Which colorectal cancers are missed by double contrast barium enema?

BACKGROUND: The relative merits of either barium enema or colonoscopy for investigating lower gastrointestinal tract symptoms is still unclear. We studied the value of double contrast barium enema (DCBE) as the initial evaluation modality. We reviewed our 10-year experience of double contrast enemas as read by consultant radiologists. The study also aimed to identify which lesions are usually missed. PATIENTS AND METHODS: We reviewed clinical data for all patients who underwent DCBE within the 6 months prior to surgical resection of colorectal cancer between April 1989 and April 1999. Patient demographics and tumour characteristics were analysed for their effects on the likelihood of the lesions being missed at DCBE. RESULTS: There were 706 patients included in the study, 54.2% were male and the mean age was 63.7 years (SEM=0.5 years). The site along the colon and rectum of tumours missed by DCBE corresponded with the frequency of tumour occurrence at each site. The overall rate of missed lesions was 4.1% (29 of 706 patients); these patients were found on subsequent endoscopy to harbour cancer. Tumours less than 3 cm in length and with lesser extent of circumferential involvement were more likely missed at DCBE (p=0.05 and p=0.01, respectively). Age, sex, and tumour grade and stage were not significant predictors of the likelihood of missed lesions. Of the 29 patients with missed lesions, 77.2% had a serum concentration of carcinoembryonic antigen (CEA) above the normal range (3.5 microg/l). The mean follow-up was 65.3 months (SEM=1.8 months). The overall survival for this series was 60.1%. The inaccuracy of the initial DCBE was not found to cause statistically significant differences in the stage of the tumour at diagnosis nor the overall survival of the patients in our series. CONCLUSIONS: Smaller cancers without circumferential involvement may be missed when DCBE is performed to evaluate lower gastrointestinal symptoms. Further evaluation by colonoscopy must be recommended when symptoms persist, especially in the context of a raised CEA level.

Prospective randomised trial comparing ayurvedic cutting seton and fistulotomy for low fistula-in-ano.

The aim of this study was to evaluate the role of ayurvedic setons in the treatment of low fistula-in-ano. One hundred and eight patients were randomised into either conventional fistulotomy (F) or ayurvedic cutting seton insertion (C). Endpoints investigated included time to wound healing and complications of surgery. Post-operative pain scores were measured daily using a visual analog scale. Anal function was compared using a continence score. Pre- and postoperative manometry and ultrasound were also performed. After exclusions, there were 54 patients in group F and 46 in group C. There were no differences in age, sex or follow-up duration between the two groups. Healing time was similar between the groups. Group C reported more pain following operation and on the first 2-4 postoperative days, but both groups experienced the same amount of pain subsequently. In conclusion, chemical seton was more painful than conventional fistulotomy in the first few days following surgery. However, there was no difference in time to wound healing, complications or functional outcome.

Biofeedback is effective treatment for levator ani syndrome.

PURPOSE: The effects of biofeedback (BF) on pain relief and anorectal physiology in patients with levator ani syndrome (LAS) were prospectively studied. METHOD: Sixteen consecutive patients (9 men, 7 women; mean age, 50.1 (range, 39-66) years) with LAS were treated with BF from July 1993 to October 1995. Mean duration of pain was 32.5 (standard error of the mean, 6.7) months. All underwent a full course of BF using a manometric balloon technique. Mean follow-up was 12.8 (standard error of the mean, 2.6) months. Pain score and anorectal physiology tests were administered prospectively by an independent observer before and after BF. RESULTS: After BF, the pain score was significantly improved (before BF: median, 8 (range, 6-10); after BF: median, 2 (range, 1-4); P < 0.02). Analgesic requirements were also significantly reduced (all 16 patients needed nonsteroidal anti-inflammatory drugs (NSAID) before BF; only two patients needed NSAID after BF; P < 0.03). There were no significant changes to the anorectal physiology parameters after BF. To date, there have been no side effects or regressions. CONCLUSION: Although BF had a negligible effect on anorectal physiologic measurements in LAS, it was effective in pain relief, with no side effects.