Disease profile of colon and rectum carcinoma at Pelonomi Hospital, Bloemfontein

A retrospective study evaluated all new cases of colorectal cancer which presented over a 7-year period at Pelonomi Hospital, Bloemfontein. The aim of the study was to compare patients younger than 40 years with the group older than 40 years. Most patients presented late, with advanced disease. A high proportion of patients were younger than 40 years (32.4%). No significant differences in sex ratio, tumour position, differentiation or stage of tumour were detected between the two groups. Of note was a high proportion (45%) of right-sided colon cancer in both groups. The younger patients did not have more advanced disease at presentation than the older group. Their prognosis, when matched stage for stage, was similar.

Outcome of restorative proctocolectomy when the diagnosis is suggestive of Crohn's disease

Twenty of 81 patients treated by restorative proctocolectomy for presumed ulcerative colitis had some features of Crohn's disease: 10 were classified as definite Crohn's disease and 10 as indeterminate colitis. These pathological features were first apparent during synchronous colectomy and pouch construction in 10 of 11 cases. In the remainder, histological features of possible Crohn's disease were first identified during rectal excision (n = 6), preliminary subtotal colectomy (n = 2), and after pouch excision (= 2). Complications were marginally more common in patients with features of possible Crohn's disease: pelvic sepsis 30% (Crohn's disease 30%, indeterminate colitis 30%) v 20%, fistulas 45% (Crohn's disease 30%, indeterminate colitis 60%) v 16%; ileal stenosis 40% (Crohn's disease 40%, indeterminate colitis 40%) v 21%, pouchitis 50% (Crohn's disease 50%, indeterminate colitis 50%) v 26%, and small bowel obstruction 25% (Crohn's disease 30%, indeterminate colitis 30%) v 13%. Pouch excision or a persistent proximal stoma has been necessary in six patients with possible Crohn's disease (30%) (Crohn's disease 3 cases 30%, indeterminate colitis 3 cases 30%) compared with nine (15%) of the remainder. Median hospital stay, however, was the same and stool frequency in those with a functioning pouch were comparable. These results show that there is a higher complication rate if there are features of Crohn's disease but that the medium term functional results are acceptable if the pouch can be retained.

Fistula complicating restorative proctocolectomy

Twenty-seven patients developed a fistula after 168 restorative proctocolectomies. Thirteen fistulas were enterocutaneous (two with communication to the bladder); their origins were from the pouch (three patients), the ileoanal anastomosis (three), the pouch appendage (three), a previous loop ileostomy (two) and iatrogenic small bowel injury (two). Two patients had Crohn's disease. The pouch was removed in four patients, one of whom died from chronic small bowel obstruction; the remaining nine have satisfactory pouch function after fistula excision. Ten pouch-vaginal fistulas occurred, all from the ileoanal anastomosis; four were extrasphincteric. Four of these patients had underlying Crohn's disease. Only two patients, with Crohn's disease and indeterminate colitis, required pouch excision; the remainder have good pouch function after treatment of the fistula. There were three pouch-perineal fistulas, all from the ileoanal anastomosis; these were successfully managed by seton fistulotomy. There was one pouch-vesical fistula, successfully treated by excision of the fistula and pouch appendage.

Randomized trial of loop ileostomy in restorative proctocolectomy

A randomized controlled trial was performed to assess the role of loop ileostomy in totally stapled restorative proctocolectomy. Entry criteria included all patients who were not on corticosteroids in whom on-table testing revealed a watertight pouch with intact ileoanal anastomosis. Of 59 patients undergoing restorative proctocolectomy over 36 months, 45 were eligible and were randomized to loop ileostomy (n = 23) or no ileostomy (n = 22). The age and diagnosis of the groups were similar. There were no deaths; two ileoanal anastomotic leaks occurred, one in each group. Ileoanal stenosis occurred in five patients with and one without an ileostomy. The incidences of wound and pelvic sepsis, bowel obstruction and pouchitis were similar. Twelve patients (52 per cent) developed ileostomy-related complications. The median total hospital stay was 23 (range 13-75) days with ileostomy and 13 (range 7-119) days without (P < 0.001). This study indicates that there is a low risk of pelvic sepsis which is not increased by avoiding a protective ileostomy. Loop ileostomy was associated with a high incidence of complications.

The role of mammography to evaluate palpable breast tumours

Mammography is the best screening tool at present available to detect early breast cancer in asymptomatic women. Its diagnostic ability to clarify the true nature of a palpable tumour in symptomatic breast disease remains controversial. To investigate this, case records of 115 women over 35 years, who presented clinically with a palpable and solid breast tumour over a 5 1/2-year period at Universitas Hospital, Bloemfontein, were retrospectively reviewed. All women were pre-operatively evaluated by clinical examination, mammography and fine-needle aspiration cytology and all patients subsequently underwent open surgical biopsy. Results of this triple diagnostic regimen were correlated to the final histopathological diagnosis. No differences in diagnostic accuracy could be found between mammography and either clinical or cytological diagnosis alone. Combining the clinical finding with that of either mammography or cytology significantly improved the diagnostic ability of both. Malignant disease diagnosed by cytology alone negated the additional diagnostic role of mammography in this context. However, to enable confirmation of a benign tumour, mammography proved to be an essential addition to clinical and cytological evaluation. Mammography correctly detected multicentricity in 7% of malignant tumours, proving it to be essential before breast-conserving surgery could be carried out for malignant tumours.

Temporary loop ileostomy following restorative proctocolectomy

A retrospective study compared the outcome of restorative proctocolectomy in patients who had a covering ileostomy (n = 53) with those who had no proximal stoma (n = 32). Those who had a loop ileostomy had a higher incidence of anastomotic leakage (21 per cent), pelvic abscess (32 per cent) and postoperative fistula (28 per cent) than those with no covering ileostomy (6, 12 and 12 per cent respectively). Intestinal obstruction occurred in 23 per cent of those with an ileostomy, compared with 6 per cent in those who had no stoma. The functional outcome was identical.

Pre-operative evaluation of palpable breast tumours

The diagnostic accuracy of clinical examination, mammography and fine-needle aspiration cytology in identifying malignancy was retrospectively assessed in 207 women with palpable breast masses undergoing breast biopsy for histological examination. Clinical examination was more sensitive (96%) than mammography (81%) or cytology (69%). Cytological examination was totally specific for malignancy. The combined evaluation of clinical examination, mammography and cytological examination revealed a 100% diagnostic accuracy for concordant triplet results. Where discordant triplet results were recorded, 75% of tumours were malignant. Biopsy and frozen section are thus recommended if the 'triplet' provides conflicting results. Preliminary biopsy and frozen section may be unnecessary when the diagnostic triplet unequivocally demonstrates malignancy, or when cytological examination reliably reveals the presence of malignancy. Where the components of the triplet all point to benignity, the patient may be confidently followed up without the necessity of biopsy. The adoption of these guidelines may safely reduce the number of open breast biopsies by about 50-60%.