bluuebunny/crossref_metadata_2025 huggingface dataset:
Anal endosonography in haemorrhoidal disease: do anatomical changes have clinical implications?
Authors: Poen  , Felt‐Bersma  , Cuesta  , Meuwissen
Published: March 2003

Objective

This study was designed to evaluate anal endosonographic findings in patients with internal haemorrhoids and to test whether endosonographic parameters can serve as prognostic factors for treatment outcome and recurrence.

Patients and methods

One hundred and twenty‐nine patients (72 males, 57 females, mean age 48 years (range 19–82 years)) were treated for grade 1 to grade 3 internal haemorrhoids with either rubber band ligation (n = 62) or infrared photocoagulation (n = 67). Evaluation before and 1 month after the last treatment consisted of a symptom questionnaire, digital examination, proctoscopy and anal endosonography. The thickness of the submucosa (SMT) and internal (IST) and external anal sphincters (EST) was measured in four quadrants and averaged. Comparisons were made with 40 age‐ and sex‐matched healthy controls. Follow up was 19.2 ± 7.8 months (mean ± s.d.). Multivariate analysis was performed to identify endosonographic factors for treatment outcome and recurrence.

Results

Eighty‐six patients had grade 1, 34 grade 2 and nine grade 3 haemorrhoids. At endosonography, most but not all haemorrhoids were recognized as anterior thickening of the submucosal layer with a partial hypoechoic appearance. Compared with healthy controls SMT (2.6 ± 0.8 mm vs 2.3 ± 0.5 mm, P < 0.03), IST (1.7 ± 0.5 mm vs 1.5 ± 0.5 mm, P < 0.03) and EST (8.7 ± 1.6 mm vs 7.7 ± 1.4 mm, P < 0.001) were increased. Submucosal thickness correlated with the degree of haemorrhoids (r = 0.19, P = 0.04). No difference in endosonographic appearance of anal morphology was found after treatment. With multivariate analysis no endosonographic factors could be identified which could predict treatment outcome or symptom recurrence.

Conclusion

Haemorrhoids are associated with endosono‐ graphic thickening of submucosal tissue, internal and external anal sphincter. Therefore, both sphincters as well as changes in the submucosa might be of pathophysiological importance. Endosonographic changes cannot predict treatment outcome or symptom recurrence.
Home rectal evacuation prior to a colorectal clinic appointment: a prospective, randomized, controlled, single‐blind trial
Authors: Lobo  , Riddick  , Iftikhar  , Gudgeon
Published: March 2003

Objective

The presence of faeces in the rectum can limit the effectiveness of diagnostic rigid sigmoidoscopy and therapeutic proctoscopy. This study was undertaken to determine whether home self‐administration of a Microlette Micro‐enema® or two glycerine suppositories improves the view on rigid sigmoidoscopy and to assess patient acceptability.

Patients and methods

Patients referred with colorectal symptoms were prospectively randomized into three groups of 50. Patients in Groups I and II were sent a Microlette Micro‐enema® or two glycerine suppositories, respectively, along with instructions for home self‐administration. Group III comprised unmedicated controls.

Results

Compliance was 98%. There was no significant difference in faecal loading between Groups I and II, but both groups had significantly more patients with empty rectums in comparison with Group III (P < 0.001). The median (interquartile range) distances in cm from the anal verge reached on rigid sigmoidoscopy in Groups I, II and III were 15.0 (15.0–20.0), 18.0 (15.0–20.0) and 15.0 (4.25–15.0), respectively (Groups I vs III and Groups II vs III P < 0.001; Groups I vs II P = 0.03). Quality of views on rigid sigmoidoscopy were best in Group II (Groups I vs III and Groups II vs III P < 0.001; Groups I vs II P = 0.04). Four patients in Group I and two in Group II found home self‐administration of the enema/suppositories inconvenient or unacceptable.

Conclusion

Home self‐administration of two glycerine suppositories prior to a colorectal clinic visit is simple, inexpensive and acceptable to patients and allows better views on rigid sigmoidoscopy.
The clinical course of intra‐abdominal desmoid tumours in patients with familial adenomatous polyposis
Authors: Church  , McGannon  , Ozuner
Published: March 2003

Objective

Desmoid tumours are benign growths of fibro‐aponeurotic tissue that are rare in the general population but pose problems in patients with familial adenomatous polyposis (FAP). Many reports of patients with desmoid tumours are unhelpful because of small numbers, inclusion of patients with and without FAP, failure to separate tumours in different sites and use of a wide variety of treatment combinations. The purpose of this study was to avoid some of these deficiencies by reviewing the clinical course of a large number of patients, all of whom have intra‐abdominal desmoids and FAP.

Patients and methods

The medical records of patients with intra‐abdominal desmoids treated at this institution were identified through the database in the David G. Jagelman FAP Registry and reviewed. Only patients who received all or part of their treatment at the Cleveland Clinic were included. Protocols for desmoid follow up call for periodic measurement of the dimensions of the tumour, either by clinical examination or on computed tomography (CT) scan. The interval between examinations ranges from 3 months to 2 years, depending on the presence of symptoms and the rate at which the tumour is growing. A change in greatest diameter of >50% is deemed significant growth or regression.

