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BACKGROUND AND OBJECTIVES: Rural general practitioners (GPs) are responsible for delivering primary and secondary care to rural populations in Australia. There is limited literature investigating the performance of GP endoscopists. The aim of this study was to investigate the colonoscopy performance of three GP endoscopists in rural Queensland against current Australian quality indicator (QI) standards. METHOD: A cross sectional study investigated eligible colonoscopies between January 2018 and February 2021 by three GP endoscopists in three rural hospitals in Queensland, Australia. RESULTS: A total of 1674 colonoscopies were investigated. The GP endoscopists demonstrated high QI performance, above the recommended benchmarks. Caecal intubation rate, adenoma detection rate, sessile serrated adenoma/polyp detection rate and clinically significant serrated polyp detection rate were 97.9%, 49.5%, 16% and 14.1% respectively. The major colonoscopy-related complications rate was 0.06%. DISCUSSION: Rural GP endoscopists potentially can deliver safe, high-quality colonoscopy services for rural communities and can have an integral part in facilitating colorectal cancer prevention and treatment in rural communities.
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Colonoscopía , Hospitales Rurales , Humanos , Queensland , Australia , Estudios TransversalesRESUMEN
BACKGROUND: This study reports the quality-of-life assessment of the ALCCaS trial. The ALCCaS trial compared laparoscopic and open resection for colon cancer. It reported equivalence of survival at 5 years. Quality of life was measured as a secondary outcome. OBJECTIVE: This study aimed to report on the quality of life data of the ALCCaS Trial. DESIGN: This study reports a randomized controlled trial comparing laparoscopic with open colonic resection. SETTINGS: The study was conducted in Australasia. PATIENTS: Patients with a single adenocarcinoma of the right, left, or sigmoid colon, presenting for elective treatment, were eligible for randomization. INTERVENTIONS: Open and laparoscopic colonic resections were performed. MAIN OUTCOME MEASURES: Patient symptoms and quality of life were measured using the Symptoms Distress Scale, the Quality of Life Index, and the Global Quality of Life Score preoperatively, and at 2 days, 2 weeks, and 2 months postoperatively. RESULTS: Of the 592 patients enrolled in ALCCaS, 425 completed at least 1 quality-of-life measure at 4 time points (71.8% of cohort). Those who received the laparoscopic intervention had better quality of life postoperatively in terms of the Symptoms Distress Scale (p < 0.01), Quality of Life Index (p < 0.01), and Global Quality of Life (p < 0.01). In intention-to-treat analyses, those assigned to laparoscopic surgery had a better quality of life postoperatively in terms of the Symptoms Distress Scale (p < 0.01) and Quality of Life Index (p < 0.01), whereas Global Quality of Life was not significant (p = 0.056). The subscales better for laparoscopic resection at all 3 postoperative time points were appetite, insomnia, pain, fatigue, bowel, daily living, and health (p < 0.05). LIMITATIONS: The primary limitation was the different response rates for the 3 quality-of-life measures. CONCLUSIONS: There was a short-term gain in quality of life maintained at 2 months postsurgery for those who received laparoscopic relative to open colonic resection. See Video Abstract at http://links.lww.com/DCR/A691.
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Adenocarcinoma/cirugía , Colectomía/métodos , Colon Sigmoide/cirugía , Neoplasias Colorrectales/cirugía , Laparoscopía/métodos , Calidad de Vida/psicología , Anciano , Anciano de 80 o más Años , Australasia/epidemiología , Colon Sigmoide/patología , Neoplasias Colorrectales/psicología , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Humanos , Análisis de Intención de Tratar/métodos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Resultado del TratamientoRESUMEN
Enteropathy-associated T cell lymphoma (EATCL) is an intestinal neoplasm of intra-epithelial T lymphocytes associated with coeliac disease. Although the incidence is rare, EATCL runs an aggressive disease course and produces multi-focal ulcerative lesions most commonly in the proximal small bowel. As such, patients may present with intestinal perforation, obstruction or haemorrhage. Management of EATCL requires a combination of early diagnosis and treatment by surgical resection followed by chemotherapy to achieve treatment success. Overall however, the treatment completion rate remains at 50% and EATCL carries a poor prognosis with a 5-year survival rate of <20%.
