Talking about young patients with colon cancer, here’s another young man with rectal cancer about a month ago… He is 33 years old.

He had passage of blood mixed in the motion for a few months. It was fortunate that he was seen early by a gastroenterologist who found a hard area in the rectum on finger examination and proceeded to colonoscopy. He was surprised to find that the pathology report was positive for cancer, but a repeat biopsy also yielded the same result. There were no polyps in the colon and rectum.

A low “anterior resection” (i.e. resection of the rectum but preserving the anus) was performed. Fortunately, this cancer was in an early stage, and he required no further therapy.

It is uncommon for the under 50 population to suffer from colorectal cancer, except in specific high-risk circumstances such as familial adenomatous polyposis (multiple polyps in the colon and rectum), hereditary non-polyposis colorectal cancer (very strong family history of colorectal cancer) and prolonged history of ulcerative colitis (a form of inflammatory bowel disease).

However, any patient who presents with rectal bleeding needs to be examined. Do not refuse a physical examination, at least a finger rectal examination : it helped save this young man.

The cardinal signs of intestinal obstruction are abdominal pain and bloating, vomiting and inability to pass motion or flatus. When a patient comes with these symptoms, it is usually a surgical emergency. The main causes to consider would be either a physical block in the intestine, or a loss of peristaltic movement of the intestine.

This 25-year-old man came from a hospital in the neighbouring state with intestinal obstruction. They had already performed a colonosopic examination and an obstruction was found in the colon. For some reason, an operation was not performed.

He came to my hospital and I decided that an urgent laparotomy was needed. The abdomen was extremely bloated already. This was what was found:

Whatever the age of the patient, obstruction is obstruction. The point is, obstruction due to a mechanical cause needs a laparotomy to relieve it. No matter what the age of the patient.

Presenting at the 2007 meeting of the Society of Surgical Oncology (SSO), Jennifer Gnerlich of the Washington University School of Medicine, St. Louis reports that

Data from an epidemiologic study have provided support for the surgical removal of the primary breast cancer in patients diagnosed with stage IV breast cancer. According to the study, women who underwent surgery were 37% less likely to die than women who did not undergo surgery after controlling for demographic and clinical factors known to affect survival.

Although the current indication for surgery in these patients is to control local wound complications, she suggested that benefit beyond palliation may be possible.

Stage IV breast cancer is one which has evidence of spread to distant sites from the breast. Examples would include lung, liver, bone and brain. Usually these patients would be treated palliatively (meaning, to treat with the aim of comforting the patient rather than to aim for cure). The choice as to whether to perform surgery to remove the tumour or the breast depends on whether it will help to make life more comfortable for the patient.

This report, however, makes the surgical community think again… perhaps operating on the tumour might help some of these patients in terms of survival.

This data was from a retrospective (looking back at patients on record) review of patients who were newly diagnosed with stage IV breast cancers entered into the Surveillance, Epidemiology and End Results (SEER) program database in the US between Jan. 1, 1988 and Dec. 31, 2003. Of the 9,734 patients who met this description, 4,578 (47%) underwent surgery (including mastectomy, complete removal of the breast, and partial excision).

The median survival is longer, averaging 36 months for those who received surgery versus 21 months for those who did not. (Median survival is the length of time that the 50% of the population is still alive from the time of the diagnosis.) It is still contraversial and is not yet clear that it will help until prospective studies address the issue (i.e. studies that follow patients from the time a diagnosis is made, not looking back at records).

This is an issue that, unfortunately, is too commonly seen. When a patient has a breast cancer, she is anxious to do “all that can be done”, even if it is diagnosed in the advanced stage. To most doctors, the quality of life is of primary concern in this situation, and the length of survival has become secondary. Nevertheless, if surgery can prolong good quality survival for advanced breast cancer patients, I don’t see why it should not be offered. I guess we’ll have to wait for other, stronger, evidence to understand whether it should be offered and to whom (what group of patients) it should be offered.

Perhaps those who do not have a taboo against discussing this subject might want offer a glimpse of how you feel about this issue?

General surgery on the net

On the lighter side, I would like to recommend a surgical blog by colleagues from around the globe: Rambodoc. It’s a humerus (sic) look at surgery.

The authors are familiar names on Surginet, a general surgical mailing list where we discuss general surgical issues. Surgeons and trainees will benefit from the discussions on this mailing list on surgical issues and non-surgical issues, some of them hilarious. I personally have been following this mailing list for many years.

I’d recommend a using separate webmail account to receive mail from this list though, ‘cos it’s high-volume and sometimes the busy surgeon could easily get swamped by the sheer volume of the emails. That, of course, is relative :-). Follow the Surginet link above to register.

We often take for granted the simple act of drinking. Where does the drink go? Here’s a drink of barium, which shows on an X-ray. This is done to diagnose patients with difficulty in swallowing.

However, this patient couldn’t swallow properly, food and drinks get stuck in the throat. See the bulge marked with red? That’s a tumour blocking the smooth passage of food down the oesophagus. So, be happy that you can swallow well.. it’s something that we don’t even think twice about when we drink.

Now, what are the risk factors of oesophageal cancer? Among them are cigarette smoking, gastro-oesophageal reflux and too much of these:

A hard message to swallow but as Mary Poppins says, “A spoonful of sugar makes the medicine go down.”

Eventually, after drinking, the water goes gets excreted. The majority of the water excretion is done via the urine. A urogram shows the passage of urine from the kidneys at the top to the bladder at the bottom.