Colorectal Disease (Colorectal Dis)

Publications in this journal

• Article: Bridging the gap: how higher surgical training programmes can produce consultant laparoscopic colorectal surgeons.

  Susan J Moug, Kathryn McCarthy, Craig Nesbitt
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  ABSTRACT: In the UK, colorectal surgery has evolved from traditional open surgery to a minimally invasive approach. In 2001, a UK survey found only 11.3% of malignant colorectal resections and 10% of anterior resections were performed laparoscopically(1) . However, subsequent publications including the CLASICC trial that led to revised NICE guidelines, have changed the landscape with 34% of elective cases in 2010-2011 being performed laparoscopically (2,3,4,5) . This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Hand-assisted laparoscopic right colectomy: a consideration of hand-device placement and trocar arrangement.

  Wen-Jian Meng, Zi-Qiang Wang, Zong-Guang Zhou
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  ABSTRACT: We read the recent article reporting a randomized controlled trial comparing hand-assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy for right-sided colonic cancer [1]. We believe it is an important study demonstrating the safety and feasibility of HALC for this condition and we would like to make the following comments focused on hand-device placement and trocar arrangement. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Vertical rectus abdominis myocutaneous flap reconstruction of the perineal defect after abdominoperineal excision is associated with less morbidity.

  Tom Barker, Graham Branagan, Edmund Wright, Alexandra Crick, Caroline McGuiness, Helen Chave
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  ABSTRACT: AIM: The short term outcome was examined of perineal vertical rectus abdominis myocutaneous (VRAM) flap reconstruction following abdominal perineal excision (APE). METHOD: Retrospective case note review of all patients undergoing APE and primary vertical rctus abdominal muscule (VRAM) reconstruction between July 2001 and February 2012 in a District General Hospital tertiary referral centre for APE. Complications were categorised using the Clavien-Dindo classification, which grades complications from I-V in order of increasing severity. RESULTS: Fift five consecutive patients (31 male, median age 65 (38-84) years underwent APE with VRAM flap reconstruction, 15 for anal cancer and 40 for rectal cancer. Median length of stay was 11 days but was significantly shorter in the laparoscopic group compared to the open group (8 vs. 12 days; p<0.01) and in patients who did not experience a had no complication (p<0.05). Four (7%) patients had major complications (Grade 3 and above) directly related to the flap or donor site. CONCLUSION: VRAM reconstruction of the perineum can be safely performed following APE with results that compare favourably with other techniques. Most flap complications are minor, although these are still associated with an increase in the length of hospital stay. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Association between Helicobacter pylori infection and the risk of colorectal neoplasia: a systematic review and meta-analysis.

  Q Wu, Z-P Yang, P Xu, L-C Gao, D-M Fan
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  ABSTRACT: AIM: The existing evidence on the relationship between Helicobacter pylori infection and the risk of colorectal neoplasia is inconsistent. We conducted a systematic review with a meta-analysis to explore this relationship and to determine whether the relationship varies according to the study characteristics. METHOD: We searched the PubMed database and the reference lists of pertinent articles published up to July 2012. Summary odds ratios (ORs) with their 95% confidence intervals (CIs) were estimated using a random-effects model. RESULTS: Twenty-seven studies including 3792 cases of colorectal adenoma (CRA) and 3488 cases of colorectal cancer (CRC) were identified. Overall, H. pylori infection was associated with an increased risk of CRA (OR = 1.66, 95% CI 1.39-1.97, I(2) = 54.3%) and CRC (OR = 1.39, 95% CI 1.18-1.64, I(2) = 35.8%), although there was significant heterogeneity among the studies. Subgroup analysis revealed that the positive correlation did not differ by sex, geographic variation, or subsite of neoplasia, but might vary by the method of detection of H. pylori. The study was underpowered to determine the risk of colorectal neoplasia associated with CagA-positive H. pylori. CONCLUSION: This meta-analysis demonstrates a positive association between H. pylori infection and the risk of colorectal neoplasia. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Phase II study of concomitant chemoradiotherapy with local hyperthermia and metronidazole for locally advanced fixed rectal cancer.