Results

Seventy patients with intra‐abdominal desmoid tumours in the setting of FAP were identified. Mean age at desmoid diagnosis was 31 years; there were 24 men and 46 women. A family history of desmoids was present in 53% of families known to have FAP. Abdominal wall tumours were also present in 18 patients. Most desmoids presented after surgery (53/70) and multiple tumours were found in 24 patients. The commonest presentation of desmoid tumours was as an abdominal mass. One third of patients had no symptoms at presentation. Treatment included surgery (32), medicine (41) chemotherapy (10) and radiation (4). Eleven patients received no treatment. At the time of review 12 patients were dead (11 from desmoids), 15 were symptomatic and 41 asymptomatic. In seven cases the desmoid disappeared, two spontaneously, two after excision, and three after chemotherapy. Thirty‐four patients were being treated at the time of review, 29 with sulindac.

Conclusion

The outcome in these cases shows that most intra‐abdominal desmoid tumours in FAP are indolent mass lesions that may vary a little in size and do not cause serious harm to the patient. Medical treatments are usually ineffective; surgery is at best unwise and at worst the cause of disastrous complications. A small proportion of desmoids grow rapidly and usually lead to the patient's death. For these patients, anti‐sarcoma type chemotherapy is the only hope.
Is colon cancer management in a comprehensive cancer centre evidence‐based?
Authors: Ray‐Coquard  , Philip  , Négrier  , Desseigne  , Rivoire  , Fervers  , Farsi  , Chauvin
Published: March 2003

Objectives

 Between 1993 and 1994, the 80 physicians in the French comprehensive cancer centre, Léon Bérard, developed and implemented Clinical Practice Guidelines (CPGs) based on an analysis of the literature and a␣consensus of intra‐institutional experts. This study reports the impact of CPGs on the management of colon cancer and the identification of patients’ characteristics linked with CPGs’ compliance rates.

Patients and methods

 A ‘before‐after’ study, using records of colon cancer patients, was performed. Records for all patients newly referred with colon cancer in 1993 and 1995 (n = 77 and n = 81, respectively) were selected in 1993 and 1995. Medical decisions on these records were analysed to assess their compliance with the CPGs. Univariate and multivariate analyses of compliance factors for the CPGs were performed on the cohort of 128 patients. A systematic search of the literature was performed to determine the scientific evidence for non‐compliant decisions.

Results

 The compliance rate for colon cancer was significantly higher in 1995 than in 1993, 70% (62/88) (95% confidence interval (CI), 60–80%) vs 50% (34/68) (95% CI, 38–62%) (P = 0.009). Using logistic regression, year of management 1995 (OR 2.8; 95% CI, 1.12–6.9), metastatic stage (OR 4.12; 95% CI, 1.43–11.8), and Karnofsky scale > 70 (OR 11.5; 95% CI, 1.14–41.4) were identified as independent factors for compliance with the CPGs. In 1993 and 1995, 71% (48/68) (95% CI, 60–81%) and 81% (71/88) (95% CI, 73–89%), respectively, of medical decisions for colon cancer, conformed to the CPGs or were judged to be based on ‘scientific evidence’.

Conclusion

 Compliance rates were significantly higher in 1995. The development and implementation of CPGs for cancer management seemed to result in significant changes in medical practice. Moreover, the patients’ characteristics appeared to influence compliance with the guidelines.
A novel method to avoid pelvic adhesions following Hartmann’s procedure
Authors: Velitchkov  , Vassilev  , Belokonsky  , Losanoff  , Kjossev
Published: March 2003

Objective

 To report the preliminary results of a novel method to avoid adhesions in the pelvis following Hartmann’s procedure.

Patients and methods

 Nine patients (seven males, 88%) aged 20–63 years underwent Hartmann’s procedure between 1994 and 1997. On completing the procedure a round sheet of polyethylene foil was placed on the pelvic floor aimed at avoiding the formation of adhesions between the rectal stump and small bowel.

Results

 Laparoscopically assisted reversal was performed 1 month later in five (58%) patients, and between 1.5 and 2 months later in the remaining four. No adhesions between the small bowel and other viscera, to the foil, and rectal stump were found. The completion of the colorectal anastomosis met no difficulty and there was no morbidity.

Conclusion

 This method may offer significant surgical benefit, but more work is required to evaluate the technique further.
An analysis of site‐specific attributable pathologies for colorectal symptoms: diagnostic yield of colonoscopy
Authors: Zbar  , Pignatelli  , Sherman  , Toomey  , Kmiot
Published: March 2003

Objective

 The aim of this prospective study was to audit the diagnostic yield of colonoscopy for an unselected cohort of patients referred with lower intestinal symptoms.

Patients and methods

 Seven hundred and forty‐four consecutive patients over a 12‐month period were analysed. The main reasons for referral included rectal bleeding, iron deficiency anaemia, altered bowel habit, abdominal pain, colonoscopic follow up (for colitis, prior endoscopic polypectomy and after colorectal cancer resection) and screening (positive family history of colorectal cancer).

Results

 Rectal bleeding had a diagnostic yield of 69.4% (neoplastic yield of 23.8%). Over 50% of patients with anaemia had normal colonoscopies (23.7% yield for colorectal neoplasia). Only one carcinoma was found in 133 patients colonoscoped for abdominal pain or altered bowel habit (0.75%). New carcinoma diagnoses were made in 1.6% (1/59) of patients followed up after cancer resection and in 1.5% of those patients with prior endoscopic polypectomy (1/65).

Conclusion

 Colonoscopy is valuable as a routine investigation in patients presenting with rectal bleeding or iron deficiency anaemia.
Full thickness transrectal advancement flap for high anal fistula
Authors: Rieger  , Stitz  , Lumley
Published: March 2003

Objective

To determine the results of full thickness transrectal advancement flap for the treatment of high anal fistula.

