Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting.

INTRODUCTION: In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. METHODS: The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process. RESULTS: The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists. CONCLUSION: These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.

Short and long-term outcomes of a randomised controlled trial of vertical periumbilical wound versus transverse left iliac fossa wound for specimen retrieval in laparoscopic anterior resections.

BACKGROUND: The ideal incision for laparoscopic specimen extraction is not known. There has been no randomised study thus far evaluating extraction site in laparoscopic colorectal surgery. The aim of our study was to compare post-operative outcomes, pain scores and quality of life scores of vertical periumbilical (VW) versus transverse left iliac fossa (TW) incisions for specimen extraction in laparoscopic anterior resections. METHODS: Using an assumption of pain score of 5 in the VW group versus pain score of 2 in the TW group, on day one post-operatively, and based on a 80% statistical power of analysis to achieve a statistical difference with reduction in pain scores, the sample size per arm calculated was 16. Forty patients undergoing laparoscopic anterior resection were randomised to VW (n = 20) or TW (n = 20). Primary endpoint was post-operative pain. Secondary endpoints were post-operative outcomes, wound cosmesis using Hollander Cosmesis Score and quality of life assessment using EQ-5D at 2 weeks and 2 months post-operatively. RESULTS: Median pain score on the first post-operative day was 2 in both groups (p = 0.360). There was no significant difference in wound infection rates, operative time or post-operative recovery. Cosmesis scores and EQ-5D scores were also similar in both groups. At a median follow-up of 30 months, the incidence of extraction site incisional hernia was similar. CONCLUSION: Transverse and vertical incisions in laparoscopic colorectal surgery have similar post-operative outcomes, with similar pain scores, cosmesis scores, quality of life scores and incisional hernia rates.

Serum methylation levels of TAC1. SEPT9 and EYA4 as diagnostic markers for early colorectal cancers: a pilot study.

OBJECTIVE: To identify methylated genes in serum with diagnostic potentials for early colorectal cancer (CRC). METHODS: Serum methylation levels of up to 12 genes were measured in two sets of serum samples with the second set from 26 stage I CRC patients and 26 age/gender-matched controls. RESULTS: Serum methylation levels of TAC1, SEPT9, and EYA4 were significant discriminants between stage I CRC and healthy controls. Combination of TAC1 and SEPT9 rendered 73.1% sensitivity with 92.3% specificity. CONCLUSION: Serum methylation levels of TAC1. SEPT9 and EYA4 may be useful biomarkers for early detection of CRC though a validation study is necessary.

Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms.

AIM: To investigate the effect of reducing dietary fiber on patients with idiopathic constipation. METHODS: Sixty-three cases of idiopathic constipation presenting between May 2008 and May 2010 were enrolled into the study after colonoscopy excluded an organic cause of the constipation. Patients with previous colon surgery or a medical cause of their constipation were excluded. All patients were given an explanation on the role of fiber in the gastrointestinal tract. They were then asked to go on a no fiber diet for 2 wk. Thereafter, they were asked to reduce the amount of dietary fiber intake to a level that they found acceptable. Dietary fiber intake, symptoms of constipation, difficulty in evacuation of stools, anal bleeding, abdominal bloating or abdominal pain were recorded at 1 and 6 mo. RESULTS: The median age of the patients (16 male, 47 female) was 47 years (range, 20-80 years). At 6 mo, 41 patients remained on a no fiber diet, 16 on a reduced fiber diet, and 6 resumed their high fiber diet for religious or personal reasons. Patients who stopped or reduced dietary fiber had significant improvement in their symptoms while those who continued on a high fiber diet had no change. Of those who stopped fiber completely, the bowel frequency increased from one motion in 3.75 d (± 1.59 d) to one motion in 1.0 d (± 0.0 d) (P < 0.001); those with reduced fiber intake had increased bowel frequency from a mean of one motion per 4.19 d (± 2.09 d) to one motion per 1.9 d (± 1.21 d) on a reduced fiber diet (P < 0.001); those who remained on a high fiber diet continued to have a mean of one motion per 6.83 d (± 1.03 d) before and after consultation. For no fiber, reduced fiber and high fiber groups, respectively, symptoms of bloating were present in 0%, 31.3% and 100% (P < 0.001) and straining to pass stools occurred in 0%, 43.8% and 100% (P < 0.001). CONCLUSION: Idiopathic constipation and its associated symptoms can be effectively reduced by stopping or even lowering the intake of dietary fiber.