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OBJECTIVE: : We report a multicentered randomized controlled trial across Australia and New Zealand comparing laparoscopic-assisted colon resection (LCR) with open colon resection (OCR) for colon cancer. BACKGROUND: : Colon cancer is a significant worldwide health issue. This trial investigated whether the short-term benefits associated with LCR for colon cancer could be achieved safely, without survival disadvantages, in our region. METHODS: : A total of 601 patients with potentially curable colon cancer were randomized to receive LCR or OCR. Primary endpoints were 5-year overall survival, recurrence-free survival, and freedom from recurrence rates, compared using an intention-to-treat analysis. RESULTS: : On April 5, 2010, 587 eligible patients were followed for a median of 5.2 years (range, 1 week-11.4 years) with 5-year confirmed follow-up data for survival and recurrence on 567 (96.6%). Significant differences between the 2 trial groups were as follows: LCR patients were older at randomization, and their pathology specimens showed smaller distal resection margins; OCR patients had some worse pathology parameters, but there were no differences in disease stages. There were no significant differences between the LCR and OCR groups in 5-year follow-up of overall survival (77.7% vs 76.0%, P = 0.64), recurrence-free survival (72.7% vs 71.2%, P = 0.70), or freedom from recurrence (86.2% vs 85.6%, P = 0.85). CONCLUSIONS: : In spite of some differences in short-term surrogate oncological markers, LCR was not inferior to OCR in direct measures of survival and disease recurrence. These findings emphasize the importance of long-term data in formulating evidence-based practice guidelines.
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Adenocarcinoma/cirugía , Colectomía/métodos , Neoplasias del Colon/cirugía , Laparoscopía , Anciano , Australia , Femenino , Humanos , Masculino , Recurrencia Local de Neoplasia/epidemiología , Nueva Zelanda , Resultado del TratamientoRESUMEN
BACKGROUND: Lymph node yield (LNY) is a measure of quality of care and a strong prognostic factor for outcome from colorectal cancer (CRC). The main aims of this study were to determine LNY across multiple Australian centres and the clinico-pathologic factors that influence yield. METHODS: Analysis of data from prospective CRC databases at 11 Australian centres between January 1988 and May 2008 was undertaken utilizing the linkage and analysis resources of BioGrid Australia. The LNY depending on different clinico-pathologic patient characteristics was evaluated. RESULTS: In total, 10,082 cases (54.1% men, 45.9% women) were identified. Median LNY was 12 (range 0-174). LNY increased significantly (P < 0.001) over time, from a mean of 8.5 in 1988 to 13 in 2008. LNY also varied significantly between surgical centres. Female gender, younger age, right-sided disease, higher T and N stage, specific operation types and absence of preoperative radiotherapy were all significantly associated with higher LNY. CONCLUSIONS: While varying across centres, the median LNYs in Australia are acceptable and have improved significantly over recent years. Multiple clinico-pathologic factors significantly influence the number of nodes retrieved.
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Neoplasias Colorrectales/secundario , Escisión del Ganglio Linfático/métodos , Ganglios Linfáticos/patología , Garantía de la Calidad de Atención de Salud , Abdomen , Anciano , Neoplasias Colorrectales/cirugía , Femenino , Estudios de Seguimiento , Humanos , Ganglios Linfáticos/cirugía , Masculino , Estadificación de Neoplasias , Estudios ProspectivosRESUMEN
BACKGROUND: This paper describes the distinctions between major surgical and pharmaceutical trials and questions the application of a common ethical paradigm to guide their conduct and reporting. METHODS: Surgical trials differ from other trials in cumulative therapeutic effects, operator dependence, the clinical setting, interdependence of short- and long-term outcomes, and equipoise. A principal tenant of randomized controlled trial management is the maintenance of interim data confidentiality. Its application to complete surgical short-term data is examined across a variety of common clinical trial circumstances that influence data integrity and the reliability of conclusions regarding the benefit-to-risk profile of experimental interventions. RESULTS: Complete perioperative results describe important treatment ends that cannot influence primary outcomes. These short-term results may inform patient consent, teaching and provide valuable procedural insights to surgeons outside trial precincts. CONCLUSION: Structured experimentation standards are necessary. But, the common paradigm applied across all clinical trials and the prohibition on short term data reporting may not serve the achievement of safe and effective advancements in surgery.
