Rectal tumor height has been observed to increase after complete mobilization.
OBJECTIVES: 1.) to measure tumor height in resectable rectal cancers before and after complete mobilization, 2.) to describe changes in tumor height measurements at different levels of the rectum, and 3.) to determine the probability of a two centimeter increase in tumor height after mobilization in low rectal cancers.
METHODS: Prospective cross-sectional series including all resectable rectal cancer treated at our hospital from January to December, 2003. Proctoscopy measurements of rectal tumor height after induction of anesthesia were compared to measurements done after complete rectal mobilization. Logistic curve fitting was used to calculate the probability of a two centimeter increase in tumor height for low rectal cancers after complete mobilization.
RESULTS: In the 12-month period, 37 patients with adenocarcinoma of the rectum were seen. Ages of patients ranged from 26 to 86, with mean age of 57.8 years. Thirty-three patients had resectable rectal cancer. Tumor height ranged from zero to 11 cm, with mean height of 5.7 cm. After complete mobilization, tumor height increased in 50 percent of upper rectal cancers, 92 percent of mid-rectal cancers, and 32 percent of low rectal cancers. Logistic curve fitting showed probability of a two-centimeter increase in tumor height was 52 percent at seven centimeters, 40 percent at six centimeters, 28 percent at five centimeters, and 19 percent at four centimeters.
DISCUSSION: The decision to perform APR for low rectal cancers must not be based solely in pre-operative tumor height measurements since pre-operative measurements of rectal tumor height can increase when the rectum is completely mobilized.

Human ; Proctoscopy ; Rectumrectal Neoplasms ; Adenocarcinoma ; Anesthesiology ; Anesthesia ; Probability

The American Joint Committee on Cancer presently recommends obtaining at least seven to 14 lymph nodes in radical colon and rectum resections.
OBJECTIVES: 1.) To determine the number of lymph nodes recovered in our rectal cancer resection specimens, and 2.) to compare the number of our lymph node harvest with current international recommendations.
METHODS: Records of patients who underwent resection for adenocarcinoma of the rectum from 2001 to 2002 were reviewed. From the final pathology report, the number of lymph nodes recovered per specimen was described. This was correlated with the depth of tumor penetration (T) and the intra-operative staging of nodal status (N) by the surgeon.
RESULTS: Forty-seven patients underwent resection for adenocarcinoma of the rectum. Ages of patients ranged from 21 to 74 years, with a mean of 52 years. The lymph nodes recovered from the specimens ranged from zero to 15, with an average of 3.1 nodes per specimen. T4 tumors had the highest average rate of lymph node recovery at four nodes per specimen. In 16 patients, metastasis to regional lymph nodes were identified (16/47 or 34 percent node positive). The range of nodes recovered in node positive patients ranged from one to 15, with an average of six nodes. Thirty-one patients were node negative (31/47 or 66 percent). The average nodes recovered per specimen in this group was 1.8, ranging from zero to 12.
SUMMARY: From our review, almost 90 percent of our reports did not meet the minimum standard of recovering at least seven lymph nodes in rectal cancer resection specimens. In 94 percent of node negative patients, no sound therapeutic plans could be made due to inadequate lymph node harvest.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Rectum ; Lymph Nodes ; Rectal Neoplasms ; Adenocarcinoma ; Colon ; Lymph Node Excision ; Surgeons

OBJECTIVES: The objectives of this paper were: 1) to determine the relative frequency of colorectal cancer in the young, and 2) to compare the clinical features of young patients with colorectal cancer to those patients in the older age group.

METHODS: A total of 322 colorectal cancer patients (136 colon, 186 rectum) seen and treated by our section from 1995 to 1999 were reviewed.