Patients and methods

A retrospective case study analysis.

Results

A primary healing rate of 71% was achieved and overall with further operative procedures, 97% healed. Only one patient, who had Crohn’s disease, has not healed and has a stoma. Four patients had a successful second full thickness flap repair after primary failure. The result for patients with intestinal Crohn’s disease was less satisfactory, with a recurrence rate of 50% in six patients. Disturbed continence was seen in four (12%) patients.

Conclusion

The results of full thickness transrectal advancement flap were satisfactory in the treatment of high anal fistulae. The overall rate of healing was high and there was a low incidence of disturbed continence.
p27kipl protein expression: an independent prognostic factor in rectal carcinoma stages I–III
Authors: Pucciarelli  , Esposito  , Fassina  , Alaggio  , Masin  , Toppan  , Chieco‐Bianchi  , Lise
Published: March 2003

Objective

To evaluate the impact of some molecular markers on lymph node metastases, overall (OS) and disease‐free survival (DFS) in rectal cancer.

Patients and methods

We investigated p27kip1, p53, nm23, and vascular endothelial growth factor (VEGF) expression in 109 primary rectal cancer specimens (stage I, n=38; stage II, n=24; stage III, n=20; and stage IV, n=27) from patients operated on between 1990 and 1995 at Clinica Chirurgica II.

Results

Tumour differentiation (P=0.0469), depth of rectal wall invasion (T status) (P=0.0000), distant metastases (P=0.0000), vascular invasion (P=0.0000), and p27kip1 expression (P=0.0022) were associated with lymph node metastases (N status). During follow up (median duration 47 months), 48 patients died, and 25 patients (stages I–III) had recurrences. At multivariate analysis, T and N status, and intratumoural necrosis were independent risk factors for OS. The relative risk (RR) of death for patients with lymph node metastases, advanced T status and intratumoural necrosis was 3.3 (P=0.0002), 2.03 (P=0.0127), and 1.47 (P=0.1935), respectively. When analysis included only stage I–III patients, N status and p27kip1 protein expression were found to be independent risk factors for OS. The RR of death for patients with lymph node metastases and those without p27kip1 expression was 2.98 (P=0.0251), and 3.57 (P=0.0231), respectively. At multivariate analysis, N status, p27kip1 expression, and intratumoural necrosis were independent risk factors for DFS. The RR of recurrence for patients with lymph node metastases, intratumoural necrosis and absence of p27kip1 expression was 6.29 (P=0.0001), 3.04 (P=0.0168), and 3.25 (P=0.0387), respectively.

Conclusion

Absence of p27kip1 expression is a useful marker of tumour aggressiveness in rectal carcinoma stages I–III, and an independent predictor for OS and DFS.
Gastric pouch interposition between ileum and anus after total proctocolectomy
Authors: Rat  , Cheynel  , Benoit  , Rousseau  , Bilosi  , Favre
Published: March 2003

After a total proctocolectomy for familial adenomatous polyposis or for ulcerative colitis, an ileal pouch–anal anastomosis is not possible in some circumstances. In case of Crohn’s disease (CD), an ileal pouch‐anal‐anastomosis is contraindicated by most authors. We have devised a means to avoid a permanent ileostomy in these situations. It consists of transposing between ileum and anus the left half of the vertical part of the stomach, in the shape of a pouch vascularized through the right gastroepiploic pedicle. This plasty was performed on a 35‐year‐old female after a proctocolectomy for CD. There was no post‐operative complication. The functional results remained satisfactory after 9 months: two to five stools per 24 h, no urgency, occasional seepage during night. The main disadvantage was the necessity of high dose proton pump inhibitor therapy to prevent anal burning sensation.
Manual dilatation of the anus—still widely practised in the West of Scotland
Authors: Coull  , McCourtney  , Finlay  , Dalling
Published: March 2003

Objective

Two main surgical options exist for the current treatment of chronic anal fissure: manual dilatation of the anus (MDA) and lateral internal sphincterotomy (LIS). The high incidence of incontinence after MDA is widely documented. One study carried out in the West of Scotland in 1992 showed that 49% of patients undergoing MDA subsequently suffered some degree of incontinence. This study was set up to determine the number of surgeons in the region who continue to use MDA in their clinical management of chronic anal fissure.

Methods

All consultant and higher surgical trainees in General Surgery in the West of Scotland were circulated with a postal questionnaire in November 1996 requesting how long they had been in post and to state their current preferred treatment of choice for chronic anal fissure.

Results

Almost half the consultant surgeons (47%) in the West of Scotland favour MDA as their treatment of choice and its utilization increases according to seniority. In contrast, registrars and junior consultants predominantly use LIS.

Conclusion

These data show a high incidence of MDA as the treatment of choice for chronic anal fissure amongst consultant surgeons in the West of Scotland. The implications of such a practice are discussed.
Colon examination in patients with proven colorectal cancer
Authors: Jones  , Evans
Published: March 2003

It has been recommended that all patients with proven colorectal cancer should have a total colon check. This prospective study examines the practical implementation of this recommendation. It demonstrates the extent to which clinical practice may appear to drift away from a guideline, whilst remaining entirely justifiable. This has implications for future attempts to audit the implementation of guidelines.
Transanal endoscopic microsurgery (TEM): a tool for minimizing the extent of surgery in synchronous colorectal tumours
Authors: Lev‐Chelouche  , Margel  , Ravid  , Goldman  , Rabau
Published: March 2003

Objective

Synchronous colorectal neoplasms are a common pathology which at times necessitate extensive abdominal surgery. When one of the lesions is located in the rectum, the operation harbours even higher rates of morbidity and mortality. In such cases, we suggest a two‐step procedure, comprising TEM resection for the rectal tumour followed by a less extensive abdominal resection for the second.

