Showing papers in "International Journal of Colorectal Disease in 1997"

Pathological features of rectal cancer after preoperative radiochemotherapy

Abstract: The standard therapy for rectal carcinoma is surgical, however, preoperative radiochemotherapy will play an increasing role especially in locally advanced disease. To estimate the prognosis and the effect of radiochemotherapy the postradiochemotherapeutical pathological features are important to assess. We examined the surgical specimens of 17 patients after preoperative radiochemotherapy to estimate and grade the histological reactions. A proposal for a grading system for tumor regression (not yet available in the literature) has also been described. All but one of the carcinomas showed different degrees of tumor regression. A total regression was not observed after standardised pathological work up. In only one case a locally curative resection was not possible. We think that preoperative radiochemotherapy is able to reduce tumor mass thus achieving operability in non-curatively operable cases. We recommend standards of pathological work up and regression grading for further studies comparing surgery and radiochemotherapy of rectal carcinoma.

Risk of invasive carcinoma in colorectal adenomas assessed by size and site.

Abstract: . Background: The risk of invasive carcinoma developing in colorectal adenomas is influenced by a number of characteristics of both patients and adenomas, and the composition of the sample analysed. Patients and methods: Between 1978 and 1993 more than 20 000 polyps were prospectively documented at the Erlangen Registry of Colorectal Polyps, and analysed statistically by logistic regression. Results: The size of the adenomas proved to be the most important factor for adenomas equal to or larger than 15 mm as compared with smaller lesions. In 5137 diminutive adenomas (≤5 mm) invasive carcinoma was never found. Adenomas in the right-sided colon had a lower risk than those in the left colon or rectum, but with increasing adenoma size, the malignancy rate showed a right-sided shift. In adenomas of up to 36 mm in diameter, invasive carcinoma was found more often when they were located in the rectum or left colon while adenomas larger than 36 mm were more likely to harbour invasive carcinoma when located in the right or left colon rather than in the rectum. Conclusions: A multivariate analysis of 11380 adenomas detected at the first total colonoscopy showed that the factors size and site, both of which can be assessed by endoscopic inspection alone, were found to enable a statistically and clinically adequate assessment of the malignancy risk.

Cancer in the anal canal (transitional zone) after restorative proctocolectomy with stapled ileal pouch-anal anastomosis

Abstract: The first case of an adenocarcinoma developing in the retained anal canal mucosa (transitional zone) after restorative proctocolectomy with a stapled ileal pouch anal anastomosis is presented. The cancer was detected during routine follow-up 16 months after pouch formation for long standing ulcerative colitis, complicated by a cancer in the upper rectum. The patient was treated with an abdominoperineal excision of the ileal pouch and anus.

Continence after colorectal reconstruction following resection: impact of level of anastomosis

Abstract: In 48 patients who had undergone anterior resection for rectal cancer with straight colorectal reconstruction, clinical and manometric results were correlated with the level of anastomosis. Patients were divided into four groups by anastomotic level: ≤3, 4 – 6, 7 – 9, and ≥10 cm. Functional outcome with regard to frequency of bowel movements, minor leakage, fecal incontinence, ability to defer stool and to differentiate consistency showed increasing impairment the lower the anastomotic level. Frequency, leakage owing to the inability to defer stool, incontinence for solid stool, inability to discriminate flatus from stool, and incomplete emptying were significantly different (P 6.5 cm) demonstrated similar findings, suggesting that impaired function after rectal resection is due to reduced function of the neorectum. Thus, as much residual rectum as possible should be preserve without risking cure. If the level of the anastomosis is expected to be below 6 cm, or if the residual rectum is less than 4 cm, the construction of a colon pouch to increase neorectal capacity should be considered.

