Outcomes Following Surgery for Distal Rectal Cancers: A Comparison between Laparoscopic and Open Abdomino-Perineal Resection.

PURPOSE: Oncologic outcomes following laparoscopic abdomino-perineal resection (APR) for distal rectal cancer are infrequently reported. This study aims to compare the long term outcomes between laparoscopic and open APR in distal rectal cancers. METHODS: A retrospective review of all patients who underwent APR for distal rectal cancer from May 2001 to November 2009 was performed. RESULTS: Forty-two patients, median age 60 (24 - 86) years, formed the study group. Laparoscopic resection was attempted in 16 patients and was successful in all but one. Patients with recurrent diseases, previous abdominal operations and neoadjuvant chemoradiation were more likely to undergo open APR. There were no differences in the T-staging, number of lymph nodes harvested or the final stage of the disease between the two groups. The laparoscopic APR group had a shorter median length of hospitalization (7 vs. 10 days, p < 0.05), but longer operative duration (300 vs. 240 minutes, p > 0.05). Excluding the 9 (21.4%) patients with metastatic disease on presentation, 13 (39.4%) developed recurrence after a median follow up of 24 (4 - 107) months. Twenty (47.6%) patients died from their advanced disease subsequently while one (2.4%) died from a noncancer related cause. Analysis showed that tumour stage and circumferential resection margin positivity were associated with a poorer survival. The types of approach had no significant impact on the survival. CONCLUSION: Laparoscopic APR for distal rectal cancer yields similar oncologic outcomes as open APR. Long-term outcome is determined by the tumour stage and circumferential resection margin and not the approach.

Identification of the internal anal opening and seton placement improves the outcome of deep postanal space abscess.

AIM: This study aimed to determine if successful seton placement at the initial drainage procedure improves outcomes in the management of deep postanal space abscesses. METHOD: A retrospective review was performed of all patients who underwent initial drainage of a DPA space abscess between December 2002 and August 2010. A seton was placed through the internal opening if it could be identified. RESULTS: Thirty-two patients of median age 41 (21-64) years formed the study group. Twenty-four (75.0%) had a seton inserted at the initial drainage procedure. The patients underwent a total of 56 operations. The median interval from the initial to the final operation was 5 (2-18) months with 17 (70.8%) patients having the final operation within 6 months. In the 8 (25.0%) patients whose internal opening could not be found, 26 operations were required with a median interval from the initial to the final surgery of 11 (3-24) months. Patients who had a seton successfully inserted at drainage underwent significantly earlier definitive surgery and required fewer operations (P < 0.038). CONCLUSION: Identification of an internal opening with placement of a seton at the initial drainage procedure is associated with earlier definitive surgery and fewer operations.

Hand-assisted laparoscopic abdomino-perineal resection utilizing the planned end colostomy site.

BACKGROUND: Aim of the study was to determine the feasibility and outcomes of utilizing the planned end colostomy site for placing the hand-assist device in performing hand-assisted laparoscopic abdominoperineal resections (HAL APR) in patients with low rectal cancer. METHODS: Patients with low rectal cancers not suitable for a sphincter salvage proctectomy were recruited. HAL APR was performed by placing the hand-assist device over the planned colostomy site. Standard total mesorectal excision (TME) was performed, and the specimen was delivered via the perineal incision. Patient data and perioperative variables were obtained from the institution colorectal cancer database and analyzed. RESULTS: Six patients underwent HAL APR from November 2004 to January 2006. Mean operative time was 213 min with no conversions or intraoperative complications. One patient developed post-operative ileus which resolved spontaneously. There were no other morbidities or mortalities. Mean hospitalization was 6.8 days. After a mean follow-up of 13.3 months, one patient developed a parastomal hernia which was subsequently repaired during liver resection for liver metastases. No other long-term complications occurred. CONCLUSION: HAL APR with the hand device placed at the planned stoma site is technically feasible. Without creating an additional incision, the operation is oncologically comparable and renders similar short-term outcomes as SL methods, maintaining the benefits of a minimally invasive approach.

Hand-assisted laparoscopic colectomy versus standard laparoscopic colectomy: a cost analysis.

OBJECTIVE: There is a relative dearth of literature comparing hand-assisted (HALC) to standard (SLC) laparoscopic colectomies. HALC seems beneficial in terms of shorter operative times and lower conversion rates, but this is counterbalanced by a greater inflammatory response, larger incisions and higher direct costs. Nevertheless, these results are not consistent throughout existing studies and there are to date no detailed cost comparisons. Our hypothesis was that HALC would not incur significantly higher institutional costs compared with standard laparoscopic techniques. METHOD: Patients undergoing either SLC or HALC between August 2004 and September 2006 were retrospectively reviewed. All patients were managed using a standard protocol. Outcomes assessed included operative times, conversion rates, pain scores, time to resolution of ileus, length of stay and complications. Total costs were calculated from the day of surgery. Statistical analyses included chi(2), Fisher's exact test, the Mann-Whitney U-test or nonparametric bootstrapping method. RESULTS: Seventy-three patients underwent SLC while 101 had HALC. Demographics and indications for surgery in both groups were similar; the majority were performed for colorectal cancers. Operative times were shorter (147.5 vs 172.5 min, P < 0.05) and complication rates lower (28.7%vs 45.2%, P < 0.025) for HALC. There was no significant difference in the other clinical outcomes. Operative costs and cost of consumables were higher for HALC (US$4024.2 vs US$3568.1, P = 0.01 and US$1724.7 vs US$1302.7, P < 0.001, respectively). However, total costs were not significantly different (HALC US$8999.8, SLC US$7910.7, P = 0.11). CONCLUSION: Institutional costs are not significantly higher for HALC compared with SLC.