Patients and methods

During 1998, six patients (mean age 74 years) with two synchronous colorectal neoplasms were operated using TEM resection for the rectal lesion (villous adenoma (n=3), adenocarcinoma (n=3)), followed 2–4 weeks later by abdominal surgery (Rt. colectomy (n=2), Lt. colectomy (n=4)) for the synchronous lesions, all of which were adenocarcinomas.

Results

There was no mortality and only minor reversible complications after both operations. Mean post‐operative stay after TEM excision was 3 days and rehabilitation was satisfactory enabling performance of the second operation after 2–4 weeks. All rectal tumours were resected with clear margins. Two were at stage T1 and one T2. Median follow up is 8 months with no evidence of recurrent neoplasm in any patient.

Conclusion

TEM excision of a rectal neoplasm, combined with transabdominal resection of a synchronous colonic tumour, allows the extent of surgery to be minimized, resulting in lower morbidity and mortality rates.
Magnetic resonance imaging of perianal fistulas: predictive value for Parks classification and identification of the internal opening
Authors: Holzer B. , Rosen H. R. , Urban M. , Anzböck W. , Schiessel R. , Hruby W.
Published: March 2003

Objective

MRI has been reported to be valuable in the investigation of patients with fistula in ano. The aim of this study was to evaluate the results of preoperative magnetic resonance imaging (MRI) in such patients using a surface coil and to compare it with surgical findings.

Patients and methods

In a prospective study, 28 patients (19 males, nine females, median age 39 years) with perianal fistula underwent preoperative MRI. Parks classification as well as the identification of an internal opening into the anal canal and/or rectum were compared with the surgical findings.

Results

Classification during surgery revealed five extrasphincteric, eight transsphincteric, seven suprasphincteric and eight intersphincteric fistulas. All patients with intersphincteric, suprasphincteric and transsphincteric fistulas were correctly classified by MRI. The comparison of MRI and surgical results revealed a concordance in 27 of 28 (96%) patients in terms of classification (κ 0.95, P < 0.01) and in 21 (75%) patients regarding the identification of the internal opening (sensitivity 63%, specificity 92%).

Conclusion

Our results indicate that MRI of perianal fistulas with the use of extra‐anal surface coils can accurately assess the surgical anatomy. It is a rapid, well‐tolerated technique which might play an important role in the management of perianal fistula.
Local methods of treatment of rectal cancer
Authors: Cook  , McC. Mortensen
Published: March 2003

Over 11 000 new cases of rectal cancer are reported in the UK each year. Recent technical advances have increased interest in local management of the disease. The introduction of screening for colorectal cancer will potentially lead to an increased number of early rectal cancers suitable for local curative treatment. In addition, as the proportion of elderly patients in the population rises, local methods of treatment of rectal cancer will become increasingly important in this group of patients with comorbid disease. A literature search was performed on Medline database for English language publications on local treatments of rectal carcinoma. Preoperative assessment, selection of patients, local therapeutic and palliative methods of treatment were evaluated. Local methods of treatment can be used for potentially curative operations for rectal cancer. Preoperative endoanal ultrasound appears to be the most useful investigation for determining depth of local invasion. Transanal endoscopic microsurgery has extended the boundaries of local surgery and permits access to the mid and upper rectum with results similar to those of conventional local techniques. Laser therapy and transanal resection provide the best form of palliation for more advanced rectal carcinomas.
Peri‐operative management of patients having external anal sphincter repairs: temporary prevention of defaecation does not improve outcomes
Authors: Ingham Clark C. L. , Wilkinson K. H. , Rihani H. R. , McDonald P. J. , Northover J. M. , Phillips R. K. S.
Published: March 2003

Objective

To determine whether there was any detectable difference in outcomes of external anal sphincter repair depending on whether patients were managed routinely with a covering stoma, a constipating dietary regimen or a laxative dietary regimen in the early postoperative period.

Patients and methods

A consecutive retrospective series of 299 anal sphincter repairs undertaken on 286 patients within a single institution was studied. Patients were divided into three groups depending on the peri‐operative regimen followed: routine use of a covering stoma (group 1), routine use of a postoperative constipating dietary regimen (group 2) and routine use of a laxative dietary regimen (group 3). Choice of peri‐operative regimen depended on surgeon preference alone. Short‐term outcomes (length of stay, complications) and long‐term outcomes (functional reported degree of continence, anal ultrasound and physiology test results) were assessed in relation to peri‐operative group as well as aetiology of sphincter damage.

Results

Short‐term results (complications of surgery) were obtainable in all patients; long‐term results were available for 89% of patients. Length of stay was similar for all 3 groups (excluding re‐admission for stoma closure). Complication rates were not significantly different between the three groups. Functional improvement in continence was reported by 68% of group 1, 69% of group 2 and 79% of group 3 (differences not statistically significant). An anatomical sphincter defect was detected postoperatively in 8% of patients in group 1, 9% in group 2 and 7% of group 3. Poorer outcomes were achieved in older patients and in patients with previous ileo‐anal pouch formation. Early faecal impaction and repair breakdown were independently associated with poor long‐term outcomes.