Causes of failure and life expectancy of the ileoanal pouch

Abstract: 180 ileoanal pouches constructed over 10 years and followed for at least 2 years (154 for Inflammatory Bowel Disease (IBD) and 26 for Familial Adenomatous Polyposis (FAP)) were reviewed. 23 pouches have been excised to date, 8 remain defunctioned (pouch failure FAP 7.7%, IBD 18.8%). The reasons for excision were: ischemia (n = 6), pelvic sepsis (n = 5), severe stenosis (n = 3), underlying Crohn's disease (n = 3), poor function (n = 5) and fistula (n = 1). The reasons for defunction were: Crohn's disease (n = 1), pelvic sepsis (n = 5) and ileoanal stenosis (n = 2). The projected overall pouch survival rate (Life table analysis) at 5 years was 81% (confidence interval 74–87%). Beyond 7 years, the figures to calculate survival became unreliable (small numbers). There was a significant association between pouch failure and pelvic sepsis (Fisher's exact test P < 0.0001) and between failure and fistula formation (P < 0.02). Multiple regression analysis showed pelvic sepsis and recurrent pouchitis to be independent factors of pouch failure. Pouch failure can occur many years after initial operation. Long-term follow up is recommended.

Is screening for thyroid carcinoma indicated in familial adenomatous polyposis

Abstract: Forty-five polyposis patients with thyroid carcinoma constituted 1.2% of the patients in the Leeds Castle Polyposis Group database. The patients were diagnosed during 1959–1995; 44 were females at a median age of 25 years (range 10–40) and 37 (82%) had papillary carcinoma. At the end of 1995 only one patient (9%) had died from thyroid carcinoma, and the ten-year cumulative survival was 84% (95% confidence limits 72–97). Due to the low incidence of thyroid carcinoma in FAP and the good prognosis we do not recommend a regular thyroid screening in polyposis, as this is unlikely to result in a reduction of the mortality, but will only aggravate existing cancrophobia in these strained patients.

Internal anal sphincter repair.

Abstract: The results of repair to the internal and sphincter alone has been evaluated in five patients with persistent anal incontinence following surgery which affected the internal anal sphincter. All had passive incontinence for solid or liquid stool. Symptoms, anorectal manometry, and anal endosonography were evaluated before and after surgery. After surgery three patients felt improved but had still persistent symptoms, and no patients achieved full continence. Three patients showed an increased maximal and resting pressure, but only one of them was within the normal range. Post operatively, all the anal ultrasound scans showed a persistent internal sphincter defect, and two showed an unsuspected external anal sphincter defect. Although some patients felt symptomatically improved, the overall clinical, manometric and radiological findings after internal and sphincter repair were disappointing.

The pattern of recurrent colorectal cancer in a prospective randomised study and the characteristics of diagnostic tests

Abstract: In a prospective randomised study, 597 patients subjected to curative surgery for colorectal cancer were allocated to either a group with frequent follow-up or a control group with follow-up every 5 years. The pattern of recurrence is reviewed. An equal number of recurrences was detected in the two groups, but the recurrence was diagnosed 9 months earlier in patients followed frequently, and the diagnostic characteristics of various tests dependent upon how often they were used. It is unlikely that frequent follow-up after curative surgery for colorectal cancer has a large positive influence upon survival, but a small benefit from an intensive follow-up program cannot be ruled out. The present results indicate that clinical examination, digital rectal examination, proctoscopy, colonoscopy and chest x-ray should be included in such a programme, whereas others (blood haemoglobin, faecal occult blood test, double contrast braium enema, serum alanine aminotransferase, and serum bilirubin) should be avoided, having a low sensitivity for detecting recurrent colorectal cancer.

The effects of chronic ill health and treatment with sulphasalazine on fertility amongst men and women with inflammatory bowel disease in Leicestershire