RESULTS: In the five-year period, 32 colon cancer patients (24 percent) and 41 rectal cancer patients (22 percent) were less than 40 years old. The overall frequency of young patients with colorectal cancer was 23 percent. For colon cancer, there was a predominance of right-sided lesions in young patients (69 percent versus 31 percent in the older group). Both groups of patients had advanced disease (chi square, p=0.38). Aggressive histology of cancers was seen in 63 percent of the younger patients and 24 percent of the older patients (chi square, p=0.007). Most of the rectal cancers seen in both groups were distal third lesions (90 percent in young patients and 86 percent in older patients). Both groups of patients presented with advanced disease at the time of surgery (chi square p=0.71). Pathologic examination showed an aggressive tumor type in 30 percent of the young patients and 25 percent in the older group (chi square p=0.72).

CONCLUSION: The clinical features that we observed in young colorectal cancer patients were similar to those of earlier reports.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Adolescent ; Rectum ; Colorectal Neoplasms ; Colonic Neoplasms ; Rectal Neoplasms

RATIONALE/OBJECTIVES: The Turnbull-Cutait transanal pullthrough procedure with delayed coloanal anastomosis has been widely used before the advent of intestinal stapling devices. It is a viable option for rectal reconstruction for benign and malignant conditions, and is able to maintain intestinal continuity without the use of a temporary diversion. It has also been used in salvage operations for pelvic sepsis, failed anastomosis, and tumor recurrence that will otherwise require a permanent ileostomy. This study will describe the technique, as well as the outcomes of patients who underwent the procedure. METHODS: This is a retrospective descriptive study conducted to report the outcomes of patients who underwent the Turnbull-Cutait transanal pull-through with delayed coloanal anastomosis at the Philippine General Hospital from January 2008 to December 2013. Eleven patients were identified using an institutional retrospective database. Clinical data and outcomes were collected using a standard form. RESULTS: Ten of the 11 patients had an unremarkable postoperative course. One patient had an anastomotic dehiscence. The mean operative time was 229.9 minutes for the 1st stage and 28.2 minutes for the second stage, with a mean blood loss of 463.6 cc for both stages. The mean interval between the two stages was 7.9 days, with an average postoperative length of stay of 8.27 days. The average follow-up was 4.5 years. Functional outcomes were acceptable (average Wexner score 5.63), except for one patient who had an anastomotic dehiscence. No perioperative mortality was noted. CONCLUSION Turnbull-Cutait trans-anal pullthrough procedure with delayed coloanal anastomosis appears to be a safe procedure. The study suggests that it is an alternative strategy in rectal cancer in providing a sphincter-saving surgery, with the establishment of gastrointestinal continuity, and without the need for a proximal diversion. Stoma-less surgery has a notable health economic impact especially in developing countries because it eliminates the costs associated with the use of stoma appliances.

Recent evidence has shown that a five-centimeter distal margin is not required for cancers of the rectum. These findings proved significant in that selected patients with low rectal lesions can be offered curative operations that can preserve normal sphincter function, an intact route of defecation, and have a better quality of life. From August 2000 to July 2001, we began our series of examining specimens after rectal resection to determine the negative distal margin. The specimens for pathologic examination were cut at 0.5 cm intervals up to 2.0 cm from the raised distal edge of the tumor. The objective of this paper is to determine the distance of intramural tumor spread of rectal cancer from the macroscopic tumor edge. During the one-year period, a total of 11 specimens from rectal cancer patients were examined, ages of the patients ranged from 29 to 77 years. Eighty-two percent of patients had locally advanced (T3 and T4) lesions. Lymph node involvement was seen in 72 percent. Analysis of distal margins showed the following: five of 11 (45 percent) were positive for malignant cells at 0.5 cm from the tumor edge, four of 11 (36 percent) positive at 1.0 cm, one of 11 (nine percent) positive at 1.5 cm, and no malignant cells were seen at 2.0 cm distal margin. Our early results support the adequacy of a 2 cm distal resection margin for rectal cancer surgery. (Author)

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Rectum ; Margins Of Excision ; Defecation ; Rectal Neoplasms ; Digestive System Surgical Procedures ; Patient Selection ; Lymph Nodes

OBJECTIVE: The paper aimed to described and document the multidisciplinary process being ascribed to in the care of the colorectal cancer patient at the UP-PGH as conducted by the UP-PGH Colorectal Cancer and Polyp Study Group.