Conclusions

Neither routine use of a covering stoma nor a postoperative constipating regimen produced better results following external anal sphincter repair than did the use of a postoperative laxative regimen which encouraged early passage of loose stool without the need for straining.
The dose response of the internal anal sphincter to topical application of glyceryl trinitrate ointment*
Authors: Cundall J. D. , Gunn J. , Easterbrook J. R. , Tilsed J. V. T. , Duthie G. S.
Published: March 2003

Introduction

Glyceryl trinitrate (GTN) ointment has been used for the treatment of chronic anal fissure based on the assumed pathophysiology that the fissure is due to internal anal sphincter hypertonia and that GTN causes relaxation.

Method

48 patients, with a diagnosis of haemorrhoids, underwent 24 h anal manometry following application of different concentrations (placebo, 0.1%, 0.2%, 0.4%) of GTN ointment.

Results

We have found that there was a progressive relaxation with increasing doses (placebo −8.8%, 0.1% GTN −21.9%, 0.2% GTN −27.2%, 0.4% GTN −33.1%). One way ANOVA showed this progression was significant (P=0.020), with the difference lying between placebo and 0.4% GTN (Tukey multiple comparisons, P=0.017). Only 3 patients experienced headaches and these were split evenly between the treatment arms.

Conclusion

The internal anal sphincter has a dose related response to GTN and when dose application is strictly applied higher doses may be used without an increase in side‐effects.
Long‐term outcome after colectomy in severe idiopathic constipation
Authors: Nylund G. , Öresland T. , Fasth S. , Nordgren S.
Published: March 2003

Objective

The specific aim of the investigation was to assess the long‐term results of subtotal colectomy with ileorectal anastomosis in patients with severe idiopathic constipation.

Patients and methods

40 patients with severe idiopathic constipation were operated on between 1981 and 1993. Patients were accepted for a colectomy and an ileo‐rectal anatomosis after a thorough gastro‐intestinal investigation. Pre‐operative bowel frequency was less than 2 movements per week, and slow transit was documented. Postoperative complications occurred in eight patients. Early re‐operation was performed in 2 patients for small bowel obstruction.

Results

Mean follow‐up was 11 (range 5–16) years. The defaecation frequency at follow‐up was 3.0 ± 1.9 per day. Twenty‐nine patients stated that they were satisfied and 11 were dissatisfied with the procedure. The outcome did not correlate with observed signs of outlet obstruction, blunted rectal sensation or presence of a psychiatric diagnosis. At 5–16 years after the procedure 33 patients still retain the ileo‐rectal anastomosis. Seven patients have had further procedures: Five patients have an ileo‐anal pouch, one has a continent ileostomy and one has a conventional ileostomy. Small bowel obstruction was encountered in 17 patients, in 10 of these surgical treatment was necessary.

Conclusion

It is concluded that colectomy and ileorectal anastomosis for the treatment of severe idiopathic constipation causes an increase in the number of bowel motions, but is deemed successful only by 3 out of 4 patients. Secondary morbidity is considerable.
Resources for coloproctology
Authors: Marks C. G.
Published: March 2003

Introduction from the Editor

The Association of Coloproctology of Great Britain and Ireland undertook a project to define the resources required for Colorectal surgical practice in the UK. This was carried out by the Clinical Services Committee chaired by Professor Christopher Marks. A summary of the Report is published below.
The effectiveness of new criteria for colorectal fast track clinics
Authors: Harinath G. , Somasekar K. , Haray P. N.
Published: March 2003

Introduction

Fast Track Colorectal Clinics are becoming a requirement to meet the government's 10‐day rule for patients with suspected cancers to be seen by a specialist. However, such clinics soon tend to get overwhelmed by huge numbers of referrals, many of them inappropriate. The Association of Coloproctology of Great Britain and Ireland has published criteria for appropriate referral. We evaluated the sensitivity of these criteria and attempted to recommend appropriate changes.

Methods

Data of 50 consecutive colorectal cancers from our DGH since January 2000 has been collected in relation to demographics, presenting signs and symptoms, haemoglobin levels as well as treatment. The new Criteria were then applied strictly to these cases and we evaluated whether these patients would have been eligible for fast track referral, if these criteria had been in force since January 2000.

Results

Forty‐one (82%) of 50 patients would have been eligible for referral as follows: 11 (22%) rectal bleeding with diarrhoea; 8(16%) persistent diarrhoea without bleeding (>60 years), 12 (24%) bleeding without anal symptoms (>60 years), 0 (0%) palpable right sided abdominal mass, 7 (14%) palpable rectal mass, 16 (32%) iron deficiency anaemia (<11 g/dl in men & <10 g/dl in women), 10 (20%) patients qualifying on more than one criterion. However, 9 (18%) patients had presenting features that would have excluded them from a fast track referral as follows: 4 (8%) only abdominal pain + weight loss (48, 54, 72, 75 years old), 2 (4%) change in bowel habit + no rectal bleeding (54, 57 years old), 1 (2%) palpable mass at a site other than the right side of the abdomen.