Abstract: The aims of the study were to ascertain whether patients have similar a fertility rate to the background population in Leicestershire and whether they have a similar rate of congenital malformations compared to the background population in Leicestershire. Over 1400 patients were invided to participate with an overall response rate of 81% after three successive mailings. The response rate was similar for both sexes and between the disease groups. The crude infertility rate for the group was 21%. The mean number of children for the whole group was 1.7 ± 1.3 but both men and women with Crohn's disease had significantly less children than would be expected, (men with Crohn's disease 1.5, women with Crohn's disease 1.2). There were 39 children (2% of overall births) with congenital abnormalities reported by patients with inflammatory bowel disease and in 29 cases the parents reported taking sulphasalazine (Table 3). Although this figure compares well with the 1.8% reported congenital abnormality rate for Leicestershire within the patient group in this study congenital malformations were significantly related to sulphasalazine use, z = 4.3, P < 0.0001. In conclusion sulphasalazine not only as causes morphological abnormalities in spermatozoa but may increase the chances of having congenitally abnormal offspring amongst men with IBD. The effects of other 5-aminosalacylic acids have yet to be studied in detail.

Effects of age on anal function in normal women

Abstract: Purpose: To study effects of age on anal function in healthy women. Methods: A study of 75 women with no known anorectal disease, aged 20 to 83 (mean 50) years, mean parity 2 (range 0–4). Perineal position at rest (PR), descent during straining (PS), maximum resting pressure (MRP) maximum squeeze pressure (MSP) of the anal sphincters, and pudendal nerve terminal motor latency (PNTML) were measured. Data were analysed using the multiple regression technique including age and parity in the model. Results: Increasing age was significantly associated with a weakening of anal function. PR and PS were both lowered (P < 0.0001 and P = 0.0001). Anal sphincter pressures were reduced (MRP: P = 0.004, MSP: P = 0.015), and age was associated with an increased mean PNTML (P < 0.0001). All associations seemed to be linear. Parity was associated with a lowering of both PR and PS but not with the other parameters. Age accounted for 13–44% of the total variability seen in the tests of pelvic floor function. Conclusion: Age leads to a consistent reduction in anal function and this is likely to increase the risk of faecal incontinence in old age. From the current data we suggest that in normal women with an uncomplicated obstetric history increasing age is associated with significant changes in anal function whereas long-term effects of vaginal deliveries play a minor role. Moreover our results suggest gradual changes throughout adult life, rather than large changes occurring after menopause.

The value of endorectal ultrasound in the assessment of adenomas, T1- and T2-carcinomas

Abstract: In a prospective study we examined the value of endorectal ultrasound (ERUS) in the preoperative staging of potentially locally excisable tumours. During the study period from 1.1.1991 to 1.3.1996 a total of 160 rectal tumours in 152 patients were staged endosonographically (uT/uN) and compared postoperatively with the histologic result (pT/pN) at the University Hospital of Wurzburg. Thirty-eight (24%) patients had an adenoma and 15 (9%) a T1-carcinoma. In 29 (18%) cases a T2-cancer was diagnosed, further 67 (42%) and 11 (7%) patients presented with a T3 and T4 tumour, respectively. The sensitivity for adenomas and T1-Ca (uT0/1) was 81%, the specificity 98%. For T2 tumours, the sensitivity was only 41% and the specificity 92% as the majority (17 of 29) of pT2 neoplasias were overstaged (uT3). The overall staging accuracy (T1-4) was 77.5%. Two patients with a pT1-Ca and seven with a pT2-Ca had lymph node metastases which were detected preoperatively in five. The accuracy for lymph node staging was 83%. We conclude that adenomas and T1 tumours can be assessed with a high grade of accuracy using ERUS. In these tumours ERUS can be used to assist clinical decision-making (transanal vs. abdominal operation). Owing to the lack of sensitivity ERUS is of no help in the assessment of T2 carcinomas.

Fate of the rectal stump after colectomy and ileorectal anastomosis for familial adenomatous polyposis

