July-September 2016
Volume 9 | Issue 3
Page Nos. 187-274
Online since Wednesday, April 18, 2018
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Editorial p. 187
Klaus E Matzel
DOI:10.7707/hmj.659
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STATE-OF-THE-ART REVIEW
Surgery for colon cancer – complete mesocolic excision p. 189
Klaus Weber
This review presents the concept of complete mesocolic excision (CME) for colon carcinomas. It focuses on an anatomical preparation in embryological preformed planes. Different tumour locations require individual operative strategies. In contrast to other malignancies, lymphatic metastasis in colon cancer is initially based on fixed rules. The extent of lymph node dissection and mesocolic resection for each tumour depends on the location of potential tumour deposits in lymph nodes along supplying arteries and aberrant lymph node stations.
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Pathological assessment of colon cancer specimens p. 197
Nicholas P West
Pathologists play an important role in the treatment of colon cancer by undertaking a meticulous pathological assessment and producing an optimal pathological report. The specimens should be photographed and the plane of surgery described to provide a permanent record of the quality of surgery. The recommended grading system has been shown to predict patient outcome. In addition, pathologists should assess the degree of central radicality to determine whether complete mesocolic excision (CME) has been undertaken. The specimen should then be carefully dissected to ensure that all of the potential high-risk features are assessed, including the status of the non-peritonealised resection margin and the presence or absence of extramural venous invasion. All of the lymph nodes within the specimen should be examined and ancillary techniques used if required. Finally, molecular pathology is now an important component of patient management and laboratories should have access to immunohistochemistry for the mismatch repair proteins to identify microsatellite instability, and also sequencing technologies to determine the mutational status of KRAS, NRAS and BRAF genes for patients being considered for antiepidermal growth factor antibody treatment.
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Quality management during development and implementation of complete mesocolic excision in colon carcinoma p. 205
Susanne Merkel, Werner Hohenberger
In a prospective observational study, the implementation of complete mesocolic excision (CME) from 1978 through to 2014 was examined in light of process and outcome quality during ongoing developments in treatment for colon carcinoma. Data from 2019 patients with stage I–III colon carcinoma were analysed by comparing five time periods –1978–1984 (pre-CME), 1985–1994 (CME development), 1995–2002 (CME implementation), 2003–2009 (CME) and 2010–2014 (CME) – with a special focus on indicators of process and outcome quality. Over the 37-year period, the patients became older, and right-sided carcinoma was more common and more likely to present at stage I, which is associated with a favourable prognosis. Fewer patients had regional lymph node metastases. The proportion of patients with histology-negative lymph nodes (pN0) with at least 12 examined regional lymph nodes increased significantly, to 100%, as did the curative (R0) resection rate, and the application of adjuvant chemotherapy in stage III colon carcinoma increased to 79%. The 5-year rate of locoregional recurrence decreased significantly, from 6.7% to 2.1% (p=0.008). The cancer-related 5-year survival rate increased significantly, from 78.9% to 90.6% (p<0.001). In multivariate analysis, the date of treatment in the series chronology was found to be an independent prognostic factor for locoregional recurrence (p=0.018) and cancer-related survival (p=0.001). In summary, the quality indicators of process and outcome quality improved with CME. Adjuvant chemotherapy at stage III and multidisciplinary approaches in patients with metachronous distant metastases also improved outcomes. Strict quality management is mandatory to accompany changes in treatment.
Adjuvant and palliative systemic treatment for colon cancer p. 219
Antonia Busse
Currently, treatment of advanced colorectal cancer (CRC) is based on multidisciplinary approaches. Systemic chemotherapy with fluoropyrimidines plays an important role in the adjuvant and neoadjuvant treatment of locally advanced CRC and is the cornerstone of treatment in the metastatic setting. Targeted therapies with monoclonal antibodies directing epidermal growth factor receptor and vascular endothelial growth factor significantly improve the treatment outcome for metastatic CRC (mCRC), but they play no role in adjuvant treatment. Nevertheless, despite significant advances in the treatment of mCRC, the disease will progress in the majority of patients and median overall survival with the current available treatment is only about 18–30 months. Efforts to overcome the limited efficacy of current treatments are ongoing, including evaluation of immunotherapeutic approaches and combination therapies with new biological agents. Current treatment standards and new developments in locally advanced and mCRC are reviewed with focus on systemic therapy.
