Browsing by Author "Deen, K.I."

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Abdominal resection rectopexy with pelvic floor repair versus perinealn rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse
(1994) Deen, K.I.; Grant, E.; Billingham, C.; Keighley, M.R.
A randomized trial was performed to compare abdominal resection rectopexy and pelvic floor repair (n = 10) with perineal rectosigmoidectomy and pelvic floor repair (n = 10) in elderly female patients with full-thickness rectal prolapse and faecal incontinence. There were no recurrences of full-thickness prolapse following resection rectopexy but one after rectosigmoidectomy. Continence to liquid and solid stool was achieved in nine patients, with faecal soiling reported in only two, after resection rectopexy and in eight, with soiling in six, following rectosigmoidectomy. The median (range) frequency of defaecation was only 1 (1-3) per day following resection rectopexy compared with 3 (1-6) per day after rectosigmoidectomy. There was an increase in the mean(s.d.) maximum resting pressure after resection rectopexy (19.3(15.28) cmH2O) compared with a reduction following rectosigmoidectomy (-3.4(13.75) cmH2O) (P = 0.003). Mean(s.d.) compliance was also greater after resection rectopexy than following rectosigmoidectomy (3.9(0.75) versus 2.2(0.78) ml/cmH2O, P < 0.001). Abdominal resection rectopexy gives better functional and physiological results than perineal rectosigmoidectomy.
Abdominal suture rectopexy without large bowel resection for rectal prolapse does not result in constipation: data from prospective bowel function evaluation, anorectal physiology and transit studies
(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Sabaratnam, V. Y.; Rathnayake, G.; Deen, K.I.
INTRODUCTION: Traditionally, suture rectopexy has been combined with sigmoid resection for rectal prolapse to prevent postoperative constipation. Furthermore, preservation of lateral ligaments will not result in constipation. Suture rectopexy alone without resection, is being popularised. OBJECTIVE: To study the influence of suture rectopexy without resection on colonic transit and postoperative constipation. PATIENTS AND METHODS: Forty-six patients (median (range) age 32(19-82) years) with rectal prolapse underwent suture rectopexy alone without division of lateral ligaments from March 1999. Prospectively, bowel function and anorectal physiology (ARP) were evaluated before and after surgery in a subset of 15 patients. Follow up (median, range) has been 12 (1-42) months. RESULTS: Follow up was complete in 36 patients. Recurrent prolapse was seen in 5 (full thickness 3 (8.3%); mucosa! prolapse 2 (5.5%)). Physiological data in a subset of 15 patients revealed no significant difference in anorectal physiology before and 3 months after the operation (table). Similarly there was no significant difference in the rate of evacuation of transit markers on day 3 and 5. Maximum resting pressure (median and range) was 25(7-50) mmHg and 33.2(7- 80, P value 0.026) before and after surgery. The median (range) maximum squeeze pressure were 67.5(19-i30) and 90(28 - 157, P 0.!64) before and after surgery. The maximum tolerable volume (ml) was 230 ( ! 80 -340) before surgery and 200 (50-290) after surgery (P. 0.139). Transit (as an excretion percentage) was 100% before and after surgery (P = 0. 197). CONCLUSION: Abdominal suture rectopexy without resection for rectal prolapse improves constipation and does not result in significant change in colonic transit. We recommend this procedure either by open operation or by laparoscopy.
Accuracy of histopathology reporting in colorectalcancer (crc): we need a proforma
(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Siriwardana, P.N.; Rathnayaka, G.; Deen, K.I.
INTRODUCTION: The quality of a histopathology report in CRC will determine prognosis and the need for adjuvant therapy. OBJECTIVE: To evaluate the completeness of pathology reports in colorectal cancer.METHODS: In 82 consecutive patients (rectal cancer 47, colon cancer 35) based on the minimum data set by the Royal College of Pathologists, UK. Pathology reports were reviewed by a single person who looked for 17 pathology data sets for colon cancer and 15 for rectal cancer. Completeness of reporting(%) was classified as 40 - 50%, 60 - 70% or 80 - I 00%. RESULTS: 47 of rectal cancer group, 5 (11%) reports were 40-59% complete and 23 (49%) and 19 (40%) were 60-79% and 80-100% complete respectively. In the colon cancer group 04 ( 11.5%), 13.(37%) and 18 (51.5%) were in the categories of 40-59%, 60-79% and 80-100% respectively. The presence or absence of tumour at the resection margin was reported in 91.5%. Information on the distance of tumour to distal resection margin was present in 68% of reports. Apical node involvement was commented in 33%. CONCLUSION: There is a wide variation in the quality of pathology reports in colorectal cancer. We have found a lack of vital data in up to two thirds of the reports.