  Yu A Barsukov, S S Gordeyev, S I Tkachev, M Yu Fedyanin, A G Perevoshikov
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  ABSTRACT: AIM: Locally advanced fixed T4 rectal cancer has a poor prognosis and no standard treatment strategy. The aim of this study was to investigate safety and efficacy of neoadjuvant chemoradiotherapy using hypofractionated radiotherapy combined with local hyperthermia, capecitabine, oxaliplatin, metronidazole. METHOD: Radiotherapy was given to a total dose of 40 Gy in 10 fractions. Capecitabine 650 mg/m2 bid was given on days 1-22 and intravenous oxaliplatin 50 mg/m2 was administered on days 3, 10, 17. Local hyperthermia 41-45°C during 60 minutes was performed on days 8, 10, 15, 17. Metronidazole 10 g/m2 was administered per rectum on days 8 and 15. Surgery was carried out within 6-8 weeks after neoadjuvant treatment. The primary endpoint was R0 resection rate. Secondary endpoints included 2-year disease-free survival, 2-year overall survival, local recurrence rate, grade III-IV tumour regression (Dworak), treatment toxicity. RESULTS: From July 2006 to February 2011, 64 previously untreated patients were enrolled. R0 resection was carried out in 59 (92,2%). Five (7,8%) remained inoperable. Seven (10,9%), patients had grade IV and 30 (46.9%) had grade III regression. The main grade III toxic events included diarrhoea (15.6% [n=10]), vomiting (3,1% [n=2]), proctitis (3,1% [n=2]) and skin reaction (1,6% [n=1]). Only one(1.6%) patient had grade IV diarrhoea and vomiting. The median follow-up was 24.9 months. Two-year overall survival was 91% and 2-year disease-free survival was 83%. CONCLUSION: Hyperthermia combined with chemotherapy to produce radiosensitization for locally advanced fixed primary rectal cancer is followed by a high R0 resection rate, with toxicity comparable to standard regimens. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Re: Luo et al, Diabetes mellitus and the incidence and mortality of colorectal cancer: a meta-analysis of 24 cohort studies.

  D Mansouri, Dc McMillan, Em Crighton, Pg Horgan
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  ABSTRACT: We read the recent meta-analysis by Luo et al(1) that reported a link between diabetes mellitus and an increased risk of colorectal cancer and increased mortality. The authors have included twenty four studies that span a considerable geographic area and time frame and have performed subgroup analysis to help avoid the various confounding factors. However, no adjustments have been made to take into account differing diabetic treatments among the patients studied. There is now increasing evidence that the commonly used anti-diabetic drug Metformin may be associated with a reduced incidence of cancer including colorectal cancer (2). This has been found in both population studies (3) and also in animal and human models where surrogate markers for early colorectal carcinogenesis have been used(4, 5). This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Outcome of 12 month surveillance colonoscopy in high risk patients in the NHS Bowel Cancer Screening Programme.

  Thomas Jw Lee, Claire Nickerson, Andrew F Goddard, Colin J Rees, Richard Jq McNally, Matthew D Rutter
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  ABSTRACT: AIM: Current British guidelines recommend surveillance colonoscopy at 12 months for individuals found to have ≥5 adenomas or ≥3 adenomas of which at least one is ≥1cm in size. This study describes the yield of surveillance colonoscopy in this group and explores patient and clinical factors which may be associated with the presence of advanced adenomas or cancer at surveillance. METHOD: Data were retrieved from the national database of the NHS Bowel Cancer Screening Programme. The detection of advanced colonic neoplasia (ACN) was used as the main outcome variable. Multivariable analysis was used to analyse relationships between patient factors (age, gender, body mass index, smoking and alcohol use) and clinical findings (number, size and nature of adenomas detected during index colonoscopy) with the outcome variable. RESULTS: 1760 individuals were included in the study. The yield of ACN at 12 month surveillance was 6.6% (116/1760) of which 14/1760 (0.8%) had colorectal cancer. 9/14 (64.3%) of these cancers were Dukes stage A at diagnosis. The presence of a villous adenoma or a right sided adenoma at screening colonoscopy was associated with odds ratios of 1.98 (95% CI 1.11-3.53, p=0.012) and 1.76 (1.13-2.74, p=0.020) respectively for detection of ACN at surveillance. CONCLUSION: 12 month surveillance colonoscopy is necessary in this group of patients. The presence of villous or proximal lesions at baseline is associated with increased risk of ACN at surveillance. Site and histological type of baseline lesions may be relevant to determining the surveillance interval. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: The results of surgery for colorectal hepatic metastases following expansion of the indications in 2005.