Endoscopic stenting and elective surgery versus emergency surgery for left-sided malignant colonic obstruction: a prospective randomized trial.

PURPOSE: This study aims to evaluate the role of colonic stenting as a bridge to surgery in acutely obstructed left-sided colon cancer. METHODS: Patients with acute left-sided malignant colonic obstruction with no evidence of peritonitis were recruited. After informed consent, patients were randomized to colonic stenting followed by elective surgery or immediate emergency surgery. Patients who had successful colonic stenting underwent elective surgery 1 to 2 weeks later, while the other group had emergency surgery. Patients in whom stenting was unsuccessful also underwent emergency surgery. RESULTS: Twenty patients were randomized to stenting and 19 to emergency surgery. Fourteen patients (70%) had successful stenting and underwent elective surgery at a median of 10 days later; the rest underwent emergency surgery. Technical stent failure occurred in five patients (25%). One patient failed to decompress after successful stent deployment. All patients underwent definitive colonic resection with primary anastomosis. Two of 20 patients in the stenting group required defunctioning stomas compared to 6 of 19 in emergency surgery group, p = 0.127. Overall complication rate was 35% versus 58% (p = 0.152) and mortality was 0% versus 16% (p = 0.106) in the stenting group and emergency surgery group, respectively. Postoperatively, the stenting group was discharged from hospital earlier (median of 6 versus 8 days, p = 0.028) than the emergency surgery group. CONCLUSION: Colonic stenting followed by interval elective surgery may be safer, with a trend towards lower morbidity and mortality when compared with the current practice of emergency surgery for left-sided malignant colonic obstruction.

Results of 7302 stapled haemorrhoidectomy operations in a single centre: a seven-year review and follow-up questionnaire survey.

BACKGROUND: This study aims to evaluate the results of all 7302 stapled haemorrhoidectomy operations performed in a single centre. METHOD: A retrospective review of all 7302 patients who underwent stapled haemorrhoidectomy at our department over seven years was conducted. The hospital database was reviewed for subsequent readmissions and re-operations. A questionnaire survey was also sent out to all the patients. RESULTS: A total of 302 patients (4.1%) were admitted with post-operative bleeding and 281 stopped with conservative measures. Twenty one required surgical haemostasis. A total of 301 patients (4.1%) were admitted for an inability to void and 191 (2.6%) had true acute retention of urine, requiring catheterization. There were 124 patients (1.7%) admitted for pain, but all resolved with oral analgesia subsequently. Anal stricture requiring surgery occurred in only 86 patients (1.2%). Serious complications such as staple line dehiscence or anorectal sepsis occurred in seven patients. There were a total of 14 recurrences requiring readmission over this seven-year period, of which 12 were treated successfully with a second haemorrhoidectomy. A total of 1834 patients returned their questionnaire surveys and 95% of the patients reported complete resolution or improvement of their symptoms. Only 27 patients reported subsequent severe bleeding requiring medical attention. CONCLUSION: Stapled haemorrhoidectomy is safe, and most patients are satisfied with the long-term outcome.

Laparoscopic resection for colorectal polyps: a single institution experience.

BACKGROUND: Endoscopic polypectomy, although routinely used for the treatment of colorectal polyps, may be limited by polyp size, location and histology. Laparoscopic resection for malignant polyps and polyps not amenable to endoscopic removal has the advantage of adequate disease clearance as well as the short-term benefits of laparoscopic surgery. This study evaluates the outcomes of such an approach. METHODS: Patients who had laparoscopic resection for colorectal polyps between January 2005 and July 2008 were identified from a prospective database. Polyps that were malignant, large, difficult to snare or incompletely excised, were included. Demographics, perioperative details and histopathology were analysed. RESULTS: Seventy-eight patients (44 male) with a median age of 62.5 years (range 24-86) were studied. The majority (79%) were laparoscopic anterior resections for sigmoid or rectal polyps. Median operating time was 125 min (range, 65-225). Eight cases (10.3%) were converted to open mainly due to adhesions. There was no post-operative mortality. Perioperative complications occurred in seven patients (8.9%). Median hospital stay was 6 days (range 4-78). Median polyp size was 20 mm (range, 5-75). There were 44 benign polyps (55.7%); majority were tubulovillous adenomas (n= 22), and tubular adenomas (n= 10). Thirty-five patients (44.3%) had invasive cancer, with T1 (n= 27) and T2 (n= 2) tumours. Three of these patients (8.6%) had lymph node metastases. Median number of lymph nodes sampled was six (range 0-23). CONCLUSION: Laparoscopic resection is safe and effective for colorectal polyps not amenable to colonoscopic removal, and is especially important for adequate clearance in the case of malignant polyps.

