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Even though anal incontinence affects a significant proportion of the population, causing a major burden to both patient and society, it still remains "the last closet issue". Less than a third of patients will share this problem with their physician. Consequently, the incidence of anal incontinence is difficult to determine, varying from 2-50%. Since this disabling condition is often associated with urinary incontinence and/or pelvic organ prolapse, a multidisciplinary team approach is required. A wide range of therapeutic options are available. When dietary, medical and rehabilitative treatments have failed, sacral neuromodulation should be considered in selected cases. More invasive surgery is usually undertaken in the presence of major structural defects. The aim of this article is to suggest a comprehensive way of identifying and treating anal incontinence.

The evolution of visceral surgery is characterized by defining with ever increasing precision the real role of new techniques. Hernia repair, abdominal compartment syndrome, pancreatic and colorectal cancers, as well as haemorrhoids, confirm this reality. Although laparoscopy has clear indications in hernia repairs, many still prefer open approach. The abdominal compartment syndrome, now better understood thanks to laparoscopy, is increasingly important in intensive care. The role of laparoscopy for pancreatic and colorectal cancers is still limited. The development of minimally invasive techniques has led to a reduced morbidity of surgery for haemorrhoids and better results. The economic impact of new technologies must remain a primary concern.

Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal, dominantly inherited disease leading to a marked increase in cancer susceptibility, notably colorectal cancer, affecting up to one in 400 individuals in the Western world. Four genes responsible for the majority of cases have been identified. Colorectal cancer in affected people tends to be right sided, occur at an earlier age, and there is a propensity for synchronous or metachronous lesions. Extra-colonic tumours may occur with an elevated frequency, most importantly cancer of the endometrium, but also stomach, hepatobiliary system, small bowel, proximal ureter and renal pelvis, and ovary. On account of these features, management guidelines for members of HNPCC kindreds require modification from those generally advised for patients with sporadic tumours. The cardinal feature for the identification of affected families is the family history. All clinicians have a duty to identify such patients under their care as appropriate screening and surgery should lead to an improved prognosis for such patients and their families.

Amongst family members at risk of developing familial adenomatous polyposis (FAP) to distinguish between those who are affected by the disease and those who are not, in order to provide optimal treatment to those requiring it whilst excluding those without the disease from the endoscopic surveillance programme.A programme of endoscopy, ophthalmologic examination for retinal pigment lesions associated with FAP and genetic analysis was proposed to a patient suffering from FAP and 3 of his children considered to be at risk.One person at risk eventually proved to have the disease. He had diffuse recto-colic polyposis as well as the typical retinal lesions found in his father and was treated by prophylactic proctocolectomy. He had inherited the mutated paternal allele. The other 2 children had neither polyposis nor retinal lesions and had inherited the normal allele from their father.Retinal lesions seen at fundoscopy allowed the diagnosis of FAP to be made before endoscopic confirmation in one patient at risk for FAP, but their absence did not exclude the diagnosis in the other 2. In these patients genetic analysis revealed that they had inherited the normal paternal allele and hence would not develop FAP.Systematic investigation of a family suffering from FAP allowed the members at risk to be identified. Two subjects at risk were able to be excluded from further follow-up and the remaining patient was able to be treated in an optimal fashion. An algorithm is proposed for the screening of patients at risk.

Numerous acquired genetical mutations are now well described by molecular biology and seem to be related to tumour progression. K-RAS mutation is of interest in colorectal cancer where it could be correlated to an aggressive tumoral behaviour leading to a high risk of recurrence or metastasis.

Cancer of unknown primary site is a common clinical entity, accounting for 5% of all cancer patients. The diagnostic evaluation of these patients must permit to exclude treatable tumors. We reviewed the charts of 85 patients admitted with this diagnostic. We propose an algorithm for investigation of these patients.

Malrotation is a rare aetiological factor of intestinal occlusion in adult. We report our experience of 16 cases collected from 1976 to 1991. The incidence is about 0.2-0.5% with two peaks, at 25 and 55 years respectively. Mean age is of 41 years. The symptoms were occlusion in more than 90%. A contrast enema was performed in acute as well as in chronic situations. The surgical treatment whatever it is, is the treatment of choice but has to be put in balance with age.

