Purpose: Slow transit constipation (STC) is a debilitating condition mainly affecting young women. Total colectomy (TC) is an option for patients with severe symptoms who are unresponsive to conservative measures. Open TC has been the procedure of choice but is associated with long term SBO and ongoing symptoms. It is difficult to determine if these ongoing symptoms are related to gut dysmotility or to post operative adhesions. Laparoscopic TC appears equivalent open TC with the advantage of being able to perform a diagnostic laparoscopy at a later stage to divide or exclude adhesions as a cause of chronic obstructive symptoms or pain.Methods: All consecutive patients undergoing a laparoscopic TC ± rectopexy for STC from 1991–2007 were reviewed.Results: 84 patients (81 female, 3 male) were included. Average operating time was 188 min, average LOS 8 days. Conversion rate was 1.2%. There were no post op mortalities. Anastomotic leaks occurred in 2.4%, pelvic collections in 2.4%, intra‐abdominal bleeds in 4.7% and 3.5% developed wound infections. Bowel frequency was significantly improved however, 31% had at least 1 episode of obstructive symptoms. Ongoing pain was experienced by 38%. 57% underwent a further procedure a majority of which was a laparoscopy ± division of adhesions.Conclusion: Lap TC is a feasible and acceptable option for patients with STC with reasonable operating times, low conversion rates and acceptable mortality and morbidity. Bowel frequency is significantly improved however long term chronic pain and SBO are common. Lap TC allows for a minimally invasive laparoscopy to be performed to divide or exclude adhesions as a cause for obstructive symptoms or ongoing pain.

Introduction:  Colorectal cancer is a major disease concern in Australia. We at RBWH would like to present our experience regarding open or laparoscopic management of metastatic colorectal cancer to the liver. Methods:  A retrospective study was undertaken including patients who underwent elective one stage surgery for colorectal cancers from March 1985 to March 2000. Patients who were diagnosed with liver metastases at the time of surgery or who subsequently developed liver metastasis were included in this study. They were then analysed in 2 groups: laparoscopic assisted and open procedures. Results:  There were 84 patients in the open group with an age range from 33 to 88 and a mean of 66 years. The mean period of follow up was 20 months. During the same period 53 patients underwent laparoscopic assisted surgery. Age ranged from 31 to 78 with a mean of 60 years. The mean period of follow up was 16 months. The most common pathology in both groups was moderately to poorly differentiated ulcerative adenocarcinoma with nodal involvement (ACPS C or D). Conclusion:  In this small series laparoscopic surgery was found to be safe. There was no significant difference in survival comparing traditional open surgery with laparoscopic assisted resections for colorectal cancer with liver metastases.

Objective The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia.Method The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results.Results Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P = 0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16% vs 9%, P = 0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P = 0.0005).Conclusion A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.

PURPOSE: Since 1991, a laparoscopic-assisted resection has been used at the Royal Brisbane Hospital selectively for patients with colorectal cancer. This article audits the intermediate to long-term postoperative complications and cancer follow-up data. METHODS: All patients undergoing a laparoscopic resection for cancer were prospectively followed up with regard to long-term outcomes. RESULTS: One hundred eighty-one patients have been studied. One hundred fifty-four patients had potentially curative procedures performed in the study period. Median follow up was 71 (range, 7–108) months. The overall recurrence rate in this group was 6 percent (21 recurrences). There was one port site recurrence after a potentially curative procedure (0.6 percent) and one port site recurrence after a palliative resection. Perioperative mortality was 1 percent (2 patients). Only six patients suffered an adhesive small-bowel obstruction postoperatively. There was one incisional hernia. Unadjusted five-year median survival data for Australian Clinico-pathological Staging A was 91 percent (3.5 percent recurrence); for Australian Clinico-pathological Staging B, 83 percent (15 percent recurrence); and for Australian Clinico-pathological Staging C, 74 percent (26 percent recurrence). CONCLUSION: In selected patients a laparoscopic resection for colorectal cancer produces acceptable intermediate to long-term oncologic outcomes and a low long-term complication rate.