Altered pelvic floor physiology in uterovaginal prolapse: evidence for a pan-pelvic floor disorder
(1998) Deen, K.I.; Gunasekera, P.C.
Altered pelvic floor physiology in women with uterovaginal prolapse (UVP)
(Sri Lanka Medical Association, 1997) Deen, K.I.; Gunasekara, P.C.
INTRODUCTION: Although an association between Uterovaginal prolapse (UVP) and urinary incontinence is known, the prevalence of anoreetal dysfunction in UVP remains largely unexplored. AIM: To evaluate the prevalence of u re ih roves Seal and anorectal dysfunction in UVP. METHODS: 27 women (median age - 52 years, range 31 - 68 years) with UVP were evaluated by functional and anoreetal physiologic assessment. Data were compared with 20 age matched controls without UVP. Urethrovesical fimcfion was assessed by a 5 point functional score (micturitition frequency, nociuria, urgency, stress incontinence and residual sensation of urine), where 0- no dysfunction, 1,2-minimal, 3,4 - moderate and 5 implied severe dysfunction. Anoredal function was evaluated by clinical assessment and anoreetal physiology. Anal canal pressures were measured by microballoon manomelry. RESULTS : Moderate to severe urethrovesical dysfunction was seen in 33% of patients compared with none of (lie control group (P = 0.052, test of proportions). Anorectal mucosal prolapse was seen in 63% of patients compared with 13% of controls (p = 0.045, test of proportions). Maximum resting (MRP) and squeeze anal pressures (MSP) did not differ significantly between patients and controls. MRP [median, (range)] - Patients; 51 mm Hg (20 - 87) vs. Controls; 60mm 1 Ig (25 - 80), P>0.05; MSP [median, (range)] - Patients; 82 mm Hg (39 - 165) vs. Controls; 100mm Ilg (60 - 185, p>0.05, Wiieoxon test. However, the length of Hie high pressure zone (I IPZ) was significantly less in patients compared with controls (111*2 I cm - Patients = 56% vs. IIPZ 1cm - Controls = 10%, P=0.038, test of proportions). Abnormal anal electroscnsilivity (> 14 inAmps) was seen in 52% of patients compared with none in the control group (P=0.024) and abnormal vaginal electrosensation (> 12mAmps) in 55% of patients vs. 10% Of controls (P = 0.031), test of proportions. CONCLUSION: A greater proportion of women with UVP exhibited either urethrovcssical or anoreetal dysfunction or both compared with controls indicating a pan-pelvic floor weakness. Theses abnormalities should be considered in overall management of women with UVP
Anal sphincter defects. Correlation between endoanal ultrasound and surgery
(Lippincott Williams and Wilkins, 1993) Deen, K.I.; Kumar, D.; Williams, J.G.; Olliff, J.; Keighley, M.R.
OBJECTIVE: This study was performed to (1) correlate and sphincter defects, identified by endoanal ultrasound with operative findings, and (2) define the appearance of such sphincter defects as seen at operation. SUMMARY BACKGROUND DATA : Endoanal ultrasonography is a minimally invasive method of imaging the anal sphincter complex and enables identification of anal sphincter defects. Little is known about the accuracy and limitations of endoanal ultrasound in identifying such defects. Furthermore, there are no data about the appearances of these endosonic sphincter defects as seen at operation. METHODS: Forty-four patients (40 women; age range, 26 to 80 years; mean age, 56 years) with fecal incontinence, undergoing pelvic floor repair, were investigated by endoanal ultrasound before operation. Endosonic findings were correlated with the appearances of external anal sphincter, internal anal sphincter, and intersphincteric space, at operation. Diagnosis of the site and type of defect was made by macroscopic appearances. Uncertainty about the type of sphincter defect was resolved by obtaining muscle biopsies for histology. RESULTS: All external sphincter defects seen by endoanal ultrasound (n = 23) were confirmed at operation. Twenty-one of 22 internal sphincterdefects identified by endosonography also were confirmed at operation. In ten patients with a neuropathic anal sphincter complex, the morphology was normal on endosonography, and this was confirmed at operation. (Sensitivity and specificity of 100% for external anal sphincter; 100% and 95.5%, respectively, for internal and sphincter) CONCLUSIONS: These data show that endoanal ultrasound is an accurate method of identifying anal sphincter defects.