Abstract: The justification of colectomy and ileorectal anastomosis as the primary treatment for familial adenomatous polyposis (FAP) remains questionable because of the rectal cancer risk. We estimated both the cancer risk and the need of rectal excision for benign polyposis in 100 FAP patients. We also evaluated the effects of sulindac therapy and the complications of polyp fulgurations during the follow-up time of the median of 10.6 years (2 to 29 years) after ileorectal anastomosis. There were 46 women and 54 men with a mean age of 32 years (17–67 years) at the operation. Forty-two patients were propositi and 15 had colon cancer primarily. Cumulative risk of rectal cancer and combined risk of cancer and rectal excision for other causes were estimated (Kaplan-Meier analysis) both from the date of surgery and from birth. Nine patients developed rectal cancer, while 12 others has the rectum excised for benign conditions. The cumulative rectal cancer risk was 4%, 5.6%, 7.9% and 25% at 5, 10, 15 and 20 years after the operation, respectively. Rectal excision rates were 7.3%, 13.7%, 23.6%, and 36.6%, correspondingly and finally 73.8%. Age-dependent rectal cancer risks were 3.9%, 12.8% and 25.7% at 40, 50 and 60 years, and the rectal excision rates 9.5%, 26.3% and 44%, respectively. Sulindac caused at least partial regression of rectal adenomas in 71% of patients without major adverse effects, but the long term effects of sulindac and impact on malignant transformation of rectal adenomas are not known. Our results favour proctocolectomy and ileonal anastomosis as the primary operation for FAP instead of colectomy and ileorectal anastomosis.

Screening for colorectal neoplasia with faecal occult blood testing compared with flexible sigmoidoscopy directly in a 55 – 56 years' old population

Abstract: Reduced mortality from colorectal cancer may be achieved by screening with faecal occult blood testing. Screening for neoplasia in the rectum and sigmoid colon with flexible sigmoidoscopy is suggested to be more effective, particular among persons between 50 and 60 years of age. A cohort of 6367 persons 55 – 56 years of age were randomised to screening with rehydrated Hemoccult II tests (HII group) or with flexible videosigmoidoscopy directly (FS group). In the HII group 59% (1893/3183) attended, compared to 49% (1353/3184) in the FS group. Of the 1893 persons who attended in the HII group, 4% had a positive HII test and in 13% (10/78) of them a neoplasm ≥1 cm in the rectum or sigmoid colon was diagnosed by endoscopy. The corresponding rate in the FS group was 2.3%. Overall the number of persons with a neoplasm ≥1 cm diagnosed in the HII group was 10 and in the FS group 31. A subgroup in the flexible sigmoidoscopy group, who also performed rehydrated HII tests, showed a sensitivity of the HII test for neoplasia ≥1 cm of 26% and a specificity of 95.6%. To find a neoplasm ≥1 cm in the rectum or sigmoid colon, 44 examinations were needed when using flexible sigmoidoscopy directly and 7 examinations when only those with positive HII tests were examined. In mass screening for neoplasia in the rectum and sigmoid colon, the relatively low prevalence of colorectal neoplasia at 55 – 56 years of age makes primary selection with rehydrated Hemoccult testing an alternative to the resource-consuming endoscopy of all invited persons.

Results of restorative proctocolectomy in the elderly.

Abstract: Twenty eight of 227 patients undergoing restorative proctocolectomy for inflammatory bowel disease, familial adenomatous polyposis or functional disease were over the age of 50 years: ages 50 to 60 (n = 13), 60 to 70 (n = 10), and over 70 (n = 5) Major complications occurred in 5 patients over the age of 50 (18%) compared with 43 patients under the age of 50 (23%) Three patients above the age of 50 had their pouch excised (11%) compared with 23 under the age of 50 (12%) Functional outcome was assessed with a 12 point symptom score This was similar in all age bands: under 50 years (mean = 22; sd±22; n = 109), 50 to 60 years (mean = 25; sd±25; n = 12), 60 to 70 years (mean = 28; sd±23; n = 7) and over 70 years (mean = 40; sd±37; n = 5): P>005) When analysed for ulcerative colitis alone, no significant differences were seen between the two age groups Restorative proctocolectomy in the elderly gives results which are comparable to the younger population

