The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI.

OBJECTIVE: The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland. METHOD: A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide. RESULTS: Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48-60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding. CONCLUSION: Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.

Relation between stage, grade, proliferation, and expression of p53 and CD44 in adenomas and carcinomas of the colorectum.

AIMS: To investigate the changes in and relations among p53, CD44 and MIB-1 expression in adenocarcinomas of the colorectum and to determine whether these changes are progressive across the adenoma-carcinoma sequence. METHODS: Expression of p53 protein, CD44 adhesion molecule and MIB-1 proliferation antigen was detected using immunohistochemistry in 68 colorectal carcinomas and 32 colorectal adenoma. The staining characteristics were compared with degree of dysplasia in adenomas, and differentiation and Dukes' stage in carcinomas. Results were analysed and assessed using Spearman's rank correlation and independent t tests. RESULTS: p53 staining was present in som adenomas and correlated with the degree of dysplasia. There was significantly more staining in carcinomas than adenomas and significant correlation between staining and Dukes' stage. CD44 staining was maximal in adenomas, diminished in carcinomas and was minimal in metastasising carcinomas. There was inverse correlation between p53 and CD44 expression across the adenoma-carcinoma-metastasising carcinoma sequence. MIB-1 expression was highest in carcinomas but did not correlate with either p53 or CD44 expression. CONCLUSIONS: There are progressive changes in p53, CD44 and MIB-1 expression in adenomas and carcinomas. A combination of these tests may prove useful in assessing which patients with adenomas are at greatest risk of progressing to carcinoma.

An evaluation of Fecatwin/Feca EIA; a faecal occult blood test for detecting colonic neoplasia.

A combination guaiac and immunological test Fecatwin/Feca EIA for the detection of faecal occult blood was used in the investigation of 535 symptomatic patients in order to assess the value of this combined test in the detection of colorectal neoplasia. The addition of the immunological part of the test led to an improvement in specificity for colorectal cancer from 80% to 91% and an increase in the positive predictive value of the test for colorectal cancer from 14% to 24%. However, there was a fall in sensitivity from 75% to 67%. There was no substantial advantage in the addition of the immunological part of the test to justify the extra laboratory workload incurred.

Is an immunological faecal occult blood test better than Haemoccult? A cost-benefit study.

Immunological faecal occult blood (FOB) tests have theoretical advantages over their guaiac counterparts in that they are specific for human haemoglobin. HemeSelect is a semi-quantitative immunological FOB text. Faecal material is eluted into test diluent and serial dilutions are performed. The manufacturers recommend that erythrocyte agglutination at 1:8 dilution is considered a positive reaction. However, further serial dilutions can be carried out and the highest dilution at which the test remains positive determined. At 1:8 dilution, the test has been shown to be more sensitive for symptomatic colorectal cancer than Haemoccult. The aim of this study is to compare the positive rates, neoplastic yield and costs of Haemoccult with HemeSelect at various dilutions in asymptomatic average risk subjects aged 50-74. 1489 subjects satisfactorily completed both tests, 145 (9.7%) returned positive Hemeselect tests (read at 1:8 dilution, 38 patients with neoplasms > or = 1 cm) and 17 positive Haemoccult tests (1.1%). All positive Hemeselect tests were further serially diluted. As the Hemeselect dilution increased to 1:16, 1:32, 1:64 and 1:128 so the positive rate and yields of neoplasms > or = 1 cm progressively fell to 6.8% & 35, 3.6% & 20, 2.7% & 18 and 1.5% & 12, compared with 1.1% and eight neoplasms > or = 1 cm for Haemoccult. In spite of the unit cost of the Hemeselect test being greater than Haemoccult, the cost per neoplasm > or = 1 cm was lower for Hemeselect at 1:8 and 1:16 dilutions than Haemoccult. However, for an equivalent neoplastic yield, Haemoccult was cheaper. Hemeselect is a versatile test whose positive rate can be tailored according to the risk of the group being screened.

The surgical treatment of intestinal obstruction due to left sided carcinoma of the colon.

