Elective Surgical Resection Research Articles

The Cost Effectiveness of Colonic Stenting As a Bridge to Curative Surgery in Patients with Acute Left-Sided Malignant Colonic Obstruction: A Canadian Perspective

Acute colonic obstruction will develop in up to one-third of patients with colon cancer. Traditionally, patients with acute colonic obstruction require emergency surgery for creation of a diverting colostomy, followed by surgical resection of the tumour if there is no evidence of metastatic disease. Over the last several years, colonic stents has also been proven to be efficacious for relieving malignant obstruction in both the palliative setting and as a bridge to surgical resection. The aim of this study was to determine the most cost-effective strategy for patients with acute malignant left-sided colonic obstruction in a Canadian setting. Methods: We developed a decision analytical model to calculate the cost-effectiveness of three competing strategies: 1) emergent colonic stenting (CS) followed by elective surgical resection and reanastomosis, 2) emergent resective surgery (RS) followed by creation of either a diverting colostomy or primary reanastomosis, 3) emergent diverting colostomy (DC) followed by elective surgical resection and reanastomosis. The costs were estimated from the perspective of Manitoba's provincial health plan. Clinical outcomes evaluated included the proportion of patients requiring a permanent or temporary stoma, the total number of operations required by a patient, and overall mortality. Results: The use of CS results in fewer total operative procedures per patient (mean operations 1.03 vs. 1.32 with RS and 1.9 with DC), a lower mortality rate (5% vs. 11% with RS and 13% with DC) and a lower likelihood of requiring a permanent stoma (7% vs. 14% with RS as well as DC). CS is slightly more expensive than DC, but less costly than RS (11,851 with DC vs. $13,164 for CS vs. $13,820 with RS). The incremental cost effectiveness ratio (ICER) associated with the use of CS vs. DC is $1,415 to prevent a temporary stoma, $1,516 to prevent an additional operation, and $15,734 to prevent an additional death. Conclusions: Colonic stenting for patients with acute colonic obstruction secondary to a resectable colonic tumor is comparable in cost to surgical options and reduces the likelihood of requiring both temporary and permanent stomas, and may also be associted with lower procedure related mortality. Colonic stenting should be offered as the initial therapeutic modality for Canadian colorectal cancer patients presenting with acute obstruction as a bridge to definitive surgical resection. Tabled 1 Cost per patient (\$CDN) Mean Operations per patient % requiring temp. stoma % requiring permanent stoma % mortality Emergency Colonic Stenting (CS) 13,164 1.03 7 2 5 Emergency Resective Surgery (RS) 13,820 1.32 44 14 11 Emergency Diverting Colostomy (DC) 11,851 1.90 100 14 13 Open table in a new tab

Prenatal Diagnosis of Familial Type I Choledochal Cyst

Familial choledochal cysts are extremely rare. High-resolution ultrasound now allows for the antenatal diagnosis of these anomalies. After delivery, elective surgical resection should be planned; however, increases in size, deterioration of liver function, and ascending cholangitis frequently force early intervention. We report an unusual occurrence of siblings with type I choledochal cysts and review the existing literature on cause, genetics, classification, diagnosis, and management of this disease.

Surgical outcomes after total mesorectal excision for rectal cancer

This study reviewed the results of surgery for distal rectal cancer following the introduction of total mesorectal excision (TME) for rectal cancer. Two hundred sixty-four patients who had undergone elective curative surgical resection of rectal cancer within 12 cm of the anal verge were included. Comparisons were made between patients who had different surgical procedures. The overall operative mortality rate was nil, and the morbidity 39.4%. With a mean follow-up of 34 months (range 5-105 months), local recurrence occurred in 21 of the patients. The 3- and 5-year actuarial local recurrence rates were 9% and 12%, respectively for the whole group. Abdominoperineal resection (APR) was necessary in 65 of 264 (24.6%) of the patients, with a very low local recurrence rate in this subgroup (5% at 3 years). On multivariate analysis, only stage was a significant prognosticator of overall survival (P = 0.012). With the practice of TME, APR was still necessary in 25% of patients with rectal cancer within 12 cm of the anal verge. Type of surgery and tumor distance from the anal verge influenced local recurrence rates, but only initial tumor stage was associated with long-term survival.