  Yunshi Zhong, Dexiang Zhu, Li Liang, Qinghai Ye, Ye Wei, Li Ren, Xiangou Pan, Jia Fan, Jianmin Xu, Xinyu Qin
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  ABSTRACT: AIM: Safety and survival were investigated in patients treated according to expaned surgical indications for colorectal hepatic metastases. METHOD: A retrospective analysis of all consecutive patients who underwent resection of colorectal hepatic metastases at Zhongshan Hospital from 2000 to 2010 was conducted. The patients were divided into two groups based on a change in the surgical indications introduced in 2005. Patients in Group I underwent hepatic surgery between 2000 and 2004, and those in Group II between 2005 and 2010. The clinicopathological data and survival rates of both groups were analyzed. RESULTS: There were 530 patients who underwent hepatic surgery between 2000 and 2010. After the expansion of surgical indications, the rate of surgical resection rose from 25.1% to 35.1% (P < 0.05). There was no significant difference in perioperative mortality (2.2% vs. 0.9%) or morbidity (20.9% vs. 29.8%). Recurrence occurred in 27.5% and 36.7%, in Groups I and II and 5-year overall survival was 43% and 49% (not significant). CONCLUSION: Expanding the indications for surgical resection of hepatic metastases increased the resection rate but had no significant effect on survival. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Colorectal neoplasia in longstanding ulcerative colitis - a prospective study from a low prevalence area.

  Bhadravathi Marigowda Shivakumar, Balasubramanian Lakshmankumar, Lakshmi Rao, Ganesh Bhat, Deepak Suvarna, C Ganesh Pai
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  ABSTRACT: AIM: Despite increasing recognition of ulcerative colitis (UC) in Asia in recent decades, reports on the occurrence of colorectal neoplasia (CRN) in UC are scarce and surveillance for this complication is not routinely practiced in this region. We aimed to assess the outcome of a newly initiated pilot screening program for screening CRN among UC patients in India. METHOD: In this prospective study from an academic hospital setting, UC patients at high risk of CRN were offered screening by magnifying chromo colonoscopy and the frequency of neoplastic lesions was assessed. RESULTS: 29 (70.7%) of 41 eligible patients [a median age of 46 (IQR 36-54.5) years; 17 (58.6%) male] enrolled for surveillance; 41 colonoscopies were undertaken over 42 months. The median disease duration was 10 (IQR 7.5-14.5) years. Sixteen (55.1%) had extensive colitis. On initial screening, low grade dysplasia (LGD) was seen in 5 (17.2%) and high grade dysplasia (HGD) in 3 (10.3%). Of the latter 3, one accepted proctocolectomy immediately, one underwent surgery for adenocarcinoma, and one refused surgery.. Twelve follow up colonoscopies in 9 patients revealed 3 new LGD. CONCLUSIONS: HGD and subsequent adenocarcinoma can be detected with careful follow up in Indian patients with longstanding UC but acceptance of surveillance and subsequent therapy are suboptimal. We found evidence that screening and surveillance programmes are useful for detecting neoplasias in UC, and need to be customized for this region. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: "Be Clear on Cancer." The impact of the UK national bowel cancer awareness campaign.

