Who gets Hartmann's reversed in a regional centre?

BACKGROUND: Many patients who undergo a Hartmann's procedure do not have their stoma reversed. We analysed parameters and co-morbidity scales to assess their accuracy in predicting likelihood of undergoing reversal. MATERIAL AND METHODS: Retrospective analysis of 165 patients from a prospective colorectal database who were discharged home following a Hartmann's procedure at Barwon Health (Geelong, Australia), a regional centre, between 2002 and 2010. Parameters measured included age, sex, time to reversal, ICU admission and pathology results were recorded. Patients' ASA, POSSUM and Elixhauser co-morbidity scales were retrospectively analysed. RESULTS: Reversal of Hartmann's was performed in 74/165 (45%) patients after a median of 294 days (range 70-902). Age (mean 58.5 vs 72.9 years, p < 0.001), ICU stay (34/74 vs 66/91, p < 0.001), ASA (p < 0.002), Elixhauser co-morbidity count (mean 1.14 vs 1.92, p < 0.002) and a malignant diagnosis (9/74 vs 31/91, p < 0.002) were all associated with a decreased reversal rate on univariate analysis. Age was the only parameter found to be significant on multivariate analysis. The complication rate was 23/74, with 7/74 noted to have major complications (Clavian-Dindo III-IV). Reasons for not reversing patients included age and co-morbidities, patient refusal, and malignant disease progression. CONCLUSIONS: More than half the patients undergoing a Hartmann's procedure did not proceed to a closure of their stoma. Age was the only parameter significant in predicting those patients undergoing reversal.

Surgery for colonic cancer in HNPCC: total vs segmental colectomy.

AIM: The high reported risk of metachronous colon cancer (MCC) in hereditary nonpolyposis colorectal cancer (HNPCC) has led some authors to recommend total colectomy (TC) as the preferred operation for primary colon cancer, but this remains controversial. No previous study has compared survival after TC with segmental colectomy (SC) in HNPCC. The aim of this study was to determine the risk of developing MCC in patients with genetically proven HNPCC after SC or TC for cancer, and to compare their long-term survival. METHOD: This is a prospective cohort study of all patients referred to our unit between 1995 and 2009 with a proven germline mismatch repair gene defect, who had undergone a resection for adenocarcinoma of the colon with curative intent. All patients were offered annual endoscopic surveillance. RESULTS: Of 60 patients in the study, 39 had TC as their initial surgery and 21 had SC. After 6 years follow up, MCC occurred in eight (21%) SC patients and in none of the TC patients (P = 0.048). The risk of developing MCC after SC was 20% at 5 years. Colorectal cancer-specific survival was better in TC patients (P = 0.048) but overall survival of the two groups was similar (P = 0.29). CONCLUSION: Patients with HNPCC have a significant risk of MCC after SC. This is eliminated by performing TC as the primary operation for colonic cancer.

Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction.

BACKGROUND: Gastroduodenal obstruction due to malignancy can be difficult to palliate. Self-expanding metal stents (SEMS) are gaining acceptance as an effective alternative to surgical bypass. METHODS: Patients not suitable for surgical bypass, with complete gastric outlet obstruction as a result of malignancy, were offered palliation with SEMS from November 2004 to December 2008. The procedure was performed under fluoroscopic guidance and conscious sedation. Data were collected prospectively. RESULTS: Seventy patients underwent SEMS placement (hepatobiliary and pancreatic malignancy, 44; antral gastric carcinoma, 19; other, seven). Follow-up was complete in 69 patients (99 per cent). Technical and clinical success rates were 93 and 95 per cent respectively. Median hospital stay was 2 (range 1-18) days, median survival was 1.8 (0.1-19.0) months, and 87 per cent had improved intake after SEMS placement, as determined by Gastric Outlet Obstruction Severity Score before and after stenting (P < 0.001). Complications included two episodes of minor bleeding. CONCLUSION: The use of SEMS to alleviate complete malignant gastric outlet obstruction in patients with limited life expectancy is successful in re-establishing enteral intake in most patients, with minimal morbidity, no mortality and a short hospital stay.

Incidence and histological features of colorectal cancer in the Northern Cape Province, South Africa.

AIM: The purpose of this study was to determine the incidence of colorectal cancer (CRC) in the Northern Cape province of South Africa, and to identify patients with histological and demographic features suggestive of hereditary non-polyposis colon cancer (HNPCC). METHOD: This is a retrospective review of all cases of primary adenocarcinoma of the colon or rectum diagnosed by the two pathology laboratories operating in the Northern Cape between January 2002 and February 2009. Demographic data were collected, as well as pathological staging of the tumours and histological features suggestive of HNPCC (according to the revised Bethesda guidelines for microsatellite instability testing). Population census data for the Northern Cape were obtained from Statistics South Africa. RESULTS: The annual incidence of CRC in the Northern Cape was 3.7/100,000 population (3.5/100,000 for men and 3.9/100,000 for women). The median age at which colorectal cancer was diagnosed was 59 years (range 16-90 years). On pathological and demographic criteria, 75/206 (36%) of the patients met at least one of the criteria of the revised Bethesda guidelines for microsatellite instability testing. CONCLUSION: CRC is rare in the Northern Cape, and one-third of the patients had demographic or tumour histological features suggestive of HNPCC.

Cancer risk in a cohort of subjects carrying a single mismatch repair gene mutation.

