The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Update on the Recommendations on Breast Cancer Screening by the Cancer Expert Working Group on Cancer Prevention and Screening

Breast cancer (BC) is the most common cancer among women in Hong Kong. The Food and Health Bureau commissioned The University of Hong Kong (HKU) to conduct the Hong Kong Breast Cancer Study (HKBCS) with the aim of identifying relevant risk factors for BC in Hong Kong and developing a locally validated BC risk assessment tool for Hong Kong Chinese women. After consideration of the most recent international and local scientific evidence including findings of the HKBCS, the Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) has reviewed and updated its BC screening recommendations. Existing recommendations were preserved for women at high risk and slightly changed for women at moderate risk. The following major updates have been made concerning recommendations for other women in the general population: Women aged 44 to 69 with certain combinations of personalised risk factors (including presence of history of BC among first-degree relative, a prior diagnosis of benign breast disease, nulliparity and late age of first live birth, early age of menarche, high body mass index and physical inactivity) putting them at increased risk of BC are recommended to consider mammography screening every 2 years. They should discuss with their doctors on the potential benefits and harms before undergoing mammography screening. A risk assessment tool for local women (eg, one developed by HKU) is recommended to be used for estimating the risk of developing BC with regard to the personalised risk factors described above.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Recommendations on prevention and screening for colorectal cancer in Hong Kong

Colorectal cancer is the commonest cancer in Hong Kong. The Cancer Expert Working Group on Cancer Prevention and Screening was established in 2002 under the Cancer Coordinating Committee to review local and international scientific evidence, assess and formulate local recommendations on cancer prevention and screening. At present, the Cancer Expert Working Group recommends that average-risk individuals aged 50 to 75 years and without significant family history consult their doctors to consider screening by: (1) annual or biennial faecal occult blood test, (2) sigmoidoscopy every 5 years, or (3) colonoscopy every 10 years. Increased-risk individuals with significant family history such as those with a first-degree relative diagnosed with colorectal cancer at age ≤60 years; those who have more than one first-degree relative diagnosed with colorectal cancer irrespective of age at diagnosis; or carriers of genetic mutations associated with familial adenomatous polyposis or Lynch syndrome should start colonoscopy screening earlier in life and repeat it at shorter intervals.

Recommendations on prevention and screening for breast cancer in Hong Kong

In Hong Kong, breast cancer is the most common cancer among women and poses a significant health care burden. The Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) was set up in 2002 by the Cancer Coordinating Committee to review and assess local and international scientific evidence, and to formulate recommendations for cancer prevention and screening. After considering the local epidemiology, emerging scientific evidence, and local and overseas screening practices, the CEWG concluded that it was unclear whether population-based breast cancer screening did more harm than good in local asymptomatic women at average risk. The CEWG considers that there is insufficient evidence to recommend for or against population-based mammography screening for such individuals. Women who consider breast cancer screening should be adequately informed about the benefits and harms. The CEWG recommends that all women adopt primary preventive measures, be breast aware, and seek timely medical attention for suspicious symptoms. For women at high risk of breast cancer, such as carriers of confirmed BRCA1/2 deleterious mutations and those with a family history of breast cancer, the CEWG recommends that they seek doctor's advice for annual mammography screening and the age at which the process should commence. Additional annual screening by magnetic resonance imaging is recommended for confirmed BRCA1/2 mutation carriers or women who have undergone radiation therapy to the chest between the age of 10 and 30 years. Women at moderate risk of breast cancer should discuss with doctors the pros and cons of breast cancer screening before making an informed decision about mammography screening every 2 to 3 years.

Randomized clinical trial of chewing gum after laparoscopic colorectal resection

BACKGROUND

Chewing gum may enhance intestinal motility after surgery. This trial studied whether chewing gum could lead to a further reduction in ileus in patients who had a laparoscopic colorectal resection and followed an enhanced recovery programme.

METHODS

Patients undergoing laparoscopic colorectal resection were randomized to a control or intervention group. Patients in the control group received a standardized recovery programme. Patients in the intervention group were, in addition, given chewing gum three times daily from day 1 until discharge. Primary outcome measures were time to first flatus and first bowel motion. Time to feeling hungry and hospital stay were secondary outcome measures.

RESULTS

Forty-one patients were randomized into each group. Thirty-seven patients underwent rectal resection and 45 had a colonic resection. Time to passage of flatus was shorter (18 versus 34 h; P = 0·007), first bowel motion occurred earlier (19 versus 44 h; P = 0·001) and time to feeling hungry was earlier (16 versus 25 h; P = 0·001) in the intervention group. There was no difference in the duration of hospital stay (5 days in the intervention group versus 5·5 days in the control group). Subgroup analyses revealed that the benefits of chewing gum were clearer in patients who had a colonic resection, with a shorter time to first flatus (20 versus 35 h; P = 0·043), first bowel motion (19 versus 53 h; P = 0·014) and feeling hungry (14 versus 40 h; P = 0·001). No adverse events were attributed to chewing gum.

CONCLUSION

Chewing gum is a simple intervention that speeds intestinal transit in patients managed with a recovery programme after laparoscopic colorectal resection.

REGISTRATION NUMBER

NCT02419586 (https://clinicaltrials.gov/).

Randomized trial comparing self gripping semi re-absorbable mesh (PROGRIP) with polypropylene mesh in open inguinal hernioplasty: the 6 years result

OBJECTIVES

The use of absorbable polylactic acid hook self-gripping polypropylene mesh in open inguinal hernia may potentially reduce operative time and enhance patient recovery. The objective of this randomized trial is to compare the outcomes following self-gripping mesh repair to polypropylene mesh secured with sutures in open inguinal hernioplasty.

METHOD

Eligible patients aged 18-80 years old, who had primary unilateral uncomplicated inguinal hernia, were randomized into either Polypropylene (PL) group or PROGRIP (PG) group just before the placement of mesh intra-operatively by computer generated code. The primary outcome was the time from mesh placement to end of operation, whereas secondary outcomes included the total operative time, amount of analgesic used, length of post-operative stay, seroma formation, chronic discomfort, chronic pain score and recurrence. The study has been registered in http://www.clinicaltrial.gov carrying an ID of NCT00960011. Patients were followed-up in outpatient clinic for up to 6 years after operation.