Conclusions

We feel that this study, although small, highlights the dangers of having very rigid criteria for such clinics. The new criteria though high in specificity have low sensitivity for safety. We recommend some modifications to the criteria as follows: rectal bleeding without anal symptoms >50 years instead of 60 years; patients with a palpable mass anywhere on the abdomen; and the adddition of a new criterion of abdominal pain with weight loss. These modifications would significantly increase the sensitivity from 82% to 94%.
Histological tumour response to pre‐operative combined modality therapy in locally advanced rectal cancer
Authors: Morgan M. J. , Koorey D. J. , Painter D. , Findlay M. , Tran K. , Stevens G. , Solomon M. J.
Published: March 2003

Background

Pre‐operative combined modality therapy (CMT) is used in locally advanced rectal cancer. Its use affects the clinicopathological staging based on the resected specimen. Assessment of the tumour response in the resected specimen may provide prognostic information. This study was undertaken to determine the histological response to pre‐operative chemoradiation and to assess the interobserver reliability of a newly developed tumour response grading system for rectal cancer.

Methods

Pre‐operative biopsy specimens and the resected specimens of 21 patients with low rectal cancer were assessed. The patients underwent pre‐operative CMT consisting of radiotherapy (45 Gy) with 5‐FU either as a continuous infusion or as a bolus intravenous infusion with leucovorin. After four to six weeks tumour response was assessed by comparing pre‐operative transrectal ultrasound (TRUS) findings (uT1‐4, uN0‐1) with postoperative histopathological assessment (pT1‐4, pN0‐1) using UICC TNM characteristics. Tumour response was defined as a decrease in T status. The histological response to CMT was based on the tumour regression grade (TRG) and ranged from fibrosis extending through the rectal wall with no residual cancer (TRG 1), to no evidence of tumour response (TRG 5). Inter‐observer reliability was assessed using weighted and unweighted kappa statistics.

Results

Local downstaging was demonstrated in 11/21 (52%) of patients. Three of 21 patients had a TRG 1 response. Thirteen of 21 (62%) patients had TRG 1–3 responses to CMT. There was no significant correlation between local downstaging and TRG. The interobserver correlation coefficient for assessment of TRG was 0.88 (unweighted kappa).

Conclusions

Local downstaging by pre‐operative CMT can be demonstrated if pre‐operative TRUS staging is compared to standard pathology staging in patients with rectal cancer. Local downstaging is not directly related to histologic response as assessed by TRG. Inter‐observer reporting of tumour regression grade (TRG) is reliable.
The influence of a colorectal service on the outcome of patients with colorectal cancer
Authors: Platell C.
Published: March 2003

Objective  To perform a prospective audit of outcomes and survival of all patients presenting to a colorectal service with colorectal cancer, and to compare these results with an historical control group.

Patients and methods  At a community based teaching hospital, a prospective audit of outcomes and survival of patients with colorectal cancer was compared with a historical control. The study included all patients referred to a colorectal service with colorectal cancer from 1996 to 2000 (5‐year period). The control group was a retrospective review of patients presenting to the same hospital with colorectal cancer from 1989 to 1994 (6‐year period). A Kaplan‐Meier survival analysis compared the overall survival (all‐cause mortality) between the two groups.

Results  When comparing the study periods 1989–95 (n = 477) to 1996–2000 (n = 323), there has been a significant reduction in postoperative stay (16.2 vs 8.0 days, P < 0.05), and a reduction in postoperative mortality (4.5%vs 2.7%, n.s.). There was a significant increase in the overall 2 years survival for patients with colorectal cancer (62% to 71%, P < 0.01). There was also a significant increase in the overall 2 years survival of patients with rectal cancer (66% to 74%, P < 0.01), patients with ACPS C colon cancers (64% to 83%, P < 0.05), and ACPS C rectal cancers (74% to 85%, P < 0.01).

Conclusions  There have been significant gains in the survival of patients presenting to a community based teaching hospital with colorectal cancer. These improvements have been most notable in patients with nodal metastases at the time of diagnosis.
Stapled anoplasty for haemorrhoids: a comparison of ambulatory vs. in‐patient procedures
Authors: Guy R. J. , Ng Cho Eng , Eu Kong‐Weng
Published: March 2003

Objective  Haemorrhoids are commonly seen in colorectal practice. Stapled anoplasty is a novel approach to the treatment of this condition and is usually performed as an in‐patient procedure. The aim of this study was to investigate the suitability of this technique for ambulatory surgery.

Patients and methods  Fifty consecutive patients undergoing stapled anoplasty under general anaesthesia as day cases (DC) (mean age 41 years; 27 females) by a single consultant surgeon over a 12‐month period were compared with 50 consecutive patients undergoing the same procedure as in‐patients (mean age 44 years; 25 females) (IP) during the same period.

Results  Eight DC patients (16%) were admitted overnight from the day surgery unit for urinary retention (3), pain (2), bleeding (2) and anaesthetic reasons (1). Three other DC patients were re‐admitted after a mean period of 4 days with bleeding (2), one of which required surgical haemostasis, and a septic complication (1). Mean hospital stay for IP cases was 2.6 (range 1–9) days. Two IP cases were re‐admitted after 4 and 11 days for bleeding and wound infection, respectively. At review 2–4 weeks after discharge, satisfaction in both groups was high. Minor staple‐line strictures were seen in 1 DC and 2 IP cases but all were easily dilated digitally. Mean costs incurred were significantly less for day surgery patients.

