A prospective randomized controlled trial comparing early postoperative complications in patients undergoing loop colostomy with and without a stoma rod.

AIM: A stoma rod or bridge has been traditionally placed under the bowel loop while constructing a loop colostomy. This is believed to prevent stomal retraction and provide better faecal diversion. However, the rod can cause complications such as mucosal congestion, oedema and necrosis. This single-centre prospective randomized controlled trial compared outcomes after creation of loop colostomy with and without a supporting stoma rod. The primary outcome studied was stoma retraction rate; other stoma-related complications were studied as secondary outcomes. METHOD: One hundred and fifty-one patients were randomly allotted to one of two arms, colostomy with or without a supporting rod. Postoperative complications such as retraction, mucocutaneous separation, congestion and re-exploration for stoma-related complications were recorded. RESULTS: There was no difference in the stoma retraction rate between the two arms (8.1% in the rod arm and 6.6% in the no-rod arm; P = 0.719). Stomal necrosis (10.7% vs 1.3%; P = 0.018), oedema (23% vs 3.9%; P = 0.001), congestion (20.3% vs 2.6%; P = 0.001) and re-admission rates (8.5% vs 0%; P = 0.027) were significantly increased in the arm randomized to the rod. CONCLUSION: The stoma rod does not prevent stomal retraction. However, complication rates are significantly higher when a stoma rod is used. Routine use of a stoma rod for construction of loop colostomy can be avoided.

Control of presacral venous bleeding with helical tacks on PTFE pledgets combined with pelvic packing.

Persistent and torrential bleeding from presacral veins is an uncommon complication during rectal resection. Control of bleeding is often difficult. We report an effective technique for controlling sacral bleeding using endoscopic helical tackers applied over pledgets of expanded polytetrafluoroethylene.

Peritonitis following stapling of a flush ileostomy.

Peritonitis following staple stabilization of a flush ileostomy has not yet been reported in the literature. We report a case of iatrogenic injury to a loop of the ileum in an unrecognized parastomal hernia which caused peritonitis after stapling of a flush ileostomy.

Rectal cancer in young adults: a series of 102 patients at a tertiary care centre in India.

OBJECTIVE: Rectal cancer in young patients is uncommon. There is little information on rectal cancer in young adults in India. The aim of this study was to determine the relative incidence of rectal cancer in young patients in India and identify any differences in histological grade and pathological stage between younger and older cohorts. METHOD: All adult patients presenting at a tertiary colorectal unit with primary rectal adenocarcinoma between September 2003 and August 2007 were included. Patients were divided into two groups: 40 years and younger, and older than 40 years. Details regarding patient demographics, preoperative assessment, management and tumour grade and stage were obtained from a prospectively maintained database. RESULTS: One hundred and two of 287 patients (35.5%) were 40 or younger at presentation. Younger patients were more likely to present with less favourable histological features (52.0% vs 20.5% (P < 0.001)) and low rectal tumours (63.0% vs 50.0%) (P = 0.043), but were equally likely to undergo curative surgery compared to the older group (P = 0.629). Younger patients undergoing surgery had a higher pathological T stage (T0-2 18.9%, T3 62.3%, T4 19.7% vs 34.5%, 56.0%, 9.5%) (P = 0.027) and more advanced pathological N stage (N0 31.1%, N1 41.0%, N2 27.9% vs 53.4%, 26.7%, 17.2%) (P = 0.014). CONCLUSION: The relative number of young patients with rectal cancer in this Indian series is higher than figures reported in western populations. The reasons for this are not clear. The histopathological features of rectal tumours in young patients in this study are consistent with similar studies in Western populations.

Hereditary colorectal cancer: screen the parents!

Hereditary nonpolyposis colorectal cancer is the most common form of hereditary colorectal cancer. Occasionally, the presentation of colorectal cancer may be at an early age when parents may be unidentified obligate carriers. The risk of colorectal cancer increases with increasing age, even in inherited disease. Therefore, it is important to screen parents of patients presenting at a young age and to obtain a complete pedigree to identify and screen those who are at risk. Two such families where the index case presented at a young age were encountered in our practice and both their mothers were found to have colorectal cancer on surveillance colonoscopy. We recommend that parents of the index cases should be screened and more detailed family pedigree obtained when patients present at a young age with colorectal cancer.

A tale behind the rectum.

Tailgut cysts, also called benign retrorectal hamartomas, are uncommon developmental cysts found behind the rectum. Here, we present a rare case of a tailgut cyst associated with uterine anomaly, sacral and vertebral anomalies and vascular duplication, in a young lady who presented with constipation and infertility.

Selecting patients with young-onset colorectal cancer for mismatch repair gene analysis.

