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A Meta-Analysis and Systematic Review of Perioperative Outcomes of Laparoscopic-assisted Rectal Resection (LARR) Versus Open Rectal Resection (ORR) for Carcinoma

Memon MA, Yunus RM, Memon B, Awaiz A, Khan S

Surg Laparosc Endosc Percutan Tech, 2018 Dec;28(6):337-348.
PMID: 30358650 DOI: 10.1097/SLE.0000000000000589

AIMS AND OBJECTIVES: The aim was to conduct a systematic review and meta-analysis of the randomized evidence to determine the relative merits of perioperative outcomes of laparoscopic-assisted (LARR) versus open rectal resection (ORR) for proven rectal cancer.
MATERIALS AND METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English-language randomized clinical trials comparing LARR and ORR. The meta-analysis was prepared in accordance with the PRISMA statement. Thirteen outcome variables were analyzed. Random effects meta-analyses were performed due to heterogeneity.
RESULTS: A total of 14 randomized clinical trials that included 3843 rectal resections (LARR 2096, ORR 1747) were analyzed. The summary point estimates favored LARR for the intraoperative blood loss, commencement of oral intake, first bowel movement, and length of hospital stay. There was significantly longer duration of operating time of 38.29 minutes for the LARR group. Other outcome variables such as total complications, postoperative pain, postoperative ileus, abdominal abscesses, postoperative anastomotic leak, reintervention and postoperative mortality rates were found to have comparable outcomes for both cohorts.
CONCLUSIONS: LARR was associated with significantly reduced blood loss, quicker resumption of oral intake, earlier return of gastrointestinal function, and shorter length of hospital stay at the expense of significantly longer operating time. Postoperative morbidity and mortality and analgesia requirement for both these groups were comparable. LARR seems to be a safe and effective alternative to ORR; however, it needs to be performed in established colorectal units with experienced laparoscopic surgeons.

Matched MeSH terms: Rectal Neoplasms/surgery*
Fulltext A case of rectal cancers in teenager: A conundrum of genetics and clinical medicine

Kumar M, Tata MD, Sahid Nik Lah NA

Ann Med Surg (Lond), 2021 May;65:102353.
PMID: 34007446 DOI: 10.1016/j.amsu.2021.102353

Introduction: Signet cell carcinoma (SRCC)of the rectum is a rare subtype of the rectum cancer which accounts for only 0.8% of colorectal cancer in adolescents and young adults (AYAs) which spread aggressively to other organs and peritoneum.
Case presentation: We present a case of 15-year-old boy from rural area, presented with chronic diarrhea and per rectal bleeding for 3 months. The diagnosis was determined by colonoscope which revealed a fungating mass identified at 10cm from anal verge. Histological examination confirmed diagnosis of signet ring cell adenocarcinoma. CT scan of the abdomen showed thickening involving the recto-sigmoid colon and rectal mass, without evidence of distant metastatic disease. The patient's carcinoembryonic antigen level was within the normal range. He underwent a colostomy and was subjected to neoadjuvant CCRT and surgery.
Discussion: This CASE highlights the importance and challenges in achieving early diagnosis and surgical intervention of signet-ring cell carcinoma in adolescents, as most cases are detected at an advanced stage coupled with the scarcity of information on these rarer subtypes which leads to a poor prognosis.
Conclusion: In managing Signet cell carcinoma of the colorectal, physician have to know that it has a poor prognosis in patients of any age. However, in young teenagers delayed diagnosis and treatment option are narrowed to palliative management. Genetic profiling of family members and similar environment population may be a key to early detection.

Matched MeSH terms: Rectal Neoplasms; Colorectal Neoplasms
Adaptation of international guidelines for metastatic colorectal cancer: an asian consensus

Cheng AL, Li J, Vaid AK, Ma BB, Teh C, Ahn JB, et al.

Clin Colorectal Cancer, 2014 Sep;13(3):145-55.
PMID: 25209093 DOI: 10.1016/j.clcc.2014.06.004

Colorectal cancer (CRC) is among the most common cancers worldwide, but marked epidemiological differences exist between Asian and non-Asian populations. Hence, a consensus meeting was held in Hong Kong in December 2012 to develop Asia-specific guidelines for the management of metastatic CRC (mCRC). A multidisciplinary expert panel, consisting of 23 participants from 10 Asian and 2 European countries, discussed current guidelines for colon or rectal cancer and developed recommendations for adapting these guidelines to Asian clinical practice. Participants agreed that mCRC management in Asia largely follows international guidelines, but they proposed a number of recommendations based on regional 'real-world' experience. In general, participants agreed that 5-fluorouracil (5-FU) infusion regimens in doublets can be substituted with UFT (capecitabine, tegafur-uracil) and S1 (tegafur, 5-chloro-2,4-dihydroxypyridine and oxonic acid), and that the monoclonal antibodies cetuximab and panitumumab are recommended for KRAS wild type tumors. For KRAS mutant tumors, bevacizumab is the preferred biological therapy. FOLFOX (folinic acid, 5-FU, and oxaliplatin) is preferred for initial therapy in Asian patients. The management of mCRC is evolving, and it must be emphasized that the recommendations presented here reflect current treatment practices and thus might change as more data become available.

