While colorectal cancer remains one of the most deadly cancers, researchers are making steady progress against this disease. For people living with advanced colorectal cancer and their loved ones, small improvements make a huge difference. We are seeing many patients with metastatic cancer responding well to treatment and living for a longer time. For decades, medications to colorectal cancer were limited to two drugs: 5-Flurouracil and Leucovorin. But in 2004, doctors began to use targeted therapies also. Avastin and Erbitux are mono-clonal antibodies, new generation cancer drugs that can specifically target cancer tumors. The problem with traditional chemotherapy is that it can't be focused--the drug affects both cancer cells and healthy cells alike. Targeted therapies affect the specific mechanisms that allow cancer cells to grow. As a result, they have fewer side effects. Avastin blocks the effect of a substance in the blood that helps tumors to grow new blood vessels. This substance is called Vascular Endothelial Growth Factor (VEGF). By preventing the creation of new blood vessels, the tumor is starved; thus slowing down the tumor growth. Erbitux blocks the effects of a different growth factor called Epidermal Growth Factor (EGF). But these drugs are only used for metastatic colorectal cancers in combination with 5-Flourouracil, Leucovorin and Camptosar. Another turning point in treating colorectal cancer is Adjuvant and Neoadjuvant therapy. Adjuvant therapy is where chemotherapy and radiation are used after surgery. Neoadjuvant therapy is an approach where the treatment is given before surgery to make the tumor smaller and easier to remove. This is more convenient and it gives better results. It is a trend that is gaining momentum around the world. With more drugs to use for colorectal cancers, doctors are now trying them in new combinations and sequences. While new drugs get most attention, surgery remains the standard treatment for people in the early stage of this cancer. People can have inflated ideas about keyhole surgeries, but it is found that for rectal cancer, laproscopic surgery has not shown to be as effective as open surgery. Although these treatment advances are a cause for enthusiasm, we need to keep it in perspective. There are two ways to look at it. You could say that it's great that over the last decade, we have doubled the life expectancy of a person with metastatic colon cancer. On the other hand, you could say that over the last ten years, all we managed to add was about twelve months. Both statements are true. Although the steps might be frustratingly small, we are still moving forward. They may not be flashy, but hopefully with time and research, all of these smaller steps may add up to something big.

Endemic in many developing countries, typhoid fever is a protracted disease that includes bacteremic phase with fever and chills during the first week, widespread reticuloendothelial involvement with rash, abdominal pain and prostration in the second week, ulceration of peyer's patches with intestinal bleeding and perforation during the third week. The infection is caused by bacterium, salmonella typhi. The spread is usually by an oro-fecal route. Contamination of water and edibles are the major source. Infected shellfish can be the source of an outbreak. The incubation period is about 10-15 days. .It is Insidious in onset with fever which rises in a stepladder pattern for 4-5 days , associated with malaise, headache drowsiness and bradycardia .Pulse is often slower than would be expected from the temperature .Complication like perforation of the intestine usually occurs after 10 to14 days of fever.The resulting peritonitis can be rapidly fatal, if not treated promptly and vigorously. It is a challenging surgical emergency in some developing countries. There is a universal consensus that ileal perforations are best treated surgically, contrary to the former belief that they are better managed conservatively. Surgery eliminates the peritoneal soilage and endotoxemia.
After a proper diagnosis is made, perforations are surgically treated depending upon the degree of fecal contamination, general health status of the patient and the number and location of perforations.Surgical techniques are selected on the basis of above factors.Various modalities of surgical options are available, these include primary closure, excision and closure, resection and anastomosis, resection and ileostomy, wedge resection, application of serosal or omental patch, and exteriorization of the perforation.When there is minimum peritoneal contamination with single perforation quite far away from the ileocecal junction and good general health of the patient , the preferred method is primary repair., but in moderate peritoneal contamination with multiple perforations very close to each other, resection anastomosis is usually the choice .Heavily contaminated peritoneal cavity, toxic and moribund patient may require an ileostomy. The mortality and morbidity rate do not depend on surgical techniques, but rather than on the general status of the patient, the virulence of the germs and the duration of the disease before the surgery.Thats why it is very important that the patient gets early initial fluid resuscitation, antibiotic therapy etc for better surgical outcome.
Although there are different methods of cure for typhoid and its complications, it is recommended that every effort be made to prevent the disease in the first place and then to educate the masses to bring the patients to hospital as soon as the symptoms begin. In case where the general condition of the patient is not good, patient has been partially treated and lost many precious hours to seek medical attention, has developed renal shut down, has metabolic and hemodynamic instability, the patients should certainly be managed surgically without delay.