BACKGROUND: Young patients with colorectal cancer are at increased risk of carrying a germline mutation in mismatch repair (MMR) genes. This study investigated the role of clinical criteria and immunohistochemistry for MMR proteins in selecting young patients for mutation testing. METHODS: A cohort of 56 consecutive patients with colorectal cancer aged less than 45 years were stratified into three groups based on clinical criteria: 'Amsterdam criteria', 'high risk' and 'young onset only'. Immunohistochemistry for four MMR proteins was carried out and the rate of compliance with clinical guidelines determined. RESULTS: Tumours from 11 patients (20 per cent) had abnormal MMR protein expression, of whom eight were referred for genetic assessment. Of 21 patients (38 per cent) in total referred to the genetics unit, six MMR gene mutations were identified, all associated with abnormal immunohistochemistry. CONCLUSION: MMR immunohistochemistry should be considered routine in young-onset colorectal cancer.

Management of anorectal melanomas: a 10-year review.

BACKGROUND: Anorectal melanoma (AM) is a rare tumour with poor prognosis. The primary modality of treatment for AM is surgery. However, the choice of operation is controversial. Historically, radical operations like abdominoperineal excision of rectum (APER) with or without inguinal lymph node dissection were preferred. However, as no stage-specific survival advantage has been seen with APER later studies have recommended wide local excision (WLE) as the preferred treatment where negative margins can be achieved. The aim of our study was to review our results. METHODS: Inpatient and outpatient charts of all patients treated for AM between 1996 and 2005 were reviewed. Patient characteristics, clinical presentation, evaluation, staging, treatment, complications and followup were studied. Patients were followed up to assess disease free and overall survival according to the stage of disease and the surgical procedure performed. RESULTS: 17 patients were treated for AM between 1996 and 2005. At presentation 4 (23%) had metastatic and 1 (6%) had inoperable disease. 12 patients (71%) had operative therapy of which 10 had APER and two had WLE. 82% of these patients were followed up for a mean duration of 8 months (range 3-30 months) and their overall and disease free survival compared. The stage specific disease free and overall survival for patients who underwent APER was 8 months and 13 months for stage I and 7 months and 10 months for stage II respectively. The disease free survival and overall survival for patients who underwent WLE, both for stage I disease, was 10 months and 27 months respectively. CONCLUSION: Despite surgical resection and emergence of various forms of adjuvant therapy, the overall prognosis of anorectal melanoma remains dismal. From a review of literature and our own experience, though limited, we conclude that WLE be recommended where negative margins can be achieved and where this is technically feasible. APER should be reserved for large tumours where WLE is not technically possible.

Intraoperative enteroscopy in obscure gastrointestinal hemorrhage.

Forty three patients were diagnosed to have obscure gastrointestinal hemorrhage (OGH) between January 1987 and April 1996. Pre-operative diagnostic investigations were useful in localizing the site of bleeding in 28 patients (65.1%). These included small bowel enema (n = 12), erythrocyte tagged scan (n = 8), Meckel's scan (n = 2) and selective visceral angiography (n = 7). Following complete evaluation all patients underwent exploratory laparotomy. At laparotomy 31 patients were found to have gross lesions. Intraoperative enteroscopy (IOE) could detect lesions in 9 of the remaining 12 patients.

Conn's syndrome: a simple diagnostic approach.

BACKGROUND: Primary aldosteronism is usually diagnosed after a battery of biochemical tests and adrenal imaging. If an adrenal tumour (Conn's syndrome) is identified, patients need surgery. However, bilateral adrenal hyperplasia is treated medically. Till 1994, we diagnosed Conn's syndrome using simple biochemical tests and a CT scan of the adrenal glands. Aldosterone and plasma renin activity assay became available in our institution in 1994 and were used subsequently in the work up of patients suspected to have Conn's syndrome. We analysed our data to determine whether simple tests such as serum and urinary potassium values combined with CT imaging of the adrenal glands are adequate to arrive at a diagnosis in these patients. METHODS: All consecutive patients (n = 17) diagnosed to have Conn's syndrome, managed by the Departments of Endocrinology and Surgical Endocrinology of this institution during a nine-year period from 1990 to 1998, were studied retrospectively. RESULTS: Until 1994, Conn's syndrome was diagnosed after documenting hypertension, hypokalaemia, inappropriate kaliuresis, metabolic alkalosis and CT scanning to localize the tumour. Serum aldosterone and plasma renin activity (PRA) were used in addition since 1994. All patients underwent adrenalectomy after adequate preoperative preparation. There was no operative mortality. Postoperatively, normokalaemia was established in all patients. Persistent postoperative hypertension was present in 43.8% of patients. CONCLUSIONS: In our experience, Conn's syndrome could be diagnosed accurately with simple investigations and CT imaging of the adrenal glands. Extensive biochemical testing, including aldosterone and PRA assay, is helpful when the diagnosis is uncertain. While hypokalaemia is curable after surgery, residual hypertension persists in about 45% of patients.

Surgical presentation of melioidosis in India.