RESULTS

From March 2009 to April 2016, 45 patients were included. The mean age of PG group (n = 22) was 62.0 ± 15.7 years old while that of the PL group was 62.6 ± 4.9 years old (n = 23). There was no significant difference regarding the smoking habit, drinking habit, comorbidities, previous hernia operation and Nyhus type of hernia between the two groups. The size of defects, the time of groin dissection and the size of incision were similar. In the PG group, there was significant reduction in the time for mesh placement (11.8 ± 3.1 vs. 21.0 ± 6.2 min, p < 0.001) and total operative time (39.2 ± 9.8 vs. 47.7 ± 8.0 min, p = 0.003). There was one recurrence in PL group and nil in PG group. Although there was a significant difference in paresthesia between 2 groups after operation, the difference disappears with time and comparable from post-operative 1 year onwards. There was no difference in chronic pain, chronic discomfort, affect daily activities, palpable mesh demonstrated throughout the whole study period till 6 years after operation.

CONCLUSIONS

The use of polylactic acid self-gripping mesh in open inguinal hernia repair effectively reduces the operating time with comparable long-term surgical outcome with traditional polypropylene mesh.

Distributions of colorectal cancer in two Chinese cities with contrasting colorectal cancer epidemiology

BACKGROUND AND AIM

The incidence of colorectal cancer (CRC) is rising rapidly in Chinese. We studied the anatomic distributions and characteristics of CRC in Hong Kong (HK) and Chongqing (CQ) with different CRC epidemiology.

METHODS

It was a retrospective study conducted in three large regional hospitals of the two cities. We identified all patients newly diagnosed with CRC between 2003 and 2012. The distribution and characteristics of CRC of the two cities were compared.

RESULTS

Of CRC, 3664 new cases were diagnosed within the study period. CRC was more common in men (>56%) in both cities. The mean age at diagnosis was significantly younger in CQ, the lower prevalence area, than in HK (62.1 vs 70.4 years; P < 0.001). Rectal cancer was the predominant (61.3%) cancer in CQ, but only 18% of cancers in HK were rectal cancer (P = 0.0001). Right-sided colonic cancer, however, was more common in HK than CQ (27.2% vs 17.4%; P < 0.001). Women had more right-sided colonic cancer than men in both cities (P < 0.002), and there was an age-related increase in right-sided colonic cancer in HK but not in CQ. Multivariate analysis showed that older age, female, and living in HK were independent risk factors associated with right-sided colonic cancer.

CONCLUSIONS

There are significant differences in the distribution of CRC between HK and CQ. The discrepancy may be partly accounted by older population and an increase in proximal colonic cancer, particularly in women, in HK.

Pulmonary artery sarcoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration

Pulmonary artery sarcoma is a rare disease with poor prognosis that has not been reported in Hong Kong. Its clinical and radiological presentation frequently mimics pulmonary embolism. Diagnosis is usually delayed until surgery, which is the treatment option that provides the best survival. Endobronchial ultrasound-guided transbronchial needle aspiration is an effective non-surgical technique for lymph node staging of lung cancer and diagnosis of mediastinal lesions via bronchoscopy. Here we discuss a case of pulmonary artery sarcoma diagnosed by this method, the second one in the literature, which serves to illustrate its potential use for early and minimally invasive diagnosis of the condition. Although such aspiration is a safe procedure, tissue sampling of extravascular extensions is advisable wherever possible.

Long-term outcome of stenting as a bridge to surgery for acute left-sided malignant colonic obstruction

AIM

This study aimed to evaluate both the short- and long-term outcomes associated with colonic stenting as a bridge to surgery in patients with obstructing adenocarcinoma of the colon.

METHOD

Patients with potentially curable acute left-sided colonic obstruction treated with stenting as a bridge to surgery (n = 28) or with emergency surgical resection (n = 39) from January 1998 to December 2008 were identified from a prospectively maintained database. Short-term data on postoperative mortality, morbidity, necessity of intensive care and length of hospital stay were compared. Overall survival and disease-free survival were also analysed.

RESULTS

Patients in the two study arms had similar demographic profiles. Those receiving preoperative stenting had a higher likelihood of a laparoscopic resection (P < 0.001). The emergency surgery group had a higher rate of postoperative complications (P = 0.024), rate of intensive care unit admission (P = 0.013) and longer total length of hospital stay (9 vs 12 days, P = 0.001). With a median follow-up of 26.5 and 31.3 months for the stenting and surgical resection groups, there was no difference in overall and disease-free survival (overall survival 30 vs 31 months, P = 0.858; disease-free survival 13 vs 12 months, P = 0.989). There was no difference in the rate of systemic recurrence (8 vs 13, P = 0.991).

CONCLUSION

Stenting as a bridge to surgery is a safe strategy for acute left-sided colonic obstruction with improved short-term outcome and comparable long-term oncological results.

The effects of intra-operative dexmedetomidine on postoperative pain, side-effects and recovery in colorectal surgery

In this double-blind, randomised study, 100 patients undergoing open or conventional laparoscopic colorectal surgery received an intra-operative loading dose of dexmedetomidine 1 μg.kg(-1) followed by an infusion of 0.5 μg.kg(-1) .h(-1) , or a bolus and infusion of saline 0.9% of equivalent volume. Forty-six patients in the dexmedetomidine group and 50 in the saline group completed the study. The area under the curve of numerical rating scores for pain at rest for 1-48 h postoperatively was significantly lower in the patients receiving dexmedetomidine (p = 0.041). There was no difference in morphine consumption, duration of recovery ward or hospital stay. From the data obtained in this study, we calculated a number needed to treat for effective pain relief of 4. Intra-operative dexmedetomidine in colorectal surgery resulted in a reduction in resting pain scores, but there was no morphine-sparing effect or improvement in patients' recovery outcome measures.

Detection of colorectal adenoma by narrow band imaging (HQ190) vs. high-definition white light colonoscopy: a randomized controlled trial

OBJECTIVES

The benefits of narrow band imaging (NBI) on enhancing colorectal adenoma detection remain questionable. We tested whether the new generation of NBI (190-NBI), which is twice as bright as the previous version, would improve adenoma detection when compared with high-definition white light (HD-WL) colonoscopy.

METHODS

It was a randomized controlled trial with tandem colonoscopy. We recruited patients who underwent colonoscopy for symptoms, screening, or surveillance. Patients were randomized for the use of either 190-NBI or HD-WL on withdrawal. Tandem colonoscopy was performed by using the same assigned colonoscope and withdrawal method. Lesions detected on first-pass and second-pass examination were used for adenoma detection and miss rates, respectively. The primary outcomes were adenoma and polyp detection rates.