Anorectal physiology and transit in patients with disorders of thyroid metabolism
(Blackwell Scientific Publications, 1999) Deen, K.I.; Seneviratne, S.L.; de Silva, H.J.
BACKGROUND: Data on anorectal physiology in patients with disordered thyroid metabolism are lacking. This prospective study was performed to evaluate anorectal physiology in patients with either hyperthyroidism and diarrhoea, or hypothyroidism and constipation in order to assess slow transit in hypothyroid patients. METHODS: Thirty patients with hypothyroidism and constipation (24 females, median age 59 years, range 23-80) and 20 patients with hyperthyroidism and diarrhoea (12 females, median age 46 years, range 36-62) were evaluated by anal manometry, rectal balloon sensation and whole-gut transit markers. Data were compared with anorectal physiology and whole-gut transit in 22 healthy controls (13 females, median age 51 years, range 24-65). RESULTS: In the hypothyroid patients, maximum resting pressure (MRP) and maximum squeeze pressure (MSP) were similar to controls (patients, median MRP 55 mmHg (18-98); controls, median MRP 41 mmHg (20-105) and patients, median MSP 83 mmHg (39-400); controls, median MSP 88 mmHg (30-230); P 0.05 for both resting and squeeze pressures). In hyperthyroid patients, median MRP and MSP were significantly lower than controls (patients, MRP 33 mmHg (8-69); controls MRP 41 mmHg (20-105) P = 0.04 and patients, MSP 60 mmHg (26-104); controls, MSP 88 mmHg (30-230); P = 0.03). Threshold sensation for impending evacuation in hypothyroid patients was significantly higher than controls, while in hyperthyroid patients, threshold sensation was significantly lower compared with controls. Maximum tolerable rectal volumes in hypothyroid patients was significantly lower compared with controls, while no significant difference was found between maximum tolerable rectal volumes in hyperthyroid patients and controls. Prevalence of delayed whole-gut transit in both hypothyroid and hyperthyroid patients was similar to controls. Furthermore, 33 percent of hypothyroid patients and 40 percent of hyperthyroid patients experienced symptoms of bowel dysfunction prior to the onset of their thyroid disorder. CONCLUSIONS: Patients with altered thyroid function and bowel dysfunction demonstrated abnormalities of anal manometry and rectal sensation.
An Appendiceal skips lesion in ulcerative colitis,(VC)
(Sri Lanka Medical Association, 1998) Hewavisenthi, S.J.de S.; Deen, K.I.
Report to create awareness that skip lesions may occur even in ulcerative colitis (VC).
Assessment of 'nucleation time' as a predictor of cholelithiasis
(Lippincott Williams And Wilkins, 2008) Abeysuriya, V.; Deen, K.I.; Kumarage, S.K.; Navarathne, N.M.
INTRODUCTION: In the formation of gallstones, crystal nucleation is a key step, which is followed by precipitation and gradual growth of cholesterol crystals. MATERIALS AND METHODS: A case-control study was carried out among 60 patients (30 patients, 14 males and 16 females, median age of 36 years, range 33-71 years, body mass index (BMI)=25.1+/-0.33 kg/m, who underwent laparoscopic cholecystectomy; 30 control individuals, 15 males and 15 females, median age of 38 years, range 33-70 years, BMI=24.5+/-0.23 kg/m, who underwent laparotomy and who had normal ultrasound scans of the gallbladder and no demonstrable stones). Bile aspirated from the common bile duct was ultrafiltered and anaerobically incubated at 37 degrees C. Incubated bile was examined daily by polarized light microscopy, for appearance of cholesterol crystals. Nucleation time (NT) of bile was assessed as the time taken for the first crystals to appear under polarized light microscopy. RESULTS: Age and BMI of control individuals were not different to those of cases studied. The overall mean NT was significantly shorter in patients versus controls (mean NT+/-SEM: patients, 1.76+/-0.2 days; vs. controls, 12.74+/-0.4 days, P=0.001). Of control individuals, females demonstrated a shorter NT compared with males (mean NT+/-SEM: females, 11.4+/-0.36 days; vs. males, 14.1+/-0.46 days, P=0.006). In contrast, there was no sex difference in NT in patients (mean NT+/-SEM: females, 1.7+/-0.24 days; vs. males, 1.8+/-0.2 days, P=0.7). CONCLUSION: NT in control individuals without gallstones was significantly prolonged compared with the NT in patients with established gallstone disease. Among the control individuals, females had a significantly shorter NT than males. Hence, the assessment of NT is predictor of cholelithiasis.
