Timing of colonoscopy after resection for colorectal cancer: are we looking too soon?

BACKGROUND: Based on current National Comprehensive Cancer Network guidelines, colonoscopic surveillance after colorectal cancer resection should begin at 1 year. OBJECTIVE: The aim of this study was to determine whether the incidence of cancer or advanced polyp detection rate was high enough to justify colonoscopy at 1 year. DESIGN: The Ochsner Clinic Tumor Registry Database was queried for patients who underwent a segmental colectomy or proctectomy between 2002 and 2010. Patients who had a preoperative colonoscopy and at least 1 documented postoperative colonoscopy were included. We considered new cancer or polyps of ≥1 cm as missed on the preoperative colonoscopy. Patients with an identified genetic trait causing a predisposition to colorectal cancer were excluded. RESULTS: Five hundred twelve patients underwent resection, and 155 met our inclusion criteria. The average age was 64 years, and 53% patients were male. There were 32.9% with stage I disease, 35% with stage II disease, 27.1% with stage III disease, and 5.2% with stage IV disease. Of these patients, 52.2% had a right colectomy, 7.1% had a left colectomy, 16.8% had a sigmoid colectomy, 22% had a low anterior resection, and 1.3% had a transanal resection. The average time to first postoperative colonoscopy was 478 days (SD ±283 days). Twenty-four patients had adenomatous polyps detected on their first surveillance colonoscopy, but only 5 (3.2%) polyps were ≥1 cm, and there was no correlation between stage of cancer and finding a polyp. No new cancers were detected, but 3 (1.9%) had an anastomotic recurrence. CONCLUSIONS: The performance of surveillance colonoscopy at 1 year resulted in the detection of only 5 missed polyps ≥1 cm and no metachronous cancers. Anastomotic recurrences were rare, and the majority were in patients who had rectal cancer that could be evaluated by in-office flexible sigmoidoscopy. Extending the time to first colonoscopy appears to be safe and would help conserve valuable resources, including physician and facility time, which is imperative in the current health care climate.

Treatment of colorectal and ileoanal anastomotic sinuses.

PURPOSE: This study is designed to describe a technique and report results for treating low anastomotic sinuses. METHODS: Restorative proctocolectomy and complicated low anterior resections were protected with diverting loop ileostomy. Contrast enemas identified anastomotic problems before ileostomy closure. Pouch-anal or colorectal anastomotic sinuses that failed to resolve with observation were treated before intestinal continuity was restored. With the patient receiving regional or general anesthesia, a rigid proctoscope or anoscope was used to identify the sinus opening. The common wall between the sinus and the bowel lumen was divided under direct vision with laparoscopic cautery scissors, and the sinus cavity was debrided with a suction cautery wand placed through the scope. RESULTS: Six patients with anastomotic sinuses have received outpatient treatment in the described manner during the past two years. Four patients had restorative proctocolectomies for ulcerative colitis, and two had low anastomosis for rectal cancer. Three patients presented with pelvic sepsis before the contrast study; the remainder were asymptomatic. Division of anastomotic sinus was performed one to eight months after diagnosis of the sinus. Following division, anastomotic cavities resolved in five patients by 1 month and in one patient by 12 months. In these six patients, there was one dilatable anastomotic stricture but no other anastomotic complications at follow-up 5 to 16 (mean, 9.2) months after sinus division. CONCLUSION: When used in conjunction with fecal diversion, sinus unroofing by division of the common wall between the sinus and bowel lumen treats low pelvic sinuses.

Perineal repair of rectal prolapse.

Perineal approaches to the repair of rectal prolapse are frequently used in elderly or high-risk patients. These repairs have lower operative mortality and morbidity than intra-abdominal repairs but in general have higher recurrence rates. This study reviews our recent results with perineal prolapse repairs, briefly summarizes the literature, and discusses the available perineal operations. Eight patients (mean age 75 years) underwent surgical prolapse repair over an 18-month period. Treatment was by Altemeier's procedure (perineal rectosigmoidectomy) in 6 patients and Delorme's procedure in 2 patients. There were no operative mortalities, and an anastomotic dehiscence in 1 patient was managed nonoperatively. All patients with preoperative constipation improved and no patient reported worsening of continence. Surgical approaches from the perineum may be used in elderly and poor risk patients to treat rectal prolapse with low mortality and morbidity. These techniques have not adversely affected fecal continence and have improved symptoms of constipation with an acceptable rate of recurrence.

Thoracoscopic pleurodesis with minocycline vs talc in the porcine model.

BACKGROUND: Eighteen adult pigs (Sus scrofa) underwent thoracoscopy and were placed into one of three groups: no sclerosant, talc pleurodesis, or minocycline pleurodesis. METHODS: Animals were then sacrificed at matched time intervals. Gross inspection of the pleural cavity estimated percentage of pleural symphysis (>25% was considered substantial) and allowed assignment of a pleurodesis score based on a scale described by Bresticker. Microscopic examination evaluated degree of fibrosis as mild, moderate, or severe. RESULTS: The talc group had significantly better pleurodesis than the minocycline group as determined by (1) the proportion of animals with substantial surface pleural symphysis (5/6 vs 1/6, p < 0.01), (2) a higher pleurodesis score (3 vs 1.3, p < 0.05), and (3) the proportion of animals with moderate fibrosis (5/6 vs 0/6, p < 0. 01). CONCLUSIONS: The authors conclude that instillation of aerosolized talc produces significantly better fibrosis and pleural symphysis than atomized minocycline in this animal model.

Surgical excision of large rectal villous adenomas.

Large villous tumors occur most frequently in the rectosigmoid and have a significant incidence of harboring a malignancy. The presence or absence of malignancy may be determined only by complete excision. Presence of invasive carcinoma on pathologic examination requires surgical intervention appropriate for that diagnosis. Recurrence depends on the technique used for tumor removal. It is highest for fulguration and local excision and lowest for operations that excise all or part of the rectum. Because most recurrences can be managed with local measures and the risk of malignancy in recurrences is relatively low, the procedure with which the tumor can be completely excised with the least morbidity should be used. Local excision with or without mucosal closure should be used as first-line surgical therapy whenever possible. It should be possible to manage most tumors in the mid and low rectum with this technique. For larger tumors and those tumors more proximal, it may be necessary to use snare cautery in combination with local excision or fulguration. Alternately, for some proximal rectal lesions the two-scope technique mentioned earlier may allow local excision. For circumferential or near circumferential tumors in the low to mid rectum, circumferential mucosectomy should be used. It has been used successfully for tumors involving the entire rectum down to the dentate line. Although this technique has a low recurrence rate, the rate of incontinence associated with it precludes its use in smaller tumors that are amenable to local excision. Transanal endoscopic microsurgery described by Beuss et al can produce good results. The authors have no experience with this technique. However, because of its expense, the need for specialized training, and the infrequency with which other transanal techniques are insufficient, we fail to see a significant role for its use. If use of this technique becomes more widespread, additional data regarding its value will become available. Posterior approaches offer no advantage for removal of tumors that can be excised by transanal techniques. Most tumors that require partial or complete rectal excision should be amenable to anterior or low anterior resection. Low anterior resection is a less morbid procedure with which most surgeons have a fairly extensive experience. For extremely large tumors that extend to the dentate line, coloanal anastomosis is appropriate. The functional results are acceptable compared with the alternative of abdominoperineal resection. Abdominoperineal resection should be reserved for those patients with a diagnosis of invasive carcinoma in whom a lesser procedure would not constitute adequate treatment.