Laparoscopic management of Spigelian hernia.

Spigelian hernia (SH) is an uncommon abdominal wall hernia. Its clinical symptoms are not characteristic, and the preoperative diagnosis is often difficult because SH can simulate the symptoms of more classical lower quadrant abdominal diseases. We report a case of SH in an 80-year-old woman that was complicated by incarceration and diagnosed by physical examination and ultrasound. At the time of presentation, she had an abdominal mass that was soft and occasionally painful, and aggravated by movements that increase intraabdominal pressure. Laparoscopic examination of the abdominal cavity identified the incarcerate jejunum ansae. The defect was a large opening in the peritoneum along the lateral margin of the rectus abdominis muscle. After dissection of the intestinal adhesions, a prosthetic polypropylene mesh was introduced and fixed with staples into the lateral abdominal wall. There were no postoperative complications. We conclude that the laparoscopic approach is a feasible alternative to the conventional open technique that is easy, safe, and allows excellent operative visualization.

Radioimmunoguided surgery of colorectal carcinoma with an 111In-labelled anti-TAG72 monoclonal antibody.

Radioimmunoscintigraphy (RIS) and radioimmunoguided surgery (RIGS) were assessed for their usefulness in patients with colorectal carcinoma. Twenty-nine patients (18 primary tumours, 10 with a suspicion of recurrence and one colonic diverticulitis) were studied. Radioimmunoscintigraphy was performed 48 and 72 h after the injection of an anti-TAG72 monoclonal antibody (CYT-103) labelled with 111In. Radioimmunoguided surgery was performed between 72 and 96 h post-injection. During surgery, a systematic screening was performed with a hand-held gamma detecting probe and a surgical index (tumour-to-normal tissue) was obtained. There were statistically significant differences between counts in normal tissue versus tumour (P < 0.001) and RIGS was considered positive for the detection of tumour if the ratio between the counts in the area suspicious of tumour and the counts in the normal tissue was greater than 1.5. The overall sensitivity for RIS and RIGS was 71.4% (55.6% in primary tumours and 100% in recurrences) and 82.1% (83.3% in primary tumours and 80% in recurrences), respectively. Radioimmunoguided surgery changed the surgical procedure in two cases with small tumour deposits. Occult regional lymph node involvement in primary tumours was not found; therefore, RIGS, as a complementary technique to RIS, is particularly useful in recurrences and can help the surgeon in the resection of small tumour deposits which are difficult to localize.

Value of postoperative surveillance after radical surgery for colorectal cancer: results of a cohort study.

PURPOSE: Early detection of recurrence after curative resection for primary colorectal cancer should improve patients' prognosis. However, the usefulness of postoperative surveillance programs has not been clarified yet. The present cohort study was aimed at assessing the effectiveness of systematic follow-up in patients with colorectal cancer who were operated on for cure, regarding both rate of tumor recurrence amenable to curative-intent surgery and rate of survival. METHODS: One hundred ninety-nine colorectal cancer patients who underwent radical primary surgery were followed according a well-defined postoperative surveillance program, which consisted of laboratory studies (including serum carcinoembryonic antigen assay) every three months, physical examination and abdominal ultrasound or computed tomography every six months, and chest radiograph and total colonoscopy once per year. Cohorts were defined according to patients' compliance with the proposed follow-up program. A multivariate regression model was constructed to predict survival. RESULTS: One hundred forty patients were considered to be compliant with the surveillance program, whereas the remaining 59 patients occasionally attended follow-up investigations or did not comply at all. Although there were no differences in the overall recurrence rate (38 vs. 41 percent; P = 0.52), curative-intent reoperation was possible in 18 patients (34 percent) of those with tumor recurrence in the compliant cohort but in only 3 patients (12 percent) in the noncompliant cohort (P = 0.05). Similarly, the probability of survival was higher in the compliant cohort, both regarding overall (63 vs. 37 percent at 5 years; P < 0.001) and cancer-related (69 vs. 49 percent at 5 years; P < 0.02) rates. Cox regression analysis disclosed that only a more advanced TNM stage (odds ratio, 8.17; 95 percent confidence interval, 1.13-59.29) and noncompliance with the postoperative surveillance program (odds ratio, 2.32; 95 percent confidence interval, 1.50-3.60) had an independent negative impact on survival. CONCLUSION: Systematic postoperative surveillance in patients with colorectal cancer who were operated on for cure increases both the rate of tumor recurrence amenable to curative-intent surgery and rate of survival.