A fistula is an abnormal epithelialized tract between two or more structures or spaces.It may involve a communication tract from one body cavity or hollow organ to another hollow organ or to the skin.It is estimated that 90% of ECF arise from surgical procedures. It occurs due to unintentional enterotomy and anastomotic breakdown as a result of a foreign body close to the suture line, tension on the suture line, complicated suturing techniques, distal obstruction, hematoma, abscess formation at the anastomotic site, or tumor.Emergent/urgent surgeries involving unprepped bowel, underresuscitation, malnourishment or previously radiated tissues are other causes for fistula development.Spontaneous fistulas can develop due to crohn's disease, malignancy, infectious processes as in tuberculosis, diverticulitis, vascular insufficiency, radiation exposure and mesentric ischemia.
Fistulas can be classified according to complexity, anatomic location or physiology. Excess fluid exudating from a wound or cutaneously is the usual first indication of an external fistula.Skin excoriation rapidly occurs secondry to the high concentration of digestive enzymes in the chyme. Internal fistulas are fissuring tracts inside the body, which erode directly into adjacent viscus. These are asymptomatic unless the distal portion of the fistula enters a structure such as the bladder , rectum or vagina. Symptoms such as recurrent diarrhea with mucus, blood, cystitis, pneumaturia, flatus or stool from the vagina, perianal/perineal skin excoriation, pressure and discomfort, should all point towards an investigation for the presence of a fistula.
Closure of the fistula either spontaneously or surgically is the ultimate goal. The five main objectives towards caring for fistula are - 1.)Fluid and electrolyte replacement. 2.) Adequate nutrition.The route of nutritional support will take the form of oral, enteral or parenteral nutrition dependent upon patient tolerance, ability to ingest sufficient quantities, the fistula tract location and bowel mucosa's absorptive capacity. 3.)Perifistular skin protection and containment of fistula effluent , which in itself is a complex challenge. Advanced assessment skills, knowledge of appropriate product selection, competence in product application and teaching of the same is very important . 4.) Infection control with use of antibiotics .5.) measures to facilitate closure of the fistula.
Medical and nursing care demand a complementary, interdisciplinary approach if successful closure of an enterocutaneous fistula is to be achieved. The patient and the family are challenged by physical and psychological stressors, which is often the result of weeks of hospitalization.As health careproviders, we should remember to treat the patient as a whole person and not 'just as a hole'. The fistula should not become the only focus of care, but rather an element of the overall treatment plan.

Surgical procedures are generally recognized by Pancreatologists as the most effective treatment for chronic pancreatitis in reducing acute exacerbations and chronic symptoms.Surgery performed for chronic pancreatitis can be classified as resection procedures or drainage jejunostomy.Types of pancreatic resection surgery include Whipple and Beger's procedures.Drainage pancreaticojejunostomy procedures include Puestow and Frey's operations.When the pancreatic duct in the body or tail is dilated beyond 6 mm, the puestow procedure is usually most effective.When disease occurs predominantly in the head of the pancreas, Frey's procedure is used.When there is a focal mass in the head without significant duct dilation, the whipple's procedure is most frequently done. Beger's procedure which preserves the duodenum, is also used as an alternative.
Several expected postoperative CT and MRI findings may be confused with disease.Periportal hepatic edema, which usually resolves in 1 month, and pneumobilia which usually persists, are seen universally.The afferent loop of the bowel that drains the pancreatic and biliary ducts may be edematous in the first 3 weeks.This appearance should not be mistaken for bowel ischemia or hemorrhage. The Roux loop may be mistaken for an abscess.In puestow procedure, the Roux loop lies between the stomach and the pancreatic body in the lesser sac and should not be misinterpreted as an internal hernia or pancreatic tumor.Transient fluid collections in the pancreatic and duodenal bed are common in the first month after surgery and do not need to be drained unless clinically indicated. Reactive lymphadenopathy is seen upto 2 months postoperatively.Perivascular cuffing around the celiac, hepatic, and mesentric arteries is seen upto 6 weeks after whipple and Beger's procedures.This finding can be mistaken for tumor recurrence.Mild pancreatic duct dilation is an expected postoperative appearance.After Frey's procedure, a large cavity may be seen in the pancreatic head and may possibly be mistaken for a pseudocyst or cystic neoplasm.Some errors can be avoided if postoperative anatomy is known to the radiologist.

Rectal prolapse is an uncommon condition akin to prolpase of utreus seen in some women after multiple childbirths. It is an abnormal protrusion of rectum outside of anus and it is quite grotesque for the patient himself and others to look at. The protrusion can range from a few centimeters to a foot or more.
This condition is often seen in children who are malnourished and suffering from chronic diarrhoea. and this protrusion can be pushed back into the pelvic cavity most of the times. Rectal prolapse in children is usually self limiting and doesnt require any treatment.
This condition is also seen in individuals with microcephaly(small undeveloped brain) and mental retardation.
Prolapse of rectum is also seen in some healthy adults who generally come to the clinic with a long history. They are usually in the habit of pushing the prolapse back into the rectum on their own. Constipation is a very common symptom and at times perienal pain and discomfort forces them to see a specialist. Ulceration and bleeding is not uncommon.

Medical management doesnt help. Most patients will require surgical treatment in the form of laparoscopic or open rectopexy wherein a synthetic wire mesh is used to anchor the rectum in the pelvis to prevent the rectum to slide down. results are usually good and a transient constipation may persist for a while after the surgery. Prolapsed rectum is a condition which should not be ignored and should be shown to a specialist ASAP.

Dr.Patta Radhakrishna MS MCh
Sr. Consultant Surgical Gastroenterologist &
laparoscopic surgeon
Apollo Hospitals(main), Chennai.