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Cancer Awareness and Prevention with Lifestyle
Human Biology is far more complicated than we imagine. Cells in our body are supposed to function and grow in a particular manner. In the process they are likely to become abnormal. Cancer is unrestricted growth of as abnormal cell. Cells get into abnormal cycle in two stages(medically ‘two hit theory’). One abnormal cell formation where in there is a genetic change in the cell (called mutation). These cancer cells have changes in the gene. These changes are related in 10 to 15% with inherent genetic abnormality , and 80 to 85% with environmental mainly lifestyle related risk factors.With mutation there is initiation processes. At any given point of time it is scary to think that there are many initiated cells in the body. In the presence of good body immunity these cells are either killed or made to remain in static phase. In the absence good immunity or presence high risk factors ( poor lifestyle) these cells get into promotion phase to get into cancer cycle. Once these cells grow excessively they start spreading through blood vessels and lymphatics.

It sounds bizarre, but lifestyle could be secret weapon against cancer. We humans have capacity to control our lifestyle for better, than any other living beings. There is a need to restrict environmental influence on us with knowledge. We need give space and time to maintain our body and mind. We need to be focused about maintaining our own body like how we take care of anything we are passionate about. It is easy to get addicted to bad lifestyle. But if we make good lifestyle a part of our routine the body gets good of everything we do. The lifestyle related factors include cigarette smoking, diet ( fried foods and red meat), alcohol , sun exposure,infections, stress, obesity, environmental pollutants, and physical activity. Therefore Cancer prevention requires smoking cessation , increased ingestion of fruits and vegetables, moderate use of alcohol, calorie restriction, exercise, minimal meat consumption, use of whole grains, use of vaccination, and regular check ups. By choosing the healthiest lifestyle options possible, you can empower yourself and make sure your cancer risk is as low as possible.

Colo-anal Anastomosis Using a Lone Star Retractor System
Karandikar S*, Rajneesh N**, Masoud A***
*Heart of England Foundation NHS trust, Birmingham, Heartlands Hospital Birmingham, UK
**St Johns Medical College Hospital, Bangalore, Karnataka, India
***Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan, UK
Running Title: Colo-anal anastomosis using Lone Star retractor
Key Words: Anastomosis, retractor, Lone Star
Article type: Case Report
Address for Correspondence: Dr. Sharad Karandikar Consultant General and Colorectal Surgeon
Heart of England Foundation NHS trust Birmingham Heartlands Hospital
Birmingham, UK, B9 5SS.

Abstract
The Lone Star retractor system, a self-retaining, latex free retractor system, has been used in colorectal surgery, gynecology, and urology in the perineal region. We present this case to highlight the ease with which a hand sewn colo-anal anastomosis is possible using the Lone Star retractor.

Introduction
The Lone Star retractor system is a self-retaining, latex free retractor system. The retractor ring is placed over the incision and the first four elastic stays are positioned into the tissue’s edge in directly opposing quadrants, using gentle tension. The counter-traction of the elastic stays stabilizes the retractor system. It is available as a reusable and disposable system. The retractor is used in colorectal surgery, gynecology, and urology in the perineal region.

The traditional retractors which have been shown to compromise sphincter function. The Lone Star gives excellent exposure without the stretch on the sphincter complex as it effaces the anal canal. The colorectal surgeon would find this system useful for complex perianal fistula surgery (advancement flap), rectal prolapse surgery (Delormes operation or Altemeier procedure) and hand sewn colo-anal or ileo-anal pouch anastomosis.

The Lone Star retractor system can be adapted to the perineum of individual patients owing to its adjustable ring. The surgeon may retract the dentate line from any desired angle by repositioning or adding elastic stays. The elastic stay hooks are available as single or double hooks and may be used in place of assistants employing traditional hand-held retractors. Available in a variety of sizes, the stay hooks provide precise retraction for superficial and deep work.
The case highlights the ease with which a hand sewn coloanal anastomosis is possible using the Lone star retractor.

Case Report
A sixty eight year old female patient presented with rectal bleeding and mucous discharge per rectum. She had good internal and external sphincter control clinically. At colonoscopy she was found to have an adenomatous field change involving the entire rectum up to the dentate line. Histology suggested this to be moderate to high-grade dysplasia. Computed Tomography and Magnetic Resonance Imaging confirmed the lesion to be involving only the rectum.

Considering that the pathology was benign, she underwent a restorative procedure. A restorative anterior resection with a disconnection at the dentate line was performed with a temporary ileostomy. This was subsequently closed with a colo-anal anastomosis using the Lone Star retractor system. Postoperatively, the patient had reasonable anorectal function and with preservation of continence.

Figure 1: Placing the Lone Star reactor to expose the dentate line and lower rectal mucosa

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Figure 2: Circumferential disconnection of the rectal mucosa (held in the Babcock’s) at the dentate line2

Figure 3: Specimen has been resected.Diathermy points to the internal sphincter. Hooks are placed at dentate line.

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Figure 4: Decending Colon pouch (held in the Bobcock’s) ready fot the colo-anal anastomosis

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Discussion

The technique for an ultra low colo-anal hand sewn anastomosis is made simple by the use of a Lone Star retractor system as highlighted in the clinical photos.
Figure 1 demonstrates the placement and the exposure achieved by the retractor. The disconnection of the lower rectal mucosa from the dentate line under vision is demonstrated in figure 2.
The demonstration of the sphincter anatomy is achieved and demonstrated in figure 3.
Lastly, figure 4 demonstrates the exposure achieved to start the colo-anal anastomosis.

Summary
In summary, complex anal surgery can be made simple and safe by appropriate instrumentation. The Lone Star retractor system is a valuable addition to the colorectal surgeon’s armamentarium.

References:

Zimmerman DD, Gosselink MP, Hop WC, et al. Impact of two different types of anal retractor on fecal continence after fistula repair: a prospective, randomized, clinical trial. Dis Colon Rectum 2003; 46:1674-1679.
Van Tets W F, Kuijpers J H, Tran K, et al. Influence of Parks’ anal retractor on anal sphincter pressures.
Dis Colon Rectum 1997; 40: 1042-1045.
Carriero A, Dal Borgo P, Pucciani F. Stapled mucosal prolapsectomy for haemorrhoidal prolapse with Lone Star Retractor System. Tech Coloproctol 2001; 5: 41-46.
Zimmerman DD, Briel JW, Gosselink MP, et al. Anocutaneous advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 2001; 44:1474- 1480