Prospective randomised study to evaluate the use of DERMABOND ProPen (2-octylcyanoacrylate) in the closure of abdominal wounds versus closure with skin staples in patients undergoing elective colectomy.

BACKGROUND: Topical 2-octylcyanoacrylate tissue (OCA) adhesive has been used as an alternative to close wounds with a comparable cosmetic outcome. The use of 2-OCA in the closure of abdominal laparotomy wounds has not been thoroughly evaluated. Our aim was to compare 2-OCA with conventional skin stapling devices in colorectal surgery. METHODS: A prospective randomised study was conducted in which 74 consecutive patients above the age of 21 undergoing open elective colectomies for benign or malignant indications were allocated to skin closure with 2-OCA or skin staples. Cosmetic outcome as assessed with the Hollander Cosmesis Scale with a single assessor, complication rates, and patient satisfaction were recorded at discharge (4-10POD) 2 weeks after discharge and then at 3 months. RESULTS: Of the 74 patients, 38 were randomised to skin staples and 36 to 2-OCA. There was no significant difference in cosmetic outcomes between the two groups as assessed with a visual analogue scale or the Hollander Cosmesis Scale but showed a trend to better cosmetic outcomes in the 2-OCA group. Patient satisfaction scores were higher but did not reach statistical significance. The time taken to close a wound with 2-OCA was significantly longer than with skin staples. There was no statistical difference in rates of wound infection. CONCLUSION: 2-OCA is a safe and effective means of skin closure in patients undergoing elective colectomies with a good and at least equivalent outcome to traditional methods of closure.

Short-term results of DST EEA 33 stapler and neu@ anoscope for stapled haemorrhoidectomy: a prospective study of 1,118 patients from a single centre.

BACKGROUND: Stapled haemorrhoidectomy has been performed with different techniques and staplers. We review our initial experience with the new DST EEA 33 stapler and neu@ anoscope. METHODS: A review of all patients who underwent stapled haemorrhoidectomy using the DST EEA 33 over a 14-month period was conducted. Short-term outcomes of bleeding, pain and retention of urine requiring admission or strictures requiring surgical intervention were studied. RESULTS: There were 1,118 patients operated from August 2007 to October 2008. The median age was 46-year-old (20-82 years) and 51% were females. The median operating time was 15 min (range 5-45 min), and median follow-up was 7 months (range 3-16 months). There were 26 patients (2.3%) who were admitted for inability to pass urine and 20 required catheterisation. Fifty-two patients (4.6%) were admitted for post-operative bleeding. In 32 cases the bleeding stopped spontaneously, while 19 patients required adrenaline injection and packing for hemostasis. Only one patient required surgical hemostasis. Thirty-three patients (2.9%) were admitted for post-operative pain and stayed for a median of 1 day (range 1-4 days). There were 14 patients (1.2%) who developed anorectal strictures requiring surgical intervention. All underwent anoplasty at a median of 3 months post-operatively (range 2-5 months), with good result. There were no recurrent haemorrhoids during follow-up. CONCLUSION: Stapled haemorrhoidectomy using the DST EEA 33 stapler is safe. The neu@ anoscope provides good visibility and handling, and is a useful tool in this procedure.

Laparoscopic versus open right hemicolectomy: a comparison of short-term outcomes.