RESULTS

A total of 360 patients were randomized to undergo either 190-NBI or HD-WL colonoscopy. Both the adenoma and polyp detection rates were significantly higher in the 190-NBI group compared with the HD-WL group (adenoma: 48.3% vs. 34.4%, P=0.01; polyps: 61.1% vs. 48.3%, P=0.02). The mean number of polyps detected per patient was higher in the 190-NBI group (1.49% vs. 1.13, P=0.07). There was no significant difference in the adenoma miss rates between the two groups (21.8% vs. 21.2%). Multivariate analysis showed that the use of 190-NBI (odds ratio (OR) 1.85; 95% confidence interval (CI) 1.10-3.12), withdrawal time (OR 1.29; CI 1.19-1.38), patient's age (OR 1.04; CI 1.01-1.06), and male gender (OR 2.38; CI 1.42-3.99) were associated with adenoma detection.

CONCLUSIONS

190-NBI colonoscopy was superior to the conventional HD-WL in detecting colorectal adenomas or polyps, but there was no significant difference in adenoma miss rates.

Tailored rectal cancer treatment--a time for implementing contemporary prognostic factors?

AIM

To report data supporting the development of tailored treatment strategies for rectal cancer.

METHOD

A comprehensive review of the literature on the impact of prognostic factors cur-rently not included in international guidelines in rectal cancer management.

RESULTS

There is considerable variation in treatment guidelines for rectal cancer worldwide, especially for Stage II and Stage III disease. Long-term side effects of chemoradiotherapy are not considered in any guideline. Detailed knowledge, and the prognostic impact, of the circumferential resection margin, tumour grade and venous invasion should be factored into the development of a treatment strategy.

CONCLUSION

Factors additional to the TNM system should improve decision making for contemporary rectal cancer treatment. Optimized radiological and pathological evaluations, and a focus on detailed clinical factors, should be the basis for treatment decisions. International guidelines should consider all known prognostic factors for long-term oncological and functional outcomes.

Circulating microRNAs as specific biomarkers for breast cancer detection

BACKGROUND

We previously showed microRNAs (miRNAs) in plasma are potential biomarkers for colorectal cancer detection. Here, we aimed to develop specific blood-based miRNA assay for breast cancer detection.

METHODOLOGY/PRINCIPAL FINDINGS

TaqMan-based miRNA profiling was performed in tumor, adjacent non-tumor, corresponding plasma from breast cancer patients, and plasma from matched healthy controls. All putative markers identified were verified in a training set of breast cancer patients. Selected markers were validated in a case-control cohort of 170 breast cancer patients, 100 controls, and 95 other types of cancers and then blindly validated in an independent set of 70 breast cancer patients and 50 healthy controls. Profiling results showed 8 miRNAs were concordantly up-regulated and 1 miRNA was concordantly down-regulated in both plasma and tumor tissue of breast cancer patients. Of the 8 up-regulated miRNAs, only 3 were significantly elevated (p<0.0001) before surgery and reduced after surgery in the training set. Results from the validation cohort showed that a combination of miR-145 and miR-451 was the best biomarker (p<0.0001) in discriminating breast cancer from healthy controls and all other types of cancers. In the blind validation, these plasma markers yielded Receiver Operating Characteristic (ROC) curve area of 0.931. The positive predictive value was 88% and the negative predictive value was 92%. Altered levels of these miRNAs in plasma have been detected not only in advanced stages but also early stages of tumors. The positive predictive value for ductal carcinoma in situ (DCIS) cases was 96%.

CONCLUSIONS

These results suggested that these circulating miRNAs could be a potential specific biomarker for breast cancer screening.

Laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic surgery for colorectal cancer has undergone tremendous advancement in the last two decades, with maturation of techniques and integration into current practice.

SOURCES OF DATA

Worldwide English-language literature on laparoscopic surgery for the management of colon and rectal cancer was reviewed.

AREAS OF AGREEMENT

A large body of evidence has attested to the improved short-term outcomes and long-term oncological safety of laparoscopic surgery for colon cancer. Laparoscopic colectomy can be recommended to suitable patients where expertise is available. Laparoscopic resection for rectal cancer is feasible, with good evidence of faster post-operative recovery and adequate surgical quality, but requires more data on long-term oncological outcomes. This review examines the evidence and current practice of laparoscopic surgery for colorectal cancer.

AREAS OF CONTROVERSY

Does laparoscopic surgery confer a survival advantage for colorectal cancer patients?

GROWING POINTS

The role of single-incision laparoscopic surgery and robotic surgery in colorectal cancer.

AREAS TIMELY FOR DEVELOPING RESEARCH

Barriers to the adoption of the laparoscopic technique.

Prognostic value of lymph node ratio in stage III colorectal cancer

AIM

Recent reports show that a positive metastatic to examined lymph nodes ratio (LNR) has prognostic value in malignancies. This study aimed to evaluate the prognostic value of LNR in patients having resection for stage III colorectal cancer.

METHOD

From January 2000 to December 2006, patients who underwent resection for stage III colorectal carcinoma were included. All clinicopathological and follow-up data were prospectively collected. The impact of LNR and other clinicopathological factors on survival were evaluated.

RESULTS

The study included 533 (52.3% male) patients with a median age of 70 years. The median number of lymph nodes harvested and the median number of positive lymph nodes examined were 11 and 2, respectively. The median LNR was 0.263 (range, 0.03-1). After a median follow up of 52.65 months, the 5-year overall survival and disease-free survival were 55.9% and 49.4%. The patients were stratified into four groups according to LNR quartiles (1, LNR ≤ 0.125; 2, 0.125<LNR≤0.263; 3, 0.263<LNR≤0.500; 4, LNR>0.500). The 5-year overall and disease-free survival were 72.8%, 63.1%, 50.0%, 39.6% (P<0.001) and 68.5%, 54.1%, 47.2%, 29.9% (P<0.001), respectively, with increasing LNR groups. On multivariate analysis, age, T stage and LNR were independent predictors of both overall and disease-free survival. Subgroup analysis revealed that the LNR had a prognostic value for disease-free survival irrespective of number of lymph nodes harvested and location of tumour.

CONCLUSION

The LNR is an independent prognostic factor for survival in colorectal cancer and is superior to the pN category in TNM staging.

Self-expanding metallic stents for acute left-sided large-bowel obstruction: a review of 130 patients

AIM

The aim of this study was to evaluate the outcomes of self-expanding metallic stent (SEMS) placement in acute left-sided large-bowel obstruction.

METHOD

From 1997 to 2008, 130 patients [mean 67 (SD 14.7)] underwent SEMS insertion for acute left-sided large-bowel obstruction. One-hundred and one procedures were palliative, and 29 patients underwent stent insertion as a bridge for surgery. The success rate and the outcome were analysed.