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Revelación/ética , Cirugía General/ética , Ensayos Clínicos Controlados Aleatorios como Asunto/ética , Sesgo , Comités de Monitoreo de Datos de Ensayos Clínicos , Confidencialidad/ética , Humanos , Difusión de la Información/ética , Evaluación de Resultado en la Atención de Salud , Acceso de los Pacientes a los Registros/ética , Ensayos Clínicos Controlados Aleatorios como Asunto/normas , Proyectos de Investigación/normasRESUMEN
AIM: Colorectal cancer (CRC) is one of the most common malignancies worldwide and adjuvant chemotherapy is proven to improve survival in patients with Dukes' C CRC. The purpose of this study was to analyze factors influencing referral to medical oncology in patients with Dukes' C colonic cancer in our institutions. METHODS: Patients who underwent resection for Dukes' C colonic cancer were assessed for factors that influence the pattern of postoperative referral to the medical oncology department, including demographic and perioperative data. RESULTS: Overall, 466 patients were identified to have Dukes' C colonic cancer, with 53.9% of these being female. Referral to medical oncology occurred for 58.4% patients. Multivariable logistic regression modeling identified age, elective admission and resection in private hospitals as factors. The likelihood of medical oncology referral in patients who had elective resection was 63% versus 41% in those who had emergency resection and resection in private hospitals was 69% versus 50% in public hospitals. CONCLUSION: Referral to a postoperative medical oncology clinic for adjuvant chemotherapy in Dukes' C colonic cancer was more likely in younger patients, those who underwent elective resection and those treated in private hospitals.
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Neoplasias del Colon/terapia , Oncología Médica , Derivación y Consulta/estadística & datos numéricos , Anciano , Quimioterapia Adyuvante , Femenino , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Humanos , MasculinoRESUMEN
To investigate the length of lymphangiogenesis in the rectal tissue distal to a rectal cancer and its effect on the resection margins of the rectum, 63 specimens of normal rectal tissue distal to the tumor were collected from the surgical resections of ten rectal cancer patients. The specimens were taken at 0.5-cm intervals between the distal end of tumor and the distal surgical margin. The mean amount of collected tissue in each patient was 6.3. The expression of VEGFR-3 and Prox1 was measured in the specimens using real-time quantitative reverse transcription polymerase chain reaction. VEGFR-3 and Prox1 were expressed in all harvested tissues. There was a reduction of expression of VEGFR-3 (nine cases) and Prox1 (ten cases) from tissue adjacent to the rectal tumor to the distal resection margin of the rectum. A downward slope of the expression levels of VEGFR-3 and Prox1 in all cases was found at less than 3.0 cm distal to the tumor. The median VEGFR-3 expression level in the tissues within 1.5 cm adjacent to the rectal cancer was higher than in those tissues beyond 1.5 cm (P = 0.024). The median Prox1 expression level in the tissues within 1.0 cm distal to the rectal cancer was higher than in those tissues beyond 1.0 cm (P = 0.003). Lymphangiogenesis may facilitate the mural spread of cancer cells. The length of development of new lymphatics in the rectal wall distal to a rectal cancer may be less than 3.0 cm. Resection of a rectal cancer should routinely include 3.0 cm distal to the tumor to ensure adequate excision of tissue subject to lymphangiogenesis and potential mural spread of the tumor.
