Abdominoinguinal incision in adenocarcinoma of the sigmoid or cecum: report of two cases

PURPOSE

This study illustrates a technique allowing resection of a sigmoid adenocarcinoma with lateral fixation and a cecal adenocarcinoma with involvement of the psoas muscle and ureter.

METHODS

The abdominoinguinal incision, an incision used in the resection of a sarcoma of the lower abdominal quadrants, was applied in the case of a sigmoid adenocarcinoma with posterolateral fixation and infiltration of the anterior abdominal wall and in a case of a cecal adenocarcinoma involving the right psoas muscle and ureter.

RESULTS

In the first case, resection of the tumor mass en bloc with resection of the sigmoid and lower anterior abdominal wall muscles, including the inguinal ligament, was performed. Reconstruction of the muscular fascial defect was done with the rotation of a right rectus abdominis flap. The patient was well 12 months later. In the second case, the cecal carcinoma was resected en bloc with the right psoas and ureter; a right nephrectomy was also performed. This patient was well eight months later.

CONCLUSIONS

The abdominoinguinal incision may provide the exposure needed to allow the resection of a sigmoid or a cecal adenocarcinoma with posterolateral fixation, often considered unresectable with conventional abdominal incisions.

[Polypectomy of the digestive tract]

Endoscopic polypectomy was one of the first therapeutic procedures, as it was done even before the appearance of colonoscopy through rigid endoscopies. Immediately after the use of monopolar current in endoscopy, polyp resection in the digestive tract has been a elective treatment, and is reserved only for surgeries which are very extensive, or those which cannot be surrounded with a wire loop. The impact of the polypectomy in colonic adenomas has been notable because of the possibility of the diagnosis of the entire surgical piece, and for the treatment of lesions with premalignant potential. The success of the complete resection of a colonic polyp is directly proportional to its size and shape, given that pendicular polyps guarantee the complete extirpation of the tumor, in that sessile polyps require additional techniques to elevate the lesion. Among the precautions in prepolypectomy are found the following: Anti-inflammatory non-steroidal (AINS) suspension; anticoagulant suspension, and adequate intestinal preparation. Hemorrhage and perforation occur in 0.1% of each. Postcoagulation syndrome is a secondary effect which only requires vigilance. The inherent complications in the use of secondary current are minimal when its technical principles are known. The success of endoscopic polypectomy depends on the refinement of the procedure, which is achieved through experience.

Bowel perforation caused by silicone drains: a report of two cases

We recently encountered two patients who suffered bowel perforation due to pressure necrosis caused by an open silicone drain placed in the abdominal cavity during surgery. These perforations healed spontaneously after removal of the drains from the site of perforation. Silicone drains are frequently placed in the abdominal cavity to prevent the collection of fluid or blood following surgery; however, a risk of this complication must be borne in mind. Our review of the English literature revealed eight cases of bowel perforations occurring due to a drainage system; six to closed suction drains, and two to open drainage tubes. Seven of these eight patients underwent repeat laparotomy for peritonitis, while the remaining one, who had a closed suction drain, was managed conservatively following discontinuation of the vacuum. Our experience and the literature review suggest that conservative management may be possible in patients without any signs of generalized peritonitis, although repeat laparotomy is required for those with generalized peritonitis. In conclusion, drains should be placed carefully in the abdominal cavity and removed early after the drainage has decreased.

Toxic cardiogenic shock in a patient receiving weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin

A 54-year-old man was treated with weekly 24-h infusion of high-dose 5-fluorouracil (2600 mg/m2) and leucovorin (100 mg/m2) for metastatic colon cancer. At first, he tolerated the treatment well and no significant toxicity was identified. After a total of eight courses of treatment, a stable disease was observed, but mild shortness of breath was found on occasion. The patient had no previous history of cardiac disease and the heart performance assessed by left ventricular ejection fraction before treatment was normal. Unfortunately, acute pulmonary edema with lethal cardiogenic shock occurred during the ninth course of treatment, in spite of intensive medical treatment. The chest X-ray showed extreme cardiomegaly. Repeated assessment of his heart function by echocardiogram and ventricular ejection fraction revealed a very poor cardiac performance. Toxic cardiogenic shock during weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin is extremely rare. To the best of our knowledge, no case has been reported in the English literature. We report a case and the relevant literature about the incidence, clinical picture and possible pathophysiology on 5-fluorouracil-related cardioxicity is reviewed.