Extended mesenteric excision in right hemicolectomy for carcinoma of the colon

Abstract: Between 1979 and 1989, 169 patients had a curative operation for right sided colonic cancer. A retrospective analysis of the incidence and degree of lymph node metastasis was performed in all and survival rate was determined in 144 patients who could be followed over a period of 5 years or more. In all patients, dissection involved the removal of right colon (i.e., caecum, ascending colon, and right side of transverse colon). Dissection of regional lymph nodes in 84 patients (group 1) involved the removal of mesocolic lymph nodes related to the segment of the removed intestine. In 60 patients (group 2) dissection was extended to the nodes situated anterior to mesenteric and retropancreatic vessels. Morbidity and mortality rates were similar in the two procedures. The number of lymph nodes and the level of apical node examined were significantly different in the two groups. The 5-year survival rates showed no statistically significant difference, but in group 2 three of the nine patients with metastasis to N4 nodes are free of disease, surviving at 7, 12 and 14 years, respectively. The principle of extensive lymph node dissection is proposed as a procedure that supplies more accurate staging and might reduce the incidence of loco-regional recurrence.

Are interpretations of video defecographies reliable and reproducible

Abstract: Video defecography is a dynamic investigation which can influence surgical decision making in constipated patients A study was therefore undertaken to assess the inter and intraobserver variability in video defecography Specifically, we sought to assess the interpretation of video defecographies by a group of observers with the same training, guidelines and standards To determine interobserver variation, four independent observers, two blinded to the patient's history, reviewed 100 randomly sequenced video defecographies performed in constipated patients The presence or absence of sigmoidocele, rectocele, intussusception or prolapse was noted Adequate or improper function of the puborectalis, anal canal opening, anorectal angle (ARA) and grade of emptying of the rectum were also assessed Two weeks after the initial assessment, intraobserver variation was determined by a repeat blinded review of unlabelled randomly sequenced studies The results of interobserver accuracy for sigmoidoceles, rectoceles, intussusception, rectal prolapse, rectal emptying, opening of the anal canal, puborectalis contraction and straightening of the ARA and rectal emptying were 895%, 460%, 875%, 975%, 865%, 885%, 830%, and 800%, respectively The intraobserver variations were 885%, 838%, 805%, 945%, 770%, 848%, 805% and 855%, respectively Prior knowledge of the patient's history did not significantly influence the outcome In summery, video defecography has an overall accuracy of 833% and as such is a valid tool in assessing constipated patients

Magnetic resonance imaging in the management of fistula in ano.

Abstract: Fistula-in-ano is a common condition in which accurate diagnosis of the fistula track is essential as inadequate assessment and surgical treatment may lead to multiple unnecessary operations and may also render the patient incontinent. Several studies have suggested that Magnetic Resonance Imaging (MRI) can accurately identify the fistula track in relation to the sphincter complex. The aim of this study was to investigate the value of the routine use of completely non-invasive pre-operative MRI in patients with suspected fistula-in-ano. Each scan was reported by a consultant radiologist on two occasions to determine whether the radiologist's opinion had changed and/or become more accurate with further experience. Surgical assessment of the fistula was performed under general anaesthesia by one surgeon without knowledge of the result of the MRI scan. The results of the surgical assessment and the MRI scan were compared and the surgical procedure completed. Thirty three patients with a clinical diagnosis of fistula-in-ano were treated and 27 subsequently confirmed to have a fistula. MRI detected 42% of tracks, identified correctly on initial assessment which increased to 50% at the end of the study, 63% and 74% of internal openings, 33% and 46% of external openings and 50% and 33% of abscesses. These data suggest that there is a learning curve for radiologists undertaking MRI scanning for fistula in ano, this is probably because the pathology of fistula in ano and anatomy of the anal sphincter complex are relatively new to radiologists. Routine MRI scanning of patients with fistula-in-ano is not necessary but there may be a role for MRI in assessing complex or difficult fistulae.

