Primary Angiosarcoma of the Colon

Angiosarcoma of gastrointestinal tract is extremely rare. Since 1948, we can find only six reported cases of primary colonic angiosarcoma. The review of the six reported cases and a report on the first colonic angiosarcoma to be seen in an adolescent male are presented. The treatment of the colon angiosarcoma is wide surgical excision. The prognosis is poor. Our case is the second one to be alive, more than 18 months after surgery, with no evidence of recurrent disease.     

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.     

Clinical implications of the genetics of sporadic colorectal cancer

Colorectal cancer (CRC) is common and at least 80% of cases are sporadic, without any significant family history. Prognostication and treatment have been relatively empirical for what has become increasingly identified as a genetically heterogeneous disease. There are three main genetic pathways in sporadic CRC: the chromosomal instability pathway, the microsatellite instability pathway and the CpG island methylator phenotype pathway. There is significant overlap between these complex molecular pathways and this limits the clinical application of CRC genetics. Recent Australian and New Zealand guidelines recommend routine testing of mismatch repair (MMR) status for new cases of CRC and selective KRAS and BRAF testing on the basis of diagnostic, prognostic and therapeutic implications. It is important that all clinicians treating CRC have an understanding of the importance of and basis for identifying key genetic features of CRC. It is likely that in the future better molecular characterization such as that allowed by the consensus molecular subtype classification will allow improved prognostication and targeted therapy in order to deliver more personalized treatment for CRC.     

The impact of surgical resection of the primary tumor on the development of synchronous colorectal liver metastasis: a systematic review

Background: In recent years different therapeutic strategies for synchronously liver metastasized colorectal cancer were described. Apart from the classical staged surgical approach, simultaneous and liver-first strategies are now commonly used. One theoretical drawback of the classical approach is, however, the stimulatory effect on liver metastases growth that may result from resection of the primary tumour. This systematic review, therefore, aims to investigate the current insights on the stimulatory effects of colorectal surgery on the growth of synchronous colorectal liver metastases in humans.

Methods: The systematic review was conducted according to the PRISMA statement. A literature search was performed using PubMed and Embase. Articles investigating the effects of colorectal surgery on synchronous colorectal liver metastases were included. Primary endpoints were metastatic tumor volume, metabolic and proliferative activity and tumour vascularization.

Results: Four articles meeting the selection criteria were found involving 200 patients. These studies investigate the effects of resection of the primary tumour on synchronous liver metastases using histological and radiological techniques. These papers support a possible stimulatory effect of resection of the primary tumor.

Conclusions: Some limited evidence supports the hypothesis that colorectal surgery might stimulate the growth and development of synchronous colorectal liver metastases.     

Use of the internet by colorectal cancer patients

OBJECTIVE: To identify the frequency of Internet use by colorectal cancer patients. MATERIALS AND METHODS: Fifty patients interviews. RESULTS: Only four patients (8%) had used the internet to access information about colorectal cancer though 36% would have used it if a site had been recommended. CONCLUSION: The Internet is a resource rarely used by patients but there is potential for its use as an adjunct to written and verbal information.     

Clinical trial assessing VSL#3 for the treatment of anterior resection syndrome

Background: Restoration of bowel continuity after a temporary loop ileostomy following rectal resection often produces impaired bowel function. The purpose of this clinical trial was to assess the efficacy of a probiotic, VSL#3 (VSL Pharmaceuticals Inc., Gaithersburg, MD, USA), in improving bowel function following ileostomy closure. Methods: Between March 2005 and April 2008, a prospective, double‐blind, placebo‐controlled randomized trial of a probiotic preparation was conducted across four South Australian hospitals. Sixty‐three patients who underwent a loop ileostomy reversal were randomized to receive 4‐week treatment of either probiotic therapy (n= 31) or placebo (n= 32). Bowel symptomology was collected through a patient‐completed bowel diary and the Gastrointestinal Quality of Life Index (GIQLI). Results: Completion rates of the 4‐week therapy regime were similar for both groups: 18 active versus 20 placebos. There was no statistically significant difference in the number of patients who withdrew or had adverse events in the two treatment groups. Reasons for patient withdrawal from the study were similar for both groups. Repeated measures analysis of variance showed no statistically significant difference between the GIQLI scores for the two treatment groups. Conclusions: The use of the probiotic preparation, VSL#3, did not alter the post‐operative bowel function of patients undergoing loop ileostomy reversal.     