A case of obstructive colitis caused by possible colostomy dysfunction

A case of obstructive colitis caused by possible stricture of colostomy is herein reported. A 58 year old female with an obstructive sigmoid colon cancer underwent an emergency descending decompression colostomy. At laparotomy, the colon proximal to the carcinoma was markedly distended and the bowel wall was thin, but the serosa appeared normal. Postoperatively, however, abdominal pain and distension persisted and low grade fever developed. Diarrhea through the colostomy continued. Nine days after the initial surgery, she underwent a left hemicolectomy. An abnormally thickened segment was identified in the resected specimen; normal mucosa was lost and several pseudopolyps were scattered. Histopathological findings of the abnormal segment were consistent with obstructive colitis. A preserved segment of normal mucosa intervened between the site of colostomy and the abnormal segment of obstructive colitis. A possible stenosis of the colostomy was considered to have caused colostomy dysfunction and subsequent obstructive colitis. She was complicated with anastomotic leakage due to the diseased colon being used for anastomosis. Obstructive colitis should be kept in mind in patients with obstructive colonic carcinomas who complain of persistent abdominal pain, distension and diarrhea in the early postoperative period after colostomy.

[A surgical case for concomitant coronary artery disease and ASO with advanced colon cancer]

We report a successful surgical case of concomitant severe coronary artery disease and ASO with advanced sigmoid colon cancer. This patient underwent two-stage operation. Resection of the sigmoid colon was carried out first, then CABG and aortofemoral bypass was carried out simultaneously. The surgical strategy of a patient with coronary artery disease and malignant neoplasm is still controvertial, however, it should be decided considering the severity and the symptoms of both disease. In this case, ascending aorta was used as a donor artery for aortofemoral bypass. This technique will bring those benefits, i.e., consecutive operation procedures in same operating field, obtaining abundant blood flow to lower limb and safe IABP catheter insertion from subcutaneously tunneled bypass graft.

The impact of 5-fluorouracil and intraoperative electron beam radiation therapy on the outcome of patients with locally advanced primary rectal and rectosigmoid cancer

OBJECTIVE

To analyze the effects of 5-fluorouracil (5-FU) chemotherapy combined with preoperative irradiation and the role of intraoperative electron beam irradiation (IOERT) on the outcome of patients with primary locally advanced rectal or rectosigmoid cancer.

METHODS

From 1978 to 1996, 145 patients with locally advanced rectal cancer underwent moderate- to high-dose preoperative irradiation followed by surgical resection. Ninety-three patients received 5-FU as a bolus for 3 days during the first and last weeks of radiation therapy (84 patients) or as a continuous infusion throughout irradiation (9 patients). At surgery, IOERT was administered to the surgical bed of 73 patients with persistent tumor adherence or residual disease in the pelvis.

RESULTS

No differences in sphincter preservation, pathologic downstaging, or resectability rates were observed by 5-FU use. However, there were statistically significant improvements in 5-year actuarial local control and disease-specific survival in patients receiving 5-FU during irradiation compared with patients undergoing irradiation without 5-FU. For the 73 patients selected to receive IOERT, local control and disease-specific survival correlated with resection extent. For the 45 patients undergoing complete resection and IOERT, the 5-year actuarial local control and disease-specific survival were 89% and 63%, respectively. These figures were 65% and 32%, respectively, for the 28 patients undergoing IOERT for residual disease. The overall 5-year actuarial complication rate was 11%.

CONCLUSIONS

Treatment strategies using 5-FU during irradiation and IOERT for patients with locally advanced rectal cancer are beneficial and well tolerated.