Sulindac for periampullary polyps in FAP patients

Abstract: Background: Gastro-duodenal polyps develop in up to 90% of familial adenomatous polyposis (FAP) patients and periampullary carcinoma is one of the most common extra-colonic malignancies in this syndrome. Periampullary adenomas have been shown to be precursor lesions to periampullary carcinoma. Sulindac, a non-steroidal anti-inflammatory drug, has been reported to cause regression of rectal polyps in FAP patients, however its role in periampullary polyp regression is unclear. Methods: In May 1993, a prospective study was begun to evaluate the role of sulindac in prevention of polyp recurrence after resection of large (>1 cm) duodenal polyps in FAP patients. Eight patients, mean age 50 years (range 35 to 65), with documented large periampullary polyps were placed on sulindac 150 mg twice daily. Prior to enrolment, all patients had their large polyps removed from the periampullary region by interventional endoscopy or by surgery. All patients had multiple small residual duodenal polyps. Follow-up was performed by one experienced endoscopist with a side-viewing video endoscope. Endoscopy was performed 6 monthly. Median follow-up time was 17.5 months (range 10 to 24 months). Results: In 3 patients, sulindac was discontinued due to side effects: abdominal cramps (n = 2) and upper G-I bleeding (n = 1). None of the patients had regression of small periampullary polyps. In addition, one patient developed an invasive periampullary carcinoma while on sulindac and 3 patients developed large recurrent periampullary polyps requiring further treatment. Summary: In our experience, sulindac is of no significant benefit for the control of periampullary polyps in FAP. Effective medical treatment of these polyps is still lacking.

A preliminary comparison of a consecutive series of open versus laparoscopic abdomino-perineal resection for rectal adenocarcinoma.

Abstract: Aim: To compare a consecutive series of patients who underwent laparoscopic abdomino-perineal resection (LAPR) versus conventional open abdomino-perineal resection (CAPR). Material and Methods: Sixteen patients (8 females) and 11 patients (4 females) underwent LAPR and CAPR respectively. Results: The median operative time was 110 (65 – 210) mins and 100 (80 – 185) mins for LAPR and CAPR respectively (P = 0.43). The median amount of blood loss were 200 (100 – 1000) mls and 100 (60 – 800) mls for LAPR and CAPR respectively. There was no significant difference in the need for post operative analgesics and time to first stoma function but the LAPR group showed significant improvement in starting fluids, diet, ambulation and discharge from hospital. Conclusion: The laparoscopic technique may be an acceptable alternative to conventional abdomino-perineal resection for the patient requiring anal resection for rectal cancer.

Ambulatory anorectal manometric findings in patients before and after haemorrhoidectomy

Abstract: The physiological abnormalities in piles before and after surgery were studied by an ambulatory prolonged anorectal manometric technique. Eighteen consecutive patients (12 men, 6 women; mean age 43.6 [standard error of mean, 3.3] years) with 3 prolapsed irreducible piles were prospectively recruited. Haemorrhoidectomy was performed with excision of 3 piles. The anal and rectal pressures were monitored before and at a mean 7.8 (1.5) weeks after surgery when the wounds had healed, for a mean period of 361.3 (47.8) min. The maximum anal pressures dropped significantly from a mean 325 (15.5) mmHg before to 213 (24.9) mmHg after surgery (P<0.05). Ultra-slow wave activity was clearly identified in 11 of 18 patients (61%) before surgery, but not found on post operative studies. The maximum rectal pressures were also significantly reduced after surgery (196.8 [23.2] mmHg before, 75.5 [10.6] mmHg after; P<0.05). These findings help to confirm that haemorrhoidectomy leads to changes in the anorectal physiological findings.

Reliability of pudendal nerve terminal motor latency

Abstract: Aim: To evaluate reliability of Pudendal Nerve Terminal Motor Latency (PNTML). Methods: Forty healthy subjects, 24 women and 16 men, and eight female patients were included. Four patients had idiopathic faecal incontinence and 4 an anal sphincter rupture after childbirth. PNTML measurement was performed by two observers with the patient in left lateral and supine position. Examinations were repeated on another day to evaluate intraindividual reproducibility. Results: Interobserver reproducibility was 92% – 116% for PNTML. Degree of agreement for PNTML between left lateral and supine position was 86% – 111%. Intra-individual reproducibility in the supine and left lateral positions was 89% – 109% and 88% – 113% respectively. Normal values for mean PNTML were higher in women compared with men, 1.91 msec (2 SD, 0.52 msec) and 1.74 msec (2 SD, 0.33 msec) respectively, t = 2.44, 37 DF, P<0.01. Conclusions: Reliability of PNTML in terms of interobserver and intraindividual reproducibility was high. Women had higher normal values for PNTML than men.