大肠良恶性肿瘤中PTEN的蛋白表达及其临床意义

目的　探讨抑癌基因PTEN在大肠良恶性肿瘤组织中的表达及其临床意义。方法　应用S -P免疫组织化学方法检测 2 8例正常大肠黏膜组织 ,3 2例大肠腺瘤的腺体及腺体旁组织 ,12例大肠息肉及息肉旁组织 ,48例大肠癌的癌组织及癌旁组织中PTEN蛋白的表达情况。结果　PTEN蛋白在所有大肠肿瘤组织的表达与其在正常粘膜组织及肿瘤旁组织表达相比均有显著性差异 ;PTEN蛋白在所有大肠肿瘤组织的表达水平 ,尤其在大肠息肉和大肠癌中 ,均显著低于正常大肠组织及其相应的肿瘤旁组织 ,且与肿瘤的大小呈显著负相关 ;癌组织中PTEN蛋白表达与癌组织分化程度呈显著正相关 ,而与其临床Dukes分期、淋巴结转移和远处脏器转移无关。结论　抑癌基因PTEN在大肠息肉 (尤其是腺瘤性息肉 )和大肠癌的发生发展中起着重要作用 ,检测PTEN蛋白表达可能对大肠息肉 (尤其是腺瘤性息肉 )和大肠癌的早期诊断、指导临床术后的进一步治疗及预后的判断有一定价值。     

Rectal cancer masquerading as an amoeboma: case report and review of the literature

Despite the prevalence of amoebiasis in many parts of the world, amoebomas are relatively uncommon. Amoebomas within the colorectum are indistinguishable from carcinomas either macroscopically or by barium enema examination and the presence of both conditions is much rarer still. Herein, we describe such a case and review the possible reasons for their coexistence.     

术前结直肠炎症对于结直肠癌局部进展的预测意义

目的研究术前结直肠非特异性炎症对结直肠肿瘤局部进展及预后的影响。方法本研究为回顾性队列研究,通过回顾中山大学附属第六医院2007年至2010年的结直肠癌患者。所有具备该中心术前肠镜资料或手术病理证实肠炎的患者纳入研究,分为炎症组(肠镜下肠炎及手术病理肠炎)及对照组;比较肿瘤分期、淋巴结转移、癌结节转移、其他手术病理资料及生存预后等指标;比较总体生存及肿瘤复发等随访情况,随访时间3年。结果回顾病例907例,纳入研究346例;其中炎症组患者共70例,包括镜下远处肠炎39例(20.2%)、镜下肿瘤原位肠炎16例(22.9%)手术病理肠炎15例(21.4%),对照组276例(78.8%)。炎症组进展期肿瘤发生率74.3%(P0.001),淋巴结转移率62.3%(P0.001),癌结节转移率40.2%(P=0.001)均高于对照组。经logistic回归分析,手术病理肠炎是进展期肿瘤(P=0.016)、淋巴结转移(P=0.017)及癌结节转移(P=0.017)的独立危险预后因素;镜下远处肠炎是进展期肿瘤(P=0.003)、淋巴结转移(P=0.017)的独立危险预后因素。结论手术前结直肠非特异性炎症与肿瘤的分期存在明确的相关性,此类病例可用于结直肠炎症与恶性肿瘤关系研究。     

Phenotypic characteristics of hereditary non-polyposis colorectal cancer by the Amsterdam criteria: an Asian perspective

Background: Hereditary non‐polyposis colorectal cancer (HNPCC) is an autosomal disease with a 68–82% lifetime risk of colorectal cancer (CRC). This study examined the phenotypic characteristics of CRC in Amsterdam criteria‐positive Asian patients from the Singapore Polyposis Registry. Methods: Hereditary non‐polyposis CRC patients, defined by the Amsterdam I and II criteria, prospectively monitored in the Singapore Polyposis Registry over a 16‐year period were reviewed. Clinical data were obtained from a computerized database and parameters, such as age of diagnosis, type and location of CRC, other associated cancers in the pedigree, cancer recurrence and survival were analysed. Results: Fifty‐two patients (31 men and 21 women) from 42 unrelated families, with a median age of 44.5 years (range 27–73 years), fulfilled either Amsterdam I or II criteria and were included in our analysis. The racial distribution was 91% (n = 47) Chinese and 9% (n = 5) Malays, with a median follow up of 44.9 months (range 2–183 months). Significantly, 69% of tumours in this Amsterdam‐defined cohort were left sided, with most being sigmoid cancers. Sixty per cent of all the tumours presented at a late stage (Dukes’ C or D). Left‐sided tumours presented with more advanced Dukes’ stage (P = 0.096) and a higher rate of metastatic disease (P = 0.08) compared with right‐sided lesions. There were, however, no significant differences in either disease‐free or overall survival between right‐sided and left‐sided tumours. Conclusion: This study emphasized the significant left‐sided predominance of CRC in Amsterdam I and II‐defined patients from our predominantly Chinese population, in contrast to those classically described in Lynch syndrome. Amsterdam criteria thus may not be suitable for diagnosing HNPCC in Asian populations and a greater emphasis should be made towards routine molecular diagnosis of mismatch repair gene defects in suspected HNPCC patients of Asian decent.     