ORIGINAL RESEARCH ARTICLES
Standard of outpatient management of renal colic p. 237
Muhammad Salman Rafiq, Muhammad Imran Rafiq, Maria Rafiq, Seema Gul Salman, Sania Hafeez
The aim of the research was to assess the standard of emergency outpatient management of renal colic at Khyber Teaching Hospital, Peshawar, Pakistan. A retrospective clinical audit of 197 randomly selected outpatients presenting with renal colic received and treated at the emergency department of Khyber Teaching Hospital, Peshawar, was carried out over a 1-year period from June 2014 to June 2015. Data were collected from the outpatient sheets of selected patients. The management they received was compared with the Royal College of Emergency Medicine's (RCEM) guidelines for the management of renal colic. The results of this research showed that management fell short of RCEM guidelines for pain score on admission, which was not assessed or recorded in any of the 197 cases. Administration of analgesia for severe pain within 20, 30 and 60 minutes of admission was better than RCEM guidelines by 9%, 25% and 2%, respectively. It fell short of RCEM guidelines for moderate pain at 30 and 60 minutes by 69.9% and 19.1%, respectively. Re-evaluation of analgesia for severe pain exceeded RCEM guidelines by 10%, but fell short of the guidelines for moderate pain by 13%. Patients not receiving analgesia should be documented in all cases but, in this respect, the audit fell short of the guidelines by 9.1%. A full blood count and urea and electrolyte levels were assessed in only 73 (37.1%) and 8 (4.1%) cases, respectively, and fell short of the guidelines by 62.9% and 95.9%, respectively. None of the patients qualifying for assessment for abdominal aortic aneurysm (AAA) was investigated or assessed for the illness and the audit fell short of the RCEM guidelines in all 47 cases (23.9%). Our conclusions are that current practices partially complied with standards set by the RCEM guidelines for the management of renal colic. This should be addressed by presentations to doctors and nurses at the emergency outpatient department on RCEM guidelines and the findings of the present audit. Categories that fell short of the RCEM guidelines included pain score on admission; re-evaluation for moderate pain; documentation in all aspects of RCEM guidelines, including reasons for not receiving analgesia; performing RCEM laboratory investigations for all cases of renal colic; and assessment and management of cases qualifying for abdominal aortic aneurysm. Posters detailing the RCEM guidelines have been set up in the emergency department and a follow-up audit has been scheduled.
Hepatic sarcoidosis masquerading as tuberculosis p. 243
Bijay Misra, Debasis Misra, Ayaskanta Singh, Girish Kumar Pati, Sanjib Kumar Kar, Manas Kumar Panigrahi, Haribhakti Seba Das, Chitta Ranjan Panda, Pranati Misra, Rabi Narayan Mallik, Shivaram Prasad Singh
Sarcoidosis is a systemic granulomatous disease of unknown aetiology. Hepatic involvement is frequent in sarcoidosis and is commonly asymptomatic. We report the case of a 50-year-old woman who presented with antitubercular therapy (ATT)-induced hepatotoxicity. The patient was prescribed ATT for hepatic tuberculosis, which was diagnosed incidentally during laparoscopic cholecystectomy; however, instead of improving on ATT, the patient deteriorated. Subsequently, a diagnosis of hepatic sarcoidosis was confirmed after reviewing the liver biopsy, and the patient improved following treatment with corticosteroids.