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Linfangiogénesis , Vasos Linfáticos/patología , Neoplasias del Recto/patología , Neoplasias del Recto/cirugía , Recto/patología , Anciano , Biomarcadores/metabolismo , Femenino , Proteínas de Homeodominio/metabolismo , Humanos , Vasos Linfáticos/metabolismo , Masculino , Persona de Mediana Edad , Pronóstico , Neoplasias del Recto/diagnóstico , Neoplasias del Recto/metabolismo , Recto/metabolismo , Estudios Retrospectivos , Resultado del Tratamiento , Proteínas Supresoras de Tumor/metabolismo , Receptor 3 de Factores de Crecimiento Endotelial Vascular/metabolismoRESUMEN
PURPOSE: The primary objectives of this trial were to evaluate the safety and feasibility of treatment and to gain a preliminary indication of the effectiveness of ethylene vinyl alcohol injections into the anal sphincters of faecally incontinent patients. METHODS: Between April 2004 and February 2006, we conducted a prospective, single-arm, procedure optimization study of ethylene vinyl alcohol injections in 21 subjects with well-characterized faecal incontinence and an intact external anal sphincter at two Australian hospitals. RESULTS: There was a significant decrease in the Cleveland Clinic Florida Faecal Incontinence Score (CCFFIS) (P= 0.0005) and the Faecal Incontinence Severity Index score (P= 0.005) after treatment. At 12 months post-treatment, the mean CCFFIS had decreased by 37% (P= 0.0021), and 47% of subjects had a > or =50% improvement in CCFFIS. There were significant improvements in embarrassment (P= 0.0455) and coping/behaviour (P= 0.0056) domains of the Faecal Incontinence Quality of Life. At 12 months, the mean anal canal length had increased by 29% (P= 0.066), with 40% of patients demonstrating increases of 50% or more. There were no further improvements following retreatment. CONCLUSIONS: Ethylene vinyl alcohol injection into the anal intersphincteric plane is feasible and well tolerated. Improvement in faecal incontinence compared with baseline was seen. Retreating initial non-responders was not successful.
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Incontinencia Fecal/terapia , Polivinilos/uso terapéutico , Adulto , Anciano , Canal Anal/fisiopatología , Estudios de Cohortes , Defecación , Estudios de Factibilidad , Incontinencia Fecal/etiología , Incontinencia Fecal/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Polivinilos/administración & dosificación , Calidad de Vida , Recto/fisiopatología , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: A prospective case series of transumbilical single-incision laparoscopic colectomies using conventional laparoscopic trocars and instruments is described. METHODS: Seven selected patients with colonic neoplasm underwent transumbilical SIL colectomy between November 2008 and March 2009. Three trocars via a single small umbilical incision were used. The bowel was mobilized and the vessels ligated intracorporeally with an extracorporeal anastomosis. RESULTS: This series of seven patients (6 men and 1 woman) had no conversion to standard multiport laparoscopy or open surgery. Six of the patients had pathology in the right colon, and one had a carcinoma at the splenic flexure. The patients had an average age of 71 years (range, 63-83 years) and an average body mass index (BMI) of 24.3 kg/m(2) (range, 21-28 kg/m(2)). The average operating time was 89 min (range, 75-115 min). No significant blood loss or complications occurred. The average length of hospital stay was 5.4 days (range, 4-11 days). The average incision length was 3.1 cm (range, 2.5-4.5 cm). Histopathology showed adequate tumor excision margins and an average lymph node yield of 15 nodes (range, 7-26 nodes). CONCLUSIONS: Single-incision laparoscopic surgery for colectomy is feasible. It can be performed without specialized instrumentation and at no extra cost. Further evaluation is required.