Acute intestinal obstruction caused by endometriosis mimicking sigmoid carcinoma

Endometriosis is a relatively frequent disease in fertile women. The intestine is involved in 12-37% of cases. Intestinal endometriosis is usually asymptomatic and complete obstruction of the bowel lumen occurs in less than 1% of cases. We report a case of endometriosis of the sigmoid, which caused complete intestinal obstruction and mimicked carcinoma of the sigmoid colon. This case demonstrates the difficulty of establishing an accurate pre- and peroperative diagnosis and the propensity of intestinal endometriosis to mimic colon cancer.

Radiation therapy for rectosigmoid and rectal cancer: results of the 1992-1994 Patterns of Care process survey

PURPOSE

To determine the US national practice standards for patients with adenocarcinoma of the rectum treated in radiation oncology facilities.

MATERIALS AND METHODS

A national survey of 57 institutions identified 507 eligible patients who received radiation therapy as a component of their treatment for rectal cancer. A stratified two-stage cluster sampling with simple random sampling at each stage for each stratum was used and on-site surveys were performed.

RESULTS

Of the 507 patients, 378 (75%) received postoperative therapy, 110 (22%) received preoperative therapy, 17 (2%) received both preoperative and postoperative therapy, and less than 0.5% received intraoperative radiation alone. To more accurately assess the utilization of modern radiation techniques as well as recommendations of the National Cancer Institute (NCI)-sponsored, randomized, postoperative, adjuvant combined modality therapy rectal cancer trials into current practice, the analysis was limited to the 243 (48%) patients with tumor, node, and metastasis staging system classification T3 and/or N1-2M0 disease who underwent conventional surgery with negative margins. Although only 7% were treated on a clinical trial, 90% received chemotherapy for a median of 21 weeks. Most were treated with modern radiation treatment techniques. In contrast, techniques to identify and help exclude the small bowel from the radiation field were not routinely used.

CONCLUSION

Despite the fact that only 7% of patients with T3 and/or N1-2M0 disease were treated on a clinical trial, such trials appear to have resulted in a positive influence on the standard of practice within the oncology community. Although there are still some deficiencies, the majority of these patients received combined modality therapy and were treated with modern radiation therapy techniques.

Association of extrarenal Wilms' tumor with a horseshoe kidney

Nephroblastoma (Wilms' tumor) is the most common renal malignancy in childhood. Extrarenal Wilms' tumor is uncommon, and the diagnosis is almost always postsurgical. The authors report two cases, located in the sigmoid mesocolon, one of these having an associated horseshoe kidney. Both were treated with excision followed by chemotherapy. They are now 36 months and 7 months postchemotherapy, respectively, and are symptom and recurrence free. Both had favorable histological findings. Association with a horseshoe kidney raises an important issue regarding the histogenesis of these tumors. The authors believe that there is a nexus between the fusion of metanephric blastema during the sixth to seventh week of intrauterine life and the "ectopic" metanephric blastema cells that may give rise to extrarenal Wilms' tumor. Association with a horseshoe kidney with an extrarenal Wilms' tumor has been reported on five previous occasions. The authors closely examine the link between the two.

[Respiratory insufficiency and absent left radial pulse after hemicolectomy]

A 65 year old female developed right thoracic pain, productive cough and fever four weeks after hemicolectomy because of a cancer of the sigmoid. In spite of antibiotic treatment the condition of the patient deteriorated and she was admitted to the hospital with pneumonia of an upper lobe. Chest X-ray visualized prominent proximal pulmonary arteries. Progressive respiratory failure developed and blood gas analysis revealed hypocapnic hypoxemia. The patient had to be intubated and ventilated mechanically. Later, left arm blood pressure measurements could no longer be taken and the radial pulse was missing. Thereafter, an ischemic syndrome of the right leg developed. Embolectomy from the superficial femoral artery was carried out the same day. The patient died five days later. Autopsy revealed an almost complete occlusion of the pulmonary arteries. The organization of thrombotic material indicated recurrence. Emboli were also found in the systemic circulation. A large patent foramen ovale together with signs of pulmonary arterial hypertension are indicative of paradoxical thromboembolism.