Hereditary non-polyposis colon cancer (HNPCC) is an autosomal dominant condition, caused by germline mutations in the mismatch repair genes, that presents with colorectal cancers at a young age, as well as extracolonic tumours. One of the causative mutations is the C1528T (Exon 13) mutation of the MLH1 gene. The purpose of this study is to document the cancer risk for subjects who carry this mutation. This is a prospective cohort study of 200 subjects who carry this mutation. We calculated the risk of developing colorectal cancer only in those subjects who had not undergone surveillance colonoscopy. The incidence of extracolonic cancers (for which surveillance is not routinely offered) was determined for the entire cohort. The results of the study are among the 71 subjects who did not undergo surveillance colonoscopy, colorectal cancers occurred in 36 (51%). They occurred at a median age of 44 years (range 17-73). Using Kaplan-Meier estimates, the risk of developing a colorectal cancer by age 65 was 92%. Eighteen subjects in the cohort of 200 were diagnosed with extracolonic tumours. The most common extracolonic malignancies were breast (6/98 women) and endometrial (3/98 women). Thus this mutation has a high penetrance for colorectal cancer, but is not associated with a high risk of developing extracolonic malignancies.

Surveillance colonoscopy improves survival in a cohort of subjects with a single mismatch repair gene mutation.

OBJECTIVE: Previous studies have shown a benefit for surveillance colonoscopy in heterogeneous groups of subjects with suspected or proven hereditary nonpolyposis colon cancer. The aim of this study was to investigate whether surveillance colonoscopy improves the survival in subjects who all carry a single mismatch repair gene defect. METHOD: This is a prospective cohort study of 178 subjects who carry a mutation of the MLH1 gene in exon 13 (C1528T). They were offered surveillance colonoscopy between 1988 and 2006, and were followed up until September 2007. RESULTS: One hundred and twenty-nine subjects underwent surveillance colonoscopy, and 49 declined. After a median follow up of 5 years, colorectal cancer was diagnosed in 14/129 (11%) subjects in the surveillance group and 13/49 (27%) in the nonsurveillance group (P = 0.019). Cancers in the surveillance group were at an earlier stage than in the nonsurveillance group (P = 0.032). Death from colorectal cancer occurred in three of 129 (2%) subjects in the surveillance group, and six of 49 (12%) in the nonsurveillance group (P = 0.021). The Kaplan-Meyer estimates for median survival from birth were 78 years in the surveillance group, and 55 years in the nonsurveillance group (P = 0.024). The Kaplan-Meyer estimates for median colorectal cancer-free survival from birth were 73 years in the surveillance group and 47 years in the nonsurveillance group (P = 0.0089). CONCLUSION: Surveillance colonoscopy was associated with improved overall and colorectal cancer-related survival in subjects carrying a single mismatch repair gene mutation.

Long-term results of palliative stenting or surgery for incurable obstructing colon cancer.

OBJECTIVE: Self-expanding metal stents are an effective means of relieving left-sided malignant colonic obstruction, and in the setting of incurable disease may provide palliation while allowing the patients to avoid surgery altogether. With modern chemotherapy regimes, patients may have a long-life expectancy, even in the presence of metastases. The purpose of this study was to investigate the long-term results of palliative stent placement, compared with patients undergoing palliative surgery. METHOD: This is a retrospective study of 55 consecutive patients who underwent colonic stenting or palliative surgery for incurable, obstructing adenocarcinoma of the left colon. RESULTS: Twenty-nine patients underwent colonic stenting, and 26 had surgery during the study period. Survival was similar in the two groups (14 months in the stent group, 11 months in the surgery group). Median hospital stay was shorter in the stent group (4 vs 13.5 days), and fewer patients in the stent group had complications (2 vs 14). Only four patients in the stent group went on to require later surgery. The median time to failure of the stents was 14 months. CONCLUSION: Colonic stenting provides effective and durable palliation for patients with incurable, obstructing adenocarcinomas of the left colon. It can be performed with less morbidity than palliative surgery, and offers similar long-term survival.

Gastrojejunostomy for gastric outlet obstruction in patients with gastric carcinoma.

OBJECTIVE: To investigate the utility of gastrojejunostomy for the palliation of gastric outlet obstruction in irresectable or incurable gastric carcinoma. METHODS: This is a retrospective review of 67 patients who underwent a gastrojejunostomy for gastric outlet obstruction caused by gastric carcinoma between 1 January 1996 and 31 May 2003. RESULTS: There were 19 complications after surgery, including 4 patients with unsatisfactory gastrojejunostomy drainage. Sixty patients were discharged from hospital having resumed normal eating. Their median survival after surgery was 9 months. CONCLUSION: Gastrojejunostomy offers worthwhile palliation and may prolong survival in a significant group of patients with irresectable gastric carcinoma and gastric outlet obstruction.

Gastrojejunostomy for gastric outlet obstruction in patients with gastric carcinoma : general surgery

Objective. To investigate the utility of gastrojejunostomy for the palliation of gastric outlet obstruction in irresectable or incurable gastric carcinoma. Methods. This is a retrospective review of 67 patients who underwent a gastrojejunostomy for gastric outlet obstruction caused by gastric carcinoma between 1 January 1996 and 31 May 2003. Results. There were 19 complications after surgery; including 4 patients with unsatisfactory gastrojejunostomy drainage. Sixty patients were discharged from hospital having resumed normal eating. Their median survival after surgery was 9 months. Conclusion. Gastrojejunostomy offers worthwhile palliation and may prolong survival in a significant group of patients with irresectable gastric carcinoma and gastric outlet obstruction