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416 POSTER Anastomosis and protective defunctioning right subhepatic colostomy as an alternative to Hartmann procedure
Poster session: Colorectal and anal cancer 413
POSTER
Radio-guided surgery in low rectal cancer E. Lucisano 1 , C. Pinto 2 , M. Levorato 3 , M. Marengo 4 , T. Balbi 5 , F. Lecce 1 , D. Cuicchi 1 , P. Almerigi 1 , R. Lombardi 1 , B. Cola 1 . 1 Chirurgia Generale Cola, Dipartimento di Chirurgia Generale e dei Trapianti, Bologna, Italy; 2 Oncologia Medica, Dipartimento di Oncologia ed Ematologia, Bologna, Italy; 3 Medicina Nucleare, Dipartimento Area Radiologica, Bologna, Italy; 4 Fisica Sanitaria, Fisica Sanitaria, Bologna, Italy; 5 Anatomia Patologica, Dipartimento Malattie dell’Apparato Digerente, del Metabolismo e della Malattie, Bologna, Italy To evaluate the lateral pelvic lymphnodes involvement that could be responsible of recurrence, we have entered upon a phase II study using radioguided surgery (RGS) to extend lateral pelvic lymphnodes dissection when it is indicated. Five patients with biopsy proven primary or recurrent low rectal cancer had received in the Azienda Ospedaliero-Universitaria of Bologna, a transanal submucosal infiltration of 1 mCi of colloid labelled with radioactive 99mTc (Nanocoll Sorin Biomedica® ). The injection was carried out in the four cardinal points strictly around the neoplasm and after 2 hours lymphscintigraphy was performed. After 16-18 hours from the injection the patients underwent radical rectal surgery. Radiodetection of the lesion and lateral pelvic lymphnodes was performed using a hand-held gamma probe. Lateral pelvic lymphnodes has been map as Japanese classification of colorectal carcinoma and were considered hot if they had, after rectum resection, a radioactivity 5 times higher than the background.The results of scintigraphy and operative radiodetection (in-vivo and ex-vivo) were checked by histological examination. At the present time our study population is still too small-to assess the effectiveness of this diagnostic and therapeutic tool but preliminary results are worthy of interest. Actually this method could be useful to identify lateral pelvic lymphnodes involvement and to select cases in which wide lymphnodes dissection is necessary to avoid local residue. 414
POSTER
Surgical treatment of colorectal cancer with acute bowel obstruction G.V. Bondar 1 , G.G. Psaras 2 , S.E. Zolotukhin 1 , A.V. Bondar 1 , A.V. Borota 1 . 1 Donetsk Cancer Center, Surgical, Donetsk, Ukraine; 2 Mariupol Cancer Center, Surgical, Mariupol, Ukraine Background: Colorectal cancer (CRC) is one of the most common malignancies in Europe. Patients often can present symptoms of acute bowel obstruction. The mainstay of treatment of colorectal cancer complicated with acute bowel obstruction is surgical. Aims: We have investigated the results of surgical treatment of patients with CRC complicated with acute bowel obstruction treated in our clinic. Materials and methods: From January 1998 to September 2002 76 patients with CRC complicated with acute bowel obstruction were treated in our clinic. There were 45 male and 31 female patients, with mean age of 68.5 year (range 21 to 89). The cancer that caused the obstruction was localized in rectum – 26 pts, in sigmoid colon – 20 pts, in transverse colon – 3 pts, in caecum – 4 pts, in descending colon – 14 pts, in ascending colon – 9 pts. The postsurgical stages were as follows: T3 (67.2%); T4 (32.8%); any T with N+, (46.6%); and any T, N with M+, (17.2%). Results: 18 patients (23.7%) with severe ileus in decompensation stage the colostomy only were performed. Postoperative mortality is 11.1% in this group. Colostomy with the resection of the bowel was performed in 13 patients (17.1%) with postoperative mortality rate – 23.1%. 45 patients (59.2%) in relative compensatory condition after preoperative preparation were operated and single-stage resection and primary anastomosis was performed. Postoperative mortality – 11.1%. The five-year survival rate of the patients was 37.6%. The quality of life after surgery was normal, the slightly increased number (mean 2.1) of daily defecations was acceptable, and bacterial colonization of the small bowel did not occur. Conclusions: Patients with acute bowel obstruction due to colorectal cancer may be treated with single-stage resection and primary anastomosis, if satisfactory preoperative compensation is achieved.