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Colectomía/métodos , Neoplasias Colorrectales/cirugía , Laparoscopios , Laparoscopía/métodos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Escisión del Ganglio Linfático , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Instrumentos Quirúrgicos , Resultado del TratamientoRESUMEN
OBJECTIVE: To examine the initial impact of the National Bowel Cancer Screening Program (NBCSP), which was launched in May 2006 and offers faecal occult blood testing to Australians aged 55 or 65 years. DESIGN AND SETTING: Review of data on colorectal cancer (CRC) cases diagnosed between May 2006 and June 2008 from a prospective database used at 19 Australian hospitals, linked and analysed by BioGrid Australia. MAIN OUTCOME MEASURES: Number of CRC cases detected through the NBCSP or symptomatic presentation, and differences by sex, stage at diagnosis, tumour location and level of socioeconomic disadvantage. RESULTS: 1628 cases of CRC were identified; 1268 had information on the patients' test status as part of the NBCSP, and 40 of these (3.2%) were recorded as being detected by the NBCSP. Of 75 CRC cases in patients aged 55 or 65 at diagnosis, 22 were NBCSP-detected. Overall, there was no difference in NBCSP-detected cases by sex. The distribution of tumour locations was similar between NBCSP-detected cases and symptomatic cases, but NBCSP-detected cancers were diagnosed at an earlier stage than symptomatic cancers (stage I, 40% v 14%; stage IV, 3% v 15%, respectively). Of patients diagnosed through the NBCSP, 63% were from areas of least socioeconomic disadvantage (deciles 8-10) and 18% were from the most disadvantaged areas (deciles 1-4) (P=0.0375). CONCLUSION: Initiation of the Australian NBCSP has had a measurable impact on CRC stage at diagnosis, and an improvement in survival would be anticipated. The lower uptake among people from disadvantaged areas is of concern.
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Neoplasias Colorrectales/diagnóstico , Tamizaje Masivo , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Australia/epidemiología , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sangre Oculta , Factores Socioeconómicos , Adulto JovenRESUMEN
BACKGROUND: Following preoperative treatment of rectal cancer with chemoradiotherapy (CRT), a complete pathological response (CPR) can be seen in the surgical specimen. The aim of this study was to assess the outcome of these patients as compared with those who did not have a complete response. METHODS: A retrospective study of the outcome of patients managed with preoperative CRT for their rectal cancer was conducted. RESULTS: Between November 1998 and July 2004, there were 530 new presentations of rectal cancer at The Queen Elizabeth and Royal Adelaide hospitals. Forty of these patients (7.5%) were treated with long-course preoperative CRT. After resection, a CPR was seen in seven patients (17.5%). These patients were all disease free at January 2006 after a median follow-up of 6.0 years (range 1.42-7.02 years). One patient had died from non-tumour-/surgery-related causes. Tumour recurrence, but not mortality, in this group was superior to the comparison group of patients without a CPR. CONCLUSIONS: None of our patients who had a CPR after preoperative CRT have recurred or died from their disease.
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Antimetabolitos Antineoplásicos/uso terapéutico , Fluorouracilo/uso terapéutico , Neoplasias del Recto/terapia , Anciano , Quimioterapia Adyuvante , Terapia Combinada , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Estadificación de Neoplasias , Dosificación Radioterapéutica , Radioterapia Adyuvante , Neoplasias del Recto/patología , Recurrencia , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
This article describes the initiation and implementation of the multicentre Australia and New Zealand prospective randomized controlled clinical study comparing laparoscopic and conventional open surgical treatments of right-sided and left-sided potentially curable colon cancer (Australasian Laparoscopic Colon Cancer Study). Six hundred and one adult patients were admitted with a clinical diagnosis of a single adenocarcinoma based on a physical examination and colonoscopy, barium enema or computed tomography scan and randomly allocated to either laparoscopic or open surgery. The primary aim of the study is to compare 5-year mortality and tumour recurrence rates between the two groups. Secondary aims include comparisons of safety (intraoperative and early postoperative complications, wound site recurrence, postoperative recovery and 30-day mortality), quality of life, in-hospital costs and short-term mortality and tumour recurrence. The data for 592 patients have been collected. There are currently 3141 person years of follow up. In all 370 patients have been assessed at 5 years. This study shows that large cooperative Australia-New Zealand surgical trials can and should be carried out to address significant clinical issues. When possible, coherence with similar, concurrent international trial protocols ensures broader analyses and applicability of results. It is important to recognize that special attention to sustained funding, surgeon credentialing, clinical protocol standardization, data management, publication policy and the protection of study credibility is required from the outset. The Australasian Laparoscopic Colon Cancer Study will achieve its aims with 5-year assessments of all entered patients in March 2010.