Complications of Colorectal Stenting: Influence of the Type of Inserted Stent

Complications of Colorectal Stenting: Influence of the Type of Inserted Stent Javier Jimenez-Perez, Victor Orive, Gregorio Urdapilleta, Fernando Mugica, Fernando Borda Introduction: Colonic self-expandable stent placement is an accepted treatment of occlusive colorectal cancer, either to palliate the condition or to prepare the patient for an elective surgical resection. Major complications related to stent placement include bleeding, perforation, migration and stent obstruction. Minor complications include pain, incontinence/tenesmus and self limited bleeding. The aim of this study is to evaluate prospectively the incidence of complications related to colorectal stenting, seeking for possible differences depending on the type of stent. Methods: 92 patients (65 males;27 females. Age 40-91 yr) were referred for colonic stenting due to colorectal neoplastic obstruction. The tumor was located in the rectum or sigmoid colon in 86.8% of cases. Stent placement was succesful in 84 patients (91.3%). A nitinol stent was placed in 42 patients and a stainless steel stent in 42 patients. Stents were inserted through the working channel of a therapeutic colonoscope in every case. Minor compliations (pain, incontinence/tenesmus, self limited bleeding), major complications (severe bleeding, perforation, migration, reobstruction) and mortality were registered. Complications incidence in relation with the type of stent was also evaluated. Chi square test was used for statistical analysis. Results: Minor complications included pain (32.1%), incontinence/tenesmus (18.4%) and bleeding (9.2%). Concerning major complications, severe bleeding occured in 4.6% of cases, perforation in 2.3%, stent migration in 4.6% and stent reobstruction in 6.9% of patients. Mortality rate was 2.3% (2/84 patients). Comparing nitinol stents with stainless steel stents, pain (6/42 vs 21/42), severe bleeding (0/42 vs 4/42) and stent migration (0/42 vs 4/42) were more frequent with stainless steel stents, reaching statistical significance only for pain (p ! 0.0005). No differences were found when comparing the rest of registered complications. Conclusions: 1. The incidence of major complications related to colorectal stenting is low, although there is mortality related to the procedure. 2. Minor complications are rather frequent inmediately after stenting, but with little long term influence on patients quality of life. 3. The incidence of complications tends to increase using stainless steel stents, probably due to the stiffness and higher expansile force of the stent.

Targets and elective colorectal cancer: outcome and symptom delay at surgical resection

To determine, for elective patients with colorectal cancer, if associations exist between the length of symptom history at surgical resection and Dukes stage, completeness of the surgical procedure and patient survival. A prospective cohort study was undertaken. Five hundred and eighty-two patients with colorectal cancer, admitted for surgical resection after outpatient consultation, divided into four equal quartiles according to length of symptom history (short: n = 131, 0-103 days; medium: n = 136, 104-177 days; long: n = 136, 178-318 days; very long: n = 137, 319-1997 days). The main outcome measures used were the Extent of tumour (Dukes stage) at resection, completeness of resectional surgery (curative vs palliative), patient survival after resection. For patients undergoing elective surgical resection of colorectal cancer we did not find an association between Dukes stage and duration of patient history (Dukes stage C tumours were seen in 37% (CI: 26.2%-48.0%) of patients with a short symptomatic history as opposed to 34% (CI: 32%-62%) with a very long symptomatic history). Elective curative resection was not associated with a significantly different symptom duration than elective palliative resection (Palliative resections were performed in 24% (CI: 11.7%-36.4%) of patients with a short symptomatic history as opposed to 16% (CI: 2.4%-29.9%) with a very long symptomatic history). The median survival time for the four elective colorectal patient groups defined by length of symptomatic history was not significantly different - (short: n = 131, 4.3 years; medium: n = 136, 5.9 years; long: n = 136, 7.1 years; very long: n = 137, 5.0 years). Tumour extent, completeness of resection and patient outcome after elective colorectal cancer resection was not found to have an association with length of patient history at the time of surgery.

