A Dukes/Jass combination--is it more discriminating?

BACKGROUND: In 1987 Jass described a modified staging system for colorectal cancer using two anatomical criteria in common with the Dukes system; extent of spread through the bowel wall and the presence or absence of lymph node involvement. Additionally it used two 'biological' criteria; the nature of the expanding margin of the tumour (pushing or infiltrating), and the presence or absence of lymphocytic infiltration within the tumour. This study aims to determine whether a combination of the Dukes and Jass staging systems provides a better predictor of five year survival in patients with colorectal cancer than Dukes stage alone. METHOD: The Dukes and Jass stages along with vital status at five years were recorded for all 612 patients undergoing resection for colorectal cancer at the Royal Bolton Hospital and the Beaumont (BMI) Hospital, Bolton between 1991 and 1998. Kaplan-Meier survival curves with log rank test were used to show how survival correlated with Jass group stratified by Dukes stage. RESULTS: Both the Dukes B and the Dukes C tumours could be divided into groups with significantly different five year survival rates when stratified by Jass group. Five year survival for Dukes stage B, Jass group II tumours was 73.74% compared to Dukes B Jass III tumours whose survival was 51.38% (P = 0.0018). Five year survival for Dukes C Jass III tumours was 43.18% and for Dukes C Jass IV survival was 24.39% (P = 0.0029). CONCLUSION: By combining the biological criteria of the Jass staging system with the anatomically based Dukes system, both Dukes B and C tumours can be divided into groups with significantly different five year survival figures.

Absence of socioeconomic variation in survival from colorectal cancer in patients receiving surgical treatment in one health district: cohort study.

OBJECTIVE: To examine whether there is an association between patient deprivation status and survival from colorectal cancer among patients receiving treatment of the same type and quality. PATIENTS AND METHODS: A survival study was conducted of all colorectal cancer patients diagnosed between 1991 and 1997 who received surgery either in the NHS district general hospital or the private hospital of one UK health district. The five-year survival rates, both all cause and colorectal cancer specific, were calculated for subgroups defined by patient age, gender, stage and deprivation status using Kaplan-Meier curves. Cox proportional hazards models were used to examine the influence of deprivation on five-year survival after adjusting for age, gender and stage. RESULTS: There were 603 consecutive colorectal patients during the study period. Five-year all-cause and colorectal cancer-specific survival rates were 41% and 53%, respectively. There was no association between deprivation status and stage at diagnosis (P = 0.308). Multivariable proportional hazards modelling (adjusting for gender, age and tumour stage) demonstrated no association between deprivation status and survival. CONCLUSION: In this single district study, no relationship between patient socioeconomic status and survival from colorectal cancer could be demonstrated. Consistency in the type and quality of treatment offered to patients by the same clinical teams may have been responsible for the equitable survival outcomes.

Anal function following third degree tears.

OBJECTIVE: To assess the anal function of women who have suffered a third degree perineal tear during parturition. PATIENTS: Fifty-three consecutive women who sustained a third degree tear, between January 1998 and March 2000, at the Princess Anne Maternity Unit, Royal Bolton Hospital were assessed. METHODS: Women were assessed at 3 months post partum using the Cleveland Clinic Incontinence Score, digital assessment of anal sphincter and endo-anal ultrasound scan. RESULTS: At 3 months post partum 75% of the participants had no symptoms of anal incontinence, 18% had mild symptoms and 7% had more severe symptoms. Anal endosonography demonstrated normal anal sphincters in 66% of participants, an abnormality in the external sphincter in 29% and a defect in both sphincters in 2%. There was poor correlation between symptoms and scan defects. CONCLUSION: The incidence of anal incontinence following repair of a third degree tear was not high and it is unlikely that we are missing a hidden pool of symptomatic women. No major change in management policy is required. The routine assessment of anal function in women who had sustained a third degree tear was appreciated by the women and enabled us to identify the small portion of women with significant symptoms.

Are we using the correct dose of metronidazole in colorectal surgery?

In a series of 20 patients undergoing elective colorectal surgery, 10 received an infusion of metronidazole 500 mg and 10 an infusion of 1500 mg commencing at the induction of anaesthesia. The concentrations of metronidazole in the plasma, rectus muscle and colon of the two groups during the course of the operation were compared. In those patients who received 1500 mg, the plasma and tissue concentrations were all well above the minimum inhibitory concentration (MIC) of metronidazole against Bacteroides fragilis. In those patients who received 500 mg, serum and tissue concentrations were at or only just above the MIC. It may be that 1500 mg would be a more effective dose of metronidazole for prophylactic use in colorectal surgery.

A comparison of serum albumin, age and the Sheffield prognostic index in the prediction of surgical complications.

The ability of the Sheffield prognostic index (S.P.I) to predict postoperative complications and death in patients undergoing gastrointestinal surgery has been compared with that of serum albumin alone, and with age. Both the S.P.I. and age were better at predicting complications than serum albumin. Serum albumin was the best predictor of death.

Management of perianal Crohn's disease.

Symptomatic anal disease (excluding skin tags) was observed in 49 out of 151 successive patients treated for Crohn's disease. Two main types of anal disease were encountered: anal ulceration (23 patients) and anal abscesses and fistulae (26 patients). The ulcer group rarely required local surgical treatment. In the fistula group, a low tract was demonstrated and laid open in 20 patients. The healing times after operation in these patients were compared with those of 18 patients with non-Crohn's fistula-in-ano treated by the same method. No significant difference between the two groups could be demonstrated. Surgical treatment of low fistula-in-ano may be undertaken in patients with Crohn's disease, provided the bowel disease is under adequate control.