Described in Switzerland in the early '60, the major features of hereditary non-polyposis colon cancer syndrome (HNPCCS) were established 20 years ago by H. T. Lynch. HNPCCS accounts for at least 60% of the colon cancer etiology. Cancer family syndrome is defined by the presence of extracolonic primary tumors in addition to colon cancer. Both syndromes are transmitted by an autosomic dominant pattern. None of the known biomarkers are specific and/or sensitive enough to rely on their predictive values of patient's risks. A typical Swiss family was investigated on the basis of the cancer-prone family history. 21% of the family members observed over 5 generations presented one or more (30% of the cases) colo-rectal neoplasms at the age of 50. 55% of the tumors were right sided. Histologically, half of the tumors were mucinous. 30% of metachronous cancer appeared within 10 years. Polyps (1-3) and flat adenomas were associated to the lesion in 57%. Extra-colonic tumors appeared in 18% of family members and in half of the colon cancer patients. The sites of these tumors were the urinary tract, ovary, small bowel, breast and stomach. Two fibroblast strains of affected individuals were established. No increased tetraploidy was noted. Preliminary results suggest that this two strains are rather sensitive to ionising radiation. Often neglected, family history of colon cancer remains the major diagnostic and decision-making tool of a such syndrome. It will necessitate special treatment of affected subjects and early screening of the relatives.(ABSTRACT TRUNCATED AT 250 WORDS)

Colo-rectal cancer in young patients is a subject of interest for many reasons. Various studies are devoted to this subject but controversies regarding the stages, the evolution and the prognosis still remains. We present intermediate results, of an ongoing study, which is directed to those particular aspects of colon cancer of the patients less than 45 years of age in a region where the global incidence of the disease is one of the highest in the world. In the past five years, we have observed 602 patients with colon cancer. 23 of them (4%) were less than 45 years old. The age at diagnosis was 38 +/- 6 years. Two-thirds of the subjects were male. 13% had had predisposing conditions for colon cancer such as FAP, ulcerative colitis or Turcot syndrome; 50% had a positive familial history for cancer. Symptoms lasted for less than 3 months in two thirds of the patients. 15% had a right sided tumor, 38% were located in the sigmoid and 28.5% in the rectum. At diagnosis, the tumors were classified as follows: 32% Dukes B, 23% Dukes C and 40% were disseminated disease. Most of them were located in the rectum, but 43% of Dukes B lesions were located in ascending or transverse colon. Grading reveal moderately to poorly differentiated tumors in 3/4 of cases. 30% of patients received an adjuvant therapy. After two years, 70% of the patients were alive. None of them with Dukes A or B but one of the patients with Dukes C were dead.(ABSTRACT TRUNCATED AT 250 WORDS)

Digestive fistulae have a quite variable clinical presentation, depending on their origin and topography. Even when very small, they can cause considerable mechanical or metabolic derangement. Surgical correction often implies an operation with important consequences. The injection of an occlusive emulsion can, in a certain number of cases, close off the fistulous tract with minimal inconvenience. We have injected several invalidating fistulae between the digestive or respiratory tract and the skin with Ethibloc. Total occlusion of the fistulae was accomplished after one or more injections. The emulsion is resorbed after around 10 days, leaving a scar. The inclusion of radio-opaque material allows intraoperative control of injection. This technique widens the therapeutic modalities applicable to a difficult medical condition. When confronted with advanced inflammatory or neoplastic disease, for example, Ethnibloc injection can be considered if the tissue quality is sufficient. Gross infection or tissue necrosis are, in our experience, relative contraindications; the occlusive emulsion cannot adhere and is rapidly evacuated by the fistula.

Stenosis of the rectum after surgery is a rare complication of low anastomosis. Infection, ischemia, foreign body reaction, technical faults or recurrence of neoplasms are the most important causes. Dilatation is attempted either manually or by instrument, if the stenosis causes discomfort and in particular if diarrhea results. Rarely resection of the stenosed segment is necessary. Stenosis in conjunction with incontinence is the most feared complication of anorectal surgery. It develops exceptionally after scarring of a large mucocutaneous defect after hemorrhoidectomy, correction of an anal fistula, a mucosal prolapse, electro-resection, infection or trauma. Anal stenosis leads to increasing constipation, a reduction of stool volume, abdominal cramps and rectal bleeding.

