Management of early rectal cancer.

BACKGROUND: Early rectal cancer (ERC) is adenocarcinoma that has invaded into, but not extended beyond, the submucosa of the rectum (that is a T1 tumour). Local excision is curative for low-risk ERCs but for high-risk cancers such management is controversial. METHODS: This review is based on published literature obtained by searching the PubMed and Cochrane databases, and the bibliographies of extracted articles. RESULTS AND CONCLUSION: ERC presents as a focus of malignancy within an adenoma, as a polyp, or as a small ulcerating adenocarcinoma. Preoperative staging relies on endorectal ultrasonography and magnetic resonance imaging. Pathological staging uses the Haggitt and Kikuchi classifications for adenocarcinoma in pedunculated and sessile polyps respectively. Lymph node metastases increase with the Kikuchi level, with a 1-3 per cent risk for submucosal layer (Sm) 1, 8 per cent for Sm2 and 23 per cent for Sm3 lesions. Low-risk ERCs may be treated endoscopically or by a transanal procedure. Transanal excision or transanal endoscopic microsurgery may be inadequate for high-risk ERCs and adjuvant chemoradiotherapy may be appropriate. There is a low rate of recurrence after local surgery for low-risk ERCs but this increases to up to 29 per cent for high-risk cancers.

Colonoscopy for screening and follow up of patients with a family history of colorectal cancer.

OBJECTIVE: To determine the minimum family history of colorectal cancer (CRC), which justifies colonoscopy and to establish whether further colonic assessment is necessary after a negative screening colonoscopy. METHOD: A retrospective review of every colonoscopy undertaken for family screening at the Royal Berkshire and Battle Hospitals, Reading between October 1996 and July 2004. RESULTS: Four hundred and thirty-two patients (261 women) with an average age of 48 years (range 14-84) were screened. Three cancers in patients over the age of 60 years and 49 adenomas were found in 37 patients. Twenty three of 281 (8%) patients with a 'low-risk' family history (one in 12 or less lifetime risk of developing CRC) had either a cancer or an adenoma. Eighteen of 151 (12%) patients with a 'high-risk' family history (one in 10 or greater) had a similar positive colonoscopy. Thirteen of 15 patients who had an adenoma aged under 45 years had a high-risk family history. Seventy-three patients subsequently underwent two or more follow-up colonoscopies. There were 22 adenomatous polyps found in 12 patients (16%) at the first screening, nine adenomas in seven patients in the second colonoscopy and four adenomas found in four patients in all subsequent colonoscopies. CONCLUSION: Patients with a low-risk family history have a similar adenoma pick-up to that of the general population. These patients need not be screened below the age of 50 unless symptomatic. Follow up of low-risk family history (FH) patients with a negative screening colonoscopy is unlikely to be beneficial.

Combined surgery and chemoradiation as a treatment for the Buschke-Löwenstein tumour.

BACKGROUND: The Buschke-Löwenstein tumour (BLT) or giant condyloma acuminata is a rare disease which affects the anogenital region. Although histologically benign, it behaves in a malignant fashion, infiltrating the surrounding tissues. The morbidity and mortality from this tumour is high, as is the risk of recurrence following treatment. It lies on the continuum between the benign condylomata acuminata and squamous cell carcinoma. The human papillomavirus is implicated in its aetiology. Treatment is controversial, with topical chemotherapy, radiotherapy, immunotherapy and radical surgery all having been employed. Chemoradiation remains the mainstay of treatment for anal cancers but has not been routinely employed in the management of the BLT without squamous cell carcinoma transformation. METHODS: Two cases of extensive perineal BLT treated with chemoradiation and subsequent surgical excision are presented. RESULTS: The first patient had a good symptomatic response to the chemoradiation but unfortunately died of recurrent disease following surgery. The second patient had a macroscopically complete response to chemoradiation and remains well following abdominoperineal excision. CONCLUSION: Pre-operative chemoradiation has proved to be useful in management for histologically proven benign BLT

Intra-operative peritoneal lavage--who does it and why?

INTRODUCTION: Intra-operative peritoneal lavage (IOPL) is widely practised but its benefits are unclear. The frequency and pattern of its use amongst general surgeons is investigated. METHODS: A postal questionnaire was sent to 153 general surgical consultants and registrars enquiring about their use of IOPL. The surgeon was asked the volume and type of lavage fluid used, under various circumstances. RESULTS: 118 (77%) questionnaires were returned. 115 (97%) surgeons used IOPL. The majority of surgeons (61%) lavaged until the fluid was clear, 20% used more than 1 l and 17% used between 500-1000 ml. In the case of the dirty abdomen (i.e. gross pus or faecal peritonitis), 47% used saline as the lavage fluid, 38% aqueous betadine, 9% water and 3% antibiotic lavage. Similar results were found in the case of a contaminated abdomen (i.e. a breached hollow viscus). 34% of surgeons used IOPL during clean cases. 36% used water lavage during intra-abdominal cancer surgery; 21% lavaged with saline and 17% with betadine. More registrars (47%) than consultants (29%) lavaged with water during cancer surgery. Consultants, however, used more aqueous betadine. CONCLUSIONS: The frequency of use and choice of lavage fluid varies widely. The successful management of the septic abdomen rests on at least 3 tenants - systemic antibiotics, control of the source of infection and aspiration of gross contaminants. There is little good evidence in the literature to support IOPL in the management of the septic abdomen. The use of IOPL during cancer surgery is supported by in vitro evidence. The current use of IOPL, as shown by this study, appears not to be evidence based.