BACKGROUND: The laparoscopic approach is increasingly becoming the gold standard for colorectal resections. While laparoscopic surgery of the left colon and rectum has been evaluated in many studies, laparoscopic resection of the right colon has not been as widely examined. The aim of this study was to examine the short-term outcomes after laparoscopic right hemicolectomies and to determine if they were superior when compared with those after open resection. PATIENTS AND METHODS: Consecutive cases of laparoscopic right hemicolectomies performed between May 2005 and December 2007, in the Department of Colorectal Surgery, Singapore General Hospital, were compared with a matched series of patients who underwent open surgery. RESULTS: From a total of 37 laparoscopic cases, 36 patients successfully underwent laparoscopic right hemicolectomies. There was one conversion, giving a conversion rate of 2.7%. These 37 patients were compared with 40 patients who underwent open right hemicolectomies. The laparoscopic arm was characterised by shorter length of incisions (5.7 vs. 11.2 cm, p < 0.001) but longer operating times (110.8 vs. 71.6 min, p < 0.001). Mean number of lymph nodes harvested and length of proximal and distal margins were similar in both groups. There were also no significant differences between the groups in terms of narcotic use, recovery of bowel function, length of stay, post-operative morbidity and 30-day mortality. CONCLUSION: Laparoscopic right hemicolectomies are as feasible and safe as the open technique. They confer improved cosmesis with smaller incisions but at the expense of longer operating time.

Brain metastases in colorectal cancers.

BACKGROUND: Although colorectal cancer is the most common cancer in Singapore, brain metastases associated with colorectal primaries are quite rare, with reported incidences ranging from less than 1% to 4%. This is a review of the incidence, presentation, and prognosis of brain secondaries from colorectal primaries in our institution. METHODS: From a prospectively collected database, 4378 patients underwent surgery for colorectal cancers between 1995 and 2003. Patients who developed brain metastases were identified and their records reviewed retrospectively. RESULTS: Twenty-seven patients who developed brain metastases were identified, for an incidence of 0.62%. Seventy-one percent of the patients had a tumor in the rectum or sigmoid; 92.6% of patients had metachronous brain secondaries. The median interval between surgery for the primary tumor and the discovery of a brain secondary was 27.5 months. The lung was the most common site of concurrent metastatic disease, with the discovery of a brain secondary a median of 9.7 months after diagnosis of the lung lesion. All patients were symptomatic. The majority of the patients received nonsurgical treatment for the brain lesion. Median survival after diagnosis of brain secondaries was 2.4 months. CONCLUSIONS: The poor survival of the patients in our series could be due to late diagnosis. It may be recommended that a brain scan be performed to screen for a brain secondary when lung and/or liver metastases are discovered, especially in a patient with a left-sided cancer. This may lead to earlier diagnosis, amenability to surgical treatment, and improved survival and quality of life.

The evaluation of CEEA 34 for stapled hemorrhoidectomy: results of a prospective clinical trial and patient satisfaction.

INTRODUCTION: Stapled hemorrhoidectomy (SH) has routinely been performed using Procedure for Prolapse and Hemorrhoids Proximate Hemorrhoidal Circular Staplers (Ethicon Endo-surgery, Cincinnati, OH). Premium Plus CEEA 34 (Tyco Healthcare, New Haven, CT) has been recently introduced for SH. This study aims to review the effectiveness of CEEA 34 for SH. METHODS: From April to June 2007, the SH procedure was performed or supervised by 5 experienced consultant surgeons. A quality of life telephone survey was performed within 4 to 6 weeks postoperatively. RESULTS: Two hundred thirteen patients (52% men and 48% women) with a median age of 46 years (range 26-78 years) underwent SH during the trial period. Median duration of surgery was 10 minutes (range 5-35 minutes). Ninety-seven percent underwent SH for third- and fourth-degree piles. Ten patients (4.7%) had bleeding postoperatively in the first week that ceased with adrenaline injection or pack, and 2 required transfusions. Eighty-three percent participated in the quality of life survey, and 92% of these patients expressed satisfaction with the outcome of the procedure. CONCLUSION: CEEA 34 for SH is safe and effective with few postoperative complications and high patient satisfaction.

Phenotypic characteristics of hereditary non-polyposis colorectal cancer by the Amsterdam criteria: an Asian perspective.