The discovery of synchronous hepatic metastases from colorectal cancer poses a tactical problem ticklish to resolve. What are favourable circumstances for curative excision of hepatic metastases? When and how to operate them? To try to respond, we analysed a collective of 36 patients between 10. 1. 1985 and 30. 12. 1986. Of the patients staged Dukes B presenting synchronous hepatic metastases (less than 4, less than 50% of hepatic involvement by the tumour) without systemic involvement, excision at the first attempt is realizable and will be a benefit for the patient. For the others, excision is to be considered in the near future after having analysed (tumour grading and staging, CEA, ploidy of primary tumour). Patients presenting extrahepatic metastases will not benefit from hepatic resection. Surgery, associated or not to regional infusion chemotherapy is discussed.

A severe or lengthy disturbance of immunity favors the development of malignant tumors. The increased incidence of lymphomas, leukemias and certain carcinomas in cases of congenital immunodeficiency, as well as of Kaposi's sarcoma and certain lymphomas in the acquired immunodeficiency syndrome (AIDS) are well known. In transplantees, patients undergoing immunosuppressive treatment for autoimmune disorders and cancer patients receiving chemotherapy, the occurrence of secondary neoplasias represents a phenomenon with a specific profile. We have seen 14 solid tumors in patients who were immunosuppressed for one of the 3 above-mentioned reasons. It is a heterogeneous group, both in terms of patient profile and tumor localisation. However, there are certain characteristics of these tumors which distinguish them from similar ones arising in the general population. The advent of more aggressive immunosuppressive therapies, the constant increase in organ transplants and the development of new cancer treatment modalities which influence the patients immune systems explain the importance of this phenomenon. Thus one must constantly be wary of these unusual tumors which occur independently of age and usual risk factors.

We report 30 cases of non-Hodgkin's gastric lymphomas (according to the Rappaport classification): 1 nodular lymphocytic lymphoma well differentiated, 7 diffuse lymphocytic lymphomas poorly differentiated, 2 diffuse mixed cellularity lymphomas, 20 diffuse histiocytic lymphomas and 4 pseudolymphomas, over a period of 21 years at the CHUV, in Lausanne (1958-1979). There are 56% of advanced stages (IIIE and IVE) according to Ann Arbor. Survival to 5 years is of 27%. The mean survival of patients who died from their lymphomas is of 5 months only. Lymph node invasion worsens considerably the prognosis (75% of survival to 5 years for stage IE against 25% for stage IIE). This phenomenon is particular to non-ganglionary lymphomas. We do not observe good remission for the diffuse histiocytic forms at an advanced stage, remission being characteristic of the ganglionary lymphomas only. Treatment is poorly codified. Surgery along seems possible for the localised forms (IE): triple therapy (surgery, radiotherapy and chemotherapy) is necessary for advanced stages and histological unfavorable forms.

Aneurysms of the cervical internal carotid artery are not rare lesions although they often remain symptomless. The authors describe the case of an eighteen-year-old boy presenting bilateral cervical internal carotid artery aneurysms of probable traumatic origin and treated conservatively. Etiology, pathogenesis, difficulties in diagnosis and choice of treatment are discussed.

The analysis of ploidy provides valuable information allowing a more precise diagnosis, a more dependable prognostic and the choice of appropriate therapy. With ploidy analysis one can assess the aggressiveness of a given tumor. Aneuploidy of tumors clearly indicates a significantly lower patient survival index. Ploidy analysis of tissue sections yields a clear overall indication of the proportion of cells exhibiting hyperploidy within the tumor mass. The application of this approach is amenable to diverse types of tumors including colo-rectal neoplasias. Additionally, it provides a correlation with the histological presentation of each tumor. The study includes DNA ploidy analysis of 212 patients with primary adenocarcinoma. Sixty-four of the cases examined had follow-ups of a least 2 years. Eighteen of this group had diploid non-proliferating tumors, of which 2 (11%) subsequently died. Nineteen of the 64 had proliferating diploid tumors, 11 (58%) of whom died within the follow-up periods. Twenty-seven patients had tumors which were clearly aneuploid, 12 (45%) of whom later died. Our study demonstrates the prognostic value of ploidy analysis. The preliminary results indicate that mortality of patients with proliferating tumors is approximately 50% after 2 years. This prognostic is independent of other more classical criteria of tumor staging, namely Dukes' classification, histological differentiation and size of tumor. In the near future, ploidy analysis should be introduced as a standard part of tumor assessment. It clearly provides a valuable prognostic allowing the selection of patients requiring a careful follow-up.