Conclusions  Stapled anoplasty is suitable for use in day‐case surgery as it is a quick and relatively painless procedure. The advantages, particularly financial, support the technique for use in an ambulatory setting, preferably in the morning, and provided detailed patient advice is given.
Clenbuterol stimulates neurotrophic support in streptozotocin‐diabetic rats
Authors: Riaz S. S. , Tomlinson D. R.
Published: March 2003

Background: The diabetic neuropathies are characterized by axonal degeneration of peripheral nerves. The commonest variant of this condition is distal symmetrical polyneuropathy, in which the principal presenting features can be explained by impaired neurotrophic support of sensory neurones.

Aims: The aims of these experiments were to determine whether deficits in nerve growth factor (NGF) content and the products of its target genes (substance P and calcitonin‐gene related peptide; CGRP) in the sciatic nerve of streptozotocin‐induced rats could be prevented using clenbuterol, which has been demonstrated to induce NGF synthesis in vitro.

Results: Diabetes of 8 weeks duration produced a reduction in measurable sciatic nerve NGF‐like immunoreactivity (NGF‐LI) content of 53% (p < 0.01). This was accompanied by depletion of substance P (of 43%; p < 0.01) and CGRP (of 45%; p < 0.01). Treatment with clenbuterol (30 μg/kg, 100 μg/kg and 300 μg/kg; daily subcutaneous injection) significantly increased the NGF‐LI and neuropeptide content of the sciatic nerve, with 30 μg/kg of clenbuterol normalising the levels in diabetic animals. The alterations in steady state sciatic nerve NGF‐LI were proportionally related to the amount of NGF‐LI delivered to the primary afferent neurones via retrograde transport. Thus, there was a significant reduction in accumulation of NGF‐LI distal to a 12‐h ligature in diabetic untreated rats (p < 0.01), which was normalized by clenbuterol (30 μg/kg; p < 0.05). Treatment of control or diabetic rats with clenbuterol did not affect the local production of NGF‐LI in the sciatic nerve adjacent to and triggered by an occluding ligature. The change in NGF‐LI content of neuronal tissue in the clenbuterol treated rats was a reflection of the capture of NGF derived from the peripheral targets of the sciatic nerve. The soleus and EDL muscles showed reductions in NGF‐LI in untreated diabetic animals. Clenbuterol significantly (p < 0.05) increased NGF‐LI in the soleus muscle.

Conclusion: Clenbuterol could be a useful tool in alleviating the deficits in neurotrophin support in diabetes.
Glucose and fatty acid metabolism in type 2 diabetes mellitus: an assessment using low‐dose insulin infusion and the hyperinsulinaemic euglycaemic clamp
Authors: Webber J. , Whitelaw D. , Smith J. M. , Nattrass M.
Published: March 2003

Aim: To assess whether resistance to the effects of insulin on lipid metabolism in type 2 diabetes mellitus parallels that demonstrated for glucose metabolism.

Methods: Thirteen patients with type 2 diabetes were studied (mean age 56.2 years, mean body mass index (b.m.i.) 28.7 kg m–2). The hyperinsulinaemic euglycaemic clamp (2 mU insulin kg–1 min–1) and a low‐dose insulin infusion technique were used in order to assess insulin effects on both glucose and lipid metabolism.

Results: Using the low‐dose insulin infusion there were significant correlations between measures of insulin sensitivity for glucose metabolism and those for NEFA (r = 0.82, p < 0.01) and glycerol (r = 0.73, p < 0.01). Mean clamp glucose disposal was 33.4 μmol kg b.w.–1 min–1. There was no correlation between clamp glucose disposal and insulin sensitivity derived from the low‐dose insulin infusion.

Conclusions: At low insulin concentrations, insulin’s effects on glucose metabolism (mainly suppression of hepatic glucose output) mirror those on inhibition of lipolysis. At the high insulin concentrations seen during the clamp, stimulation of glucose uptake provides a measure of maximal insulin action which does not parallel its physiological effects shown at lower concentrations.
Gliclazide reduces the induction of human monocyte adhesion to endothelial cells by glycated albumin
Authors: Desfaits A. ‐C. , Serri O. , Renier G.
Published: March 2003

Objective: To examine the kinetic of human monocyte adhesion to endothelial cells stimulated by glycated albumin, the contributive role of cell adhesion molecules to this effect, and the effect of gliclazide–an hypoglycemic drug with antioxidant properties–on these parameters.

Methods: In‐vitro experiments performed in the presence and absence of gliclazide consisted of: (1) time‐dependent determination of human monocyte adhesion to human endothelial cells (ECs) pre‐exposed to glycated albumin; (2) evaluation of adhesion after incubation of ECs with antibodies against cell surface adhesion molecules; and (3) determination of EC surface adhesion molecules and of the activity of the transcription factor NF‐κB.

Results: Exposition of human ECs for 1–48 h to 100 μg/ml glycated albumin led to a time‐dependent increase in human monocyte adhesion to endothelium. Pretreatment of ECs with 10 μg/ml gliclazide significantly decreased the glycated albumin‐stimulated monocyte adhesion to these cells. Anti‐antibodies against E‐selectin (ELAM‐1), vascular cell adhesion molecule‐1 (VCAM‐1) and intercellular adhesion molecule‐1 (ICAM‐1) also reduced the stimulatory effect of glycated albumin on monocyte adhesion. In glycated albumin‐treated ECs, an induction of both soluble and cell associated expression of ELAM‐1, VCAM‐1 and ICAM‐1, an augmentation in the levels of these molecule transcripts and an increase in the DNA binding activity for NF‐κB in the promoters of these antigens were observed. Gliclazide markedly inhibited the induction of all these parameters.

