Mechanical bowel preparation before elective colorectal surgery: is it necessary?

AIM: To present the worldwide accepted guidelines concerning the use of mechanical bowel preparation (MBP) before elective colorectal surgery (ECS). PATIENTS AND METHODS: We conducted a retrospective review of the Pubmed Databases for randomized controlled trials (RCTs) and meta-analyses, which included adult patients who underwent elective colorectal surgery. We compared the patients who had a preoperative MBP with those who did not. Significant factors that were taken into account were postoperative septic complications and anastomotic dehiscence. RESULTS: Our search revealed 5 RCTs and 2 meta-analyses that met our criteria. Patients who underwent emergency colorectal surgery were excluded from the study. We identified the recommendations for 6 different types of elective colorectal surgery. CONCLUSION: MBP has been for many years a standard clinical procedure for patients undergoing elective colorectal surgery. However, many recent researches suggest the omission of MBP, since there are no significant differences regarding postoperative infectious complications, such as anastomotic dehiscence and superficial surgical site infections. Furthermore, MBP is a time-consuming, expensive procedure and causes severe discomfort to the patient. More importantly, the application of MBP has been associated with serious complications in both healthy patients and patients with existing cardiac or renal disease, such as electrolyte and volume disturbances.

Screening for colorectal cancer.

A review of the literature regarding the screening strategies for colorectal cancer (CRC), particularly for average risk individuals, is analysed. The advantages and disadvantages or limitations of screening modalities for CRC, such as faecal occult blood testing (FOBT) with guaiac-based tests or the new faecal deoxyribonucleic acid tests, endoscopic screening by flexible sigmoidoscopy, colonoscopy, or CT-colonography and double contrast barium enema examination, are reported. The efficacy and cost of the screening tests are evaluated, and it is found that any of the suggested tests is more cost effective than other medical intervention or treatment as compared with no screening. The reported compliance to any form of screening test was 30-40%, a rate that is low enough. The experience of our surgical department of a screening programme, based on FOBT, on 4189 individuals over 50 years old, and application of colonoscopy in positive subjects, is reported.

Mass screening for colorectal cancer: compliance in Almopea Region.

Colorectal cancer (CRC) is the second leading cause of cancer-related morbidity and mortality in Europe and the United States. Planning for a CRC screening began in co-operation with local authorities (Pella Prefecture sponsored test kits). Our aims were to develop a screening programme for colorectal cancer using the faecal occult blood test (FOBT) in Almopea province, and to investigate the compliance of local farmers population. Cancer statistics data from Almopea have been analysed and they showed higher colorectal cancer incidence compared to the rest of Greece. We designed a one-time FOBT screening programme on the Surgery Department computer Network, in which we listed 8963 subjects, over 50 years of age. From them, 4189 underwent 3 days FOBT, and the rest were our control group. The method of successive visits to each community by the medical team and educational meeting was chosen. For allocation and gathering of tests, teams of volunteers have been organised. In case of positive FOBT (176 subjects), total colonoscopy was performed. Seventeen (17) polypoids (in 15 patients) and 20 cases of diverticulosis were detected. The compliance of FOBT group was 49% (from 4189). Colonoscopy accepted 89% from 176 patients with positive test. We concluded that our study shows poor compliance of screening population. There is a need for co-operation of medical services, local authorities, media and volunteers support organising.

Synchronous colorectal cancer.

Synchronous carcinomas of the colon and rectum are of considerable clinical significance because of their frequency, the number of extra tumours missed and the difficulty of preoperative diagnosis. A retrospective evaluation of 283 patients with primary colorectal adenocarcinomas was performed. There were 6 patients with 12 synchronous adenocarcinomas (2.12%). Colonoscopy and double-contrast barium enema revealed the synchronous cancer in 66.6% of the cases. In two cases the second cancer was found intraoperatively. In one patient an urgent laparotomy was performed because of acute abdomen caused by perforation of the ascending colon. Typical colectomies, depending upon the segment of the location of the lesion, were performed. Second cancers had a significantly more favourable stage than index colorectal adenocarcinomas. The index and the secondary cancers of synchronous colorectal adenocarcinomas showed a better histologic grade (well differentiated type) than the single cancers. Full clinical and radiological investigation is essential, before any operation is undertaken for colorectal cancer.

Application of radionics on primary and metastatic tumours of the liver.

The aim of our study is to present our initial experience on the use of radiofrequency ablation (RFA) on hepatic tumours. Four patients with tumours of the liver were submitted to RFA. The first patient underwent an emergency left lobectomy due to rupture of a tumour of the left hepatic lobe. A synchronous tumour was detected on the right lobe. He has been submitted to four sessions of RFA. The second patient was submitted to transverse colon resection (adenocarcinoma) and a year later three metastatic tumours were detected. Two sessions of RFA have been applied in this case. The third patient, with adenocarcinoma of the sigmoid and one metastatic lesion on the right hepatic lobe, and the fourth patient with breast cancer and metastatic lesion of the liver, underwent one session of RFA each. The use of RFA on metastatic or primary tumours of the liver enriches the possibilities of therapeutic treatment.

Stage of disease at time of attendance of patients with colorectal cancer at the Department of Surgery of the General Hospital of Edessa.

It is acceptable that the stage of disease at time of attendance of patients with colorectal cancer (CRC) is the defining factor for patients' survival rate. From 1986 until 1998, 417 patients were treated in the Department of Surgery of the General Hospital of Edessa with CRC. For diagnosis, established endoscopic procedures were followed. CT, USG, MRI and histology were performed for staging. 85.4% of the patients had stage II, III and IV TNM/UICC tumour at the time of attendance.

Treatment of complicated colorectal cancer. Evaluation of the outcome.

A comparison of the outcome of 66 patients with complicated colorectal cancer (CRC) who underwent an emergency operation and 217 electively operated patients in an 11-year period was retrospectively determined. The complications presented on admission were obstruction (13.4%), perforation with peritonitis (6.36%), obstruction and perforation (1.4%) and massive bleeding (2.1%). The majority of the patients electively treated were of stages II and III (45.5% and 29%) and those urgently operated on were stages III and IV (67.7% and 14.1%) respectively. Radical resections were performed in 45 patients and palliative in 21. Only ten patients from the urgently treated are still alive and free of the disease. In conclusion, the treatment of complicated CRC carries a considerable incidence of complications, morbidity and mortality, and the overall 5-year survival rate is disappointing compared to electively treated patients.