High-level microsatellite instability (AISI-H) is demonstrated in 10 to 15% of sporadic colorectal cancers and in most cancers presenting In the inherited condition hereditary nonpolyposis colorectal cancer (HNPCC). Distinction between these categories of MSI-H cancer is of clinical importance and the aim of this study was to assess clinical, pathological, and molecular features that might he discriminatory. One hundred and twelve MSI-H colorectal cancers from families fulfilling the Bethesda criteria were compared with 57 sporadic MSI-H colorectal cancers. HNPCC cancers presented at a lower age (P < 0.001) with no sporadic MSI-H cancer being diagnosed before the age of 57 years. MSI was less extensive in HNPCC cancers with 72% microsatellite markers showing band shifts compared with 87% in sporadic tumors (P < 0.001). Absent immunostaining for hMSH2 was only found in HNPCC tumors. Methylation of bMLH1 was observed in 87% of sporadic cancers but also in 55% of HNPCC tumors that showed loss of expression of hMLH1 (P = 0.02). HNPCC cancers were more frequently characterized by aberrant beta -catenin immunostaining as evidenced by nuclear positivity (P < 0.001). Aberrant p53 immunostaining was infrequent in both groups. There were no differences with respect to 5q loss of heterozygosity or codon 12 K-ras mutation, which were infrequent in both groups. Sporadic MSI-H cancers were more frequently heterogeneous (P < 0.001), poorly differentiated (P = 0.02), mucinous (P = 0.02), and proximally located (P = 0.04) than RNPCC tumors. In sporadic MSI-H cancers, contiguous adenomas were likely to be serrated whereas traditional adenomas were dominant in HNPCC. Lymphocytic infiltration was more pronounced in HNPCC but the results did not reach statistical significance. Overall, HNPCC cancers were more like common colorectal cancer in terms of morphology and expression of beta -catenin whereas sporadic MSI-H cancers displayed features consistent with a different morphogenesis. No individual feature was discriminatory for all RN-PCC cancers. However, a model based on four features was able to classify 94.5% of tumors as sporadic or HNPCC. The finding of multiple differences between sporadic and familial MSI-H colorectal cancer with respect to both genotype and phenotype is consistent with tumorigenesis through parallel evolutionary pathways and emphasizes the importance of studying the two groups separately.

Lowry, Ann C. M.D.; Simmang, Clifford L. M.D., M.S.; Boulos, Paul M.D.; Farmer, Chip K. F.R.A.C.S.; Finan, Paul J. M.D. F.R.C.S.; Hyman, Neil M.D.; Killingback, Mark F.R.A.C.S.; Lubowski, David Z. F.R.A.C.S.; Moore, Richard M.D.; Penfold, Campbell F.R.A.C.S.; Savoca, Paul M.D.; Stitz, Russell F.R.A.C.S.; Tjandra, Joe J. F.R.A.C.S. Author Information

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer.

Laparoscopic colonic resection is a viable technique. The same type of resection as at open surgery can be accomplished with minimum patient morbidity. There is a long learning curve involved with these procedures but once experience is gained, the operating times approach those of comparable open procedures.There should be no contention with the performance of a laparoscopic procedure for benign disease. Laparoscopic procedures for colorectal malignancy should only be performed at present within the context of a trial until there is evidence of improved patient outcomes.

Laparoscopic colorectal surgery is in its infancy. From a series of over 200 colorectal procedures undertaken over the last 30 months, we have performed 84 anterior resections. In 55 women and 29 men, median age 64 years (range 32-86), median weight 72 kg (range 36-125), surgery was undertaken for benign pathology (n = 57) and adenocarcinoma (n = 27). Anterior resection was completed laparoscopically in 75 cases (89%) with a median operating time of 210 min (range 85-420). Minor morbidity occurred in 17 patients (20%) with major morbidity in 10 cases (12%). There was one postoperative death. Flatus was passed a median of two days (range 1-7) after surgery and feces at a median of four days (range 2-9). Total hospital stay was six days (range 2-33). Delayed morbidity during a maximum of 30 months' follow-up included two anastomotic strictures but no evidence of malignant seeding. Laparoscopic anterior resection appears both feasible and safe for both benign and malignant disease, with the caveat that long-term outcome in malignant disease is not yet available.

Background: Radiofrequency ablation (RFA) is a minimally invasive alternative in the treatment of bone tumors. Long-term follow-up has not been described in current literature. Detailed analysis of mid- and long-term follow-up after RFA treatment for a cohort of patients with low-grade cartilaginous tumors (atypical cartilaginous tumors and enchondroma) was performed. The results, complications, and development of halo dimensions over time are presented. Methods: Data of all patients with an RFA procedure for an ACT between 2007–2018 were included. Ablation area is visible on baseline MRI, 3 months post-procedure, and is called halo. Volume was measured on MR images and compared to different follow-up moments to determine the effect of time on halo volume. Follow-up was carried out 3 months and 1, 2, 5, and 7 years after the procedure. Occurrence of complications and recurrences were assessed. Results: Of the 137 patients included, 82 were analyzed. Mean follow-up time was 43.6 months. Ablation was complete in 73 cases (89.0%). One late complication occurred, while no recurrences were seen. Halo dimensions of height, width, and depth decreased with a similar rate, 21.5% on average in the first year. Subsequently, this decrease in halo size continues gradually during follow-up, indicating bone revitalization. Conclusion: RFA is a safe and effective treatment in low-grade cartilaginous tumors with an initial success rate of 89.0%. Extended follow-up shows no local recurrences and gradual substitution of the halo with normal bone.