Distribution of lymph node metastasis and level of inferior mesenteric artery ligation in colorectal cancer

To investigate the distribution of lymph node metastasis along the inferior mesenteric artery (IMA) and clarify whether high ligation of the IMA is important or not, we examined the surgical results of 172 patients with cancer of the sigmoid colon and rectum. Histologically, lymph node metastasis was absent in 108 (63%) patients and present in 64 (37%) patients. The distribution was adjacent to the wall of the rectum (35.5%) and sigmoid colon (10.5%), along the IMA (7.7%) and sigmoid colic artery (6.3%), and at the root of the IMA (0.7%, 1 of 135 patients). The presence of lymph node metastasis was predicted by the operative findings of lymph node metastasis (p < 0.01) and serosal invasion (p < 0.05) and by the histologic type of tumor (p < 0.05). These results indicate that lymph node metastasis at the root of the IMA is rare, and complete removal of the pericolic and intermediate nodes (D2 dissection) without high ligation of the IMA is feasible for cancer of the sigmoid colon and rectum.

Successful resection of sigmoid colon cancer in a patient with factor XI deficiency

A 42-year-old-women with sigmoid colon adenocarcinoma was found to have isolated prolonged activated partial thromboplastin time (aPTT 102.5 s, normal range 24-36 s) preoperatively. Her medical history included an episode of prolonged postdelivery uterine bleeding 16 years previously. A mixed aPTT test showed immediate correction of the prolonged aPTT, indicating a coagulation factor deficiency in the intrinsic pathway. Factor assays showed factor XI was below 1% of average normal value whereas factor VIII, IX and XII activities were normal. Family screening revealed one sister among the three siblings also had isolated prolonged aPTT. The patient was transfused with four units (5mL/kg) of fresh frozen plasma the day before surgery, then with two units during surgery. The operation was uneventful with no bleeding problems. The patient recovered smoothly and is currently undergoing adjuvant chemotherapy. This is the first formal report of a patient with factor XI deficiency undergoing major surgery in Taiwan. Careful monitoring of aPTT, with fresh frozen plasma transfusion, when needed, may safely overcome bleeding problems during surgery.

[Emergency decompression of a mechanical colonic ileus before elective surgery: first clinical results of fluoroscopic stent placement]

PURPOSE

Evaluation of fluoroscopic stent placement as an emergency therapeutical approach for treatment of acute large bowel obstruction due to colorectal neoplasm.

METHODS AND MATERIAL

From January to December 1996 in 11 patients suffering from colorectal stenosis due to known or supposed malignancy the indication for the fluoroscopic placement of self-expanding metal stents was established. All patients showed clinical and radiological signs of an acute mechanical large bowel obstruction. Elective single-stage surgery was planned if the decompression had been carried out successfully.

RESULTS

Stent placement was successful in 8 cases. Functional success in respect of resolving the acute large bowel obstruction was seen in 7 out of 11 patients. Elective surgery was possible in all 7 cases creating a primary end-to-end anastomosis without major complications during the perioperative period.

CONCLUSION

Fluoroscopic placement of self-expanding metal stents in malignant colorectal stenosis is a promising method to avoid emergency surgery.

[Clinical study of synchronous double cancers of the lung and digestive tract]

Among 64 cases of surgically resected primary lung cancer from 1991 to 1997, there were 5 cases of synchronous double cancers of the lung and digestive tract. They were consisted of 4 males and 1 female and the patient age at the time of the lung resection ranged from 65 to 81 years (average: 74.6). One male was diagnosed as having lung cancer (squamous cell carcinoma) along with sigmoid colon cancer (adenocarcinoma) and others were lung cancer (adenocarcinoma) and gastric cancer (adenocarcinoma). In two patients with early gastric cancer, lobectomies were performed following endoscopic resection of gastric cancer. In three patients including two old man and woman (over 80 years old), lobectomies and gastrectomies (or sigmoidectomy) were performed at the same time. We omitted mediastinal lymph nodes dissections in two old patients and no operative complications occurred. All patients are alive now. It can be concluded that in cases of synchronous double cancers of the lung and digestive tract, we must select the best treatment that is not invasive for the patient and that simultaneous operation for double cancer can be safely performed.