METHODS: A description of the multidisciplinary team (MDT) process is presented. Data supplementing the documentation of the MDT process were, likewise, presented.

RESULTS: In 2008, 214 rectal cancer patients were admitted and managed by the Division of Colorectal Surgery. Of these, 52 patients with mid- to low-rectal tumors eventually underwent resection of the primary lesion. Forty-one (79%) underwent a sphincter-saving operation. Only 11 APRs were performed. Our APR rate was, thus, at 21 percent. Among the 52 patients, 18 underwent neoadjuvant treatment with 10 subjected to chemoradiotherapy prior to surgery, a pathologic complete response was observed in 4 patients.

CONCLUSION: With the increasing incidence of colorectal malignancies and the continuing collection of evidence supporting multimodality approach, the role of multidisciplinary team in the management of these cancers has come to the fore. UP-PGH Colorectal Cancer and Polyp Study Group has shown that the multidisciplinary team approach may be implemented amidst institutional and financial limitations without compromising the delivery of quality and efficacious cancer management.

Human ; Colorectal Neoplasms ; Neoadjuvant Therapy ; Colorectal Surgery ; Rectal Neoplasms ; Chemoradiotherapy ; Colonic Neoplasms ; Polyps ; Patient Care Team

BACKGROUND: Hirschsprung’s disease (HD) is rare in adults, since a majority of cases are corrected in childhood. OBJECTIVES: The authors describe the profile of patients with HD who reached adulthood without having undergone corrective surgery. Also, they describe the outcomes of a modified Duhamel procedure in these patients, in terms of morbidity and mortality. METHODS: This retrospective study, included patients 18 years old and above, diagnosed with HD who reached adulthood without having undergone definitive repair and managed surgically by the Division of Colorectal Surgery, UP-PGH from January 1, 2004 to December 31, 2014. A review from the Department Surgical Database was used and patients’ hospital records were used to fill out a Data Collection Form. Descriptive statistics were used to summarize the data. RESULTS: The 13 patients included in the study were diagnosed at an average age of 16.6 (± 13.16) years. The mean age at the time of definitive surgery was 23.46 (± 6.96) years. The M:F ratio was 5.5:1. The most common presenting symptom was constipation (69.23%). All had a prior proximal bowel diversion, with a transverse loop colostomy (61.54%) being the most common. The transition zone was located in the sigmoid in a third of patients. The mean time from diagnosis to definitive surgery was 6.69 years. Eight (61.54%) have since undergone stoma reversal. There was only one (7.69%) morbidity, a superficial surgical site infection. No mortalities were reported. CONCLUSION The modified Duhamel procedure is a safe definitive surgical procedure for the adult patient with HD.

Cecal volvulus is a rare cause of intestinal obstruction caused by axial twisting of the cecum that occurs in 1–1.5 % of all intestinal obstruction, with an incidence of 2.8–7.1 cases per million annually. Cecal volvulus is potentially life-threatening without prompt surgical intervention. A 57-year-old woman presented with severe abdominal pain and distention. Laboratory examinations revealed normal white blood cell count with neutrophilic predominance. Diagnosis of acute cecal volvulus was made from a “whirl sign” on abdominal computed tomography. An exploratory laparotomy confirmed the diagnosis of cecal volvulus and a segmental ileocolic resection with primary anastomosis was carried out. The patient was discharged improved and returned to her normal activities of daily living.