Results of treatment of distal rectal carcinoma since the introduction of total mesorectal excision: a single unit experience, 1994?2003

This study reviewed the results of surgery for distal rectal cancer (where the tumour was within 6 cm of the anal verge) following the introduction of total mesorectal excision for rectal cancer in one institution. One hundred and fifty-three patients who had undergone elective curative surgical resection of rectal cancer within 6 cm of the anal verge were included. The demographic, operative and follow-up data were collected retrospectively. Comparisons were made between patients who had different surgical procedures. The overall operative mortality rate was nil, and the morbidity 41%. With a mean follow-up of 37 months (range 5-100 months), local recurrence occurred in 18 of the patients. The 5-year actuarial local recurrence rates for double-stapled anastomosis, low-strength anastomosis and abdominoperineal resection (APR) were 39, 17 and 11% respectively. The local recurrence rate was significantly higher for double-stapled low anterior resection than for the other types of operation (P=0.007). On multivariate analysis type of surgery (P=0.025) and tumour stage (P=0.043), were associated with local recurrence, but only stage was a significant prognosticator of overall survival (P=0.0006). With the practice of total mesorectal excision, APR was still necessary in 40% of patients with rectal cancer within 6 cm of the anal verge. The local recurrence rate was lower in patients treated with APR than in those with double-stapled low anterior resection; however, survival rates were similar in these two groups.

Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction. Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures. Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941). Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

Elective Surgical Treatment of Diverticulitis

Elective surgical resection in cases of diverticulitis should be offered to patients who have experienced two episodes. High-risk patients such as immunocompromised individuals or transplant patients may warrant resection after one episode. It is controversial whether young patients or patients with right-sided diverticulitis need to be treated differently. Chronic diverticulitis can be successfully treated surgically in selected cases. Adequate surgical resection margins should include the top of the true rectum and the proximal extent of thickened inflamed colon to minimize the risk of recurrence. Careful operative planning and the use of proximal diversion if unsuspected significant inflammatory changes are encountered will improve surgical outcomes.

Endoscopic Implantation of Self-expanding Metal Stents (SEMS) in Acute Malignant Colonic Obstruction

Up to now emergency surgical decompression is considered to be the standard therapy for acute colonic obstruction caused by colorectal malignoma. However, endoscopic implantation of self-expanding metal stents (SEMS) not only allow rapid colonic decompression with the possibility of one-stage elective surgical resection several days later due to a better preoperative condition of the patient but also can serve as definitive nonsurgical palliative treatment in some patients. We analyzed our experience with SEMS in this indication since 2002. Methods: In 23 patients (15f, 3m, 36-94y) with acute malignant colonic obstruction (Rektum: 4, Sigma: 15, Descendens: 3, Transversum: 1) 30 SEMS (27 uncovered Wallstents and 3 UltraflexTM-Precision-Stents; length 60 mm (18) or 90 mm (12), diameter 18 mm(1), 20 mm (2), 22 mm (24) or 25 mm (3)) were implanted endoscopically. The tumorous stenosis could not be passed with the endoscope in 21/23 patients. All patients showed clinical signs of obstruction (abdominal pain, meteorism, vomiting) and the radiological signs of colonic ileus. Results: Endoscopic SEMS implantation was technically successful in all patients. In 19/23 patients (83%) SEMS implantation resulted in a sufficient improvement of colonic obstruction. In 10 of these 19 patients elective surgical resection was performed after a mean time of 3 days. In the remaining 9 patients (advanced tumor stage) surgery could be avoided, but one of them had to be resected due to stent overgrowth after 5 months. In 4/23 patients a sufficient colonic decompression was not achieved until the next day by SEMS implantation. In these patients surgical decompression was performed, but 2/4 patients died in the following days. In 2 patients stent migration occurred in the further course, both of them could be successfully treated by re-stenting. No major complication such as perforation or bleeding occurred. Conclusion: Endoscopic SEMS implantation is an effective, safe and minimal invasive treatment of acute malignant colonic obstruction. It allows either elective surgical resection after preoperative improvement of patient condition or can serve as definitive palliative non-surgical treatment in patients with advanced tumor stage.