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Adenocarcinoma/cirugía , Neoplasias del Colon/cirugía , Adulto , Australia , Colectomía , Humanos , Laparoscopía , Nueva Zelanda , Selección de Paciente , Proyectos de InvestigaciónRESUMEN
BACKGROUND: Laparoscopy has revolutionized many abdominal surgical procedures. Laparoscopic colectomy has become increasingly popular. The short- and long-term benefits and satisfactory surgical oncological treatment of colorectal cancer by laparoscopic-assisted resection remain topical. The long-term outcomes of all international randomized controlled trials are still awaited, and short-term outcomes are important in the interim. METHODS: Between January 1998 and April 2005, a multicenter, prospective, randomized clinical trial in patients with colon cancer was conducted. Six hundred and one eligible patients were recruited by 33 surgeons from 31 Australian and New Zealand centers. Patients were allocated to colectomy by either laparoscopic-assisted surgery (n = 294) or open surgery (n = 298). Patient demographics and secondary end-points, such as operative and postoperative complications, length of hospital stay, and histopathological data, will be presented in this article. Analysis was by intention-to-treat. Survival will be reported only as the study matures. RESULTS: Histopathological parameters were similar between the two groups, except in regard to distal resection margins. There was no statistically significant difference found in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in quicker return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. A statistically significant increased rate of infective complications was seen in cases converted from laparoscopic-assisted to open procedures but with no difference in reoperation or in-hospital mortality. CONCLUSIONS: Laparoscopic-assisted colonic resection gives significant improvements in return of gastrointestinal function and length of stay, with an increased operative time and no difference in the postoperative complication rate.
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Adenocarcinoma/cirugía , Neoplasias del Ciego/cirugía , Colectomía/métodos , Neoplasias del Colon/cirugía , Adenocarcinoma/patología , Adulto , Anciano , Anciano de 80 o más Años , Australia , Neoplasias del Ciego/patología , Neoplasias del Colon/patología , Femenino , Humanos , Laparoscopía , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Nueva Zelanda , Complicaciones Posoperatorias/epidemiología , Resultado del TratamientoRESUMEN
BACKGROUND: One-stop rectal bleeding clinics (RBC) are designed to diagnose and treat colorectal diseases that present with rectal bleeding. The Queen Elizabeth Hospital RBC is an open access clinic and is unique in South Australia. It offers flexible sigmoidoscopy and facilities for treating common anorectal conditions. METHODS: Data of all patients presenting to the RBC were prospectively recorded into a database. Data were collected on the patient details, presentation, medical history, physical examination, treatment and intended follow-up. RESULTS: A total of 1539 cases was seen in the clinic between March 2000 and February 2006. Flexible sigmoidoscopy was carried out in 1145 cases (75.03%). Banding or injection of haemorrhoids was carried out in 383 cases. A total of 590 patients was referred for colonoscopy and of these, 27 were diagnosed with colorectal adenocarcinoma or squamous cell cancer of the anus. Most of these patients were more than 50 years old (26 of 27; 96.30%) and had associated symptoms, such as weight loss or altered bowel habit with their rectal bleeding (23 of 27; 85.19%). CONCLUSION: Rectal bleeding clinics can facilitate early diagnosis of colorectal malignancy and can also provide a 'one-stop shop' for treating benign anorectal conditions.
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Neoplasias Colorrectales/complicaciones , Neoplasias Colorrectales/diagnóstico , Hemorragia Gastrointestinal/etiología , Servicio Ambulatorio en Hospital , Adenocarcinoma/complicaciones , Adenocarcinoma/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias del Ano/complicaciones , Neoplasias del Ano/diagnóstico , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/diagnóstico , Colonoscopía , Femenino , Humanos , Pólipos Intestinales/patología , Pólipos Intestinales/cirugía , Masculino , Persona de Mediana Edad , Recto , Australia del SurRESUMEN
OBJECTIVE: To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature. SUMMARY BACKGROUND DATA: Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers. METHODS: A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review. RESULTS: Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates. CONCLUSIONS: Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.