Detection of occult liver metastases in colorectal cancer by measurement of biliary carcinoembryonic antigen.

About a 20-25% of the patients at diagnosis of colorectal carcinoma present with occult liver metastases. The aim of this work was to determine the prognostic significance of CEA bile level for the early detection of occult metastases. We determined the CEA blood level and the CEA bile level in 182 patients with colorectal carcinoma (3 Dukes' stage A, 86 Dukes' stage B, 53 Dukes' stage C, and 40 patients with liver metastases) and also in 42 patients with simple cholelithiasis, as the control group. In the patients with cholelithiasis, the mean values of CEA serum and bile levels were normal. In patients with colorectal carcinomas the CEA serum levels ranged from 3 to 110 ng/ml, and the CEA bile level from 3 to 226 ng/ml. Patients with liver metastases, had a mean CEA serum level of 193 ng/ml, while CEA bile level was 1,225 ng/ml. In conclusion, our results suggest that the determination of CEA bile is highly useful in the diagnosis of occult liver metastases.

Endorectal ultrasonography in the follow-up of rectal cancer. Is it a better way to detect early local recurrence?

After curative surgery for rectal cancer, diverse protocols are used in order to detect early possible local recurrence. Our objective was to compare the results obtained by the endorectal ultrasonography (EUS) with other means of assessment. From 1988 to 1995, 140 patients have undergone curative surgery for rectal cancer. The pathological and sonographic lesions were evaluated according to the TNM classification. In 21 patients a local recurrence was diagnosed: 5 of those 21 were corresponding to T 3-4, N 0 and 16 to T 2-4, N 1 stage. All 21 showed evidence of local recurrence by EUS examination, 14 by digital rectal examination, 16 by colonoscopy, 18 by computed tomography, and the carcinoembryonic antigen level was high in 13 cases. In 12 patient who were asymptomatic EUS was positive in 12, digital rectal examination in 5, computer tomography in 9, colonoscopy in 8, and the CEA was increased in 4. Re-resection was possible in 15 cases, 6 with curative approach and 9 palliative. These findings suggest that EUS in care accurate in the early detection of local recurrence compared to other means of assessment review of the. The limited number of patients studies. Main form of assessment required further evaluation.

[Is there a relationship between cholelithiasis and colorectal cancer?]. / Existe relación entre la colelitiasis y el cáncer colorrectal?

PROBLEM: The pathogenesis of colorectal cancer must be perceived as a complex interaction between the genetic make-up of the individual and the environment. Recent publications stress the association between colorectal carcinoma and cholelithiasis. OBJECTIVE: A retrospective study was set up to compare the presence of cholelithiasis/cholecystectomy in patients with colorectal carcinoma vs gastric carcinoma. PATIENTS: In 481 patients with colorectal carcinoma, and in another group of 126 patients with gastric carcinoma, the incidence of prior cholelithiasis/cholecystectomy was investigated. RESULTS: In the colorectal carcinoma cases a personal history the cholelithiasis was observed more often than cholecystectomy, 88 vs 8 (P < 0.001) patients, and cholelithiasis was more commonly observed in cases of right-sided colonic cancer, than in cancer of the left colon and rectum. In the group with gastric carcinoma the cholelithiasis incidence was 5.6 percent. CONCLUSIONS: These findings suggest that a relationship was found more often between colorectal cancer and cholelithiasis, that with cholecystectomy.