Diagnostic conscious pain mapping using laparoscopy under local anaesthetic and sedation in general surgical patients.

BACKGROUND: Patients in whom extensive investigations have failed to identify the cause of abdominal pain present a challenge to surgeons. We present our initial experience of using laparoscopy under local anaesthetic and sedation in the diagnosis of chronic abdominal pain. METHODS AND PATIENTS: Nine patients with chronic abdominal pain and multiple normal investigations underwent laparoscopy under local anaesthetic and sedation. By touching and grasping intra-abdominal viscera and peritoneum, an attempt was made to reproduce the patient's pain. RESULTS: Two patients were found to have pain arising from the gall bladder and subsequently underwent laparoscopic cholecystectomy with resolution of their symptoms. A third patient had a clinical presentation of chronic acalculous cholecystitis and a normal laparoscopy. She decided to undergo laparoscopic cholecystectomy, which cured her pain. Another patient had pain arising from the appendix, which resolved after an appendicectomy. Three patients had pelvic adhesions, which caused chronic abdominal pain. After adhesiolysis, one is pain free; the others declined surgery for adhesions and their pain resolved. Conscious pain mapping was negative in two patients. CONCLUSION: Laparoscopy can be carried out in the conscious patient, who is then usually able to collaborate with the surgeon in establishing the source of the pain experienced during conscious pain mapping. Long-term effectiveness and diagnostic accuracy has not yet been established.

Closed rupture of the posterior tibial artery secondary to a soccer injury.

Arterial damage following blunt trauma is uncommon and is usually the result of high-energy injury. We report a case of posterior tibial artery rupture after a closed distal tibial fracture, sustained during a low-energy soccer tackle.

The assessment of surgical skills and a simple knot-tying exercise.

Basic surgical skills courses are mandatory for all surgical trainees taking the MRCS examination. An important aspect of these courses is the level of practical skill achieved by junior surgeons attending them. We present a simple knot-tying exercise, which may be used to assess the baseline skill level of trainees at the outset of the course and against which their progress can be judged after tuition and practice.

Spontaneous pneumomediastinum.

Spontaneous pneumomediastinum, or Hamman's syndrome, is a rare condition which may present with the symptoms of chest pain, dyspnoea, dysphagia, or neck pain. The signs of subcutaneous emphysema and Hamman's crunch (the presence of a crepitance sound that varies with the heartbeat on auscultation of the precordium) are usually present. A case of this syndrome occurring in an elderly patient with none of the recognised risk factors is presented.

Options for sphincter preservation in surgery for low rectal cancer.

BACKGROUND: Abdominoperineal excision of the rectum with a permanent end-sigmoid colostomy was the classical operation for cancer of the distal third of the rectum. A number of factors have recently led to a more conservative approach, allowing sphincter preservation when excising tumours that are not invading the anal sphincter. METHODS: The review is based on the published literature of the treatment of low rectal cancers accessed by searching Medline and other online databases. It includes a description of all the surgical options currently available for low rectal tumours, and a discussion of the advantages and disadvantages of the types of anastomosis and reconstruction. RESULTS AND CONCLUSION: It is now technically possible to remove rectal cancer that is extending into the anal canal with preservation of the anal sphincter mechanism and with a satisfactory oncological outcome. Ultra-low colorectal and coloanal anastomosis, together with a colonic pouch or coloplasty, produces acceptable function in many patients. However, there is still controversy about the risk of tumour implantation, the place of downsizing neoadjuvant therapy, and true long-term functional outcome. Despite these concerns, surgeons should strive to perform rectal resection with sphincter preservation for low-lying rectal cancer whenever possible.

Patients' and partners' perceptions of uvulopalatopharyngoplasty for snoring.

OBJECTIVE: Uvulopalatopharyngoplasty (UPPP) has become a routine operation for snoring. Many centres have published their results. Few, if any, have questioned their patient's subjective feelings regarding the operation and more importantly, the patient's partner. METHOD: The study involved postal questionnaires and a retrospective case note review. Between the years 1988 and 1995, 125 patients underwent a UPPP for snoring at Derriford Hospital, Plymouth, England, a large district general hospital. Postal questionnaires were sent to all patients and their partners, asking them about their experience of snoring and of the operation. The subjective postoperative change in the patient's snoring and their day time sleepiness was measured by the Epworth Sleepiness Score. RESULTS: The number of joint questionnaires returned was 90. The number of patients who felt that their snoring had improved after the operation within the first year was 100%, but this fell to 71% after 1 year. There was a significant improvement in the patient's daytime sleepiness after the operation. The list of complications included pain and nasal regurgitation, along with a dry mouth and altered taste. Overall, 78% of patients would recommend the procedure to others. CONCLUSIONS: The operation of UPPP is successful in reducing the severity of snoring noise in the majority of patients, as well as in improving the quality of the patient's sleep. This success, however, decreases with time and must be put in context with the relatively high morbidity.