98例低位直肠癌保留肛门手术治疗体会

目的观察低位直肠癌保肛手术的效果。方法回顾性总结98例低位直肠癌实施保肛手术的疗效。98例中,肿瘤下缘位于肛缘上4.5-8.0 cm。Dukes A期8例,B期54例,C期36例。肿瘤占据肠腔1/4-3/4,均无远处转移。98例采用Dixon手术,术中使用双吻合器26例,单吻合器72例。结果所有病例未发生骶前大出血,术后发生局限性吻合口瘘1例,经保守治疗后愈合。1年内无复发,2年内复发3例（Dukes C期）,3年内复发12例,其中局部复发3例,其余均为远处转移。结论低位直肠癌采用保肛手术是可行的,但应严格掌握手术适应证。     

Laparoscopy in the management of closed loop sigmoid volvulus

Objective To investigate the feasibility and surgical outcome of elective laparoscopic surgery for acute closed loop sigmoid volvulus. Method A prospectively electronic database of colorectal laparoscopic procedures identified nine consecutive patients with sigmoid volvulus managed by colonoscopic decompression followed by same admission laparoscopic recto‐sigmoidectomy. Results Between January 2001 and February 2007, nine patients, ASA I (one), II (four), III (four) with sigmoid volvulus were treated: seven were women. Their age distribution was 37–87 years (median 64). The volvulus was the first episode in one patient, the second episode for four and the third (or more) for the remainder. The median operation time was 115 min (45–145). No anastomosis was de‐functioned. Postoperative analgesia was parenteral paracetamol (eight) supplemented by 10 mg oral morphine in one case; a ninth patient received patient controlled parenteral morphine for 36 h. Complications included: ileus (one), myocardial infarct (one) and wound infection (one). There was one death on day 32 from a brainstem infarct. Seven had an uncomplicated recovery. The median postoperative stay was 4 days (2–32). Conclusion Laparoscopic recto‐sigmoidectomy postcolonoscopic decompression is a good option for patients with sigmoid volvulus. Surgical complications are minimal and recovery is quick.     

Tales from the frontline: the colorectal battle against SARS

Objective The recent worldwide epidemic of Severe Acute Respiratory Disease (SARS) caused over 800 deaths and had a major impact on the health services in affected communities. The impact of SARS on colorectal surgery, particularly service provision and training, is unknown. This paper reports these changes from a single colorectal unit at the centre of the outbreak. Patients and methods Hospital databases and electronic patient records covering the 4 months duration of the SARS epidemic and an equivalent period preceding SARS were compared. Data was collected for inpatient admissions, outpatient consultations, operative surgery, colonoscopy and waiting times for appointments or surgery. Results The SARS epidemic resulted in reductions of 52% for new outpatient attendances, 59% for review attendances, 51% for admissions, 32% for surgical procedures and 48% for colonoscopies. Major emergency procedures, cancer resections and complex major procedures were unaffected. Operative procedures by trainees reduced by 48% and procedures by specialists reduced by 21%. Patients awaiting early or urgent outpatient appointments rose by 200% with waiting times for colonoscopy increased by a median 3, 5 or 9 weeks for outpatient, inpatient or non‐urgent cases, respectively. The waiting time for minor elective colorectal surgery was extended by 5 months. Conclusion SARS resulted in a major reduction in the colorectal surgical caseload. The consequences were evidenced by a detrimental effect on waiting times and colorectal training. However, serious pathology requiring emergency or complex surgery was still possible within these constraints.     

Clinicopathological management of the patient with a malignant colorectal adenoma

A malignant adenoma of the colorectum is defined as an adenoma in which cancer has invaded by direct continuity through the muscularis mucosae into the submucosa [ 1 ]. The biological basement membrane of the colon is the muscularis mucosae. Thus the term ‘cancer’ cannot be applied to a neoplastic polyp which is confined to the mucosa and does not have the potential to metastases [ 2 3 4 ]. The term polypoid carcinoma is reserved for a polyp which is entirely replaced by carcinoma. There is however no practical benefit in distinguishing between the terms malignant adenoma and polypoid carcinoma [ 1 , 4 , 5 ]. The term carcinoma‐in‐situ is used by some to describe an adenoma containing severe dysplasia. Not having invaded through the muscularis mucosa, it is not a carcinoma. When the diagnosis of malignant polyp is presented by the clinician to the patient, a decision is needed as to whether the polypectomy on its own is sufficient therapy or whether the patient should be subjected to surgical resection. What are the pathological and clinical factors that contribute to this decision? This review examines the issues that require consideration to arrive at a balanced view of this difficult dilemma and to allow the patient to give informed consent to the management option decided upon.