One hundred fifty-one patients with colorectal polyps containing invasive adenocarcinoma treated by resection were studied to determine the incidence of lymph node metastasis and whether lymph node metastasis was related to the depth of invasion. Other variables evaluated included size and configuration of the polyp, grade of adenocarcinoma, presence or absence of lymphovascular invasion, and degree of differentiation. In patients with sessile polyps, the incidence of lymph node metastasis was 10 percent. Eighty percent of these lesions had lymphovascular invasion. For pedunculated polyps, the overall incidence of lymph node metastasis was 6 percent. However, there was no incidence of lymph node metastasis when the depth of invasion was limited to the head, neck, and stalk of the polyp (Levels 1, 2, and 3). Only when the depth of invasion reached to the base of the stalk (Level 4) was the risk of lymph node metastasis high (27 percent). The other risk factors were not associated with lymph node metastasis. We concluded that the most significant risk factor for lymph node metastasis in patients with invasive carcinoma in a polyp was invasion into the submucosa of the bowel wall (Level 4).
The novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of inter sphincteric fistula tract) procedure, is described in detail. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle. Attention to detail is the key for a favorable outcome.
Eighty-two patients with colon and rectal polyps containing invasive adenocarcinoma treated by polypectomy alone were studied. Seven of 34 patients (21 percent) with sessile lesions had an adverse outcome, including five local recurrences and two distant metastases. They occurred from 4 to 68 months after the polypectomy. Forty-seven pedunculated polyps with invasion to the head (Level 1) or to the stalk (Level 3) and one polyp to the base of the stalk (Level 4) had no evidence of local recurrence or signs of metastasis. Twenty-eight percent of patients were found to have adenomatous polyps, and 4 percent had malignant polyps during the follow-up examinations (range, 3-119 months; mean, 53 months). The findings suggested that pedunculated polyps with invasion to the head (Level 1), neck (Level 2), or stalk (Level 3) can be safely treated with a complete polypectomy provided that the carcinoma is not undifferentiated. Sessile lesions as well as Level 4 pedunculated lesions should be treated aggressively. If resection is not performed, a long-term follow-up in these patients is essential.
Ligation of intersphincteric fistula tract is an effective technique for the treatment of fistula in ano, including recurrent or unhealed fistula after other procedures. See Video Abstract at http://links.lww.com/DCR/A387.
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