Matched MeSH terms: Rectal Neoplasms/genetics; Rectal Neoplasms/pathology; Rectal Neoplasms/therapy*
Fulltext Adenocarcinoma of rectum metastasizing to penis

Sukumar N, Qureshi A

Med J Malaysia, 2001 Jun;56(2):255-6.
PMID: 11771091

An elderly gentleman with adenocarcinoma of the rectum who had abdominoperineal resection presented with scrotal skin and penile metastasis. Adenocarcinoma of the rectum metastasizing to the groin and penis is very rare and few cases have been reported.

Matched MeSH terms: Rectal Neoplasms/pathology*
Adjuvant chemotherapy and radiotherapy in the management of colorectal cancer

Lim Kok Hooi A

Gan To Kagaku Ryoho, 1992 Jul;19(8 Suppl):1233-5.
PMID: 1514837
Matched MeSH terms: Rectal Neoplasms/drug therapy; Rectal Neoplasms/radiotherapy*
Anorectal melanoma

Jalleh RP, Pathmanathan R, Krishnan MM, Mukherjee A

Postgrad Med J, 1988 Sep;64(755):669-71.
PMID: 3251217

Four cases of anorectal melanoma are presented. The authors believe that this is the first report of the occurrence of this tumour in Malays. Advanced disease at initial presentation accounts for the poor prognosis observed in this series. Surgery remains the principal treatment modality, although controversy exists regarding optimal extent of resection.

Matched MeSH terms: Rectal Neoplasms/ethnology*; Rectal Neoplasms/pathology
Cancer of the colon and rectum in the first three decades of life

Shahrudin MD, Noori SM

Hepatogastroenterology, 1997;44(14):441-4.
PMID: 9164516

BACKGROUND/AIMS: Recently an increasing number of young colorectal carcinoma patients attending the University Hospital, Kuala Lumpur were noted. This report represents our experience with patients suffering from colorectal cancer aged 30 years or younger.
MATERIALS AND METHODS: All cases of primary carcinoma of the colon and rectum admitted to the University Hospital during 1990 to 1994 were respectively reviewed. Inclusion criteria was that the patient had been 30 years or younger. Data collected included age, gender, race, site of tumour, presenting symptomatology, duration of symptoms, histology, extension of tumour and nodal involvement predisposing factors, treatment and follow-up.
RESULTS: 21 patients were included, 5 patients (24%) were 30 years old at diagnosis, 12 (57%) patients were aged 20-29 years and 4 patients (19%) were less than 20 years old. Thirteen of the 21 patients were female, and 8 (38%) were male, 6 of the 21 patients (29%) were Malaysian, while 1 was Indian (4%). The remainder were Chinese, 14 patients (67%). Six patients (29%) had their primary tumour located in the rectosigmoid, 4 (19%) in the left colon, 1 (4%) in the splenic flexure, 2 in the transverse colon (9%), 1 in the hepatic flexure (4%) and 5 in the caecum 24(%). One patient had a tumour too diffuse to detect a primary site at the time of operation. One patient with a family history of polyps had his entire colon removed at age 14. He had 3 separate foci of tumour. The 5-year survival rate was 25%.
DISCUSSION: Most patients with extensive disease and mucinous histology. Lesions are commonly seen beyond the transverse colon (57%). Presentation included most commonly abdominal pain, haematochezia or haemoccult positive stools.
CONCLUSION: The symptoms above should alert surgeons to colorectal carcinoma as a differential diagnosis

Matched MeSH terms: Rectal Neoplasms/epidemiology*; Rectal Neoplasms/pathology
Carcinoma of he stomach, colon, and rectum. A survey of 772 surgical biopsies from Malaya

King M, Kutty MK

Br J Surg, 1971 Feb;58(2):123-6.
PMID: 5548502
Matched MeSH terms: Rectal Neoplasms/epidemiology*
Fulltext Characteristics of young colorectal cancer in Brunei Darussalam: an epidemiologic study of 29 years (1986-2014)

Koh KS, Telisinghe PU, Bickle I, Abdullah MS, Chong CF, Chong VH

Asian Pac J Cancer Prev, 2015;16(8):3279-83.
PMID: 25921132

BACKGROUND: Colorectal cancer (CRC) is the most common gastrointestinal cancer and the incidence is increasing. CRC is more common with increasing age, but a proportion occurs in young adults, termed young CRC. This study assessed the incidence and the demographic of young CRC in Brunei Darussalam.