Forty two consecutive patients who underwent surgery for an obstructing carcinoma of the left colon over a 5 year period were studied retrospectively. Twelve patients underwent an initial defunctioning procedure with no hospital deaths but with four deaths after a mean follow-up of 25 months. Of the 30 patients who had a primary tumour resection, 7 died during the first hospital admission and a further 4 during a mean follow-up period of 23.7 months. The hospital mortality following primary resection was related to the site and timing of the anastomosis. During the first hospital admission 3 of 5 patients died after colocolic anastomosis, 3 of 10 died following ileocolic anastomosis, but only 1 of 15 died in those who did not have a primary anastomosis performed. The mean hospital stay of patients undergoing a delayed resection was 41 (s.e. (mean) 2.8) days compared to 24 (s.e. (mean) 2.8) days in those undergoing a primary resection. Primary tumour resection with a delayed anastomosis is recommended on the basis of these findings.

Hepatic resection for colorectal metastases - a national perspective.

BACKGROUND: Many consultant surgeons are uncertain about peri-operative assessment and postoperative follow-up of patients for colorectal liver metastases, and indications for referral for hepatic resection. The aim of this study was to assess the views the consultant surgeons who manage these patients. METHODS: A postal questionnaire was sent to all consultant members of the Association of Coloproctology of Great Britain and Ireland and of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The questionnaire assessed current practice for preoperative assessment and follow-up of patients with colorectal malignancy and timing of and criteria for hepatic resection of metastases. Number of referrals/resections were also assessed. RESULTS: The response rate was 47%. Half of the consultants held joint clinics with an oncologist and 89% assessed the liver for secondaries prior to colorectal resection. Ultrasound was used by 75%. Whilst 99% would consider referring a patient with a solitary liver metastasis for resection, only 62% would consider resection for more than 3 unilobar metastases. The majority (83%) thought resections should be performed within the 6 months following colorectal resection. During follow-up, 52% requested blood CEA levels and 72% liver ultrasound. Half would consider chemotherapy prior to liver resection and 76% performed at least one hepatic resection per year with a median number of 2 resections each year. CONCLUSIONS: A substantial proportion of patients are assessed for colorectal liver metastases preoperatively and during follow-up though there is spectrum of frequency of assessment and modality for imaging. Virtually all patients with solitary hepatic metastases are considered for liver resection. Patients with more than one metastasis are likely to be not considered for resection. Many surgeons are carrying out less than 3 resections each year.

Management of severe acute colitis in district hospitals.

Among 10 hospitals of the North East Thames Region, 84 patients were operated on for inflammatory bowel disease in the years 1977-81. There was one death in the 51 patients treated electively. The postoperative mortality was 24% in 33 patients coming to urgent surgery. The factors leading to this continuing high mortality are analysed as a contribution to an improvement in management.

The role of colonoscopy in coloproctological practice.

Colonoscopy has completely changed the practice of colorectal surgery. It has both diagnostic and therapeutic roles. In diagnosis, it allows direct visualization of the colon and taking of tissue biopsies for histology. The commonest therapeutic manoeuvre is polypectomy for bleeding. Colonoscopy is safe and, where facilities exist, it should be used as first-line investigation of colorectal disorders.

Curative resection for low rectal adenocarcinoma: abdomino-perineal vs anterior resection.

OBJECTIVE: Local recurrence after abdomino-perineal excision of the rectum for tumours has been reported to occur in up to a third of patients in contrast to 4% after restorative anterior resection. METHOD: Low rectal tumours were defined as tumours within 8 cm of the anal verge and were treated by either stapled low anterior resection (SLAR) or abdomino-perineal excision of the rectum (APER). One hundred and seventy-eight patients with tumours in the lower third of the rectum (30% of 591 rectal cancers) underwent surgical resection between 1980 and 2001. Data were collected prospectively; 68 (38%) had SLAR and 110 (62%) had APER with median follow up of approximately 12 years; 54 SLAR (79%) and 76 APER (69%) had curative procedures on clinical and pathological criteria. RESULTS: Local and distant recurrence occurred in seven (13%) and eight (15%) patients in the SLAR group and six (8%) and 14 (18%) patients in the APER group, respectively. Overall 5-year survival was 63% and 60% in the SLAR and APER groups, respectively CONCLUSION: For rectal cancers within 8 cm of the anal verge, both procedures achieved equivalent results measured by low local recurrence rates and overall survival.

Anal fistulas at St Mark's Hospital.

This paper presents the application of a classification of anal fistulas to an unselected consecutive series of 793 patients treated for this condition at St Mark's Hospital from 1968 to 1973 inclusive. The fistulas were divided into five categories on their anatomical relationships: superficial (16 per cent), intersphincteric (54 per cent), trans-sphincteric (21 per cent), suprasphincteric (3 per cent) and extrasphincteric (3 per cent), with the remaining cases multiple or unclassified (3 per cent). There was good correlation between the categories and presentation, physical signs and treatment of the fistulas. Two hundred and forty-nine patients had potentially difficult fistulas. Follow-up of these patients revealed healing of almost all the fistulas, but the functional results were less satisfactory (incontinence of loose stool in 17 per cent and of flatus in 25 per cent, soiling in 31 per cent).