Beware of Variations in Bile Duct and Arterial Anatomy During Laparoscopic Cholecystectomy; An Intr-operative and Cadaveric Study
(University of Kelaniya, 2007) Abeysuriya, V.; Deen, K.I.; Salgado, L.S.S.; Kumaragae, S.K.
Introduction: Comprehensive knowledge, realization of the frequency and multiplicity of abnormalities of the extrahepatic biliary tree are requisites for safe laparoscopic cholecystectomy (LC). Material and methods: Descriptive-prospective cross sectional study W'\S performed in 200 patients, who underwent LC for symptomatic gall bladder (GB) disease and 60 dissected cadavers, to observe variations in GB, cystic duct (CD), cystic artery (CA) and Calot's triangle. Ethical approval was obtained. Results: No abnormality was seen in the gallbladder in 258 (99.2%). Two (1 %) Patients, had abnormalities in the gallbladder. Those were septate and bipolar. Four cadavers (6.6 %) had abnormalities of the cystic duct; 2 absent CD, 1 hepato-cystic duct, 2 with two cystic ducts. The cystic duct was seen to form a classical Calot's triangle in 249(96%). In 11, (5(0.25%) patients, 6(10%) cadavers) the CD was abnormal; 8(73%) had flathorizontal path and 3(27%) were parallel to CBD. The average length of the CD was 3 em in 47 cadavers. Short (<3cm) and long CD (>3cm) were found in 8/60(13.3 %) and 5/60(8.3 %) respectively. In 148(57 %) the right hepatic artery (RHA) was medial to the CHD. In 107(41 %), the RHA was in the triangle of Calot's and in 5(patients 2, cadaver 3) the RHA crossed over the CHD. 231(89%) Of the cystic arteries had no variations. In 29(11 %) (patients 17, cadavers 12) we found abnormalities; 13(5 %) had two cystic arteries, 13(5 %) cystic arteries were anterior to the CHD and 3(1 %) cystic arteries were anterior to cystic duct. Conclusion: The biliary and hepatic arteries had significant variations whilst gallbladder and cystic duct positions were relatively constant in laparoscopic cholecystectomy. Awareness of the variations in the extra hepatic biliary system and related vasculature will prevent the iatrogenic injury. 143
Biliary microlithiasis, sludge, crystals, microcrystallization, and usefulness of assessment of nucleation time
(Elsevier, 2010) Abeysuriya, V.; Deen, K.I.; Navarathne, N.M.
BACKGROUND: The process of microcrystallization, its sequel and the assessment of nucleation time is ignored. This systematic review aimed to highlight the importance of biliary microlithiasis, sludge, and crystals, and their association with gallstones, unexplained biliary pain, idiopathic pancreatitis, and sphincter of Oddi dysfunction. DATA SOURCES: Three reviewers performed a literature search of the PubMed database. Key words used were "biliary microlithiasis", "biliary sludge", "bile crystals", "cholesterol crystallisation", "bile microscopy", "microcrystal formation of bile", "cholesterol monohydrate crystals", "nucleation time of cholesterol", "gallstone formation", "sphincter of Oddi dysfunction" and "idiopathic pancreatitis". Additional articles were sourced from references within the studies from the PubMed search.RESULTS: We found that biliary microcrystals account for almost all patients with gallstone disease, 7% to 79% with idiopathic pancreatitis, 83% with unexplained biliary pain, and 25% to 60% with altered biliary and pancreatic sphincter function. Overall, the detection of biliary microcrystals in gallstone disease has a sensitivity ranging from 55% to 87% and a specificity of 100%. In idiopathic pancreatitis, the presence of microcrystals ranges from 47% to 90%. A nucleation time less than 10 days in hepatic bile or ultra-filtered gallbladder bile has a specificity of 100% for cholesterol gallstone disease.CONCLUSIONS: Biliary crystals are associated with gallstone disease, idiopathic pancreatitis, sphincter of Oddi dysfunction, unexplained biliary pain, and post-cholecystectomy biliary pain. Pathways of cholesterol super-saturation, crystallisation, and gallstone formation have been described with scientific support. Bile microscopy is a useful method to detect microcrystals and the assessment of nucleation time is a good method of predicting the risk of cholesterol crystallisation.