The Philippine Council for Health Research and Development-Department of Science and Technology (PCHRD-DOST), and the Philippine College of Surgeons (PCS) signed a Memorandum of Agreement on 1 June 1999, whereby both agreed to support the formation of Evidence-Based Clinical Practice Guidelines (EBCPGs) on specific areas of surgical care in the Philippines. The areas were to be specified by the PCS, and those areas should have a reasonably large potential of improving the quality of patient care throughout the country, and can be implemented nationwide in both government and private health facilities The first clinical area selected was on when to refer for preoperative cardiac evaluation for elective noncardiac surgery, and when would the intraoperative presence of a cardiologist be beneficial. A Technical Working Group (TWG) was appointed, which: 1) searched and appraised the evidence; 2) prepared a first draft EBCPG; 3) presented the evidence to a Panel of Experts; 4) supervised the panel using the nominal group technique (6 November 1999 - PCS Building); and 5) prepared the second draft EBCPG based on the consensus recommendations of the panel. All processes strictly conformed to the methods of evidence-based guidelines formation specified by evidence-baesd medicine texts The second draft EBCPG was presented on 11 December 1999 during the 55th Clinical Congress of the PCS, and the final draft approved by the PCS Board of Regents on 29 January 2000 Literature search was conducted through the MEDLINE, COCHRANE Library an the HERDIN Database. A total of 2,156 titles, 427 abstracts and 77 full text articles were appraised. Data from 23 prospective cohort studies were encoded into the software COCHRANE Review Manager (RevMan), Version 3.0 for Windows (updated October 7, 1996). Tables were generated which contained authors, outcome rates, relative risks and the 95% confidence intervals of the relative risks. Three perioperative outcomes were identified-cardiac morbidity, cardiac death, and overall cardiac events

Human ; Risk ; Cardiologists ; Surgeons ; Research ; Publications ; Patient Care ; Health Facilities

INTRODUCTION: The use of neoadjuvant chemoradiotherapy (CRT) and total mesorectal excision (TME) has shown promising results in the management of locally advanced rectal carcinoma, and is associated with improvement in local control, disease free survival (DFS) and overall survival (OS). However, these clinical endpoints cannot be properly assessed due to poor follow up among many patients. Other endpoints such as negative circumferential resection margins (CRM), pathologic complete response (pCR) and sphincter-preserving surgery (SPS) may serve as indirect means of assessing successful treatment. This study reports the experience of the Philippine General Hospital (PGH) Colorectal Polyp and Cancer (CRPoCan) Study Group in using neoadjuvant CRT and TME in the management of locally advanced rectal carcinoma, towards quality care.
METHODS: The Integrated Surgical Information System (ISIS) database of the Department of Surgery, PGH was queried for rectal cancer patients with pretreatment clinical stage II and III disease that underwent neo-adjuvant CRT followed by TME between January 2008 and December 2009. The final surgical pathology reports of the subjects were reviewed for treatment response. Response was categorized as: (1) positive or negative CRM; and (2) with or without pCR. The study assessed whether SPS was done.
RESULTS: Of 140 potential neoadjuvant CRT patients followed by TME, 82 patients completed the treatment. Thirty two of the patients who completed treatment (39%) were eligible since the other 50 patients (61%) had no post-operative histopathology results. Among those eligible, 10 patients (31%) had pCR. Only 1 patient had a positive CRM. Of the 14 patients whose tumor distance was ?5cm from the anal verge, only 1 patient underwent SPS. The small sample size was mainly attributed to low resources or treatment. Non-availability of post-operative histopathology results was due to poor record keeping.
CONCLUSION: The PGH CRPoCan Study Group's use of neoadjuvant CRT followed by TME for locally advanced rectal carcinoma has resulted in acceptable numbers of pCR and clear CRM but has not translated into an increased number of SPS. Despite the limitations of the study, the institutionalization of the multidisciplinary team in the PGH CRPoCan Study Group and the implementation of the ISIS database program are considered the first steps towards quality health care.

Human ; Male ; Female ; Neoadjuvant Chemoradiotherapy ; Total Mesorectal Excision ; Polyp ; Surgical Pathology ; Rectal Cancer