BACKGROUND: Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal disease with a 68-82% lifetime risk of colorectal cancer (CRC). This study examined the phenotypic characteristics of CRC in Amsterdam criteria-positive Asian patients from the Singapore Polyposis Registry. METHODS: Hereditary non-polyposis CRC patients, defined by the Amsterdam I and II criteria, prospectively monitored in the Singapore Polyposis Registry over a 16-year period were reviewed. Clinical data were obtained from a computerized database and parameters, such as age of diagnosis, type and location of CRC, other associated cancers in the pedigree, cancer recurrence and survival were analysed. RESULTS: Fifty-two patients (31 men and 21 women) from 42 unrelated families, with a median age of 44.5 years (range 27-73 years), fulfilled either Amsterdam I or II criteria and were included in our analysis. The racial distribution was 91% (n = 47) Chinese and 9% (n = 5) Malays, with a median follow up of 44.9 months (range 2-183 months). Significantly, 69% of tumours in this Amsterdam-defined cohort were left sided, with most being sigmoid cancers. Sixty per cent of all the tumours presented at a late stage (Dukes' C or D). Left-sided tumours presented with more advanced Dukes' stage (P = 0.096) and a higher rate of metastatic disease (P = 0.08) compared with right-sided lesions. There were, however, no significant differences in either disease-free or overall survival between right-sided and left-sided tumours. CONCLUSION: This study emphasized the significant left-sided predominance of CRC in Amsterdam I and II-defined patients from our predominantly Chinese population, in contrast to those classically described in Lynch syndrome. Amsterdam criteria thus may not be suitable for diagnosing HNPCC in Asian populations and a greater emphasis should be made towards routine molecular diagnosis of mismatch repair gene defects in suspected HNPCC patients of Asian decent.

Modest promoter methylation of E-cadherin gene in sporadic colorectal cancers: a quantitative analysis.

Although E-cadherin expression is frequently reduced in colorectal cancers (CRCs), this does not appear to be due to gene mutation or allele loss. We investigated the hypothesis that promoter methylation could be responsible for suppression of E-cadherin expression in 142 pairs of sporadic CRCs and respective normal mucosae. E-cadherin expression was examined by Western blot. E-cadherin methylation at two promoter regions was quantitatively measured by methylation specific real time PCR (MethyLight). We found that E-cadherin protein levels were significantly lower in CRCs, even in Dukes' A tumors, compared to normal mucosae. Decreased E-cadherin protein expression in CRCs was an independent poor prognostic factor in multivariate disease-free survival analysis. However, the extent of DNA methylation was extremely modest at both regions of the E-cadherin promoter. There was no correlation between DNA methylation and E-cadherin protein levels in either tumors or matched normal tissues. These findings suggested that suppression of E-cadherin expression in CRCs is a significant event and is possibly involved in both carcinoma development and progression. However, our data did not support a crucial role of promoter methylation of the E-cadherin gene in the remarkable downregulation of E-cadherin expression in CRCs. Methylated E-cadherin gene as a CRC biomarker therefore needs further validation.

Charity colonoscopy event to commemorate the 185th anniversary of Singapore General Hospital.

INTRODUCTION: Colorectal cancer is now the cancer with the highest incidence in Singapore. However, the overall mortality rate is still about 50% because the majority of the patients present at a late stage of disease. A charity event of screening colonoscopy was offered to the public in conjunction with the 185th anniversary of Singapore General Hospital. The aim of this event was to raise awareness about early detection of colorectal cancer and the safety of colonoscopy. MATERIALS AND METHODS: We conducted a one-off free screening event for colorectal cancer using colonoscopy. Four hundred and ninety individuals responded to a multimedia advertisement for the event. Of these, 220 individuals were selected for the screening based on National Guidelines for colorectal cancer screening and financial status. RESULTS: One hundred and fifty-two individuals turned up for the colonoscopy. The median age was 55 years (range, 22 to 82), with 84 males. Significant pathology was found in 33% of the individuals (n = 51). Colorectal polyps were detected in 34 individuals (22%). A total of 45 polyps were removed, with 20 hyperplastic polyps and 25 adenomas. Eight out of 25 adenomas were located proximal to the splenic flexure. Rectal cancer was diagnosed in 1 individual (0.6%). One individual had a large dysplastic rectosigmoid ulcer and refused further intervention. There were no significant complications from any of the colonoscopies. CONCLUSIONS: Colonoscopy is an invaluable screening modality as it has a high pick-up rate for colorectal polyp and cancer in an asymptomatic population. It is also proven to be safe in our study. It has the added advantage over flexible sigmoidoscopy of detecting a significant number of proximal lesions. Also, therapeutic polypectomy can be performed in the same setting.

A susceptibility gene set for early onset colorectal cancer that integrates diverse signaling pathways: implication for tumorigenesis.