Efficacy of transarterial embolization as definitive treatment in lower gastrointestinal bleeding.

UNLABELLED: Transarterial catheter embolization (TAE) is integral in the management of lower gastrointestinal bleeding (BLGIT). The efficacy of superselective embolization has reduced the need for emergent surgical resection as a treatment modality. OBJECTIVE: To determine the outcomes of TAE in the management of BLGIT in terms of efficacy rates, recurrent bleeding rates and long term results without the need for surgical intervention. METHOD: Patients who underwent TAE for BLGIT between September 2000 and May 2006 were analysed. Data were extracted from the records for analysis. RESULTS: Sixty-eight patients with a mean age of 76 years and equal gender distribution were analysed. Sixty-nine per cent presented with haematochezia, 40% with malena. Sixty-three patients had a prior RBC scan performed, all of which were positive. Colonoscopy was attempted in 18 patients of which four managed to localize the bleeding site. Embolization was performed in these patients using mainly polyvinyl alcohol particles and/or microcoils. The morbidity rate was 21%, comprising mainly fever and nonspecific abdominal pain with only four ischaemic complications and one report of colonic infarction. Early recurrent bleeding occurred in six patients. Three were treated with repeat embolization and two required surgery. There were no mortalities. After a mean follow-up of 12 months, 12 (17.6%) patients developed further episodes of BLGIT, necessitating further intervention. CONCLUSION: Transarterial catheter embolization is effective and safe in the acute management of BLGIT and reduces the need for further definitive surgery in a majority of patients.

Emergency Hartmann's procedure: morbidity, mortality and reversal rates among Asians.

BACKGROUND: Hartmann's procedure and its reversal are associated with high cumulative morbidity rates. We assessed the outcomes of emergency Hartmann's procedures and permanent stoma rates among Asians. METHODS: A retrospective review of all emergency Hartmann's procedure performed from 1996 to 2001 was performed. RESULTS: Emergency Hartmann's procedure was performed in 98 patients with a median age of 68 years. These included 58 patients with cancer and 18 with diverticulitis; 77 patients had pre-existing comorbidities. The mortality and morbidity rates were 19% and 65%, respectively. Mortality was impacted by pre-existing respiratory or cardiac disease, age and ASA grade. Likewise, morbidity was significantly increased in the presence of comorbidities, including hypertension and cardiac disease, and age. On multivariate analysis, only age (p=0.003, OR=1.171) and respiratory disease (p=0.029, OR=11.05) affected mortality rates whilst hypertension (p=0.011, OR=5.85) and cardiac disease (p=0.044, OR=5.46) affected morbidity rates. Re-anastomosis was performed in 70 patients, and in 28 of these patients (40%) bowel continuity was re-established after a median of 9 months with a 7% morbidity rate. Reversibility was only related to patient age (p=0.011). CONCLUSIONS: Hartmann's procedure is valid among Asians, and its mortality and morbidity rates are related to patients' pre-existing health conditions. The predominant cause is colorectal cancer and permanent stoma rates are related to patient age.

Microsatellite instability and MLH1 hypermethylation - incidence and significance in colorectal polyps in young patients.

OBJECTIVE: Microsatellite instability (MSI) is observed in most hereditary nonpolyposis colorectal cancer-related colorectal cancers (CRC). The original Bethesda criteria recommends MSI testing in patients

Snake venom components and their applications in biomedicine.

Snake envenomation is a socio-medical problem of considerable magnitude. About 2.5 million people are bitten by snakes annually, more than 100,000 fatally. However, although bites can be deadly, snake venom is a natural biological resource that contains several components of potential therapeutic value. Venom has been used in the treatment of a variety of pathophysiological conditions in Ayurveda, homeopathy and folk medicine. With the advent of biotechnology, the efficacy of such treatments has been substantiated by purifying components of venom and delineating their therapeutic properties. This review will focus on certain snake venom components and their applications in health and disease.

Laparoscopic-assisted colon and rectal surgery - lessons learnt from early experience.