RESULTS

The chief causes of obstruction were primary (67%) and recurrent (16%) colorectal carcinoma. The success rate was 88% after insertion of the first stent. In nine patients, insertion of a second stent was required. Complications occurred in 20% of the insertions, with migration (10.8%) being the most common. Perforation occurred in two patients and one developed a colovesical fistula. In patients with palliative stenting, 14 (13.9%) required subsequent surgery, with a stoma placed in all except three. Among the 29 patients who underwent SEMS insertion as a bridge to surgery, subsequent surgical resection was performed in 26 patients at a mean interval of 12 days (SD 18.0). Primary anastomosis was performed in 24 patients. The mean survival for those who underwent SEMS insertion as a bridge to surgery was 40 (95% confidence interval: 24-55) months.

CONCLUSION

SEMS placement is safe and effective in relieving acute left-sided colonic obstruction. It allows subsequent definitive surgery on an elective setting and also serves as good palliation for advanced or disseminated disease.

Abstract 3027: Plasma microRNA as a potential marker for breast cancer detection

Background: Recently, the emergence of small non-protein-coding RNAs, so-called microRNAs (miRNAs), playing important roles in oncogenesis has opened new opportunities for early cancer diagnosis. We have previously shown that microRNAs (miRNAs) in plasma are promising biomarkers for colorectal cancer detection. Here, we investigated whether plasma miRNAs could discriminate patients with and without breast cancer (BC).

Methods: Using TaqMan-based low density miRNA array, miRNAs were profiled from cancerous and adjacent non-cancerous breast tissues, corresponding plasma of 5 BC patients, along with plasma from 5 healthy controls. Marker selection and validation were performed by real-time quantitative RT-PCR on a small set of plasma. Independent set of plasma from 80 BC patients, 20 gastric cancer, 20 lung cancer, 20 colorectal cancer, 20 hepatocellular carcinoma and 50 healthy controls were further validated.

Results: Of the panel of 377 miRNAs analyzed, 8 miRNAs (miR-16, miR-21, miR-27a, miR-141, miR-191, miR-200c, miR-210, miR-451) were up-regulated both in plasma and tissue samples of 5 BC patients. All 8 putative miRNA markers were validated on the plasma of 15 BC patients and 15 healthy controls. Only three miRNAs were significantly elevated in this cohort of BC patients (p&lt;0.0005). The plasma levels of the three markers in those 15 BC patients were significantly reduced after surgery (p&lt;0.05). Further validation with an independent set of plasma samples (n=210) indicated that two markers differentiate BC from normal subjects, colorectal cancer, gastric cancer, hepatocellular carcinoma and lung cancer. These two markers yielded a combined receiver operating characteristic curve area of 88.5%, the sensitivity was 92% and the specificity was 72% in discriminating BC from control subjects.

Conclusions: Plasma miRNAs significantly elevated in BC patients are identified. This can be a novel noninvasive molecular marker for BC screening.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3027.

PPI-delayed diagnosis of gastrinoma: oncologic victim of pharmacologic success

Functional neuroendocrine tumors are often low-grade malignant neoplasms that can be cured by surgery if detected early, and such detection may in turn be accelerated by the recognition of neuropeptide hypersecretion syndromes. Uniquely, however, relief of peptic symptoms induced by hypergastrinemia is now available from acid-suppressive drugs such as proton-pump inhibitors (PPIs). Here we describe a clinical case in which time to diagnosis from the onset of peptic symptoms was delayed more than 10 years, in part reflecting symptom masking by continuous prescription of the PPI omeprazole. We propose diagnostic criteria for this under-recognized new clinical syndrome, and recommend that physicians routinely measure serum gastrin levels in persistent cases of PPI-dependent dyspepsia unassociated with H. pylori.

Pleuroscopy: our initial experience in Hong Kong

OBJECTIVE

To report our preliminary experience using pleuroscopy for patients with pleural diseases.

DESIGN

Prospective cohort study.

SETTING

Tertiary referral hospital with service input from respiratory physicians and cardiothoracic surgeons in Hong Kong.

PATIENTS

Between April and November 2007, patients with undiagnosed exudative pleural effusions and proven malignant pleural effusions were recruited for diagnostic evaluations and therapeutic interventions, respectively.

INTERVENTION

Pleuroscopy with a semi-rigid thoracoscope performed under local anaesthesia and conscious sedation.

RESULTS

A total of 20 patients (16 males and 4 females; mean age, 63 years) underwent the procedure and were followed up for a mean of 19 weeks. For the 14 patients having diagnostic pleuroscopy, the yield was 79% (11 patients). The 3-month success rate for the six patients undergoing pleurodesis was 83% (five patients). Complications were mild and included self-limiting fever (20%, four patients) and localised subcutaneous emphysema (20%, four patients). No major complications or mortality were noted.

CONCLUSION

Pleuroscopy using a semi-rigid instrument is a safe and efficacious procedure for the management of pleural diseases in suitable patients.

Bronchial artery embolisation can be equally safe and effective in the management of chronic recurrent haemoptysis

OBJECTIVE

To examine the efficacy and safety of bronchial artery embolisation in patients with acute major haemoptysis and those with chronic recurrent haemoptysis.

DESIGN

Retrospective review of clinical records.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Clinical records of 70 consecutive patients who had undergone bronchial artery embolisation in Queen Elizabeth Hospital from 1998 to 2003 were reviewed. Altogether 74 bronchial artery embolisation procedures were attempted, 46 (62%) for acute major haemoptysis, and 28 (38%) for chronic recurrent bleeding. Follow-up data were available for 32 patients.

MAIN OUTCOME MEASURES

After bronchial artery embolisation, the Kaplan-Meier method and log-rank tests were used to compare the probability of recurrence in the two patient categories.

RESULTS

Overall immediate control was attained following 99% of the procedures, with a complication rate of 13%; all complications were mild and self-limiting. For the 32 patients (19 having acute major haemoptysis and 13 having chronic recurrent bleeding) with follow-up data available, the overall recurrence rate was 36% (26% in the acute and 47% in chronic group). No statistically significant difference in recurrence probability between the two groups was observed (P=0.24). Presence of active pulmonary tuberculosis was associated with increased risk of recurrence (P=0.005).

CONCLUSION

Bronchial artery embolisation was noted to be effective and safe in both acute major and chronic recurrent haemoptysis.

Atypical antipsychotic therapy for treatment of schizophrenia in Hong Kong Chinese patients - a cost analysis

OBJECTIVE

To evaluate the direct medical cost of atypical antipsychotic therapy for schizophrenia among Hong Kong Chinese patients and to identify factors affecting the cost of treatment.