Discriminant analysis of pre- and intraoperatively detected prognostic factors influencing lymph node involvement in patients with colorectal carcinoma

BACKGROUND/AIMS

The aim of this study was to establish whether, and to what extent, pre- and intraoperatively detected characteristics (demographic, anamnestic and laboratory data) and tumor characteristics can be used in the assessment of regional lymph node involvement in patients with colorectal carcinoma. The assessment also included the number of lymph nodes involved in patients with positive lymph nodes. Considering that the number of obtained lymph nodes widely varies in resected specimens, assessment parameters also included the percentage of the involved lymph nodes within the total population of lymph nodes.

METHODOLOGY

From 1992-1993, 46 patients with carcinoma of the rectum and sigmoid colon were studied, with a total number of 736 lymph nodes evaluated. Out of the total number of lymph nodes, 577 (78.4%) were benign and 159 (21.6%), malignant. Data were analyzed by multi-variant statistical methods, namely: discriminant analysis and multiple regression with the aid of SPSS/PC+ software.

RESULTS

For this patient group, we evaluated the following potentially predictive factors for lymph node involvement: age; serum hemoglobin, albumin and alkaline phosphatase levels; weight loss; and the primary tumor localization characteristics: histologic type, macroscopic growth pattern and depth of tumor invasion of the bowel wall. We found that there was no difference in the prediction of regional lymph node involvement between analysis of the aforementioned parameters and analysis of the isolated discriminators only.

CONCLUSION

A predictability likelihood of 83.78% greatly surpasses the acceptable error tolerance level of 5%. Correlation of demographic, anamnestic and laboratory data about the patient and the characteristics of the primary tumor cannot be used in distinguishing malignant lymph nodes from benign ones. These data cannot be the basis for exact intraoperative staging and thus cannot be significant criteria for decision-making about operative treatment modalities.

Systematic heterogeneity and prognostic significance of cell proliferation in colorectal cancer

The prognosis of colorectal cancer has not significantly changed during the last 30 years. While evaluation of tumour cell proliferation may provide prognostic information, results obtained so far have been contradictory Heterogeneity in tumour cell proliferation may explain these contradictions. With in vivo injection of iododeoxyuridine (IdUrd), estimation of labelling index (LI), S-phase transit time (Ts) and potential doubling time (Tpot) may be performed from a single sample. A total of 109 colorectal cancers were studied after in vivo injection of IdUrd before surgical removal. From each cancer, four to eight samples were processed for both flow cytometrical (FCM) and immunohistochemical (IHC) visualization of IdUrd incorporation. LI/IHC was morphometrically quantified at both the luminal border and the invasive margin of these tumours. LI was significantly higher at the luminal border compared with the invasive margin, although they were correlated with each other. Using combined IHC and FCM methods, rapidly growing colorectal cancers (high LI and/or low Tpot) showed an increased survival (significant for LI at the invasive margin and for Tpot at both the invasive margin and the luminal border) in the entire unselected material and for radically removed Dukes' B tumours. FCM data alone did not discriminate for survival, with the exception of Ts in diploid and radically removed Dukes' B tumours.

Management of colonic lipomas

BACKGROUND

Little is known of colonic lipomas, especially in an Asian population, and their management is controversial.

METHODS

A computerized colonoscopy database was analysed and patients with colonic lipomas were reviewed.

RESULTS

There were 16 colonic lipomas (incidence of 0.15%) in a series of 10658 consecutive colonoscopies. There were seven men and nine women, with a mean age of 61.8 years (range: 28-80 years). The size of the lipomas ranged from 1.5 to 6 cm; all those larger than 3.5 cm were symptomatic (P = 0.05). The most common symptom was mild bleeding per rectum. Right-sided lipomas were palpable while left-sided lipomas presented with obstructive symptoms. Colonoscopic removal by hot biopsy or snare polypectomy was possible where the lipomas were 2.5 cm and pedunculated. Surgery was performed in six patients (four open, two laparoscopic) for symptoms and to exclude malignancy. There was no morbidity or mortality.

