Carcinoma of the colon in children: report of a case and review of the literature

Carcinoma of the colon seen in an 11-year-old boy is reported herein. The patient had advanced carcinoma of the ascending colon and died 8 months after an ileo-transversostomy had been performed as a palliative procedure. Histologically, the tumor was found to be signet-ring cell carcinoma. 29 cases of colon carcinoma reported in Japanese children under 15 years of age are also reviewed. In 19 of these patients, surgery was done as an elective procedure after the diagnosis of colon cancer had been established, but emergency surgery was performed on 10 patients for perforation or obstruction of the bowel. Curative resection was possible in 14 patients, but of these, only 3 patients survived for more than 10 years.     

Primary resection and anastomosis for perforated left colon lesions.

The records of 33 patients with perforated left colon lesions over a 6-year period from 1992 to 1998 were examined retrospectively for clinical course and complications. All patients had a free perforation, feculent or purulent peritonitis, and/or a large inflammatory mass. All patients had primary resection and anastomosis without a protective colostomy or ileostomy. Indications included diverticulitis in 28 patients, obstructing colorectal carcinoma in 3, and iatrogenic perforations in 2. Complications occurred in 10 patients, including atelectasis in 1, urinary retention in 2, urinary tract infections in 2, wound infections in 3, line catheter sepsis in 1, and acute tubular necrosis in 1. There was one anastomotic dehiscence, which was successfully converted to a Hartmann procedure. Patients were discharged an average of 7 days after surgery. Two patients required surgery after discharge: one had a fascial dehiscence and the other an incisional ventral hernia. There was no mortality. Primary resection and anastomosis of selected perforated left colon lesions can be performed with a morbidity and mortality rate lower than that usually reported for the Hartmann procedure.     

The occurrence of severe epithelial dysplasia and its bearing on treatment of longstanding ulcerative colitis.

One hundred twenty-four patients with extensive ulcerative proctocolitis were operated upon with proctocolectomy. The mean observation time was 10.3 years. Before surgery rectal biopsies were taken in all patients. The relationship between precancerous lesion in rectal biopsies and the presence of precancer and/or cancer in the rectum or colon in the removed specimen was evaluated. Thirteen out of 14 patients showed evidence of severe rectal dysplasia as well as severe dysplasia in the large bowel specimen, and five of these patients had a carcinoma as well. The 14th patient showed severe dysplasia only in the rectum as well as a rectal carcinoma. Of 110 patients without severe rectal dysplasia, 36 showed evidence of severe colon dysplasia, and three of these patients had a large bowel carcinoma as well. Only one patient had a large bowel carcinoma without evidence of severe dysplasia in the rectum or colon. Thus, nine patients out of ten with large bowel carcinoma showed severe dysplasia in rectum and/or colon. Four of these carcinomas were unknown before surgery. Although severe dysplasia in the rectal biopsy is a strong indication of a large bowel carcinoma (6/14), a negative rectal biopsy does not exclude a large bowel carcinoma (4/110). Proctocolectomy cannot be looked upon only as a prophylactic procedure in patients with severe dysplasia in the rectal biopsy, but also as an attempt to curative surgery, as large bowel carcinoma may have already developed in a considerable number of patients where precancer is diagnosed in biopsies.     

Carcinoma of pelvic pouch following restorative proctocolectomy: report of a case and review of the literature

One of the possible long-term complications following an ileoanal pouch procedure is the development of malignancy in the mucosa of the rectal stump. Only 10 such cases have been reported so far. We report the case of a 23-year-old male who had ulcerative colitis with high-grade dysplasia and underwent an ileoanal pouch procedure. He was found to have a malignancy in the rectal stump 5 years after surgery. The malignancy presented with symptoms of refractory pouchitis. Pouch excision was performed. The risk of developing malignancy in the rectal mucosa after an ileoanal pouch procedure mandates regular follow-up in these patients, with a high index of suspicion especially in patients with delayed onset pouchitis.     