415
S123 POSTER
Management of intraoperatively demonstrated low anterior anastomosis insufficiency M. Kocic, M. Inic, S. Nikolic, M. Zegarac, Z. Kozomara. Institute for Oncology and Radiology, Belgrade, Surgery, Belgrade, Serbia The author describes the ways of immediate management of low pelvic enterorectal anastomosis insufficiency. The causes of anastomosis insufficiency are: inaccurate bowel wall preparation, its folding, interposition of neighbouring tissues, bowel or rectal stump damage during stapler device removal after firing. Material and methods: In the Period from 2001 to 2005, at our Institute integrity of sta-pled anastomoses was controled upon completion in 98 patients by examination of excised tissue rings and by intrarectal injection of Povidone Iodid, intraoperative leakage was demonstrated in 10 cases. In 4 patients it was due to partial or total anastomosis dehiscence, in those cases the reconstruction of the low anastomosis had to be performed by hand suturing. In two patients it was possible to reanastomosae the stumps from abdominal approach. In one of them the reconstruction was comleted by diverting colostomy. The other dehiscences were repaired from sacral approach and by coloanal anastomosis through stretched anus. The other 6 anastomotie leaks were repaired by additional sutures puted on by abdominal approach. Results: In one patient only after the reconstruction according to Localio technique of low colorectal anastomosis dehiscence - a postoperative leakage was demonstrated. However it was cured by conservative treatment. The other repaired anastomoses healed without any complication. 416
POSTER
Anastomosis and protective defunctioning right subhepatic colostomy as an alternative to Hartmann procedure N. Perrakis, S. Andrikopoulos, G. Matsakis, M. Katsouri, K. Ntatsis, K. Kalogerakos, H. Tzerbinis, P. Koustenis, M. Dimitrief, I. Nomikos. METAXA Cancer Hospital of Piraeus, 2nd Surgical Department, Athens, Greece Introduction: Hartmann procedure (tumor resection with end-colostomy and closure of distal remaining colon) is the most commonly used operation in cases of acute surgical treatment of emergency situations concerning the descending, sigmoid and rectal colon. Hartmann procedure is a relatively safe operation. Nevertheless, a subsequent decision of re-establishing bowel continuity requires a long and usually laborious intra-abdominal operation. Since 1990 we have been applying a technique, alternative to Hartmann procedure, which involves simultaneous tumor resection and anastomosis followed by a right subhepatic protective double-lumen colostomy. The major benefit of this technique is the relative simplicity and ease by which intestinal function can be reinstated in patients submitted to this type of surgery. Patients and Methods: Between 1990 and 2006 we have treated with this technique a total of 17 patients, presenting with left colon emergencies, 10 of which were male with a mean age of 68 years and 7 were female with a mean age of 70.5 years. We performed primary lesion resection with a concomitant anastomosis and construction of a right subhepatic colostomy. Stoma restoration was performed 4 weeks later. Results: Of the 17 patients studied, there was one case of intestinal content leak and two postoperative deaths not related to the type of operation. 417
POSTER
Irritable bowel syndrome or small bowel tumour: a mysteries diagnosis A.I. Morgan 1 , J. Smith 2 . 1 Bristol Royal Infirmary, United Bristol Healthcare, Colorectal Unit, General Surgery, Bristol, United Kingdom; 2 West Middlesex University Hospital, Colorectal, General Surgery, London, United Kingdom Abdominal Cramps, alternating episodes of diarrhoea and constipation, nausea, vomiting, bloating and abdominal distension are common symptoms in Irritable bowel Syndrome as well as Small Bowel Tumours. A 56 years old male with a family history of bowel cancer diagnosed as
POSTER