PURPOSE: The causative genes for autosomal dominantly inherited familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer have been well characterized. There is, however, another 10% to 15% of early onset colorectal cancers (CRC) in which the genetic components are unclear. In this study, we used microarray technology to systematically search for differentially expressed genes in early onset CRC. EXPERIMENTAL DESIGN: Young patients with non-FAP or non-hereditary nonpolyposis colorectal cancer, and healthy controls were age- (

Mesenteric desmoid tumors in Singapore familial adenomatous polyposis patients: clinical course and genetic profile in a predominantly Chinese population.

PURPOSE: This study examined the mutational profile of the adenomatous polyposis coli gene in relation to the development of desmoid tumors in familial adenomatous polyposis patients from a predominantly Chinese population. METHODS: This is a retrospective review of all patients with familial adenomatous polyposis coli from the Singapore Polyposis Registry. Identification of specific adenomatous polyposis coli gene mutation was performed and clinical course of associated desmoid disease obtained from case records and a computerized database. RESULTS: Two hundred five patients from 75 families afflicted with familial adenomatous polyposis coli were reviewed, with gene mutations identified in 107 patients. Of these, 23 (11.2 percent) developed desmoids. The male-to-female ratio was 1:1.3 and the ethnic distribution was Chinese (n=17) and Malay (n=6). Of the 92 patients with mutations 5' to codon 1444, 11 patients (12 percent) developed desmoids compared with 6 of 15 (40 percent) patients with adenomatous polyposis coli gene mutations 3' to codon 1444 (P<0.01). The clinical course of desmoid tumors can be divided into stable (n=11), variable (n=3), progressive (n=6), and aggressive growth (n=3). Only 3 (13 percent) patients with aggressive tumor growth required chemotherapy. There was no correlation between the site of mutation and the clinical progression of the desmoids. Seventy-four percent of these desmoids (17/23) developed at a mean interval of 2.98 years after restorative proctocolectomy, while only 30 percent (7/23) were diagnosed preoperatively or discovered during the initial surgery. The most common complications related to the mesenteric desmoids were intestinal obstruction (21.7 percent), ureteric obstruction (17.4 percent), and encasement of superior mesenteric vessels (13 percent). CONCLUSION: The clinical course of desmoids in an individual familial adenomatous polyposis patient remains unpredictable and no reliable genetic marker is available for prognostication in desmoid disease.

Cutaneous and subcutaneous metastases of adenocarcinoma of the colon and rectum.

INTRODUCTION: The interesting topic of cutaneous and subcutaneous metastasis from rectal carcinoma is discussed using 3 cases. CLINICAL PICTURE: The first case was a 70-year-old man with T3N2M0 rectal mucinous adenocarcinoma, who developed an inflammatory subcutaneous metastasis at the left scapula 2 years after anterior resection. The second case was a 51-year-old man with T4N2M0 splenic flexure mucinous adenocarcinoma, who developed metastatic disease including a subcutaneous secondary to the back. The third case was a 53-year-old woman who developed vulval recurrence 10 months after abdomino-perineal resection for a low T3N1M0 rectal adenocarcinoma. TREATMENT: All underwent wide resection. CONCLUSION: This entity is rare and usually signifies disseminated disease if found remote from the resection site and warrants a thorough metastatic work up. A high index of suspicion is recommended when encountered with unresolving skin lesions in cancer patients.

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians.

OBJECTIVE: Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70 years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70 years who had IPAA. METHODS: After Institutional Review Board approval, a retrospective review of the medical records of patients with MUC who underwent IPAA was undertaken. These patients were divided into four age groups: <30 years of age, 30-49 years, 50-69 years, >or=70 years. RESULTS: From 1989 to 2001, 330 patients underwent IPAA for preoperative clinical and histopathological and postoperative histopathologically confirmed MUC; 17 were aged>or=70 years. The mean hospital stay was 5.8 (SEM 0.7) days in the patients aged<70 years and 6.0 (SEM 0.4) days in the patients aged>or=70 years (P=0.911). Postoperative complications occurred in 39% of patients>or=70 years and in 40% in the <70 years group (P=0.08). Pouch failure occurred in two (11.8%) patients>or=70 years and in 6 (1.9%)<70 (P=0.2). CONCLUSION: IPAA is a safe and feasible option in MUC patients over the age of 70 with functional results similar to results seen in younger patients.