MATERIALS AND METHODS: All histologically proven CRC between 1986 and 2014 registered with the Department of Pathology cancer registry were reviewed and data extracted for analyses. Young CRC was defined as cancer in patients aged less than 45 years. The various population groups were categorized into locals (Malays, Chinese and Indigenous) and expatriates.

RESULTS: Over the study period, there were 1,126 histologically proven CRC (mean age 59.1 ± 14.7 years, Male 58.0%, Locals 91.8% and 8.2% expatriates). Young CRC accounted for 15.1% with the proportion declining over the years, from 29% (1986-1990) to 13.2% (2011-2014). The proportion of young CRC was highest among the indigenous (30.8%), followed by the expatriates (29.3%), Malays (14.3%) and lowest among the Chinese (10.8%). The mean age of young CRC was 35.9 ± 6.2; lowest among the indigenous (33.5 ± 6.7), expatriate (34.9 ± 6.0) groupd and the Malays (35.6 ± 6.5) compared to the Chinese (38.6 ± 4.6), a similar trend being observed in the non-young CRC groups. There were no difference between the genders and tumor locations (rectum or colon) between the young and the non-young CRC cases. Female young CRC was significantly younger than male (p<0.05) without any significant variation between the various population groups (p>0.05).

CONCLUSIONS: Our study showed that the young CRC accounted for 15.1% of all CRC with declining trend observed over recent years. Young CRC was more common among indigenous, expatriates and Malays and least common among the Chinese. There were no differences in the gender and tumor locations.

Matched MeSH terms: Rectal Neoplasms/ethnology; Rectal Neoplasms/epidemiology; Rectal Neoplasms/pathology; Colorectal Neoplasms/ethnology; Colorectal Neoplasms/epidemiology*; Colorectal Neoplasms/pathology
Chylous ascites after anterior resection for rectal carcinoma: a rare but significant incident

Chan KY, Teoh CM, Sukumar N

Asian J Surg, 2006 Jan;29(1):46-8.
PMID: 16428100

Chylous ascites specifically after anterior resection for rectal cancer has not been documented in the literature thus far. All previously reported postoperative chylous ascites developed in other types of malignancies and were diagnosed within a few days of surgery. However, the patient we report had symptoms 2 years after surgery. Intraoperatively, chylous ascites was found with multiple lymph node metastasis in the small bowel mesentery and retroperitoneal region. The rarity of chylous ascites after anterior resection in rectal carcinoma is documented and discussed.

Matched MeSH terms: Rectal Neoplasms/surgery*
Fulltext Clinical dilemma-management of low rectal cancer in a Jehovah’s Witness

Azhani C., Azmi M.N., David O.

International Medical Journal Malaysia, 2018;17(3):81-84.
MyJurnal

Jehovah’s Witness followers pose a clinical dilemma to the medical practitioners due to their religious belief of an absolute prohibition of blood transfusion under any circumstances. We present a case of Jehovah’s Witness follower who underwent an ultra-low anterior resection for rectal cancer after neo-adjuvant chemo-radiotherapy. The challenges in the perioperative management are highlighted and managed accordingly.

Matched MeSH terms: Rectal Neoplasms
Colorectal cancer in Asians: a demographic and anatomic survey in Malaysian patients undergoing colonoscopy

Goh KL, Quek KF, Yeo GT, Hilmi IN, Lee CK, Hasnida N, et al.

Aliment Pharmacol Ther, 2005 Nov 1;22(9):859-64.
PMID: 16225496

Colorectal cancer is one of the most common forms of gastrointestinal cancer in the world today. In the Asia-Pacific area, it is the fastest emerging gastrointestinal cancer.

Matched MeSH terms: Rectal Neoplasms/ethnology; Rectal Neoplasms/epidemiology; Rectal Neoplasms/therapy; Colorectal Neoplasms/ethnology; Colorectal Neoplasms/epidemiology*; Colorectal Neoplasms/therapy
Common proctological conditions

Monro JK

Journal of the Malaya Branch of the British Medical Association, 1940;3:396-9.