High-intensity focused ultrasound for the treatment of liver tumours

High-intensity focused ultrasound (HIFU) has been investigated as a tool for the treatment of cancer for many decades, but is only now beginning to emerge as a potential alternative to conventional therapies. In recent years, clinical trials have evaluated the clinical efficacy of a number of devices worldwide. In Oxford, UK, we have been using the JC HIFU system (HAIFU Technology Company, Chongqing, PR China) in clinical trials since November 2002. This is the first report of its clinical use outside mainland China. The device is non-invasive, and employs an extracorporeal transducer operating at 0.8–1.6 MHz (aperture 12–15 cm, focal length 9–15 cm), operating clinically at I sp (free field) of 5–15 KW cm −2. The aims of the trials are to evaluate the safety and performance of the device. Performance is being evaluated through two parallel protocols. One employs radiological assessment of response with the use of follow-up magnetic resonance imaging and microbubble-contrast ultrasound. In the other, histological assessment will be made following elective surgical resection of the HIFU treated tumours. Eleven patients with liver tumours have been treated with HIFU to date. Adverse events include transient pain and minor skin burns. Observed response from the various assessment modalities is discussed.

Concentrations of VEGF and VEGFR1 in Paired Tumor Arteries and Veins in Patients With Rectal Cancer

Increased plasma concentrations of vascular endothelial growth factor (sVEGF) are associated with poor prognosis of colorectal cancer patients. The aim was to investigate the contribution of the tumor to plasma concentrations of VEGF and VEGF receptor 1 (VEGFR1). Preoperative blood samples from a peripheral vein and intraoperative blood samples from a tumor artery, a tumor vein, and from a peripheral vein were drawn from 28 patients undergoing elective surgical resection of primary rectal cancer. Plasma concentrations of VEGF and VEGFR1 were determined by ELISA. Counts of white blood cells and platelets were performed in all samples. No significant difference between plasma VEGF levels in the obtained blood samples was found (0.35 < P < 0.86). Plasma sVEGFR1 concentrations were significantly increased in tumor veins compared with tumor arteries. In addition, a significant reduction in plasma sVEGFR1 concentrations from preoperative to intraoperative samples was observed. There was a significant efflux of neutrophils to the tumor, but none of the observed changes in plasma VEGF or VEGFR1 levels correlated to changes in counts of white blood cells or platelets (sVEGF: 0.33 < P < 0.73 and sVEGFR1: 0.32 < P < 0.98). No changes in sVEGF plasma concentrations from tumor arteries to tumor veins were demonstrated, whereas there was a significant increase in sVEGFR1 from tumor arteries to tumor veins. Changes in sVEGF or sVEGFR1 from tumor arteries to tumor veins were not associated with changes in counts of white blood cells or platelets.

Squamous Cell Carcinoma of the Lower Lip and Supra-Omohyoid Neck Dissection

Purpose: The aim of this study is to evaluate our approach to patients with squamous cell carcinoma of lower lip.Patients and methods: This study includes 31 lower lip squamous cell carcinomas followed up between 1994 and 2000. Primary treatment was applied to 28 patients of whom 23 were in stages I-II and five in stages III-IV. Three patients presented locoregional recurrence. Neck dissection was performed during primary lip resection in patients with palpable cervical lymph node involvement. Patients with unpalpable cervical lymph nodes were divided into two subgroups: one was submitted to elective neck dissection (n = 11) and the other had isolated lip resection (n = 8). Unilateral or bilateral selective supra-omohyoid neck dissection (SOHND) was performed according to the localisation of the disease. Radical dissection was performed in a secondary intervention, when SOHND revealed lymph node metastases. Radiotherapy and chemotherapy were applied for curative and/or adjuvant treatment in addition to surgery in patients with locoregional recurrence and metastatic lymph nodes or with perineural involvement.Results: Occult cervical metastasis within a single lymph node was found in one of the 11 No patients who underwent elective neck dissection. Delayed neck metastasis developed in one of the eight patients in whom isolated lip resection (without neck exploration) was performed. Chemoradiotherapy was administered to this patient, but he died. Neck metastasis was established histologically in four of five patients in stages III-IV. Postoperative radiotherapy was used on these patients. One of the patients in this group died due to inoperable local recurrence in the neck, another died because of distant metastasis. Local mandibular recurrence was seen in one of these patients after three years. Comment: Six patients (19%) died due to lower lip carcinoma in this series. Our findings show the importance of elective neck dissection and intact surgical resection margins.

Stenting for obstructing colorectal malignancy: an interim or definitive procedure.