CEA as a prognostic factor in colorectal cancer.

We have measured serum CEA levels in 207 patients with colorectal cancer. CEA sensitivity was related to tumor stage in tumors located in the right colon, but not in tumors located in the left colon or the rectum. CEA had prognostic value in patients with tumors located in the right colon (p < 0.001) but not in the left colon or the rectum. However, CEA did not have prognostic value independent of Dukes stage even in tumors in the right colon. Our results underline the different sensitivities and prognostic values for primary tumors in the left and right colorectal regions.

[Ambulatory treatment of hemorrhoids]. / Tratamiento ambulatorio de las hemorroides.

We present a study on 110 patients who were operated of hemorrhoids, on ambulatory basis using the elastic rubber-band ligation. Twenty-six of this patients had degree I hemorrhoids, 54 degrees II and 30 degrees III hemorrhoids. In 19 patients, only one hemorrhoidal mass was bound by session, 84 patients had two masses bound and 17 patients three or more masses. During the postoperative course 76% of the patients had a sensation of incomplete evacuation, but only a 7% of all needed analgesia. About 79% of the patients thought that they had received an excellent treatment. We conclude that this is a very simple technique, allowing excellent results with few complications.

Use of CA 19-9 in the early detection of recurrences in colorectal cancer: comparison with CEA.

The serum levels of CA 19-9 were determined in the follow-up of 370 patients with colorectal cancer and compared with CEA. An increase in CA 19-9 preceded clinical diagnosis of recurrence in 25% of 72 patients. The mean time between the rise in CA 19-9 and clinical diagnosis of relapse was 3.7 months (median 3). Sensitivity of CA 19-9 in the early diagnosis of recurrence was much lower than that obtained for CEA (75%). Only 1 patient had elevated CA 19-9 levels and normal CEA.

Radioimmunoscintigraphy of colorectal carcinoma with a 111In-labelled anti-TAG-72 monoclonal antibody.

Radioimmunoscintigraphy (RIS) of colorectal carcinoma with a 111In-labelled anti-TAG-72 monoclonal antibody (CYT-103) has been performed in 24 patients with five primary lesions and 10 suspicious of recurrence (in one of these patients two RIS were made). Histopathological confirmation of the disease and surgical liver examination were carried out in all primary tumours and in 12 possible recurrences. In the remaining eight patients a final diagnosis was established according to the clinical course and other diagnostic procedures. Planar and tomographic scans were obtained at 48 and 72 h postinjection in all patients. All primary tumours were detected by RIS. In the group with recurrences confirmed pathologically the results were nine true positive, two true negative and one false positive in a patient affected only with liver disease. The nine true positive studies corresponded to four positive by computed tomography (CT), four negative by CT and one nonconclusive by CT. Surgical liver examination results were 15 true negative and two false negative. No correlation was found between serum levels of carcinoembryonic antigen or TAG-72 and the detection of the lesions. In 10 patients human anti-mouse antibody (HAMA) levels were studied. In conclusion, RIS with an anti-TAG-72 monoclonal antibody is a useful technique for the study and localization of colorectal tumours, mainly in cases of recurrence, being also indicated in patients with normal TAG-72 serum levels.

[Intraluminal anorectal ultrasonography in the staging of anal canal cancer]. / Ecografía intraluminal anorrectal en la evaluación del estadiaje del cáncer del conducto anal.

The staging of anal canal carcinoma is essential to establish the surgical procedure, either a local excision or abdominoperineal resection. In addition to the conventional studies we have used the anorectal endosonography in seven patients with carcinoma of the anal canal. The preoperative staging was done according to the UICC classification. The endosonography gave significant information of the anal anatomy to assess an accurate diagnosis in six patients, two of them had tumors invading the vagina. In one case, the ultrasound image was underestimated. Overall accuracy of the endosonographic assessment was 85.7 percent. Anorectal endosonography correctly assesses the anatomy layers of the anal canal and offers a good tumor's staging.