Role of subtotal/total colectomy in emergency treatment of occlusive cancer of the left colon

PURPOSE: The aim of this study was to evaluate the results of management of acutely obstructed carcinoma of the left colon by emergency subtotal/total colectomy (STC) with immediate anastomosis without diversion. METHODS: STC was performed in 60 consecutive patients (mean age 72 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively-distended colon of dubious viability, signs of impending cecal perforation. RESULTS: Postoperative mortality was 6.6% (n = 4): 3 patients over 85 years of age died postoperatively as a result of cardiopulmonary complications; an 83 year-old female died as a result of an anastomotic dehiscence. Morbidity was 10% (n = 6) including one fistula which recovered without surgery. There were 5 synchronous colon cancers. Six months after surgery, the mean daily stool frequency was 2 after STC, and 3 after TC. CONCLUSION: Emergency STC achieves one stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions, ensures restoration of gut continuity via a "safe" anastomosis and removes a possible synchronous carcinoma.     

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.     

Results of radical nephrectomy for peripheral well-circumscribed renal cell carcinoma

Recently, several authorities have argued that, whenever surgically feasible, parenchyma-conserving surgery rather than radical nephrectomy should be the preferred treatment for renal cell carcinoma. They affirm that the results reported following partial nephrectomy are as good as those reported following radical nephrectomy for renal cell carcinoma. However, parenchyma-conserving surgery is usually performed only for relatively small, well-circumscribed tumors that do not involve the collecting system extensively or the renal hilum. To determine the results when radical nephrectomy is used to manage similar tumors, we reviewed the clinical records and arteriograms of 111 patients with renal cell carcinoma. Review of the arteriograms showed that parenchyma-conserving surgery could have been performed in 10 cases (9%). The disease-free survival rate for these 10 patients after radical nephrectomy was 100 percent, and they had no local recurrences. On the basis of these data, we believe that radical nephrectomy remains the best treatment for all patients who have renal cell carcinoma and a normal contralateral kidney.     

Self-expanding metallic stent insertion in the proximal colon

Objective Colonic obstruction may be relieved by the insertion of a self‐expanding metallic stent (SEMS), either for permanent palliative relief or as a bridge to surgery. Lesions proximal to the descending colon can be more difficult to intubate and stent [ 1 ]. SEMS placement in the more proximal colon lesions has been reported in only a few cases [ 2 , 4 ]. The aim of this study was to review the outcome of SEMS for obstruction at the splenic flexure and above. Method A study of all colonic stents inserted in one specialist unit was undertaken. Patients’ demographics, site and aetiology of the underlying obstruction, success or other outcome of the procedures were collected. Thirty‐day morbidity and mortality were documented. Results Seven patients had proximal lesions: four in the transverse colon and three at the splenic flexure. Six patients had colorectal carcinoma and one had extrinsic compression from a gastric carcinoma. Six of the SEMS were inserted for permanent palliation, and one as a bridge to surgery. Stent placement was technically successful in six of the seven patients. In the seventh patient, there was a failure of expansion of the stent, after successful intubation of the lesion, which was in the distal transverse colon. One patient suffered from minor self‐limiting abdominal pain in the first 24 h after the procedure. There was no other SEMS related morbidity or mortality. All of the successfully stented patients were discharged from the surgical ward within 3 days after the procedure. Median survival time was 4.3 months (range 3–12 months). Three patients are still alive. Conclusion The SEMS is a useful tool in managing acute bowel obstruction. Placement of colonic stents proximal to the descending colon is safe, feasible and effective.     

Appraisal of therapy for carcinoma of the esophagus

A review of 155 patients having esophageal carcinoma seen in a twelve year period is presented. Esophagogastrectomy was performed in thirty-nine patients and two had esophagectomy after colon bypass. Seven of these forty-one patients died after surgery and significant late complications developed in six. Functional results were good in the survivors in whom complications did not develop. Three patients have lived five years, and six are alive for shorter periods. Palliative radiation resulted in improved swallowing in twelve of fifty-five patients. The Mousseau-Barbin tube was used in nine patients with unsatisfactory results. Substernal colon bypass was carried out in seven patients with a high complication rate and poor functional results.     

Carbon dioxide laser salvage surgery after radiotherapy failure in T1 and T2 glottic carcinoma.