PURPOSE: This study was designed to compare function of patients who had undergone reconstruction following proctocolectomy for ulcerative colitis using the J or W configuration ileoanal pouch. METHODS: Of 126 patients who underwent restorative proctocolectomy between January 1981 and March 1993, 101 had surgery for ulcerative colitis. Eighty-seven of these patients were available for review by personal or postal interview. All operative procedures were performed by one surgeon. The group comprised 35 W-pouches and 52 J-pouches. RESULTS: More patients with a J-pouch had a stool frequency of greater than 8 per 24 hours (P=0.044), and they were also more likely to use a perineal pad (P=0.019). No difference in the rates of nocturnal stool frequency, fecal incontinence, or use of constipating agents between the two pouch designs was found. Significantly more patients with a J-pouch have had episodes of pouchitis (P=0.001). Of the total patient group 91.9 percent felt that restorative proctocolectomy had improved their quality of life. CONCLUSION: Minor differences in the function of the W configuration ileoanal pouch and the J configuration ileoanal pouch are demonstrated in this study.

During the period May 1986 to July 1989, a prospective, double blind, randomized trial of antibiotic prophylaxis in colorectal surgery was undertaken at the Royal Brisbane Hospital. Three hundred and thirty patients were considered eligible for the trial. Three regimens were compared: a combination of 2 g ceftriaxone and 1 g metronidazole; a single dose of 2 g ceftriaxone; or 1 g cefazolin and 1 g metronidazole, as antibacterial prophylaxis in colorectal surgery. Fifty patients were excluded from analysis. The overall incidence of wound sepsis was 7.9% (22 patients). There was no statistical difference in the incidence of wound infections between the three groups. The presence of drains and the non-performance of a bowel anastomosis at the time of surgery predisposed patients to wound infection. Staphylococcus aureus or Staphylococcus epidermidis were the cause of wound infection in 16 cases. Patients in the cefazolin and metronidazole group had a significantly higher number of postoperative urinary tract and respiratory tract infections than the other two groups combined (P less than 0.01). There did not appear to be any change in sensitivity patterns to ceftriaxone during the 3 year trial. During the 3 year period of the study, ceftriaxone was found to be a safe and effective drug in antibacterial prophylaxis in colorectal surgery.

Kirsten-ras-revertant-1 (Krev-1/Rap1A) is a recently identified tumor suppressor gene which induces flat revertants when introduced into a variety of ras-transformed cell lines in vitro. Since 47% of colorectal carcinomas have transforming mutations in ras protooncogenes, and since Krev-1 is expressed at high levels in normal colonic mucosa, we hypothesized that inactivation at the Krev-1 locus may be necessary for transformation of colonic cells. Loss of heterozygosity is a common method of inactivation of tumor suppressor genes in colorectal tumors. Therefore, we analyzed loss of heterozygosity in 52 patients with sporadic colorectal cancer. Because Krev-1 had no previously described polymorphisms, we first identified a BclI restriction fragment length polymorphism which showed 40% heterozygosity in 50 unrelated individuals. However, only one tumor from 18 informative patients showed allelic loss at the Krev-1 locus. This suggests that loss of heterozygosity is not a common mechanism of inactivation at the Krev-1 locus in colorectal cancer. However, the results do not exclude a role for Krev-1 in the etiology of this neoplasm because inactivation may occur by other mechanisms.

During the period 1973 to 1982, 35 patients with carcinoma of the anal canal were seen at this hospital. The main form of treatment was abdominoperineal excision, unless specific contraindications to this procedure were present. Between 1982 and 1984, a further 18 such patients were seen; the primary method of treatment then was combination chemotherapy and radiotherapy. Abdominoperineal excision was reserved for those patients who failed to respond to therapy or whose carcinoma recurred during the period of follow-up. The over-all five-year survival rate for the first 35 patients was 50%; the actuarial disease-free survival at two years for those who went into complete remission was 78% in the 18 patients who were seen in the second part of the study. We conclude that conservative treatment by chemoradiation is of value in the management of anal carcinomas.