CONCLUSIONS

Small or pedunculated lipomas may be safely removed colonoscopically and the diagnosis confirmed histologically. Larger lipomas require surgical resection for relief of symptoms or to exclude malignancy.

The utility of the Hartmann procedure

BACKGROUND

In 1923 the French surgeon Henri Hartmann described an operation for rectosigmoid cancer as an alternative to abdomino-perineal resection for high-risk patients. In the subsequent years, the indications for performing the Hartmann procedure have broadened to include complicated diverticulitis, ischemic bowel, iatrogenic perforations, volvulus, and colitis.

METHODS

We have retrospectively reviewed our experience in 185 patients who underwent the Hartmann procedure from January 1981 to December 1995. Charts were reviewed for indications, morbidity, and mortality and to determine the outcome of patients who underwent the Hartmann procedure.

RESULTS

The main indications for performing the Hartmann procedure were complicated diverticulitis (including perforation, obstruction, and abscesses) in 108 patients, rectosigmoid cancer in 31 patients, and other indications in 46 patients. There were a total of 27 deaths for an in-hospital mortality of 14%. All complications occurred at a rate of less than 9%. Of the 158 surviving patients, 90 (57%) eventually underwent the second stage of the operation to restore bowel continuity. The average length of time between initial resection and reanastomosis was 149 days. There were no deaths associated with the second stage of the procedure and complications occurred at a rate less than 4%.

CONCLUSIONS

This is the largest reviewed series of the Hartmann procedure. Mortality is lower than in other reported series, and morbidity is low. Our data demonstrate that the second stage of the procedure, in properly selected individuals, is a procedure that can be performed with minimal morbidity and no mortality. This is different from other published reports. We conclude that the Hartmann procedure is a safe and efficacious option for the surgeon confronted with the complex pathology of the rectosigmoid area, with acceptable morbidity and mortality.

Differences in the diagnostic criteria used by Japanese and Western pathologists to diagnose colorectal carcinoma

BACKGROUND

In view of the many studies of early stage colorectal carcinoma from Japan, it is essential to know whether the criteria for the histologic diagnosis of colorectal carcinoma are similar in Japan and Western countries.

METHODS

Eight expert pathologists from Japan (4), North America (2), and Europe (2) individually reviewed microscope slides of 20 colorectal lesions from Japanese patients who had undergone endoscopic mucosal resection or surgery because early stage carcinoma and/or adenoma was suspected. The pathologists indicated the pathologic findings on which they based each diagnosis.

RESULTS

For 11 slides that showed adenoma according to the Western pathologists with low grade dysplasia according to at least half of them, the Japanese diagnosed definite carcinoma with or without adenoma in 4 cases and adenoma in 5, and in 2 cases they were equally divided between a diagnosis of adenoma and carcinoma. For five slides showing adenoma with high grade dysplasia according to the Western pathologists, the Japanese diagnosed definite carcinoma with adenoma in three cases and adenoma in one, and in one case they were equally divided between a diagnosis of adenoma and carcinoma. For one case in which the Western pathologists were equally divided between a diagnosis of carcinoma and adenoma with high grade dysplasia, all the Japanese pathologists diagnosed definite carcinoma with or without adenoma. Three slides showed definite carcinoma with or without adenoma, according to both the Western and the Japanese pathologists. The presence of invasion was the most important diagnostic criterion of colorectal carcinoma for the Western pathologists, whereas for the Japanese the nuclear features and glandular structures were more important.

CONCLUSIONS

In Japan, colorectal carcinoma is diagnosed on the basis of nuclear and structural criteria, even in cases considered by Western pathologists to be noninvasive lesions with low grade dysplasia. This diagnostic practice may contribute to the relatively high incidence of early stage colorectal carcinoma reported in Japan as compared with Western countries.