Oral lymphangioma of the alveolar ridge – a report of a rare case p. 247
Faysal Ugurlu, Alper Kaya, Emine Tuna Akdogan, Vakur Olgac, Aysegul Sipahi
Lymphangiomas are benign hamartomatous lesions of the lymphatic vessels, which are commonly seen in the head and neck region. The most frequent locations of oral lymphangiomas are the dorsum of the tongue, followed by the palate, buccal mucosa, gingiva and lips. The various treatment options are surgical excision, radiation therapy, cryotherapy, electrocautery, sclerotherapy, steroid administration, embolization, ligation, laser surgery using neodymium-doped yttrium aluminium garnet, carbon dioxide and radiofrequency tissue ablation. We report a rare case of an oral lymphangioma affecting the posterior alveolar ridge of the maxilla. The 51-year-old male patient was referred to our clinic because of a diffuse, 2×3cm, blue–purple lesion in the right posterior alveolar ridge. The lesion was removed completely, together with adjacent healthy tissue. Histopathological examination confirmed the lesion as a lymphangioma.
Brucellosis associated with kidney injury and any form of nephropathy – a review of the literature p. 251
Anthony Kodzo-Grey Venyo
Systemic brucellosis may be associated with acute kidney injury (AKI), haemolytic–uraemic syndrome, nephrotic syndrome or various types of nephropathy. Presentation depends on the type of renal disease the patient develops. A diagnosis of brucellosis as a cause of nephropathy would require the following: isolation of Brucella in blood culture; positive serological test for brucellosis; renal biopsy evidence of the type of nephropathy; culture of Brucella from perinephric abscess or renal abscess aspirate; culture of Brucella from nephrectomy specimen; and finding a specific type of nephropathy during histological examination. Ultrasonographic and computerized tomographic findings are not specific for brucellosis; however, the scans may show an abnormal area in the kidney from which renal biopsies can be taken for pathological examination and culturing, and if there is an abscess it can be aspirated for culture. A high index of suspicion is required to diagnose the disease. The most commonly used antibiotic regimen for the treatment for brucellosis is doxycycline 100mg twice a day for 45 days in combination with streptomycin 1g/day for 15 days. The main alternative treatment is doxycycline 100mg twice a day for 45 days in combination with rifampicin 15mg/kg/day (600–900mg) for 45 days. Experience suggests that streptomycin may be replaced by gentamicin 5mg/kg/day for 7–10 days. The optimal treatment for neonates and children under 8 years old with acute brucellosis has not yet been determined but there is some experience with trimethoprim/sulfamethoxazole (cotrimoxazole) in combination with an aminoglycoside (streptomycin, gentamicin) or rifampicin. In general, other combinations of antibiotics have also been used to treat brucellosis. In cases of kidney injury and dehydration, in addition to antibiotic treatment, rehydration and clinical monitoring is required, as is monitoring urine output, repeated urinalysis and repeated serum biochemical tests for renal function estimation to assess the patient's progress. Most renal complications due to brucellosis resolve/improve after combined antibiotic treatment and rehydration, which is also most often associated with return of normal renal function or improvement in renal function. However, relapses can occur, and careful patient follow-up is required to further assess the patient clinically by regularly repeating urinalysis, renal function tests, liver function tests and full blood count and coagulation tests, as well as repeating blood and urine cultures and Brucella serology tests. Patients should be educated to avoid contact with and ingestion of unpasteurized dairy products. Pasteurization of all dairy products should be advised, encouraged and monitored. Veterinary surgeons in endemic areas should be informed and assist when a new diagnosis is made in order to help identify and treat or kill affected animals harbouring Brucella.
Integrating the hospital sector into the UAE's Green Economy Strategy p. 265
Niyi Awofeso
UAE's Green Economy Strategy seeks opportunities for economic growth, to improve community well-being and protect environmental health through green jobs and renewable energy projects, while reducing water security risks and assuring social equity. The growing hospital sector in the UAE is both a threat to and an opportunity for achieving the objectives of the Green Economy Strategy. Hospital-based health care requires substantial amounts of energy and generates large quantities of greenhouse gas emissions. To reduce the carbon footprint of hospitals requires reductions in waste and energy use, and regenerative hospital designs that not only enhance the capability to sustain life and health, but also offset some of the energy and environmental losses consequent to hospital care provision. Incorporation of hospitals into the UAE's Green Economy Strategy will facilitate the well-being outputs of the strategy, while promoting social inclusiveness, economic growth and environmental health.