Rectal hypersensitivity in the irritable bowel syndrome

Abstract: Studies of rectal sensory thresholds and compliance in patients with the irritable bowel syndrome have produced conflicting results though there is persistent evidence of rectal hypersensitivity particularly in those with diarrhoea-predominant symptoms. This study examined rectal sensation and compliance in 31 patients with constipation-predominant irritable bowel syndrome (mean age 41 years, 27 female) and 17 healthy volunteers (mean age 45 years, 17 female). A rectal balloon was inflated with fluid at a constant rate and the volume and intrarectal pressure at sensory thresholds was recorded. The volumes at first (129 ± 8 vs 229 ± 24 ml, P < 0.001 Mann-Whitney-U test), constant (159 ± 12 vs 286 ± 21, P < 0.001) and maximum tolerated sensation (290 ± 13 vs 509 ± 19, P < 0.001) were all significantly less in the irritable bowel group. There was no significant difference in intrarectal pressures at any of these volumes (29.0 ± 2.2 cmH2O vs 29.0 ± 2.5, 35.0 ± 2.5 vs 34.0 ± 2.8, 71 ± 2.5 vs 65.0 ± 3.0 respectively). Rectal compliance was significantly less in the irritable bowel group (3.6 ± 0.2 ml/cmH2O vs 8.7 ± 0.4, P < 0.001). Twenty two patients complained of abdominal pain on balloon inflation, mimicking that experienced as part of their symptoms. Patients with constipation-predominant irritable bowel syndrome have rectal hypersensitivity and reduced compliance.

Is mechanical bowel preparation really necessary for elective left sided colon and rectal surgery

Abstract: The value of mechanical bowel preparation for elective left sided colorectal surgery is debatable. This retrospective study evaluates the incidence of wound infection, wound dehiscence, abdominal/pelvic collections and anastomotic dehiscence between patients who received mechanical bowel preparation [MBP] (n = 61) and those who did not (n = 75). The case notes of 136 consecutive patients undergoing elective left sided colorectal surgery over a three year period in a district general hospital were reviewed. The incidence of infective and anastomotic complications between the two groups was not significantly different. There were two post-operative deaths, both in patients receiving MBP. We therefore conclude that the role of MBP in the era of systemic antibiotics must be questioned. A prospective randomised multicenter trial recruiting an adequate number of patients undergoing elective left sided colorectal procedures would clarify this long standing debate. Note: Presented at the Spring Meeting of the Minnesota Surgical Society in Rochester, Minnesota, USA, May, 1996 and to the American Society of Colon and Rectal Surgeons (ASCRS), Seattle, Washington, June 1996, and published in abstract form in Diseases of the Colon and Rectum (1996) 39:A47.

Endorectal ultrasonography in the follow-up of rectal cancer Is it a better way of to detect early local recurrence?

Abstract: After curative surgery for rectal cancer, diverse protocols are used in order to detect early possible local recurrence. Our objective was to compare the results obtained by the endorectal ultrasonography (EUS) with other means of assessment. From 1988 to 1995, 140 patients have undergone curative surgery for rectal cancer. The pathological and sonographic lesions were evaluated according to the TNM classification. In 21 patients a local recurrence was diagnosed: 5 of those 21 were corresponding to T 3 – 4, N 0 and 16 to T 2 – 4, N 1 stage. All 21 showed evidence of local recurrence by EUS examination, 14 by digital rectal examination, 16 by colonoscopy, 18 by computed tomography, and the carcinoembryonic antigen level was high in 13 cases. In 12 patient who were asymptomatic EUS was positive in 12, digital rectal examination in 5, computer tomography in 9, colonoscopy in 8, and the CEA was increased in 4. Re-resection was possible in 15 cases, 6 with curative approach and 9 palliative. These findings suggest that EUS in care accurate in the early detection of local recurrence compared to other means of assessment review of the. The limited number of patients studies. Main form of assessment required further evaluation.