  O Peacock, S Clayton, F Atkinson, G M Tierney, J N Lund
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  ABSTRACT: AIM: The National Bowel Cancer Awareness Campaign ("Be Clear on Cancer") was launched by the UK government in January 2012, encouraging people with bowel symptoms to present to primary care. Our aim was to evaluate the impact of the campaign on colorectal services in secondary care. METHOD: Suspected cancer 2-week-wait (2WW) patients 3 months before and 3 months after the launch of the campaign were included. Demographics, reason for referral, investigations performed, cost analysis and eventual diagnoses were collected. RESULTS: Three hundred and forty-three patients (median age 70 (36-100) years, 194 (57%) females) were seen and investigated in the 3 months prior to the launch of the campaign at an average cost of £575 per patient. Twenty-seven (8%) were diagnosed with lower gastrointestinal cancer and 29 (8%) with polyps. In the 3 months following the launch, 544 patients (median age 68 (30-92) years, 290 (53%) females) were reviewed (59% increase; p=0.004). The "did not attend" (DNA) rate fell from 10% to 1%. Thirty-two (6%) patients were diagnosed with a lower gastrointestinal cancer and 20 (4%) with colorectal polyps. The cost per colorectal cancer detected rose from £7,585.58 before the campaign to £9,662.72 post launch (p=0.04). CONCLUSION: The "Be Clear on Cancer" campaign has substantially increased the number of referrals under the 2WW rule, but mainly in the worried well. This has increased demands on both resources (59% more tests) and finance. Cost per cancer detected rose by 27% with no increase in funding to support the increased activity. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Current Status of Rectal Cancer Treatment in China.

  Jin Gu, Nan Chen
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  ABSTRACT: AIM: Colorectal cancer (CRC) is the fourth most common carcinoma in China. For economic reasons, a national colorectal cancer registry system has not been established and a large scale screening programme has not yet been implemented. Therefore, accurate statistical data concerning the incidence of colorectal cancer covering the whole country cannot be obtained. In China, the majority of hospitals in central cities and even in county hospitals are able to provide medical care for CRC patients. Due to socioeconomic disparities, medical conditions and skill levels, there is a wide variation in the treatment. Most oncologists make their clinical decisions based on the National Comprehensive Cancer Network (NCCN) guidelines although some domestic guidelines are now available. In October 11, 2011, the China Ministry of Health released the National Guideline of colorectal cancer treatment. This will give a degree of standardization of the treatment of CRC nationwide and will ensure that higher quality care will be available, especially in rural areas. Owing to language difficulties, research on CRC in China has only had a limited exposure in the international literature, due in some part to lack of understanding of the current position in the country. Chinese colorectal surgeons urgently need to exchange their knowledge and experience with international colleagues. In this article, the current situation regarding surgical treatment of rectal cancer in China is summarized. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Restorative proctocolectomy in patients with ulcerative colitis: a cross sectional Danish population study on function and quality of life.

  Søren Brandsborg, Anders Tøttrup, John Nicholls, Søren Laurberg
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  ABSTRACT: AIM: The study evaluated function and quality of life (QoL) in all patients having restorative proctocolectomy (RPC) in Denmark for ulcerative colitis (UC) from 1980 to 2010. Inclusion of all patients in one country has never previously been achieved. METHOD: All patients who had had a restorative proctectoly in Denmark from the rirst to the last case in 2010 were studied. A cross sectional questionnaire survey was performed and function and QoL were assessed using a standardized questionnaire, the Short Form 36 (SF36) and the inflammatory bowel disease questionnaire (IBDQ). RESULTS: The median duration of follow up was 11 (1-30) years. Apart from deaths, pouch failures and research protection, data on function and QoL were obtained in 1047 (85%) of 1229 patients who had a functioning pouch at the time of the investigation. More females experienced urgency than males (56% versus 44% [p=0.0021]). The median number of bowel movements/24 hours was seven (1-23) in females and six (1-20) in males (P<0.001). Pad usage was more frequent among females than males (62% versus 38% [p<0.001]). A higher incidence of major incontinence (p=0.009) and use of pads (p=0.01) was found among patients who had been operated on 21-30 years than 11-20 years previously. The prevalence of urgency was higher in patients operated on at 0-10 years compared with 11-20 years previously (p=0.009). The total IBDQ score was higher in males than females (p<0.001). Males scored higher in five of eight SF36 domains (p<0.001). CONCLUSION: Females had more urgency, frequency of defaecation and pad usage. This was associated with a reduced QoL. RPC nevertheless resulted in good function and a high degree of satisfaction in most patients. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Patterns of recurrence of obstructing colon cancers after surgery for cure: a population-based study.