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Neoplasias Colorrectales/complicaciones , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Obstrucción Intestinal/cirugía , Implantación de Prótesis/instrumentación , Stents , Humanos , Obstrucción Intestinal/etiología , Resultado del TratamientoRESUMEN
PURPOSE: Colorectal cancer patients diagnosed with stage I or II disease are not routinely offered adjuvant chemotherapy following resection of the primary tumor. However, up to 10% of stage I and 30% of stage II patients relapse within 5 years of surgery from recurrent or metastatic disease. The aim of this study was to determine if tumor-associated markers could detect disseminated malignant cells and so identify a subgroup of patients with early-stage colorectal cancer that were at risk of relapse. EXPERIMENTAL DESIGN: We recruited consecutive patients undergoing curative resection for early-stage colorectal cancer. Immunobead reverse transcription-PCR of five tumor-associated markers (carcinoembryonic antigen, laminin gamma2, ephrin B4, matrilysin, and cytokeratin 20) was used to detect the presence of colon tumor cells in peripheral blood and within the peritoneal cavity of colon cancer patients perioperatively. Clinicopathologic variables were tested for their effect on survival outcomes in univariate analyses using the Kaplan-Meier method. A multivariate Cox proportional hazards regression analysis was done to determine whether detection of tumor cells was an independent prognostic marker for disease relapse. RESULTS: Overall, 41 of 125 (32.8%) early-stage patients were positive for disseminated tumor cells. Patients who were marker positive for disseminated cells in post-resection lavage samples showed a significantly poorer prognosis (hazard ratio, 6.2; 95% confidence interval, 1.9-19.6; P = 0.002), and this was independent of other risk factors. CONCLUSION: The markers used in this study identified a subgroup of early-stage patients at increased risk of relapse post-resection for primary colorectal cancer. This method may be considered as a new diagnostic tool to improve the staging and management of colorectal cancer.
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Biomarcadores de Tumor/sangre , Neoplasias Colorrectales/diagnóstico , Recurrencia Local de Neoplasia/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Líquido Ascítico/patología , Antígeno Carcinoembrionario/sangre , Antígeno Carcinoembrionario/genética , Neoplasias Colorrectales/genética , Neoplasias Colorrectales/cirugía , Femenino , Humanos , Queratina-20 , Queratinas/sangre , Queratinas/genética , Laminina/sangre , Laminina/genética , Masculino , Metaloproteinasa 7 de la Matriz/sangre , Metaloproteinasa 7 de la Matriz/genética , Persona de Mediana Edad , Recurrencia Local de Neoplasia/genética , Estadificación de Neoplasias , Lavado Peritoneal , Pronóstico , ARN Mensajero/análisis , Receptores de la Familia Eph/sangre , Receptores de la Familia Eph/genética , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
BACKGROUND: Chronic anal fissure is a significant cause of morbidity. Internal sphincterotomy has long been the operative treatment of choice. Concerns remain, however, on its effects on continence. Botulinum toxin has been used as an agent for chemical sphincterotomy, causing temporary alleviation of sphincter spasm and allowing the fissure to heal. The aim of the present study was to compare the results of sphincterotomy to botulinum toxin. METHODS: The study was designed as a randomized controlled trial. All adult patients over the age of 18 with chronic idiopathic fissure in ano who had failed conservative treatment were included in the trial. Patients were randomized to receive either Botox or sphincterotomy. Pain, healing of fissure and continence scores were the outcomes assessed. RESULTS: A total of 38 patients were studied. Seventeen patients were randomized to receive Botox and 21, sphincterotomy. Patients in the Botox group were found to have significantly higher 2-week pain scores and reoperation rates, and poor healing. Continence scores were not significantly different in the two groups. CONCLUSION: Sphincterotomy gives better results than Botox in the treatment of fissure. Botox, however, is safe with no complications and no detriment to continence and could be used in certain situations.