Radio-guided surgery in low rectal cancer E. Lucisano 1 , C. Pinto 2 , M. Levorato 3 , M. Marengo 4 , T. Balbi 5 , F. Lecce 1 , D. Cuicchi 1 , P. Almerigi 1 , R. Lombardi 1 , B. Cola 1 . 1 Chirurgia Generale Cola, Dipartimento di Chirurgia Generale e dei Trapianti, Bologna, Italy; 2 Oncologia Medica, Dipartimento di Oncologia ed Ematologia, Bologna, Italy; 3 Medicina Nucleare, Dipartimento Area Radiologica, Bologna, Italy; 4 Fisica Sanitaria, Fisica Sanitaria, Bologna, Italy; 5 Anatomia Patologica, Dipartimento Malattie dell’Apparato Digerente, del Metabolismo e della Malattie, Bologna, Italy To evaluate the lateral pelvic lymphnodes involvement that could be responsible of recurrence, we have entered upon a phase II study using radioguided surgery (RGS) to extend lateral pelvic lymphnodes dissection when it is indicated. Five patients with biopsy proven primary or recurrent low rectal cancer had received in the Azienda Ospedaliero-Universitaria of Bologna, a transanal submucosal infiltration of 1 mCi of colloid labelled with radioactive 99mTc (Nanocoll Sorin Biomedica® ). The injection was carried out in the four cardinal points strictly around the neoplasm and after 2 hours lymphscintigraphy was performed. After 16-18 hours from the injection the patients underwent radical rectal surgery. Radiodetection of the lesion and lateral pelvic lymphnodes was performed using a hand-held gamma probe. Lateral pelvic lymphnodes has been map as Japanese classification of colorectal carcinoma and were considered hot if they had, after rectum resection, a radioactivity 5 times higher than the background.The results of scintigraphy and operative radiodetection (in-vivo and ex-vivo) were checked by histological examination. At the present time our study population is still too small-to assess the effectiveness of this diagnostic and therapeutic tool but preliminary results are worthy of interest. Actually this method could be useful to identify lateral pelvic lymphnodes involvement and to select cases in which wide lymphnodes dissection is necessary to avoid local residue. 414
POSTER
Surgical treatment of colorectal cancer with acute bowel obstruction G.V. Bondar 1 , G.G. Psaras 2 , S.E. Zolotukhin 1 , A.V. Bondar 1 , A.V. Borota 1 . 1 Donetsk Cancer Center, Surgical, Donetsk, Ukraine; 2 Mariupol Cancer Center, Surgical, Mariupol, Ukraine Background: Colorectal cancer (CRC) is one of the most common malignancies in Europe. Patients often can present symptoms of acute bowel obstruction. The mainstay of treatment of colorectal cancer complicated with acute bowel obstruction is surgical. Aims: We have investigated the results of surgical treatment of patients with CRC complicated with acute bowel obstruction treated in our clinic. Materials and methods: From January 1998 to September 2002 76 patients with CRC complicated with acute bowel obstruction were treated in our clinic. There were 45 male and 31 female patients, with mean age of 68.5 year (range 21 to 89). The cancer that caused the obstruction was localized in rectum – 26 pts, in sigmoid colon – 20 pts, in transverse colon – 3 pts, in caecum – 4 pts, in descending colon – 14 pts, in ascending colon – 9 pts. The postsurgical stages were as follows: T3 (67.2%); T4 (32.8%); any T with N+, (46.6%); and any T, N with M+, (17.2%). Results: 18 patients (23.7%) with severe ileus in decompensation stage the colostomy only were performed. Postoperative mortality is 11.1% in this group. Colostomy with the resection of the bowel was performed in 13 patients (17.1%) with postoperative mortality rate – 23.1%. 45 patients (59.2%) in relative compensatory condition after preoperative preparation were operated and single-stage resection and primary anastomosis was performed. Postoperative mortality – 11.1%. The five-year survival rate of the patients was 37.6%. The quality of life after surgery was normal, the slightly increased number (mean 2.1) of daily defecations was acceptable, and bacterial colonization of the small bowel did not occur. Conclusions: Patients with acute bowel obstruction due to colorectal cancer may be treated with single-stage resection and primary anastomosis, if satisfactory preoperative compensation is achieved.