INTRODUCTION: Current evidence shows that laparoscopic bowel surgery is associated with a lower incidence of postoperative ileus, lower postoperative pulmonary and wound complication rates, shorter hospital stays and a quicker return to activity than open surgery. This paper aims to report our early experience with laparoscopic-assisted colorectal procedures in our Centre for Advanced Laparoscopic Surgery and the important lessons we have learnt from this. MATERIALS AND METHODS: All laparoscopic-assisted colon and rectal surgical (LAC) procedures performed between January 2000 and December 2003 were reviewed. Clinical and operative records of these patients were reviewed. Data retrieved included patient demographics, selected intraoperative parameters, and postoperative outcomes. In order to provide a comparable reference, an equal number of matched open procedures over the same period were accrued and similarly analysed. All patients were managed on a standard carepath. All data were entered into a database and analysed using a statistical software package. RESULTS: Forty-two laparoscopicassisted colorectal procedures were performed from June 2000 to December 2003. A similar number of diagnosis-matched patients with open colorectal procedures were used as comparison. The diagnoses included cancer (68.5% versus 73.8%), diverticulosis (5.7% versus 9.5%) and polyps (14.3% versus 9.5%). Seven were converted to open surgery because of bleeding, adhesions and locally advanced disease. Laparoscopic-assisted procedures performed included 1 right hemicolectomy, 5 left hemicolectomies, 9 anterior resections, 1 abdominal-perineal resection, 3 sigmoid colectomies, 11 colostomies and 1 Hartmann's procedure. Mean perioperative time (146 min versus 125 min, P = 0.173) was comparatively longer. Mean duration for analgesic requirement (2.25 days versus 2.64 days, P = 0.05), mean length of stay (5.31 days versus 9.07 days, P < 0.05), mean time to commencement of diet (2.91 days versus 4.05 days, P < 0.001) and mean time to first bowel movement (2.57 days versus 4.10 days, P < 0.001) were all comparatively shorter. General morbidity rates (17.1% versus 21.4%, P = 0.35) were lower. No local wound complications were found in our laparoscopic-assisted group. Patients who had undergone open surgery instead of the planned laparoscopic-assisted procedures fared more poorly. CONCLUSIONS: Laparoscopic-assisted colorectal procedures performed in well-selected patients are associated with shorter hospital stays, quicker return of bowel function and lower morbidity when compared to the matched open procedures. Early experience should be acquired from performing technically simple procedures in patients with benign conditions before progressing to definitive resections in those with cancer.

The Torg--Pavlov ratio in cervical spondylotic myelopathy: a comparative study between patients with cervical spondylotic myelopathy and a nonspondylotic, nonmyelopathic population.

STUDY DESIGN: A radiologic study to compare the Torg--Pavlov ratios between patients with cervical spondylotic myelopathy and a nonspondylotic, nonmyelopathic population. OBJECTIVES: To determine and compare the Torg--Pavlov ratios between the two groups of patients. SUMMARY OF BACKGROUND DATA: Patients with congenital cervical spinal canal stenosis are more likely to develop cervical spondylotic myelopathy. The Torg--Pavlov ratio eliminates errors related to magnification, a problem with determination of spinal canal stenosis from direct measurements of plain cervical spine radiographs. There has only been one other study that directly compares the Torg--Pavlov ratio between patients with cervical spondylotic myelopathy and a normal control population. METHODS: The preoperative plain lateral cervical spine radiographs of 28 patients with cervical spondylotic myelopathy requiring surgical decompression were compared with radiographs of 88 nonspondylotic, nonmyelopathic patients. The Torg--Pavlov ratio was computed for each level from C3 to C7. RESULTS: The study showed that the Torg--Pavlov ratio is significantly smaller (P < 0.001) in myelopathic patients (mean 0.72 +/- 0.08) compared with the control patients (mean 0.95 +/- 0.14). This was so when individual levels and the mean values were compared. Age was also found to be a significant factor (P = 0.002), although lesser in magnitude when compared with the Torg--Pavlov ratio (P = 0.0001). CONCLUSIONS: The Torg--Pavlov ratio is significantly lower in patients with cervical spondylotic myelopathy compared with a nonspondylotic, nonmyelopathic population. It could possibly be used to predict the likelihood of developing cervical spondylotic myelopathy.

Complete nucleotide sequence and genome organization of hibiscus chlorotic ringspot virus, a new member of the genus Carmovirus: evidence for the presence and expression of two novel open reading frames.

The complete nucleotide sequence of hibiscus chlorotic ringspot virus (HCRSV) was determined. The genomic RNA (gRNA) is 3,911 nucleotides long and has the potential to encode seven viral proteins in the order of 28 (p28), 23 (p23), 81 (p81), 8 (p8), 9 (p9), 38 (p38), and 25 (p25) kDa. Excluding two unique open reading frames (ORFs) encoding p23 and p25, the ORFs encode proteins with high amino acid similarity to those of carmoviruses. In addition to gRNA, two 3'-coterminated subgenomic RNA (sgRNA) species were identified. Full-length cDNA clones derived from gRNA and sgRNA were constructed under the control of a T7 promoter. Both capped and uncapped transcripts derived from the full-length genomic cDNA clone were infectious. In vitro translation and mutagenesis assays confirmed that all the predicted ORFs except the ORF encoding p8 are translatable, and the two novel ORFs (those encoding p23 and p25) may be functionally indispensable for the viral infection cycle. Based on virion morphology and genome organization, we propose that HCRSV be classified as a new member of the genus Carmovirus in family Tombusviridae.