Symptomatic colonic lipoma: differential diagnosis of large bowel tumors.
Bardaji M. Roset F. Camps R. Sant F. Fernandez-Layos MJ.
Department of Surgery, Hospital General de Manresa, Barcelona, Spain.
Symptomatic colonic lipomas, although unusual, continue to present difficulties in the preoperative differential diagnosis between malignant and benign colonic neoplasm. Although new imaging techniques are available, they are frequently diagnosed at laparotomy, and definitive histology is required. Local excision is adequate treatment, but segmental excision may be necessary when there is doubt about the diagnosis, or when a complication occurs.
Hereditary non-polyposis colorectal cancer.
Green SE. Bradburn DM. Varma JS. Burn J.
Department of Surgery, University of Newcastle Upon Tyne, UK.
Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal dominant condition in which affected individuals develop colorectal cancer or extracolonic cancers, most commonly endometrial, at an early age. Recent advances in molecular genetics have led to the identification and sequencing of four genes thought to be responsible for the majority of cases of hereditary non-polyposis colorectal cancer. A description of the disease along with details of the underlying genetics and pathological features are presented. Current management and screening policies in these pedigrees are not clearly established. This article discusses some of the controversies in the light of predictive testing.
Rectocele is associated with paradoxical anal sphincter reaction.
Mellgren A. Lopez A. Schultz I. Anzen B.
Department of Surgery, Danderyd Hospital, Stockholm, Sweden.
Rectocele is a frequent finding in constipated patients. However, constipation is not always relieved by rectocele repair, which may be due to other overlooked reasons for constipation. The study was designed to investigate patients with rectocele, in order to elucidate concomitant colorectal disorders and their association with rectocele. One hundred and twelve female patients suffering from severe constipation and rectal emptying difficulties were investigated using defecography, electrophysiology, anorectal manometry and colon transit time. Fifty-six patients with rectocele demonstrated by defecography were compared with 56 patients without rectocele, but with other abnormal findings at defecography. The frequency of paradoxical anal sphincter reaction (PSR) was higher in patients with rectocele (60%) than in patients without rectocele (24%). The present study supports an association between rectocele and PSR. We suggest that constipated patients with a rectocele should be investigated thoroughly before rectocele repair is considered. Further studies on the effect of biofeedback training in patients with rectocele and PSR are indicated.
Delay in the presentation of colorectal carcinoma: a review of causation.
Carter S. Winslet M.
University Department of Surgery, Royal Free Hospital, School of Medicine, London, UK.
This review paper studies the reasons behind the delay in presentation of colorectal carcinoma. Such delay can occur at three different levels: delay on the part of the patient, delay by the general practitioner prior to patient referral and delay incurred at the hospital after patient referral. There is some evidence that patient delay has decreased in recent years; general practitioner delay is disputed by some authors, but there is considerable evidence that it exists. Hospital delay can be influenced by the general practitioner; there is evidence that it has increased in recent years and is likely to increase further with the current pressure on in-patient beds.
Surgery for local pelvic recurrence after resection of rectal cancer.
Saito N. Koda K. Takiguchi N. Oda K. Soda H. Nunomura M. Sarashina H. Nakajima N.
First Department of Surgery, Chiba University School of Medicine, Japan.
This retrospective study evaluated outcome with regard to procedure, local control, and survival after curative surgical resection with and without preoperative radiotherapy for local pelvic recurrence. A total of 58 consecutive patients with local pelvic recurrence of rectal cancer after previous curative resection for primary tumors were reviewed. Of these, 36 underwent both initial resection and follow-up in our department; the remaining 22 had initial surgery and follow-up elsewhere. Of the 58 patients 27 underwent curative re-resection, 9 had palliative resection, and 22 were treated by conservative therapy. Among the 27 patients with curative resection 17 received preoperative radiotherapy (40 Gy) plus surgery and 10 surgery only. No patients were lost to follow-up; median follow-up time was 36.3 months. The overall rate of curative resection was 46.6%: 55.6% in our own follow-up group and 31.8% in the others. With regard to surgical procedure, abdominoperineal resection (APR) with or without sacral resection was standard following previous low anterior resection, and total pelvic exenteration (TPE) with or without sacral resection was common following APR. There was a high incidence of morbidity (71.4%) after TPE. Re-recurrence was observed in 12 (44.4%) after curative re-resection. There was local re-recurrence in 6 (22.2%). The local re-recurrence rate was 11.8% (n = 2) with radiotherapy plus surgery, and 40.0% (n = 4) with surgery alone. The estimated 5-year survival following curative re-resection was 45.6% (61.2% with radiotherapy plus surgery, 29.6% with surgery alone). Both survival and local control with radiotherapy plus surgery tended to be better than with surgery alone. Thus, in selected patients pelvic local recurrence of rectal cancer can be re-resected curably by APR or TPE (with or without sacral resection) combined with preoperative radiotherapy.
Prophylactic pancreaticoduodenectomy for premalignant duodenal polyposis in familial adenomatous polyposis.
Causeret S. Francois Y. Griot JB. Flourie B. Gilly FN. Vignal J.
Department of Surgery, Hopital Lyon Sud, Pierre Benite, France.
The frequency of duodenal adenomas in patients with, familial adenomatous polyposis is high. Duodenal adenoma has malignant potential, and duodenal adenocarcinoma is one of the main causes of death in patients who have had previous proctocolectomy. A conservative approach to the treatment of duodenal adenomas (nonsteroidal anti-inflammatory drugs, endoscopy, polypectomy through duodenotomy) is inefficient and unsafe. When invasive cancer occurs in duodenal adenomas, the result of surgery is poor. We have performed prophylactic pancreaticoduodenal resection (PDR) for nonmalignant severe duodenal polyposis in five patients since 1991. No operative mortality was observed. One patient developed a pancreatic fistula which was successfully managed by medical treatment. The mean follow-up was 35 months. All five patients are still alive and have a good functional outcome. Prophylactic PDR may be indicated in familial adenomatous polyposis when duodenal polyposis is severe. Stages III and IV of Spigelman's classification, periampullary adenoma, age above 40, and family history of duodenal cancer are factors that may lead to the decision to perform prophylactic PDR.
Laparoscopic colorectal resection for diverticulitis.
Kohler L. Rixen D. Troidl H.
II Department of Surgery, University of Cologne, Germany.
This study evaluated outcome in patients undergoing laparoscopically assisted sigmoid resection for diverticular disease. A total of 29 consecutive patients were treated surgically for colonic diverticulitis; in 27 of these laparoscopy was performed. The review of medical records from a control group of 34 patients undergoing open resection were used for comparison. The conversion rate was 7.5%. Using the laparoscopic technique the duration of surgery was longer (165 vs. 121 min, P < 0.05), blood loss less (182 vs. 352 ml, P < 0.05), and subsequent blood transfusion less (0 vs. 61%). The incidence of complications following laparoscopic resection was lower (two anastomotic leakages, two wound infections) than in the conventional group. Convalescence in the laparoscopic group was more rapid and hospital stay shorter (7.9 vs. 14.3 days, P < 0.05). In the laparoscopic group patients expressed less pain at rest and in motion. The cost of the laparoscopically assisted procedure was less than that of conventional resection (7185 vs. 8975 DM). In this series laparoscopically assisted sigmoid resection for diverticulitis proved safe. Recovery was faster, hospital stay was shorter, and patients expressed less pain than in conventional open surgery.