415
S123 POSTER
Management of intraoperatively demonstrated low anterior anastomosis insufficiency M. Kocic, M. Inic, S. Nikolic, M. Zegarac, Z. Kozomara. Institute for Oncology and Radiology, Belgrade, Surgery, Belgrade, Serbia The author describes the ways of immediate management of low pelvic enterorectal anastomosis insufficiency. The causes of anastomosis insufficiency are: inaccurate bowel wall preparation, its folding, interposition of neighbouring tissues, bowel or rectal stump damage during stapler device removal after firing. Material and methods: In the Period from 2001 to 2005, at our Institute integrity of sta-pled anastomoses was controled upon completion in 98 patients by examination of excised tissue rings and by intrarectal injection of Povidone Iodid, intraoperative leakage was demonstrated in 10 cases. In 4 patients it was due to partial or total anastomosis dehiscence, in those cases the reconstruction of the low anastomosis had to be performed by hand suturing. In two patients it was possible to reanastomosae the stumps from abdominal approach. In one of them the reconstruction was comleted by diverting colostomy. The other dehiscences were repaired from sacral approach and by coloanal anastomosis through stretched anus. The other 6 anastomotie leaks were repaired by additional sutures puted on by abdominal approach. Results: In one patient only after the reconstruction according to Localio technique of low colorectal anastomosis dehiscence - a postoperative leakage was demonstrated. However it was cured by conservative treatment. The other repaired anastomoses healed without any complication. 416
POSTER
Anastomosis and protective defunctioning right subhepatic colostomy as an alternative to Hartmann procedure N. Perrakis, S. Andrikopoulos, G. Matsakis, M. Katsouri, K. Ntatsis, K. Kalogerakos, H. Tzerbinis, P. Koustenis, M. Dimitrief, I. Nomikos. METAXA Cancer Hospital of Piraeus, 2nd Surgical Department, Athens, Greece Introduction: Hartmann procedure (tumor resection with end-colostomy and closure of distal remaining colon) is the most commonly used operation in cases of acute surgical treatment of emergency situations concerning the descending, sigmoid and rectal colon. Hartmann procedure is a relatively safe operation. Nevertheless, a subsequent decision of re-establishing bowel continuity requires a long and usually laborious intra-abdominal operation. Since 1990 we have been applying a technique, alternative to Hartmann procedure, which involves simultaneous tumor resection and anastomosis followed by a right subhepatic protective double-lumen colostomy. The major benefit of this technique is the relative simplicity and ease by which intestinal function can be reinstated in patients submitted to this type of surgery. Patients and Methods: Between 1990 and 2006 we have treated with this technique a total of 17 patients, presenting with left colon emergencies, 10 of which were male with a mean age of 68 years and 7 were female with a mean age of 70.5 years. We performed primary lesion resection with a concomitant anastomosis and construction of a right subhepatic colostomy. Stoma restoration was performed 4 weeks later. Results: Of the 17 patients studied, there was one case of intestinal content leak and two postoperative deaths not related to the type of operation. 417
POSTER
Irritable bowel syndrome or small bowel tumour: a mysteries diagnosis A.I. Morgan 1 , J. Smith 2 . 1 Bristol Royal Infirmary, United Bristol Healthcare, Colorectal Unit, General Surgery, Bristol, United Kingdom; 2 West Middlesex University Hospital, Colorectal, General Surgery, London, United Kingdom Abdominal Cramps, alternating episodes of diarrhoea and constipation, nausea, vomiting, bloating and abdominal distension are common symptoms in Irritable bowel Syndrome as well as Small Bowel Tumours. A 56 years old male with a family history of bowel cancer diagnosed as