OBJECTIVES: Recurrent glottic carcinoma after radiotherapy (RT) may be managed by open neck or endoscopic surgery. The impact of endoscopic treatment with CO(2) laser for recurrent glottic carcinoma after RT is reported. METHODS: We present the oncologic and vocal outcomes of a retrospective study based on a series of 16 patients with rT1 and rT2 glottic carcinoma who were endoscopically managed between February 1995 and December 1999 after RT failure. All patients were males with a mean age of 68.7 years (range, 50 to 87 years). Before RT, the lesions had been staged as T1 N0 in 11 patients and T2 N0 in 5, and after RT as rT1 N0 in 12 and rT2 N0 in 4. According to the European Laryngological Society classification, a total of 9 transmuscular, 3 total, and 4 extended cordectomies were performed. Mean follow-up was 45 months (range, 9 to 79 months). RESULTS: Endoscopic salvage surgery was successful in 14 patients. One of them developed a second recurrence and was definitively cured with an additional endoscopic procedure. Two of the 16 patients had recurrent disease after salvage laser surgery and died due to progression of disease. Ultimate local control with laser alone at 3 years was 87.1%, according to the Kaplan-Meier method. Laryngeal preservation was obtained in all survivors after endoscopic rescue surgery. Voice analysis showed a clear correlation between the amount of vocal cord tissue resected and decrease of the vocal outcome. CONCLUSIONS: The present series indicates that selected recurrences after primary RT for T1 and T2 glottic carcinoma are eligible for endoscopic salvage surgery with oncologic results comparable to those with open neck procedures but with a lower complication rate and a favorable functional outcome.     

Incurable colorectal carcinoma: the role of surgical palliation

About 20 per cent of patients with carcinoma of the colon or rectum present with metastatic disease. Surgeons are frequently asked to consider resection or other operative procedures in these patients for palliation. We performed this review to determine whether patients presenting with known metastatic colorectal cancer derive benefit from surgical intervention. We performed a retrospective review of all patients with M1 carcinoma of the colon or rectum who were identified from the University of Mississippi Medical Center Cancer Registry from April 1985 through February 2003. Patients who underwent hepatic and/or pulmonary resection with curative intent were excluded from analysis, as were patients with metachronous metastases. Eighty patients with M1 colorectal cancer who did not undergo surgery with curative intent were identified, and in 74 of these, complete medical records and follow-up were available. Forty-nine of the 74 patients (66%) underwent an operation, and 25 were managed nonoperatively. Indications for surgery included bowel obstruction, active hemorrhage, severe anemia from gastrointestinal bleeding with requirement for blood transfusions, intractable pain, and perforation of the colon. Average survival was 11.2 months for operative patients versus 6.5 months for nonoperative patients (P < 0.05). Thirty-six patients who underwent resectional procedures had a postoperative hospitalization of 7.5 days and a median survival of 11.5 months. Thirteen patients who had a nonresectional procedure had an average postoperative stay of 9 days and a median survival of 4 months. Median survival in those who did not undergo an operation was 4.8 months. Although metastatic colorectal carcinoma cannot usually be cured by surgical intervention, many patients who present with metastatic disease will benefit from palliative operations with relatively short hospitalizations and reasonable survival. Those who are not candidates for resection of the primary tumor have shorter survival times. Surgery can alleviate many of the distressing symptoms in patients with metastatic colorectal carcinoma.     

Laparoscopic-assisted colectomy with lymph node dissection for invasive carcinoma of the colon

The results of performing laparoscopic-assisted colectomy in 20 patients with invasive carcinoma of the colon were analyzed in this study. The site of the lesion was the right colon in 5 patients, the transverse colon in 1, the left colon in 13, and the rectosigmoid in 1. In 2 patients, the laparoscopic procedure needed to be converted to an open laparotomy. Limited lymph node dissection (R1+, R2) was carried out in 10 patients and extensive node dissection (R3) was carried out in 9 patients. The histological depth of invasion in the 18 patients who underwent laparoscopic-assisted colectomy was the submucosa in 9, the muscularis propria in 2, and the extramuscular layer in 7. There were 3 patients who developed postoperative complications, 1 of whom underwent reoperation due to perforation of the colon. The postoperative course of the patients who underwent laparoscopic surgery was compared with that of a retrospectively selected control group of patients who had undergone open laparotomy. The postoperative recovery of the patients who underwent laparoscopic surgery was significantly faster than that of those who had undergone open laparotomy. Thus, we consider that laparoscopic-assisted colectomy with lymph node dissection is technically feasible provided that patients are properly selected. This procedure may be indicated not only for colonic carcinoma in the early stage, but also for that with invasion of the muscularis propria or the extramuscular layer.     