METHODS

In this retrospective database analysis, patient data were retrieved from three Hong Kong public hospitals. Patients aged 2 18 years who received an initial prescription for olanzapine, risperidone, quetiapine or amisulpride between April 1 and September 30, 2003; and had an ICD-10-coded diagnosis of schizophrenia were included. Patient data were collected for a maximum duration of 1 year before and after treatment initiation. Primary outcome measures were the schizophrenia-related direct medical costs. Demographic and clinical factors were analyzed by multiple regression analysis to identify influential factors for the cost of atypical antipsychotic therapy.

RESULTS

A total of 325 patient records were reviewed and 82 patients were included in the analysis. Cost per patient per month for clinic visits (US$ 67 +/- 41 versus US$ 78 +/- 41), medications (US$ 8 +/- 12 versus US$ 97 +/- 83), and the total cost per patient per month (US$ 314 +/- 898 versus US$ 431 +/- 914) increased significantly after treatment initiation (US$ 1 = HK$ 7.8). Previous duration of hospitalization (RR = 1.00, 95% CI = 1.00 1.01), history of substance abuse (RR = 1.26, 95% CI = 1.05 1.52) and use of depot antipsychotics (RR = 1.22, 95% CI = 1.05 - 1.42) were associated with higher cost of atypical antipsychotic therapy.

CONCLUSION

The total direct medical cost increased significantly after initiation of atypical antipsychotic therapy in a cohort of Chinese patients with schizophrenia. History of drug abuse, use of depot antipsychotics and prior duration of hospitalization were positive predictors of cost of therapy.

Evaluation of outcome of laparoscopic colorectal resection with POSSUM, Portsmouth POSSUM and colorectal POSSUM

BACKGROUND

This study evaluated the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM), Portsmouth (P) POSSUM and colorectal (CR) POSSUM in laparoscopic colorectal resection.

METHODS

Observed mortality and morbidity rates in 400 patients who underwent laparoscopic colorectal resection were compared with those predicted by POSSUM, P-POSSUM and CR-POSSUM.

RESULTS

Observed mortality and morbidity rates were 0.5 and 19.0 per cent respectively. Mortality rates predicted by POSSUM, P-POSSUM and CR-POSSUM were 10.8, 4.0 and 5.6 per cent respectively, and the morbidity rate predicted by POSSUM was 43.0 per cent. The predicted and observed mortality and morbidity rates showed significant lack of fit. The conversion rate to open surgery was 11.5 per cent. The mortality rate for patients having conversion was 2 per cent and was not significantly different to that predicted by P-POSSUM (4 per cent; P = 0.493) or CR-POSSUM (5 per cent; P = 0.370). In this group, the observed and POSSUM-predicted morbidity rates were also similar (43 versus 48 per cent respectively; P = 0.104).

CONCLUSION

POSSUM, P-POSSUM and CR-POSSUM overestimated mortality and morbidity in patients who underwent laparoscopic colorectal resection. However, the mortality rate in patients who required conversion fitted the models of P-POSSUM and CR-POSSUM, and the morbidity rate was comparable to that predicted by POSSUM.

Benign metastasising leiomyoma: a rare but possible cause of bilateral pulmonary nodules in Chinese patients

We report three cases of benign metastasising leiomyoma, which is a rare cause of multiple lung nodules, in three Hong Kong Chinese females. One patient presented with pleuritic chest pain, another was asymptomatic, while the last presented with haemoptysis. All three patients had previously undergone surgical resection of uterine leiomyomas. Multiple lung nodules mimicking lung metastases were demonstrated on chest radiographs, and all three diagnoses were obtained from lung biopsies. Hormonal therapy was given to two patients with variable responses. To the best of our knowledge, this is the first report of benign metastasising leiomyoma in Hong Kong Chinese population. It highlights the importance of considering this rare and benign disease in premenopausal females presenting with multiple lung nodules.

Laparoscopic colorectal resection for polyps not suitable for colonoscopic removal

BACKGROUND

Endoscopic removal of large sessile polyps is sometimes technically difficult and is associated with an increased risk of complications. Moreover, the incidence of invasive carcinoma within these polyps is not negligible. Laparoscopic colorectal resection has been recommended in the treatment of these large polyps. This study aimed to evaluate the outcomes of laparoscopic colorectal resection for polyps that were not suitable for colonoscopic removal.

METHODS

Forty-five patients (28 men and 17 women) who underwent laparoscopic colorectal resection with the preoperative diagnosis of colorectal polyps were analyzed. The reasons for surgical resection were large sessile polyps (n = 34), difficult position (n = 2), recurrence after transanal endoscopic microsurgery (n = 1), and the presence of intramucosal malignancy on histology after colonoscopic polypectomy (n = 8).

RESULTS

The mean age of the patients was 66.7 years (range, 33-89). Previous abdominal operation had been performed in 12 patients (26.7%). Two patients underwent subtotal colectomy because of multiple polyps (14 and 19, respectively). Synchronous resection of other organs was performed in two patients (a right salpingo-oophorectomy and a right adrenalectomy). Intraoperative complications occurred in two patients, and two patients (4.5%) required conversion because of perforation of the colon during dissection and dense adhesions, respectively. There was no postoperative mortality. Complications occurred in seven patients (15.6%), and they included postoperative ileus (n = 4), anastomotic leakage (n = 1), urinary retention (n = 1), and urinary tract infection (n = 1). Reoperation was required in one patient for anastomotic leakage. The median hospital stay was 6 days. The histopathology of colorectal polyps showed tubular (n = 12), tubulovillous (n = 13), and villous adenoma (n = 12); mixed adenomatous/hyperolastic polyps (n = 2); inflammatory polyp (n = 1); and colonic lipoma (n = 1). Four patients, who had previous polypectoray with intramucosal malignancy, had no residual pathology. The median size was 3.0 cm. Invasive carcinoma was found in 16 patients (35.6%). The median number of lymph node sampling was six, and two patients had lymph node metastases.

CONCLUSIONS

Colonic polyps that were not amendable for colonoscopic removal were associated with a high incidence of malignant invasion. Laparoscopic colectomy offers safe and effective management of these polyps with the benefits of early postoperative recovery.

Previous abdominal operations do not affect the outcomes of laparoscopic colorectal surgery

BACKGROUND

Previous abdominal surgery has been regarded as a relative contraindication for laparoscopic surgery. However, studies on laparoscopic cholecystectomy have showed that the presence of prior abdominal procedures does not affect the outcomes of surgery. This study aimed to investigate the impact of previous abdominal surgery on laparoscopic colorectal surgery.