  M Cortet, A Grimault, N Cheynel, C Lepage, Am Bouvier, J Faivre
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  ABSTRACT: AIM: Little is known about patterns of recurrence in obstructing colon cancer (OCC) at a population level. The aim of this study was to determine the risk of recurrence following potentially curative surgery in OCC compared with that in uncomplicated CC. METHODS: Data was obtained from the population-based digestive cancer registry of Burgundy (France). Local and distant failure rates were calculated using actuarial methods. A multivariate analysis was performed using a Cox model. RESULTS: OCC represented 8.5 per cent of all colon cancers resected with curative intent (n=3375). The 5-year cumulative local recurrence rate was 14.2% for OCC and 7.6% for non-obstructing CC (p=0.003). In the multivariate analysis, obstruction was an independent risk factor for local recurrence (HR: 1.53 [1.01-2.34], p=0.047). The risk of local recurrence increased with advanced stage and age at diagnosis. The 5-year cumulative rate for distant metastases was also higher in OCC than in non-obstructing CC (36.1% vs. 23.1%; p<0.001). The relative risk of distant metastasis was borderline significant in the multivariate analysis (HR: 1.25 [0.99-1.59], p=0.057). Stage at diagnosis, macroscopic type of growth, period of diagnosis and sex were also significant prognostic factors. Age and subsite were not significant in the multivariate analysis. CONCLUSION: It is possible to conduct special surveys in population-based registries to determine the recurrence rate of CC. Recurrence remains a substantial problem and is more frequent in OCC than in non-obstructing colon cancers. Efforts must be made to diagnose CC earlier. Mass screening is a promising approach. This article is protected by copyright. All rights reserved.
  Colorectal Disease 05/2013;
• Article: Audit: for the patient, the surgeon or the health care provider?

  Peer Wille-Jørgensen
  Colorectal Disease 05/2013; 15(5):517.
• Article: Invited commentary.

  Robin Phillips
  Colorectal Disease 05/2013; 15(5):596-7.
• Article: Reply to stelzner et Al.

  D Asplund, E Haglind, E Angenete
  Colorectal Disease 05/2013; 15(5):628.
• Article: Report from the Spanish Association of Coloproctology/Asociación Española de Coloproctología (AECP).

  A Codina-Cazador, S Biondo, E Espin
  Colorectal Disease 05/2013; 15(5):518.
• Article: Randomised controlled trial:Comparison of two surgical techniques closing the wound following ileostomy closure: purse string versus direct suture.