Biofeedback with and without surgery for fecal incontinence improves maximum squeeze pressure, saline retention capacity and quality of life
(Springer India, 2008) Munasinghe, B.N.L.; Rathnayaka, M.M.G.; Parimalendran, R.; Kumarage, S.K.; de Zylva, S.; Ariyaratne, M.H.J.; Deen, K.I.
A Case of embryonal sarcoma of the liver
(Sri Lanka Medical Association, 2010) Pathirana, A.; Siriwardana, R.C.; Deen, K.I.; Rupasinghe, Y.
No Abstract Available
The Changing face of the journal
(College of Surgeons of Sri Lanka, 2010) Deen, K.I.
No Abstract Available
Clinical outcome of patients having neo-adjuvant therapy(NAT) for rectal cancer: a case control study
(The College of Surgeons of Sri Lanka and SAARC Surgical Care Society, 2003) Wijesuriya, S.R.E.; Deen, K.I.; Hewavisenthi, J.; Ratnayake, G.
INTRODUCTION: From July i 999 we have employed NAT on a selective basis in the management of rectal cancer. OBJECTIVE: To explore the value of NAT in patients with rectal cancer in the short term. To study the effect of Neo Adjuvant Therapy for rectal carcinoma in the short term. METHODS: Two abdomino perineal resections and 24 anterior resections were done in the NAT group and 5 and 2 l in the no NAT group. There were 2 perioperative deaths in NAT group and one in the no NAT group (P 0.75). There were 7 Cancer related deaths in the NAT group and 6 in the no NAT group (P = l). The survival was 15 month (5 -45) for the NAT group and 16 (3 -54) for the non NAT group (P = I). There were no difference in the recurrences (2 vs 4 P ""0.67) metastasis (4 vs 4 P = 1) or complication (8 vs 2 p =0.08) abdomino perineal resections were performed in 2 patients in the NAT group and 5 in the no NAT group. Anterior resections were performed in 24 patients and 24 patients in NAT and no NAT groups. CONCLUSION: Overall there was no significant difference in the clinical out come between those given NAT and those not given.
Clopidogrel and surgery "be aware"
(College of Surgeons of Sri Lanka, 2010) Liyanage, C.A.H.; Jayaweera, K.K.D.G.; Deen, K.I.
INTRODUCTION: Clopidogrel has been used more recently to prevent thrombosis in occlusive arterial disease. It is known that clopidogrel increases bleeding during surgery. We performed a questionnaire survey of surgeons in Sri Lanka regarding their experience with clopidogrel. OBJECTIVES: To share the experience of surgeons from diverse fields regarding surgery on patients on clopidogrel. METHOD: A retrospective descriptive study was performed using a questionnaire. RESULTS: 48 completed questionnaires were received. 21 (44%) Surgeons reported complications relating to clopidogrel. Spontaneous haemorrhage was reported by 8, which manifested as ecchymotic patches in the majority. Most surgeons 36 (75%) preferred aspirin over clopidogrel and 10 (21%) opted for clopidogrel. The majority recommend stopping of clopidogrel at least for 14 days. However, the opinions of the rest varied from 7 to 28 days. CONCLUSIONS: Surgeons felt clopidogrel has the potential to cause complications following surgery. Majority were of the opinion that it is safe practice to stop clopidogrel for at least 14 days which is more than the 5 days recommended by the formularies. A significant majority were comfortable to have the patient on aspirin compared with clopidogrel.
Closed loop small bowel obstruction caused by a retained faecolith complicating acute appendicular perforation
(College of Surgeons of Sri Lanka, 1999) Gunawardena, P.A.H.A.; Deen, K.I.
Case report of an 11 year old boy presented with a 36 hour history of central abdominal pain which localized in the right iliac fossa, vomiting and fever. A diagnosis of appendicitis was made. He developed abdominal distension and vomitting on the third post-operative day. The primary cause of the complication was the retained faecolith which was not found at the time of apendicectomy, despite extension.
Colonoscopic ultrasound is associated with a learning phenomenon despite previous rigid probe experience
(Springer India, 2009) Siriwardana, P.N.; Hewavisenthi, S.J.de S.; Pathmeswaran, A.; Deen, K.I.