METHODS

This study enrolled 295 consecutive patients who underwent laparoscopic colorectal surgery from May 2000 to May 2003. The patients were divided into two groups: those with previous abdominal surgery (n = 84) and those without a prior operation (n = 211). The outcomes of surgery for the two groups were compared with respect to the duration of surgery, blood loss, conversion rate, time to return of bowel function, resumption of diet, complications, and the hospital stay.

RESULTS

The study included 158 men and 137 women. The median age of the patients was 70 years (range, 33-91 years). Significantly more female patients and patients with benign diseases had prior abdominal surgery. Conversion was required for 17.8% of the patients with and 11.4% of the patients without previous surgery (p = 0.181). There were no differences in the operating time or blood loss between the two groups. The time to bowel movement and resumption of diet were similar in the two groups. The median hospital stay was 7 days for both groups. Of the 39 conversions, 28.2% were necessitated mainly by the presence of adhesions. In the patients who underwent conversion because of adhesions (n = 11), nine had prior surgery and two did not (p = 0.001).

CONCLUSIONS

The presence of prior surgery does not affect the operating time or blood loss of patients undergoing laparoscopic colorectal surgery. The conversion rate is not increased for patients with prior surgery. The postoperative outcomes in terms of ileus, complication rate, and hospital stay are not worse for patients with prior surgery. Previous abdominal surgery should not be considered as a contraindication for laparoscopic colorectal surgery.

Abdominoperineal resection is associated with poor oncological outcome

BACKGROUND

The aim of this study was to compare the operative results and oncological outcomes of patients who had mid or distal rectal cancer treated by abdominoperineal resection (APR) with those treated without sphincter ablation (non-APR).

METHODS

Five hundred and four consecutive patients (308 men and 196 women) with rectal cancer within 12 cm from the anal verge underwent radical resection with curative intent. Sharp mesorectal dissection was used. Operative results and long-term outcomes were compared between those treated by APR and those by non-APR.

RESULTS

Sixty-nine patients had APR and 435 patients were treated with radical resection without perineal resection (anterior resection, 419; Hartmann's operation, 16). The overall operative mortality and morbidity rates were 1.6 and 31.0 per cent respectively. Age, sex, duration of surgery, blood loss, duration of hospital stay, operative mortality and overall morbidity were similar in the two groups. Local recurrence was more frequent after curative APR than after non-APR (23 versus 10.2 per cent at 5 years; P = 0.010). Five-year cancer-specific survival rates after APR and non-APR were 60 and 74.0 per cent respectively (P = 0.006). APR was an independent factor for poor cancer-specific survival in multivariate analysis.

CONCLUSION

Although postoperative mortality and morbidity rates were similar in patients with or without sphincter ablation, local control and survival were worse in those treated by APR.

Early outcomes of 100 patients with laparoscopic resection for rectal neoplasm

BACKGROUND

Laparoscopic resection has been shown to be a feasible option in patients with colorectal diseases. However, there have been only a few studies on laparoscopic resection for rectal neoplasm. This report aimed to evaluate the early outcomes of patients treated by laparoscopic rectal resection for neoplasm.

METHODS

From May 2000 to April 2003, 100 patients underwent laparoscopic resection for rectal neoplasm with mesorectal excision. Data on the patients' demographics, operative details, and outcomes were collected prospectively. In those with successful laparoscopic resection, comparison was made between patients with predominantly intracorporeal surgery (ICS) and those with anterior resection performed with extracorporeal rectal transection and anastomosis following intracorporeal bowel mobilization and vessel ligation (IECS).

RESULTS

Sixty-six men and 34 women (median age, 69 years; range, 40-85) were included. Operations included 91 anterior resections, eight abdominoperineal resections, and one Hartmann's procedure. Conversion was required in 15 patients and no conversion was needed in patients treated by laparoscopic abdominoperineal resection. One patient died 30 days after surgery because of liver failure. Postoperative complications occurred in 31 patients. Among them, three had anastomotic leakage and all of them could be treated conservatively. Reoperation was required in one patient with intestinal obstruction. Patients with conversion were found to have significantly more blood loss, longer time to resume diet, a longer hospital stay, and a higher morbidity rate when compared to those with successful laparoscopic surgery. Among those with successful laparoscopic procedures, no difference was observed between patients with ICS (n = 57) and those with IECS (n = 28), except that a shorter incision and less blood loss were found in patients in the former group.

CONCLUSIONS

Laparoscopic rectal resection with mesorectal dissection is feasible. The operating mortality and reoperation rates were low. Conversion was associated with an increased morbidity rate, leading to a longer hospital stay. Laparoscopically assisted anterior resection with rectal transection by a transverse stapler through the abdominal incision produced similar results when compared to a procedure that was predominantly intracorporeally performed.

Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.

Comparison of stenting with emergency surgery as palliative treatment for obstructing primary left-sided colorectal cancer

BACKGROUND

Self-expanding metallic stents provide an alternative to surgery as definitive palliation in patients with obstructing colorectal cancer. This study aimed to compare the outcome of patients with obstruction due to primary left-sided colorectal cancer treated by palliative stenting with outcome in patients who had undergone surgery.

METHODS

Patients with incurable obstructing primary colorectal cancer distal to the splenic flexure treated with emergency surgery (n = 31) or placement of a metallic stent (n = 30) from November 1997 to June 2002 were included. Data on the mortality, morbidity, necessity of intensive care and hospital stay for the two groups were compared. The subsequent outcomes, including the incidence of stoma creation and survival, were also analysed.

RESULTS

The two groups were similar in terms of age, sex distribution and presence of co-morbidity. Insertion of metallic stents was successful in 29 of 30 patients. Hospital death occurred in four and eight patients in the study and control groups respectively (P = 0.335). Fewer patients with placement of a stent required intensive care (1 versus 11; P = 0.001) and the median hospital stay was shorter in patients with stenting (4 versus 8 days; P = 0.008). A stoma was subsequently created in four patients with stenting, whereas 15 patients who had emergency operation required a stoma (P = 0.005). The difference in median survival between the two groups was not statistically significant (107 versus 119 days; P = 0.088).

CONCLUSION

Self-expanding metallic stents are effective in the palliation of obstructing colorectal cancer. Placement of stents is associated with a shorter hospital stay, less likelihood of intensive care and a lower incidence of stoma creation, when compared with emergency surgery. Thus insertion of a metallic stent should be considered in patients with incurable obstructing colorectal cancer.

A sensitive guaiac faecal occult blood test is less useful than an immunochemical test for colorectal cancer screening in a Chinese population

BACKGROUND

Colorectal cancer screening by guaiac faecal occult blood test has been shown to reduce the incidence and mortality of colorectal cancer in Western populations. The optimal faecal occult blood test, whether guaiac or immunochemical, for colorectal cancer screening in the Chinese population remains to be defined.