BACKGROUND: Melioidosis, the disease caused by Burkholderia pseudomallei, is common in Southeast Asia. It has also been reported from India, where some investigators feel it is under-diagnosed and under-reported. We report our experience with melioidosis presenting as abscesses at unusual sites. METHODS: All consecutive patients with culture proven B. pseudomallei, who presented to a single surgical unit between 1995 and 1998, were evaluated. RESULTS: Three patients presented with splenic abscesses and one with a soft tissue abscess in the neck. One patient developed septicaemia. All patients responded favourably to ceftazidime and/or co-trimoxazole which was started as soon as the diagnosis was confirmed. CONCLUSION: Melioidosis is under-diagnosed in India, probably due to a low index of suspicion of this disease among clinicians. It should be considered as a possibility when abscesses are encountered at unusual sites. The pus must then be cultured to identify the causative agent.

Post-cholecystectomy benign biliary stricture with portal hypertension: is a portosystemic shunt before hepaticojejunostomy necessary?

BACKGROUND: Portal hypertension develops in 15-20% of patients with benign bile duct stricture. Hepaticojejunostomy in such patients is associated with considerable morbidity and mortality. Preliminary portosystemic shunting has been suggested to reduce intra-operative bleeding. We present our experience without preliminary shunting in such patients. PATIENTS AND METHODS: Fourteen consecutive cases of biliary stricture with portal hypertension over a 13-year period (1989-2001) were retrospectively analysed. RESULTS: Thirteen patients were operated upon. One patient had a preliminary portosystemic shunt. In another patient, shunt was attempted. One stage hepaticojejunostomy was possible in 11 patients. There were no intra-operative deaths. Nine of the 13 survived and were available for follow-up. One patient had cholangitis. Another had jaundice related both to chronic liver disease and a strictured hepaticojejunostomy. The remaining 7 patients are asymptomatic and anicteric although alkaline phosphatase levels remain elevated in 5 of them. CONCLUSIONS: Hepaticojejunostomy without preliminary portosystemic shunting is possible in patients with portal hypertension and benign biliary stricture with acceptable morbidity and mortality rates.

Carcinoid tumor of common hepatic duct.

Primary carcinoid tumors of the biliary tract are extremely rare. We report a 36-year-old woman with recurrent acute cholangitis who was diagnosed to have a carcinoid in the common hepatic duct, with enlarged local nodes. She underwent local resection. I-131 metaiodobenzyl guanidine (MIBG) scanning postoperatively showed no uptake in the tumor bed.

VIPoma of pancreas in a child.

An eleven-year-old girl had massive watery diarrhea. She was found to have pancreatic VIPoma. It responded favorably to surgical resection of the tumor. There was no tumor recurrence at 18 months of follow-up.

Duodenal ulcer perforation: have H2 receptor blockers reduced mortality?

Elective surgery for peptic ulcer is becoming rare with the use of more effective medical therapy. However, life threatening complications have not reduced in number. A retrospective study was carried out to compare perforation rates per 10,000 admissions, mortality rates from perforated duodenal ulcers per 10,000 admission and the proportion of patients with perforated duodenal ulcer who died, before and after the introduction of H2 receptor blockers in a large teaching hospital in South India. Perforation rates were not significantly different between the two periods under study. There was a small, but statistically significant (p = 0.047) drop in mortality per 10,000 admissions and a significant drop in proportion of patients with perforated ulcer who died (p = 0.028). Inspite of effective medical therapy, there is a subset of patients with duodenal ulcer who continue to perforate. Efforts should be directed towards identifying this subset and offering them early surgery. Mortality rates have not changed significantly.

Diagnosis and management of gastrointestinal angiodysplasia.

Eighteen patients with gastrointestinal angiodysplasia were seen in a single surgical unit over a period of 8 years. The mean age at onset of symptoms was 33 years. The average duration of symptoms was 54 months (range 2 days-16 years). Three patients had gastric angiodysplasia, two had colonic angiodysplasia, both diagnosed endoscopically preoperatively. The remaining patients required further investigation, which included small bowel enema (SBE), erythrocyte tagged scan (ETC), selective visceral angiography and intraoperative enteroscopy (IOE). SBE was useful but not diagnostic in 3, ETC in 3 and angiography in 5. Four patients required IOE for a diagnosis. Follow up of 17 months is available on all patients. Four had recurrence of symptoms. One required re-exploration and resection of 3 feet of small bowel and right hemicolectomy, another is on hormonal therapy and maintaining normal haemoglobin. Two others are asymptomatic on oral iron therapy.

Malignant 'multinodular' oncocytoma of parotid gland--a case report and literature review.

The pathological findings in a multinodular malignant oncocytoma of the parotid gland in a male 62 years of age, with tumour infiltration into the adjacent skin and skeletal muscle and with regional lymph node metastasis is presented.

Primary papillary carcinoma in a thyroglossal cyst.

Papillary carcinoma arising in a thyroglossal cyst is rare. There is controversy regarding optimum management. We report a case managed by Sistrunk's procedure and external radiotherapy and review the literature on the subject.