Safety of bowel resection for colorectal surgical emergency in the elderly

OBJECTIVE: Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study. PATIENTS AND METHODS: In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma. RESULTS: The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction. CONCLUSION: Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.     

Surgical therapy in Barrett's esophagus.

Seventy-six patients with Barrett's esophagus were cared for during a 10-year period. Fifty-six patients (74%) presented with complications of the disease. There were 20 strictures, 7 giant ulcers, 11 cases of dysplasia, and 29 patients with carcinoma. In patients with benign disease, 93% had mechanically defective sphincters and 83% had peristaltic failure of the lower esophageal body. Esophageal pH monitoring showed excessive esophageal exposure to pH less than 4 in 93% and excessive exposure to pH more than 7 in 34% of the patients tested. Ninety-three per cent of patients with excessive alkaline exposure had complications, compared to only 44% with normal alkaline exposure (p less than 0.01). Gastric pH monitoring, serum gastrin levels, and gastric acid analysis supported a duodenal source for the alkaline exposure. Antireflux surgery was performed using Nissen fundoplication in 30, Belsey partial fundoplication in 3, and Collis-Belsey gastroplasty in 2. Six required resection with colon interposition. Good symptomatic control was achieved in 77% after antireflux surgery. Four patients had symptoms and signs of duodenogastric reflux; three required a bile diversion procedure. Fifteen patients had an en bloc curative resection with colon interposition. One patient with high-grade dysplasia on biopsy was found to have intramucosal carcinoma after simple esophagectomy. Five tumors were intramucosal, seven were intramural, and four were transmural. Lymph node involvement occurred only in the latter two. Actuarial survival 5 years after curative resection was 53%. Median survival time for patients after palliative resection or no resection was 12 months. Study of en bloc specimens indicated that extent of resection should be adapted to extent of disease: esophagectomy for intramucosal disease, en bloc esophagectomy with splenic preservation for intramural and transmural disease. Serum CEA was useful in detecting recurrent disease after surgery when the primary tumor stained positively for CEA.     

Metachronous carcinoma of the colon: report of a clinical case

The Authors deal with a rare case of 'meta-metachronous' carcinoma of the colon. A seventy years old man was admitted to ward after being diagnosed an adenocarcinoma of the transverse colon. The anamnestic data pointed out that the patient had already been operated twice for the colon carcinoma, which had been diagnosed in the left colon and in the cecum respectively seven and two years before. A colonoscopy performed sixteen months before did not show any lesion of the residual colon. It is likely that tiny lesions, which were still in the adenoma phase, were not diagnosed by the endoscopy; it is also possible that the adenoma-carcinoma sequence was extremely fast. On the basis of this experience the Authors recommend that patients with metachronus carcinoma undergo either frequent controls or a preventive subtotal colectomy.     

Genotype and phenotype factors as determinants for rectal stump cancer in patients with familial adenomatous polyposis. Hereditary Colorectal Tumors Registry

OBJECTIVE: To identify factors influencing the occurrence of cancer in the rectal remnant in patients with familial adenomatous polyposis (FAP) after colectomy and ileorectal anastomosis (IRA). SUMMARY BACKGROUND DATA: The risk for rectal cancer in patients with FAP after colectomy and IRA remains a major concern. METHODS: Between 1955 and 1997, 371 patients (206 men, 165 women) from the Registry of Hereditary Colorectal Tumors underwent colectomy and IRA as a primary surgical procedure. Survival was estimated using the Kaplan-Meier method. Cox proportional hazard models were fitted to assess the relative excess risk of rectal cancer and to control for confounding factors. A multivariate analysis was performed to assess the relation between cancer risk in the rectum and sex, age, number of rectal polyps, colon cancer, and APC germline mutation. RESULTS: Median follow-up was 81 months. Eighty-nine patients (24%) had colon cancer at the time of surgery. The APC mutation was found in 200 patients. In 27 patients, cancer developed in the retained rectum 1 to 26 years after surgery. The incidence of rectal carcinoma appears to increase with time: at 10, 15, and 20 years after surgery, the cumulative risk was 7.7%, 13.1%, and 23.0%, respectively. Multivariate analysis identified as independent predictors the presence of colon cancer at IRA and a mutation occurring between codons 1250 and 1464; both factors increased the risk nine times. CONCLUSIONS: The presence of cancer at IRA and APC mutation type are the most important risk factors for the future development of cancer in the rectal remnant in patients with FAP.     