AIM

To compare the performance characteristics of a sensitive guaiac-based faecal occult blood test (Hemoccult SENSA) and an immunochemical faecal occult blood test (FlexSure OBT) in a Chinese population referred for colonoscopy.

METHODS

One hundred and thirty-five consecutive patients who were referred for colonoscopy and who met the study inclusion criteria took samples for the two faecal occult blood tests simultaneously from three successive stool specimens, with no dietary restrictions. All tests were developed and interpreted by a single experienced technician who was blind to the clinical diagnosis. The sensitivity, specificity and positive predictive value for the detection of colorectal adenomas and cancers were estimated for the two tests.

RESULTS

The sensitivity, specificity and positive predictive value for the detection of significant colorectal neoplasia (adenomas > or = 1.0 cm and cancers) were 91%, 70% and 18% for Hemoccult SENSA and 82%, 94% and 47% for FlexSure OBT. The specificity and positive predictive value were significantly higher for FlexSure OBT than for Hemoccult SENSA (P < 0.001 and P = 0.016, respectively). Combining the positive results from both faecal occult blood tests did not improve the accuracy.

CONCLUSION

The positive predictive value of the immunochemical faecal occult blood test for the detection of significant colorectal neoplasia was 29% better than that of the sensitive guaiac-based test. This may relate to the Chinese diet and requires further study. The poor specificity of the sensitive guaiac-based test, without dietary restriction, makes it less useful for colorectal cancer screening in a Chinese population.

Radiofrequency ablation as a salvage procedure for ruptured hepatocellular carcinoma

Spontaneous rupture of hepatocellular carcinoma is a distinct presentation causing acute abdomen. Different treatment approaches have been advocated including emergency hepatectomy, initial hemostasis by hepatic artery ligation or transarterial embolization and second-stage hepatectomy. Unrecognized ruptured hepatocellular carcinoma during laparotomy is often encountered in countries where the incidence of hepatocellular carcinoma is low. Radiofrequency ablation is a new localized thermal ablative technique for the treatment of unresectable hepatic tumors including hepatocellular carcinoma. We report a case where radiofrequency ablation was used as a salvage procedure for ruptured hepatocellular carcinoma during emergency laparotomy.

Short term outcome and risk factors for adverse clinical outcomes in adults with severe acute respiratory syndrome (SARS)

BACKGROUND

Severe acute respiratory syndrome (SARS) was diagnosed in Hong Kong in over 1700 patients between March and early June 2003.

METHODS

115 patients diagnosed with SARS were admitted to Queen Elizabeth Hospital, a large regional hospital in Hong Kong, from March 2003, of whom 100 were either discharged or were dead at 31 May. The patients were prospectively studied after admission to assess their short term outcomes and the risk factors associated with adverse outcomes, defined as death or the need for mechanical ventilation

RESULTS

At the time of writing 18 patients had died, with a crude mortality rate of 15.7% and a 21 day mortality of 10% (standard error 3%). Thirty nine patients (34%) were admitted to the intensive care unit, 30 of whom (26%) required mechanical ventilation. Multivariate analysis showed that age above 60 (hazards ratio (HR) 3.5, 95% CI 1.2 to 10.2; p=0.02), presence of diabetes mellitus or heart disease (HR 9.1, 95% CI 2.8 to 29.1; p<0.001), and the presence of other comorbid conditions (HR 5.2, 95% CI 1.4 to 19.7; p=0.01) were independently associated with mortality. However, only the presence of diabetes mellitus and/or cardiac disease (HR 7.3, 95% CI 3.1 to 17.4; p<0.001) was associated with adverse outcomes as a whole.

CONCLUSION

SARS is a new disease entity that carries significant morbidity and mortality. Specific clinical and laboratory parameters predicting unfavourable outcomes have been identified.

The value of flexible sigmoidoscopy for patients with bright red rectal bleeding

OBJECTIVE

To review the diagnostic yield of flexible sigmoidoscopy in patients presenting with bright red rectal bleeding.

DESIGN

Retrospective study.

SETTING

University teaching hospital, Hong Kong.

SUBJECTS AND METHODS

Patients who underwent flexible sigmoidoscopy between January 1995 and April 1996 for investigation of bright red rectal bleeding were recruited. The extent of the endoscopic examination, complications, and endoscopic findings were recorded.

RESULTS

A total of 1052 patients were included in the study. The mean length of endoscopic examination was 55 cm. There were no complications attributed to the procedure. Thirteen (1.2%) patients aged from 41 to 87 years were found to have malignant tumours that were not palpable on digital examination. All the tumours were moderately differentiated adenocarcinoma. Two patients had synchronous liver metastasis at presentation. Adenomatous polyps were detected in 81 (7.7%) patients, of whom 76 were older than 40 years. The majority of polyps were tubular adenomas associated with mild or moderate dysplasia. Other endoscopic findings included hyperplastic and juvenile polyps, proctocolitis, diverticulosis, irradiation colitis, ischaemic colitis, rectal ulcers, and infective colitis. The overall diagnostic yield was 21.1%. No mucosal lesion was detected by flexible sigmoidoscopy in 78.9% of patients in whom the rectal bleeding was due to either haemorrhoids or anal fissure.

CONCLUSIONS

Cancer was detected in 1.2% and adenomatous polyps in 7.7% of patients with bright red rectal bleeding using flexible sigmoidoscopy. All cancers and 94% of adenomatous polyps were detected in patients older than 40 years. Flexible sigmoidoscopy appears to be a valuable initial investigation for bright red rectal bleeding in patients older than 40 years.

Ambulatory stapled haemorrhoidectomy: a safe and feasible surgical technique

OBJECTIVE

To compare outcomes following stapled haemorrhoidectomy as an in-patient versus day-surgery procedure.

DESIGN

Prospective non-randomised study.

SETTING

University affiliated hospitals, Hong Kong.

SUBJECTS AND METHODS

Forty-eight consecutive patients who underwent stapled haemorrhoidectomy were included in the study. Twenty-four patients had the procedure in an ambulatory setting and the other 24 were treated as in-patients. The symptoms, operative details, postoperative complications, length of hospital stay, pain scores, analgesic requirements, and patient satisfaction scores were collected. Comparison was made between those patients undergoing ambulatory surgery and those treated as in-patients.