  Niloufar Dusch, Diana Goranova, Florian Herrle, Marco Niedergethmann, Peter Kienle
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  ABSTRACT: AIM: Surgical site infection (SSI) is a common complication following ileostomy closure (IC) with a frequency of up to 40%. This prospective randomised controlled trial was initiated to compare two surgical techniques closing the wound following IC: direct suture (DS) versus purse string suture (PSS). The primary endpoint was the SSI rate. Secondary endpoints were cosmetic outcome (using two validated scales POSAS and BIQ) and the influence of other factors on the SSI rate. METHODS: A total of 99 patients were screened. 84 patients were then included in this study. Forty-three patients were randomised into the PSS group, 41 into the DS group. Follow-up was performed within 3 days following surgery, at discharge, and 30 days and 6 months after the operation. RESULTS: In the PSS group there were no cases of SSI compared to 10 cases (24%) in the DS group (p= 0.0004). There were no statistically significant differences in cosmetic outcome between the two groups. No other statistically significant factors influencing the incidence of SSI could be identified. CONCLUSION: The rate of SSI is significantly lower following PSS than DS, with a similarcosmetic outcome.. Purse sting suture closure should be considered as standard of care for wound closure after ileostomy reversal. © 2013 The Authors. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.
  Colorectal Disease 05/2013;
• Article: Supervised surgical training and its effect on the short term outcome in laparoscopic colorectal surgery.

  Arunachalam Krishna, Mike Russell, Gillian L Richardson, Matthew Jfx Rickard, Anil Keshava
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  ABSTRACT: AIM: Laparoscopic colorectal surgery is technically demanding and requires supervised training. This paper examines the short-term outcome following a component-based training in laparoscopic colorectal surgery. METHOD: Surgical outcome following laparoscopic colorectal resection was recorded on a prospective database. Cases were divided into three groups; including those performed by the fellows, those completed by the consultant and those completed by a combination of both consultants and fellows. Analysis of data was carried out for all colorectal resections and also for the subgroup of colorectal cancer patients. RESULTS: 511 cases were examined between June 2006 and January 2011. There was no statistically significant difference in operating time between fellows and consultants but the operating time was significantly longer for those procedures where both the consultants and fellows performed components of the operation. Conversion rate, post operative morbidity, recovery and length of stay were similar for all three groups for the whole patient cohort and also the subgroup of cancer patients. In the cancer subgroup, there was no difference in the pathological stages across the 3 groups. CONCLUSION: Closely supervised training in laparoscopic colorectal surgery is not associated with any adverse effect on the short-term outcome. This article is protected by copyright. All rights reserved.
  Colorectal Disease 04/2013;
• Article: Adenoma, advanced adenoma and colorectal cancer prevalence in asymptomatic 40 to 49-year-olds with a first-degree family history of colorectal cancer.

  Giovanna Del Vecchio Blanco, Micaela Cretella, Omero Alessandro Paoluzi, Anna Caruso, Elena Mannisi, Francesca Servadei, Samanta Romeo, Enrico Grasso, Pierpaolo Sileri, Mario Giannelli, Livia Biancone, Giampiero Palmieri, Francesco Pallone
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  ABSTRACT: BACKGROUND: First-degree relatives (FDR) of patients with colorectal cancer (CRC) have an increased CRC risk. Few studies have addressed if adenoma and advanced adenoma risk is increased among individuals with family history of CRC aged 40-49 years. AIM: To define prevalence and location of adenoma, advanced adenoma and CRC according to age in asymptomatic individuals with family history of CRC. METHODS: Retrospective study of asymptomatic FDR of CRC patients, aged 40 to ≥70 years, undergoing first screening colonoscopy over a three year period . RESULTS: Among 464 individuals studied, adenoma and advanced adenoma prevalence was 18.1% and 6.4%, respectively. According to age intervals, prevalence of adenoma and advanced adenoma was 14% and 3.5% in 40-49 age group, 14.4% and 6.3% in 50-59 age group, 27% and 8% in 60-69 age group, 25% and 14% in ≥70 age group, with no significant difference among the four groups. No difference in lesion location was found, with similar numbers of pre-neoplastic lesions was found in right and left colon. CRC was diagnosed in three subjects (0.64%), one of them in 40-49 age group. CONCLUSION: In our population of FDR of CRC patients aged 40-49 years, prevalence of adenoma and advanced adenoma was similar to that observed in older subjects with the same CRC risk. Our data support the current indication to perform screening colonoscopy earlier than 45 years in subjects at high CRC risk. This article is protected by copyright. All rights reserved.
  Colorectal Disease 04/2013;