Antegrade continence enema and its application in Africa

BACKGROUND: Antegrade continent enema (ACE) procedure has been accepted worldwide as the salvage procedure for intractable constipation and faecal incontinence after anorectal malformation surgery. Its application only has been reported from the developed countries. METHODS: The authors performed four such operations on incontinent children in a poor socioeconomic group in South Africa. RESULTS: Three patients had previous surgery for anorectal malformation, and one had intractable encopresis. The patients kept clean with water washouts only, starting 1 week after the operation. CONCLUSIONS: The ACE procedure can be used easily by patients in disadvantaged communities of Africa, and its use requires minimal but sympathetic supervision only. The authors recommend that all pediatric surgeons dealing with these unfortunate children should perform this procedure after a trial period of medical treatment. This is also the first report of the ACE procedure performed for an encopretic child.     

Alpha-Fetoprotein-Producing carcinoma of the colon: Report of a case

We report herein the rare case of a 67-year-old man in whom alpha-feto-protein (AFP)-producing carcinoma originated in the transverse colon, describing the clinical course of the patient and the histological features of the tumor. At the age of 63, the patient had been diagnosed as having sigmoid colon carcinoma, and surgery was carried out. However, 4 years later, his fecal occult blood test was positive, and further investigation revealed a transverse colon carcinoma with liver metastasis. The serum AFP measured preoperatively was 10978 ng/ml. Resection of the transverse colon and a liver biopsy were performed, following which his serum AFP level decreased to 4804 ng/ml. Histology of the ulcerated lesion in the transverse colon showed a poorly differentiated adenocarcinoma with a medullary growth pattern. Using an immunohistochemical staining method, AFP-producing cells were detected in the transverse colon carcinoma and the liver metastasis. Based on our experience of this patient and a review of the literature on the few cases previously reported, we conclude that AFP-producing coloretal carcinoma has a tendency to produce blood-borne metastasis and to be associated with a poor prognosis.     

Early diagnosis of adenocarcinoma developing in Barrett's esophagus

Fifty-eight patients had surgery for carcinoma of the esophagus at Scripps Clinic, La Jolla, Calif, from 1976 to 1986. Esophagectomy with reconstruction by colon interposition was done in 24 patients with adenocarcinoma arising in columnar-lined epithelium (Barrett's). In 5 patients, obstructive symptoms had not yet developed and the diagnosis was made by endoscopy performed for evaluation of gastroesophageal reflux. Dysphagia had just started in 12 additional patients and no weight loss had been noted. The operation was palliative in 14 patients and potentially curative in the other 10. Only 3 patients had negative lymph nodes. Ten patients were alive after 2 to 11 years. Encouraging results were indicated for surgical treatment of adenocarcinoma of the esophagus developing in Barrett's epithelium. A good outcome can be obtained with resection even in patients with lymph node metastases.     

结肠灌洗在左半结肠癌致肠梗阻一期切除吻合术中的应用价值

为探讨结肠灌洗在左半结肠癌致肠梗阻一期切除吻合术中的应用价值,回顾2012年3月至2013年4月我院行一期切除吻合术治疗、术中给予结肠灌洗的40例左半结肠癌致肠梗阻患者资料（观察组）,片与同期于术前肠道准备下行一期切除吻合术治疗的40例非梗阻性左半结肠癌患者（对照组）进行对比分析。结果显示,两组患告均顺利完成手术,术后尤吻合门漏发生。观察组手术效果良好37例,欠佳3例（切口感染3例）;对照组手术效果良好38例,欠佳2例（切口感染1例。肠瘘1例）。两组患者手术效果比较差异无统计学意义,P〉0．05。观察组患者术后第2天、第3天肠蠕功频率明显快于对照组．P〈0．05;第4天两组差异无统计学意义,P〉0．05。结果表明．左半结肠癌致肠梗阻患者应用术中结畅灌洗法行一期切除吻合术可达到与非梗阻性左半结肠癌患者一期手术相同的疗效,证明在半结肠癌致肠梗阻一期切除吻合术中结肠灌洗的安全性与有效性,其应用价值值得肯定。