The purpose of this paper is to review and report our experience with colorectal stenting in the management of malignant large bowel obstruction. Twelve consecutive patients with malignant left-sided large bowel obstruction between June 1998 and January 2001 underwent insertion of self-expanding metallic stents. One patient required two stents. Eight stents were inserted under fluoroscopic guidance, and five were inserted with combined fluoroscopic and endoscopic guidance. Patients were followed up until death, stent removal or the time of publication. Thirteen stents were inserted. Eleven patients with acute large bowel obstruction had relief of obstruction with stenting, and one of these patients required a second stent because relief had been incomplete. One patient was stented in order to subsequently close a problematic stoma. Technical success was 92.9% and clinical success was 100%. Three patients proceeded to surgical resection. In nine patients, the stent was left as the definitive procedure. Of these, six patients have died within 4 months. Complications included one case of migration, one case of reobstruction, one intestinal haematoma and one case of cheesewiring. Colorectal stenting is an important treatment modality for malignant large bowel obstruction. It may be definitive treatment alone, or a bridge to elective surgical resection.

Malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic resections.

Acute left-side colonic obstruction is a surgical emergency whose management is controversial. Recently metallic expandable stents have been used to relieve obstruction either to palliate the condition or to prepare for an elective surgical resection. We propose a new minimally invasive therapeutic strategy for the management of malignant colonic obstructions: emergency endoscopic stenting followed by elective laparoscopic one-stage resection. The first four cases are presented. The stents were positioned successfully in all cases, and all the patients had an immediate restoration of bowel functions. After a period that varied from 4 to 5 days, they underwent a one-stage laparoscopic resection and were discharged 5 to 7 days after the operation. There were no postoperative complications. Malignant colonic obstruction can be managed by a sequential minimally invasive endolaparoscopic approach with an excellent postoperative outcome, good patient comfort, and a short hospital stay without the need for diverting stomas. A study involving a larger number of patients is needed to determine whether this approach is superior to traditional open surgery in terms of morbidity, mortality, quality of life, and recurrences.

Surgical Management of Diverticulitis

Diverticular disease, and particularly diverticulitis, has an increasing incidence in Westernized countries because of low-fiber diet. Diverticular disease may be classified as asymptomatic, atypical, acute or uncomplicated, and complicated. Conservative or medical management is usually indicated for acute or uncomplicated diverticulitis, with elective surgical resection generally being recommended after two documented episodes. Complicated diverticulitis, because of the high rate of recurrent problems, is generally managed promptly with sigmoid resection. Sigmoid resection for diverticulitis, under appropriate circumstances, has one of the highest success rates of any of the common gastrointestinal procedures.

Clinical experience with colonic stent placement

Fluoroscopic-guided colonic stent placement has grown in acceptance in treating both benign and malignant acute colonic occlusions for both palliative and surgical decompression purposes. Seventeen patients underwent self-expandable metallic colonic stent placement. Thirteen patients had acute obstruction requiring surgical decompression. The remaining four patients had stent placement for palliative purposes. Stents were deployed using the standard Tejero-Mainar technique of crossing the lesion with a torquable guidewire and catheter, replacing the wire for a stiff wire, then deploying the stent across the lesion. Fifteen patients (88%) received successful colonic stent placement; 14 (93%) patients achieved decompression within 6 hours. This enabled the presurgical group to undergo elective resection in 2 weeks and enabled the palliative group to decompress and return to their respective care centers for further treatment. Complications included five cases of migration and one death in which a patient received excessive barium enema before successful stent placement. There was a higher incidence of migration in treating extrinsic lesions versus colonic cancer, lesions in the proximal rectosigmoid colon, and those lesions requiring two stents. Migrated stents in the rectum could be retrieved with fluoroscopic techniques. Overall, placement of self-expandable metallic stents for acute colonic obstructions has proven relatively easy and safe to perform with great benefits to the patients allowing them to undergo elective surgical resection and avoiding a temporary colostomy. Newly discovered complications such as migration will need to be addressed. Fluoroscopic-guided colonic stent placement has grown in acceptance in treating both benign and malignant acute colonic occlusions for both palliative and surgical decompression purposes. Seventeen patients underwent self-expandable metallic colonic stent placement. Thirteen patients had acute obstruction requiring surgical decompression. The remaining four patients had stent placement for palliative purposes. Stents were deployed using the standard Tejero-Mainar technique of crossing the lesion with a torquable guidewire and catheter, replacing the wire for a stiff wire, then deploying the stent across the lesion. Fifteen patients (88%) received successful colonic stent placement; 14 (93%) patients achieved decompression within 6 hours. This enabled the presurgical group to undergo elective resection in 2 weeks and enabled the palliative group to decompress and return to their respective care centers for further treatment. Complications included five cases of migration and one death in which a patient received excessive barium enema before successful stent placement. There was a higher incidence of migration in treating extrinsic lesions versus colonic cancer, lesions in the proximal rectosigmoid colon, and those lesions requiring two stents. Migrated stents in the rectum could be retrieved with fluoroscopic techniques. Overall, placement of self-expandable metallic stents for acute colonic obstructions has proven relatively easy and safe to perform with great benefits to the patients allowing them to undergo elective surgical resection and avoiding a temporary colostomy. Newly discovered complications such as migration will need to be addressed.

Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery--results of a multicenter study.

To evaluate the efficacy of treatment with self-expandable metallic stents for acute colonic obstruction before elective surgical resection. In 71 patients with malignant obstruction seen from October 1993 through December 1996, lesions were located in the transverse colon in one patient, in the descending colon in 22 patients, and in the rectosigmoid region in 48. A total of 72 self-expandable metallic stents were implanted within 24 hours of diagnosis. Technical success was obtained in 64 patients (90%). In two cases (3%), it was not possible to advance across the obstructing mass. In five cases (7%), the prostheses were poorly positioned at the site of obstruction, requiring placement of a new stent in three cases. Clinical improvement and resolution of the obstruction were confirmed in 66 patients (93%) within 96 hours. Minor complications developed in nine cases (13%). One patient (1%) underwent surgery to resolve a colonic perforation caused by wires at the ends of the stent. The mean time between stent placement and surgery was 8.6 days (range, 6-16 days). Implantation of colorectal stents is a safe treatment of acute malignant colonic obstruction before resection.

Initial Clinical Experience with Colonic Stent Placement

Background: The purpose of this study is to review initial experience with a colonic stent as an alternative to colostomy in patients with colonic obstruction. Methods: Ten patients diagnosed with acute colonic obstructions from both benign and malignant causes underwent stent placement. Self-expandable metallic stents were deployed using fluoroscopic guidance. Patients were followed up clinically until removal of the stent or death. Results: Nine of the 10 patients who underwent colonic stent placement achieved clinical decompression within 6 hours. Six patients underwent standard mechanical bowel preparation and elective resection of obstructing lesions. The other 4 patients received stent placement for palliative purposes. Complications included 4 cases of migration and 1 death. Migrated stents in the rectum were easily retrieved and replaced using fluoroscopic techniques. There were no perforations. Conclusion: Placement of self-expandable metallic stents for acute colonic obstructions may allow patients to undergo elective surgical resection avoiding possible colostomy.

POMB/ACE chemotherapy for mediastinal germ cell tumours.

Mediastinal germ cell tumours (MGCT) are rare and most published series reflect the experiences of individual institutions over many years. Since 1979, we have treated 16 men (12 non-seminomatous germ cell tumours and 4 seminomas) with newly diagnosed primary MGCT with POMB/ACE chemotherapy and elective surgical resection of residual masses. This approach yielded complete remissions in 15/16 (94%) patients. The median follow-up was 6.0 years and no relapses occurred more than 2 years after treatment. The 5 year overall survival in the non-seminomatous germ cell tumours (NSGCT) is 73% (95% confidence interval 43-90%). One patient with NSGCT developed drug-resistant disease and died without achieving remission and 2 patients died of relapsed disease. In addition, 4 patients with bulky and/or metastatic seminoma were treated with POMB/ACE. One died of treatment-related neutropenic sepsis in complete remission and one died of relapsed disease. Finally, 4 patients (2 NSGCT and 2 seminomas) referred at relapse were treated with POMB/ACE and one was successfully salvaged. The combination of POMB/ACE chemotherapy and surgery is effective management for MGCT producing high long-term survival rates.

Relief of malignant obstruction of the rectosigmoid colon with a self-expanding metallic stent

SummaryWe describe a patient with obstructing recurrent carcinoma of the rectum. We have relieved the obstruction by the insertion of a self-expanding metallic stent across the stricture. This has permitted bowel preparation and elective surgical resection with primary anastomosis. The patient has been spared emergency two-stage surgery with a temporary colostomy.