Conclusions: Glycated albumin stimulates human monocyte adhesion to ECs by inducing cell associated ELAM‐1, ICAM‐1 and VCAM‐1. Gliclazide effectively inhibits monocyte adhesion to ECs by reducing glycated albumin induction of EC adhesion molecules and NF‐κB activation. These results suggest that gliclazide may be beneficial in the prevention of endothelial disturbances associated with hyperglycemia in diabetic patients.
Intracerebroventricularly administered corticotropin‐releasing factor inhibits food intake and produces anxiety‐like behaviour at very low doses in mice
Authors: Momose K. , Inui A. , Asakawa A. , Ueno N. , Nakajima M. , Fujimiya M. , Kasuga M.
Published: March 2003

Aim: Previous studies have demonstrated that corticotropin‐releasing factor (CRF) produces behavioural, physiological and immunological responses similar to those induced by stress. However, these findings have been validated largely in laboratory rats.

Methods: We examined the effects of intracerebroventricular (i.c.v.) administration of CRF on anxiety and food intake in mice. Using the elevated‐plus maze, we measured anxiety levels after i.c.v. CRF in mice. We also measured food intake for 2 h after i.c.v. CRF.

Results: CRF increased the normal preference for the closed arms of the maze at a very low dose of 3 pmol, indicating an anxiogenic effect. CRF powerfully suppressed food intake at the doses of 3–300 pmol for over 2 h.

Conclusion: Our results demonstrate that i.c.v. CRF evokes anxiogenic behaviour and suppresses feeding with the same dose–response relationships in mice. CRF may thus play a role in integrating the overall responses to stress through co‐ordinated actions in the brain of this species.
Carbohydrate depletion has profound effects on the muscle amino acid and glucose metabolism during hyperinsulinaemia
Authors: Ebeling P. , Tuominen J. A. , Laipio M. L. , Virtanen M. A. , Koivisto E. , Koivisto V. A.
Published: March 2003

SUMMARY

Aim  We investigated the effect of carbohydrate availability and euglycaemic hyperinsulinaemia on intramuscular and plasma amino acids in 14 healthy men (age 26.5 ± 0.9 years, b.m.i. 22.9 ± 0.5 kg/m2).

Methods  Insulin was infused (1.5 mU/kg/min) for 240 min both after a carbohydrate depleting exercise and after carbohydrate loading. Muscle samples were taken before and after hyperinsulinaemia. Plasma and intramuscular amino acid concentrations were measured.

Results  Insulin‐mediated glucose disposal was similar after carbohydrate depletion (65.2 ± 1.9 μmol/kg/min) and loading (66.9 ± 2.8 μmol/kg/min). Carbohydrate depletion was associated with decreased alanine and increased branched chain amino acid (BCAA) concentrations in muscle and plasma. Blood lactate was lower after carbohydrate depletion (477 ± 25 μmol/l) than loading (850 ± 76 μmol/l, p < 0.001). In carbohydrate depletion, hyperinsulinaemia resulted in a greater increase in intramuscular (from 927 ± 48 nmol/g muscle to 2029 ± 104 nmol/g muscle, p < 0.001), than plasma (from 197 ± 6.7 μmol/l to 267 ± 11 μmol/l, p < 0.001) alanine. After carbohydrate loading muscle alanine did not rise significantly (from 1546 ± 112 nmol/g muscle to 1781 ± 71 nmol/g muscle) whereas plasma alanine decreased (from 339 ± 26 μmol/l to 272 ± 13 μmol/l, p < 0.05).

Conclusions  (1) Carbohydrate availability has profound effects on the interrelationship between glucose and amino acid metabolism and on the form of storage for glucose‐derived carbons. (2) For most amino acids changes in plasma levels of amino acids are not related to changes in concentrations of intramuscular amino acids during hyperinsulinaemia.
The effects of magnesium sulphate and EDTA in the hypercholesterolaemic rabbit
Authors: Evans D. A. Price , Tariq M. , Sujata B. , McCann G. , Sobki Samia
Published: March 2003

Numerous clinical reports suggest the beneficial effects of chelation therapy for the treatment of atherosclerosis. However, the results of these studies are inconclusive and controversial. The purpose of this present study was to examine the prophylactic and therapeutic effects of chelation liquid (CHL) in experimental atherosclerosis. Twenty New Zealand white rabbits were fed a 1% cholesterol‐supplemented diet for 45 days. In the prophylactic phase of the study subcutaneous 300 mg EDTA + 500 mg magnesium sulphate (MgSO4) injections (five rabbits) and isotonic saline (five rabbits) were given to test and control groups, respectively, along with cholesterol rich diet. The CHL treatment ameliorated the rise of serum cholesterol and serum triglyceride concentrations, lowered serum calcium concentrations and reduced the aortic atheroma. In the therapeutic phase of the experiment the cholesterol diet was stopped and the remaining 10 animals were returned to normal diet. Five of these rabbits were given CHL injections and other five animals were given isotonic saline injections for 121 days. Although the level of cholesterol and triglyceride were not significantly different in the two groups, the serum calcium concentration and the percentage of the area of flate aortic specimen occupied by atheroma were significantly lower in the CHL treated rabbits as compared to controls. It is concluded that CHL injections have a definite prophylactic effect on atherogenesis in the cholesterol‐fed rabbit, and may have some therapeutic value in the regression phase. Further confirmatory studies are suggested.