Matched MeSH terms: Rectal Neoplasms
Fulltext Continent pouch ileostomy

Tay SK, Meah FA, Isa MR, Phang KS

Med J Malaysia, 1994 Sep;49(3):310-4.
PMID: 7845289

Continent pouch ileostomy is fashioned for patients who need a proctocolectomy. It is usually indicated for cases of ulcerative colitis and familial adenomatous polyposis where the anal sphincter can no longer maintain normal function or has to be removed. A case of familial adenomatous polyposis with features of Gardner's syndrome is reported. The patient presented with carcinoma of the rectum. Abdominoperineal resection followed by completion pancolectomy was performed. A continent pouch ileostomy was fashioned for him. He resumed work as a labourer within six months. The pouch was troublefree, needed to emptied four to six times a day and was fully continent of fluid, flatus and faeces until his demise three years later from liver secondaries. Continent pouch ileostomy is a better alternative than permanent end ileostomy. All care should be taken to rule out the existence of Crohn's disease. It is proposed that continent pouch ileostomy should be offered to patients needing permanent ileostomy if the expertise is available.

Matched MeSH terms: Rectal Neoplasms/pathology; Rectal Neoplasms/surgery*
Fulltext Delayed Bowel Perforation after Routine Distal Loopogram Prior to Ileostomy Closure

Poh KS, Hoh SY, Aziz R, Chong SS, Roslani AC

Open Med (Wars), 2020;15:261-265.
PMID: 32292822 DOI: 10.1515/med-2020-0037

Ultra-low anterior resection for low rectal cancer is usually done with a covering ileostomy as a safety measure to reduce the consequences of distal anastomotic failure. In many centres, distal loopogram is performed routinely, prior to the closure of the loop ileostomy, to assess the integrity of anastomosis. Distal loopogram is generally considered a safe procedure with very low complication rates, especially when water-soluble contrast is used. We report two cases of delayed bowel perforation which led to severe sepsis and generalized peritonitis after distal loopogram prior to ileostomy closure. Our cases highlight the potential dangers of distal loopogram. Therefore, the routine usage of this procedure should be scrutinized and the patient needs to be properly counselled prior to the procedure.

Matched MeSH terms: Rectal Neoplasms
Diagnostic conundrum of a perineal tumour: a rectal gastrointestinal stromal tumour mimic

Shi R, Chew MH, Leow WQ

Malays J Pathol, 2017 Dec;39(3):293-296.
PMID: 29279593

Gastrointestinal stromal tumour (GIST) is a common mesenchymal tumour arising in the gastrointestinal tract, but not frequently encountered in the rectum. Herein, we describe a case of a rectal GIST which mimicked histomorphological features of a schwannoma; thus, making intraoperative frozen section evaluation challenging. Although subsequent immunohistochemistry and molecular findings readily confirmed the diagnosis of a GIST, we wish to draw attention to three clues that will help the pathologist steer clear of this potential diagnostic pitfall. One, GISTs are relatively more common than schwannomas in the rectum. Two, schwannomas usually have very little mitoses. Three, rectal GISTs commonly exhibit nuclear palisades. We also discuss the diagnostic, prognostic and therapeutic functions of immunohistochemical and molecular investigations. As the surgical intent for rectal GISTs is for en-bloc excision with wide margins, we surmise that the intraoperative consult should include GIST as a possible differential diagnosis for rectal mesenchymal tumours. In view of the potential for neoadjuvant treatment with imatinib before surgical excision to preserve sphincter function, a multidisciplinary approach is recommended for establishing most effective treatment strategy in these rare complex cases.

Matched MeSH terms: Rectal Neoplasms/diagnosis*; Rectal Neoplasms/pathology
Fulltext Five-Year Review of Histopathological Findings of Colorectal Cancer Patients Operated in Hospital Tengku Ampuan Afzan Kuantan Pahang Malaysia

Azmi, M.N., Zailani, M.A., Norashikin, M.N., Asma Assaedah, Norra, H., Kalavathy, R., et al.