RESULTS

There were 25 women and 23 men in the study. The mean age was 46.6 years (standard deviation, 12.1 years). The mean operating time was 29.3 minutes (standard deviation, 9.9 minutes). An incomplete 'doughnut' after stapling was found in one patient. There were no other adverse intra-operative events or complications. Postoperative morbidities occurred in eight patients but none required further surgery. One patient in the day-surgery group could not be discharged because of urinary retention and three required re-admission to hospital because of secondary haemorrhage (n=1) or fever (n=2). There were no differences in the postoperative complications, pain scores, analgesic requirements, and patient satisfaction scores between the two groups. The total mean hospital stay was significantly shorter for those undergoing day-surgery stapled haemorrhoidectomy (0.46 versus 1.9 days, P<0.01). The mean follow-up period was 4.6 months (standard deviation, 4.0 months). All patients reported symptomatic improvement during this time and there was no incidence of faecal incontinence. One patient had a soft stricture, one had a fissure, and two had residual skin tags. All of these problems were conservatively managed, without the need for further surgical procedures.

CONCLUSIONS

Stapled haemorrhoidectomy is a safe and effective operation for haemorrhoids. It is a feasible procedure to perform as day-surgery. The hospital stay can be significantly shortened, thus reducing the costs associated with in-patient care.

Hepatic resection for colorectal liver metastases: prospective study

OBJECTIVE

To assess the operative and long-term survival outcomes of hepatic resection for colorectal liver metastases during an 11-year period in a tertiary referral centre in Hong Kong.

DESIGN

Prospective study.

SETTING

University teaching hospital, Hong Kong.

SUBJECTS AND METHODS

Between January 1989 and December 1999, 72 patients underwent hepatic resection for colorectal liver metastases. Clinical, pathological, and outcome data were prospectively collected and analysed. Factors affecting long-term survival were also evaluated.

RESULTS

Twenty-five (34.7%) patients were found to have synchronous hepatic metastasis at the time of colorectal resection. Fifty-two (72.2%) patients underwent major hepatic resection. The operative morbidity and hospital mortality rates were 19% and 4%, respectively. The 5-year survival rate after hepatectomy was 31.9%. The median disease-free survival and median overall cumulative survival were 18.5 months and 30.8 months, respectively. On multivariate analysis, a high preoperative serum carcinoembryonic antigen level (>200 ng/mL) and tumour involvement of the resection margin at histology were the two independent risk factors that adversely affected survival outcome.

CONCLUSION

Hepatic resection for colorectal liver metastases can be performed safely, with minimal operative mortality and acceptable morbidity, and results in satisfactory survival. High preoperative serum carcinoembryonic antigen level and histological involvement of resection margin by cancer adversely affect the survival outcome.

Radiation stricture of rectosigmoid treated with self-expanding metallic stent

Radiation stricture of the rectosigmoid with obstruction is a difficult clinical problem, and surgery is associated with high mortality and morbidity. We report a case involving radiation stricture of the rectosigmoid in an 80-year-old woman who presented with acute colonic obstruction. A self-expanding metallic stent was successfully inserted, and the obstruction was relieved. The stent remained patent for 4 months without any complications until the patient died of sepsis resulting from pneumonia and bedsores. The literature on the use of a metallic stent to manage a benign colon condition was reviewed.

Strategies in the management of mid and distal rectal cancer with total mesorectal excision

In the last two decades, dramatic improvement in outcome has been made in the management of rectal cancer. This has been brought about mainly by advancements in surgical technique for radical resection. With the recognition of the importance of the circumferential margin and presence of spread in the lymphovascular tissues in the mesorectum, total mesorectal excision is now commonly recognized as the optimal surgical technique for cancer of the mid and distal rectum. Not only have local control and disease-specific survival improved with the practice of total mesorectal excision, but various bodily functions have also been preserved following surgery for rectal cancer. New issues have arisen with the practice of total mesorectal excision and the strategies for management of rectal cancer require re-evaluation. In this article, the rationale and the outcomes of total mesorectal excision are reviewed. Issues such as the high anastomotic leakage rate following sphincter-preserving surgery, the poor results of abdominoperineal resection, the role of adjuvant therapy and bowel function disturbances will be addressed. Lastly, the status of the laparoscopic approach to rectal cancer with the principle of total mesorectal excision are discussed.

Randomized clinical trial comparing loop ileostomy and loop transverse colostomy for faecal diversion following total mesorectal excision

BACKGROUND

The aim of this study was to compare loop ileostomy and loop transverse colostomy as the preferred mode of faecal diversion following low anterior resection with total mesorectal excision for rectal cancer.

METHODS

Patients who required proximal diversion after low anterior resection with total mesorectal excision were randomized to have either a loop ileostomy or a loop transverse colostomy. Postoperative morbidity, stoma-related problems and morbidity following closure were compared.

RESULTS

From April 1999 to November 2000, 42 patients had a loop ileostomy and 38 had a loop transverse colostomy constructed following low anterior resection. Postoperative intestinal obstruction and prolonged ileus occurred more commonly in patients with an ileostomy (P = 0.037). There was no difference in time to resumption of diet, length of hospital stay following stoma closure and incidence of stoma-related complications after discharge from hospital. A total of seven patients had intestinal obstruction from the time of stoma creation to stoma closure (six following ileostomy and one following colostomy; P = 0.01).

CONCLUSION

Intestinal obstruction and ileus are more common after loop ileostomy than loop colostomy. Loop transverse colostomy should be recommended as the preferred method of proximal faecal diversion.

Impact of total mesorectal excision on the results of surgery of distal rectal cancer

BACKGROUND

This study reviewed the results of surgery for distal rectal cancer (tumours within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution.

METHODS

Two hundred and five patients who had undergone surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected prospectively. Comparisons were made between patients who had different surgical procedures.

RESULTS

Abdominoperineal resection (APR) was performed in 27.8 per cent of patients, falling from 36.0 per cent in the first 3 years to 20.0 per cent in the last 3 years of the study. The overall operative mortality rate was 1.5 per cent and the morbidity rate 30.2 per cent. With a mean follow-up of 36 months, local recurrence occurred in 28 of the 185 patients who had curative resection. The 5-year actuarial local recurrence rates for double-stapled anastomosis, peranal coloanal anastomosis and APR were 11.2, 34.6 and 23.5 per cent respectively. The local recurrence rate was significantly lower for double-stapled low anterior resection than for the other types of operation. The overall 5-year survival rate in patients with low anterior resection and APR was 69.1 and 51.1 per cent respectively (P = 0.12).

CONCLUSION

With the practice of total mesorectal excision, APR was necessary in only 27.8 per cent of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was much lower in patients with double-stapled low anterior resection than in those treated with APR or peranal anastomosis.