscopic decompression. Efficacy, safety, and outcome of endoscopic decompression was assessed. METHODS: Colonoscopic decompressions from 1988 to 1994 were reviewed. Resolution without further endoscopic intervention was defined as clinical success. RESULTS: Acute colonic pseudo-obstruction was diagnosed in 50 patients. Thirty-three cases followed surgery or trauma and 17 developed during severe medical illness. Orthopedic joint surgery was most common. Nineteen of 50 patients (38%) had severe underlying medical disease. Forty-one patients (82%) had one colonoscopic decompression with clinical success in 39 (95%). Nine patients (18%) required multiple (2 to 4) colonoscopic decompressions with clinical success in 5 (56%). A decompression tube positioned in the right colon (57%) and in the transverse colon (33%) had similar clinical success. In 8 procedures a decompression tube was not placed, with poor clinical success (25%). The overall clinical success of colonoscopic decompression was 88% (44 of 50). An endoscopic perforation occurred in 1 patient (2%). Overall hospital mortality was 30%. CONCLUSIONS: Colonoscopic decompression is effective and safe for acute colonic pseudo-obstruction that does not respond to conservative therapy. Most patients will respond to one colonoscopic decompression with decompression tube placement. Complete colonoscopy and cecal tube placement is unnecessary.
This report concerns a screening programme for colorectal cancer using Fecatest, a relatively sensitive test for faecal occult blood, in a factor-based population. A total of 2420 workers between 40 and 65 years of age returned kits for testing following suitable dietary restriction. In Factory A, in which screening was offered as part of an annual medical examination, 989 men agreed to participate, a compliance rate of 45%. In Factory B, in which screening was offered in their weekly pay packets, 1431 men participated, a compliance rate of 22%. An overall positivity rate of 5.8% was found, 4.6% in Factory A and 6.6% in Factory B. Five cancers were found, two of the rectum, one at the recto-sigmoid junction, one in the sigmoid colon and one in the transverse colon. Two of these lesions were at Dukes Stage A, one at Stage B and two at Stage C. In addition, 25 adenomatous polyps were found in 17 men. In 13 these were characterized as tubular adenomata and in 4 as tubulovillous adenomata. The mean age at diagnosis in the polyp cases was 52.6 years and in the cancer cases 58.8 years. Increased specificity is obtained by excluding participants below 46 years of age. The detection rate in the 46-65 year range is approximately 1 in 100 for adenomatous polyps and 1 in 300 for cancer in the population screened. This detection rate is higher than most comparable studies using a less sensitive Guaiac test on older populations.
BACKGROUND/PURPOSE: Functional colonic obstruction (pseudo-obstruction) encompasses a broad group of motility disorders. Medical management of colonic pseudo-obstruction is complex and often fails, leading to surgical referral. In most cases (excepting Hirschsprung's disease) the surgeon is unable to precisely localize the area of functional obstruction. Total colonic manometry can directly measure intraluminal pressures and contractile function along the entire length of the colon. The authors propose that total colonic manometry can be used by the pediatric surgeon to guide the timing and extent of surgical therapy in refractory functional colonic obstruction. METHODS: Four patients were evaluated for functional colonic obstruction. All underwent barium enema and rectal biopsy with a diagnosis of Hirschsprung's disease in one patient. All patients underwent colonoscopy and total colonic manometry. Manometric tracings were obtained while fasting, after feeding, and after pharmacologic stimulation both preoperatively (n = 4) and postoperatively (n = 3). RESULTS: Total colonic manometry identified an abrupt end of normal peristalsis in 2 of the non-Hirschsprung's patients (one in the proximal colon and one in the transverse colon). Medical therapy failed in both of these patients, and they underwent diverting ostomy proximal to the loss of normal peristalsis. The third non-Hirschsprung's patient essentially had normal manometry and was able to have her colon decompressed successfully on a laxative regimen. Repeat manometry after colonic decompression showed return of normal peristalsis in 2 of these patients and continued abnormal peristaltic activity in the third. Definitive surgical intervention based on the results of total colonic manometry was performed on the latter. All 3 patients achieved normal continence. A fourth patient had Hirschsprung's disease confirmed by rectal biopsy and underwent a 1-stage neonatal modified Duhamel procedure, which was complicated by postoperative functional obstruction. Manometry showed a lack of peristaltic function beginning in the right colon. An ileostomy was performed, and timing of ileostomy closure was guided by the return of normal colonic peristalsis seen on manometry. CONCLUSIONS: These initial cases show the utility of total colonic manometry in the management of colonic pseudo-obstruction syndromes. In addition to its diagnostic utility, direct measurement of colonic motor activity can be valuable in deciding the need for and timing of diversion, the extent of resection, and the suitability of the patient for restoring bowel continuity. In Hirschsprung's disease, total colonic manometry can potentially be used to determine suitability for primary neonatal pull-through versus a staged approach. J Pediatr Surg 36:1757-1763.