International Medical Journal Malaysia, 2007;6(1):1-14.
MyJurnal

PURPOSE: This review was performed to determine the association between demographic characteristics and the histopathological findings of colorectal cancer (CRC) patients operated in Hospital Tengku Ampuan Afzan (HTAA) Kuantan Pahang Malaysia. METHODS: We retrospectively reviewed the histopathological reports of 119 CRC cases operated in HTAA from January 2001 to December 2005 which met the inclusion criteria of histologically proven adenocarcinoma. The following demographic characteristics which include age, gender, and ethnicity were assessed. The histopathological related variables which include the site of primary tumor, Astler and Coller stage, tumor differentiation and lymph node metastasis were analyzed. Chi square test was used for categorical variables. Data with low expected counts were assessed using Fisher’s exact tests. RESULTS: There were 59 males and 60 females with age ranging from 23 to 93 years. 81.5% of the patients were older than 50 years (p=0.038). Malays accounted for 58.8% of the total cases, followed by Chinese (36.1%) and Indian (5%). Rectosigmoid region and rectum were the most common sites for primary tumor (55.6%). Cancer in male predominantly occurred in the rectum (p=0.023). Malays were commonly diagnosed with stage C2 (54.3%) while Chinese were diagnosed with stage B2 (58.1%) (p=0.011). Fifty percent of the patients who are less than 50 years old were diagnosed with stage C2 (p=0.024). There was significant change from well to moderately differentiated adenocarcinoma (p=0.000). Sixty percent of female patients diagnosed to have cancer with lymph node metastasis (p=0.044). Significant lymph node metastasis was also observed among Malay patients (p=0.022). CONCLUSION: The findings from the present review suggest that there are several associations between demographic distribution and histopathological characteristics of CRC. More than fifty per cent of CRC are found in the rectosigmoid region and the rectum. CRC are more common in Malay race and rectal cancer is predominantly affecting the male. About forty five percent of patients harbor metastases in the lymph nodes and fifty percent of the younger age group were presenting with nodal metastases.

Matched MeSH terms: Rectal Neoplasms; Colorectal Neoplasms
Fulltext Huge solitary rectal schwannoma mimicking malignant polyp with a successful transanal excision

Sanjeev Sandrasecra, Sindhu Karpayah, Muhammad Ash-Shafhawi Adznan, Firdaus Hayati, Nornazirah Azizan, Rohamini Sibin

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):62-62.
MyJurnal

Introduction: Rectal schwannoma is a rare gastrointestinal mesenchymal tumour with only a few numbers of cases has been reported. It is predominant in the stomach and small bowel, but uncommon in the colon and rectum. Case description: A 74-year-old man presented with features masquerading as low rectal malignancy with a malignant looking pedunculated polyp measuring 10 x 8 cm on colonoscopy. Punch biopsy revealed a diagnosis of benign tumour of schwannoma. After failure of multiple attempts of endoscopic resection, a decision of transanal excision was made. The histopathological assessment was consistent with the preoperative diagnosis and supported by immu-nohistochemistry of S-100 protein. His postoperative recovery was uneventful as he was discharged on the following day. There is no evidence of tumour recurrence on follow up. Conclusion: A huge tumour of the rectum is not always malignant. However, patient with features of low rectal tumour warrants an immediate referral to the surgical team as this non-communicable disease is a public health concern. Preoperative diagnosis is paramount for a necessary surgical intervention.

Matched MeSH terms: Rectal Neoplasms
Fulltext Intramural gas: would it be life-threatening

Azna Aishath Ali, Syamim Johan, Chiak, Yot Ng, Firdaus Hayati

Borneo Journal of Medical Sciences, 2020;14(3):63-64.
MyJurnal

The CECT scan of the abdomen at axial and coronal views show gas bubbles tracking along the inner wall of the ascending colon and hepatic flexure, which is separated from the intraluminal gas within the bowel. These intramural gas bubbles appear to be outlining the bowel wall circumferentially. The bowel wall appears to be thickened however the inner mucosa is not enhanced. There are no ascites in the images provided. The colon of the hepatic flexure and transverse colon appears dilated. No significant atherosclerotic plaque in the visualised arteries. Based on the clinical presentations and CECT features in Figure 1 and Figure 2, the best diagnosis for him is benign pneumatosis intestinalis (PI) secondary to obstructed low rectal cancer. He was subjected for a trephine transverse colostomy to relieve the obstruction with simultaneous transanal rectal mass biopsy. Once the histology is available, he subsequently will be referred for concurrent chemo-radiotherapy as neoadjuvant treatment and later for a low anterior resection, provided that it is a localized disease.

Matched MeSH terms: Rectal Neoplasms
Fulltext Isolated metacarpal bone metastasis from advanced rectosigmoid carcinoma

Fadli, A.R., David, O., Azmi, M.N., Zailani, M.H.

International Medical Journal Malaysia, 2012;11(1):59-62.
MyJurnal

Distant metastasis is a common sequelae of stage III colorectal adenocarcinoma. Liver and lungs are the
most common sites for distant metastases, but, metastases to extremities are very rare. We report a case of rectosigmoid adenocarcinoma, which metastasizes to left first metacarpal bone, which is the first occurrence in our experience. The investigations and management of the patient are discussed.

Matched MeSH terms: Rectal Neoplasms

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