The complications of synchronous combined excision for adenocarcinoma of the rectum at St Mark's Hospital.

The complications of synchronous combined excision of the rectum for adenocarcinoma in 227 patients were analysed. Urinary retention with infection occurred in 78 patients (34-4 per cent) and was the commonest complication. There was a significant correlation between tumours involving the anterior quadrants of the rectum and urinary complications. Primary suture of the perineal wound with closed drainage was associated with a higher incidence of complications than open drainage. The cumulative risk of a paracolostomy hernia in the sixth postoperative year was approximately 33 per cent. Extraperitoneal colostomy gave some protection against paracolostomy herniation.

Stapled anastomoses in colorectal surgery: a prospective study.

OBJECTIVE: To evaluate the safety and efficacy of stapled anastomosis in left sided colorectal reconstructions. DESIGN: Prospective study. SETTING: District hospital, UK. SUBJECTS: 218 Consecutive patients who underwent elective colorectal reconstructions with stapled anastomoses between July 1980 and July 1994. INTERVENTIONS: 154 Anterior resections of the rectum using single or double stapled anastomoses, 37 rejoining after Hartmann's operations, and 28 restorative proctocolectomies with formation of J pouch ileoanal anastomoses. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: There were 5/154 clinical anastomotic leaks after anterior resection of the rectum and 1/28 after stapled J pouch ileoanal anastomoses. There were no leaks after rejoining of Hartmann's. The overall clinical leak rate was therefore 3%. 11/154 tumours recurred locally after anterior resection of the rectum (7%) during a mean follow up of 18 months, and 8 (73%) developed within 2 years of operation. All but one recurrence developed after single stapled anastomosis. Dukes' staging remains the most reliable prognostic indicator of the local recurrence of the tumour. There were five postoperative deaths after anterior resection but none after Hartmann's procedure or J pouch ileoanal anastomosis, giving an overall postoperative mortality of 2.3%. CONCLUSION: The use of stapling instruments in left sided colorectal anastomosis is safe and technically easy, with a low clinical anastomotic leak rate and an acceptable rate of local recurrence after anterior resection of the rectum.

Operative cholangiography: criteria which make exploration of the common bile duct desirable.

The purpose of this study was to evaluate the individual criteria and combination of criteria examined by operative cholangiography which make exploration of the common bile duct desirable. The overall accuracy of exploration of the common bile duct (89 per cent) was similar to that of previous series. In the normal group the accuracy of the criteria established by Le Quesne (1960) is confirmed. The most reliable criteria in the abnormal cholangiograms were the presence of single or multiple filling defects in the common bile duct, the absence of free flow of contrast medium into the duodenum and an abnormality of the terminal narrow segment. Measurements to aid assessment of free flow into the duodenum are suggested. In 34 of 40 positive explorations the common bile duct diameter was 14 mm or less; 10 common bile ducts which contained stones were less than 10 mm in diameter. Excess filling of the intrahepatic ducts was often impossible to judge in the abnormal group and was the least valuable criterion. Attention is drawn to the advantage of an immediate radiological report.

The barium infusion in small intestinal obstruction.

During a two-year period 26 patients with suspected small bowel obstruction were examined by infusing barium into the small intestine. Mechanical obstruction was confirmed in 25 patients and the level of obstruction was shown in all except one who had carcinoma of the caecum. Surgery was avoided in nine patients-six of whom had Crohn's disease, two had adhesions and the investigation showed no abnormality in one patient. There were no complications associated with the examination or with the subsequent operation.

The septic complications of sigmoid diverticular disease.

In 2 years 41 patients were treated surgically for septic complications of diverticular disease of the sigmoid colon. Nine patients had fistulae arising from sigmoid diverticular disease. Resection of the sigmoid was undertaken as the primary procedure in 8 patients with anastomosis in 5. Thirty-two patients had pericolic abscesses or peritonitis. The outcome (morbidity, length of stay) of the 21 patients who underwent primary resection was compared with that of the 11 patients treated by defunctioning colostomy alone. The better results in the larger group of 21 patients indicate that primary resection should be the treatment of choice for the septic complications of diverticular disease.