Colonoscopic ultrasound (CUS) enables total colonoscopic examination combined with staging of tumor. Rigid probe transrectal ultrasound (TRUS) is reliable in assessing rectal cancer. Both the modalities are associated with an initial learning curve. We evaluated the predictability CUS in preoperative staging of rectal cancer during the learning curve, despite experience with TRUS. Forty-four patients with non-obstructing rectal cancer were assessed by colonoscopy and colonic ultrasound using a 7.5 MHz rotating transducer. Accuracy of ultrasound staging was compared with pathological staging. Tumor staging and nodal staging at pathology and ultrasound were named pT, pN and uT, uN, respectively. The pathological staging was pT1 in two (4.5%), pT2 in 16 (36%), pT3 in 21 (48%) and pT4 in five (11.5%) rectal cancer specimens. CUS understaged the tumor in 11 cases and overstaged it in 10 cases. Overall, the positive predictive value was 61%, negative predictive value 73%, sensitivity 61%, and specificity 73%. Lymph nodes were not visualized in 14. The overall un-weighted kappa of CUS staging of RC was 0.18 (poor). The predictive value in tumor staging of CUS is suboptimal in the learning phase, despite previous experience with TRUS.
Colorectal cancer burden and trends in a South Asian cohort: experience from a regional tertiary care center in Sri Lanka
(Biomed Central, 2017) Chandrasinghe, P.C.; Ediriweera, D.S.; Hewavisenthi, J.; Kumarage, S.K.; Fernando, F.R.; Deen, K.I.
OBJECTIVE: Colorectal cancer (CRC) burden is increasing in the south Asian region due to the changing socio-economic landscape and population demographics. There is a lack of robust high quality data from this region in order to evaluate the disease pattern and comparison. Using generalized linear models assuming Poisson distribution and model fitting, authors describe the variation in the landscape of CRC burden along time since 1997 at a regional tertiary care center in Sri Lanka. RESULTS: Analyzing 679 patients, it is observed that both colon and rectal cancers have significantly increased over time (pre 2000-61, 2000 to 2004-178, 2005 to 2009-190, 2010 to 2014-250; P < 0.05). Majority of the cancers were left sided (82%) while 77% were rectosigmoid. Over 25% of all CRC were diagnosed in patients less than 50 years and the median age at diagnosis is < 62 years. Increasing trend is seen in the stage at presentation while 33% of the rectal cancers received neoadjuvant chemoradiation. Left sided preponderance, younger age at presentation and advanced stage at presentation was observed. CRC disease pattern in the South Asian population may vary from that observed in the western population which has implications on disease surveillance and treatment.
Colorectal cancer in the young, many questions, few answers
(Baishideng Publishing Group, 2016) Deen, K.I.; Silva, H.; Deen, R.; Chandrasinghe, P.C.
At a time where the incidence of colorectal cancer, a disease predominantly of developed nations, is showing a decline in those 50 years of age and older, data from the West is showing a rising incidence of this cancer in young individuals. Central to this has been the 75% increase in rectal cancer incidence in the last four decades. Furthermore, predictive data based on mathematical modelling indicates a 124 percent rise in the incidence of rectal cancer by the year 2030 - a statistic that calls for collective global thought and action. While predominance of colorectal cancer (CRC) is likely to be in that part of the large bowel distal to the splenic flexure, which makes flexible sigmoidoscopic examination an ideal screening tool, the cost and benefit of mass screening in young people remain unknown. In countries where the incidence of young CRC is as high as 35% to 50%, the available data do not seem to indicate that the disease in young people is one of high red meat consuming nations only. Improvement in our understanding of genetic pathways in the aetiology of CRC, chiefly of the MSI, CIN and CIMP pathway, supports the notion that up to 30% of CRC is genetic, and may reflect a familial trait or environmentally induced changes. However, a number of other germline and somatic mutations, some of which remain unidentified, may play a role in the genesis of this cancer and stand in the way of a clear understanding of CRC in the young. Clinically, a proportion of young persons with CRC die early after curative surgery, presumably from aggressive tumour biology, compared with the majority in whom survival after operation will remain unchanged for five years or greater. The challenge in the future will be to determine, by genetic fingerprinting or otherwise, those at risk of developing CRC and the determinants of survival in those who develop CRC. Ultimately, prevention and early detection, just like for those over 50 years with CRC, will determine the outcome of CRC in young persons. At present, aside from those with an established familial tendency, there is no consensus on screening young persons who may be at risk. However, increasing awareness of this cancer in the young and the established benefit of prevention in older persons, must be a message that should be communicated with medical students, primary health care personnel and first contact doctors. The latter constitutes a formidable challenge.