Solitary rectal ulcer syndrome--an underdiagnosed condition.

Abstract: Une etude retrospective de tous les patients presentant un syndrome d'ulcere solitaire du rectum prouvea la biopsie au cours d'une periode de cinq ans dans un hopital de district est rapporte. Il s'agit d'une serie de 34 patients egalement repartis entre les deux sexes. L'âge moyen des hommes est de 56,6 ans (31 a 84 ans) et des femmes de 55 ans (14 a 77 ans). L'intervalle entre les manifestations cliniques et le diagnostic va de une semaine a 10 ans avec une mediane de 5 mois. Le saignement est de loin le symptome le plus frequent. Des efforts d'exoneration, le sentiment d'une evacuation incomplete, une constipation et un prolapsus sont egalement frequemment notes. Treize des patients presentent un prolapsus du rectum d'importance variable a l'examen. Tous les malades ont une hyperemie ou une ulceration du rectum et ont eu une confirmation histologique sur la base des criteres reconnus. La majorite des patients a ete traitee de maniere conservatrice. Douze patients ont necessite un geste chirurgical. Un prolapsus muqueux partiel a ete traite par excision locale chez 5 malades et par injection d'une solution d'huile phenolee chez 2 patients. Trois patients ont subi une rectopexie par voie abdominale, un a subi une intervention de Delorme et deux ont subi une intervention de Delorme et deux ont subi une resection anterieure basse. Un deces postoperatoire est survenu dans cette serie et un deces sans relation avec le syndrome d'ulcere solitaire du rectum. Le suivi postoperatoire va de 0 a 200. L'incidence de l'ulcere solitaire du rectum est de 3,6 par 100 000 par an dans notre region; cette incidence est significativement plus elevee que dans des etudes precedentes; notre collectif de patients est notablement plus âge et les manifestations cliniques n'etaient pas toujours classiques. Nous aimerions suggere en consequence que ce diagnostic d'une lesion rare soit plus souvent suspectee.

Small bowel length in inflammatory bowel disease.

Abstract: Small intestinal length has a particular significance in patients with inflammatory bowel disease (IBD). A determination of intestinal length by a standardised and simple technique is of interest for surgical decision making in primary and recurrent disease and in the evaluation and management of postoperative malabsorption. The aim of the present investigation was to analyse intestinal length in patients with IBD and define a standard method for this measurement. Material and methods: Two consecutive series of patients, Crohn's disease (n = 279) and ulcerative colitis (n = 315) and a control group (n = 77) underwent standardised intra-operative small intestinal length measurement. Results: Small intestinal length correlated to weight and height and was less in women than in men (P < 0.001) in both IBD groups and the controls. The small bowel in patients with Crohn's disease was significantly shorter than in patients with ulcerative colitis and in controls, P < 0.001. Also in Ulcerative Colitis small bowel length was significantly less than in controls, P < 0.001. In CD patients there was no difference in bowel length with regards to the anatomical extent of the disease. Original small bowel length in patients with CD and one or two bowel resections (n = 67) was not different from that in patients with three or more resections (n = 88). Conclusion: Small bowel length correlated to weight, height and sex. Patients with CD had a significantly shorter small intestine at first laparotomy, compared with U.C. patients and controls. In CD-patients there was no difference between the anatomical subgroups.

Association between age and local recurrence of rectal cancer: results from a retrospective study of 902 patients.

Abstract: Due to the ageing of the general population, there has been a relative increase of elderly patients with rectal cancer. The relation between age and the risk of local recurrence after apparently curative surgery for cancer of rectum and rectosigmoid was studied in a retrospective study of 902 patients, diagnosed from 1984 through 1991 in the southwestern part of the Netherlands. Three age-groups were defined: 15-64 (n = 328), 65-74 (n = 327) and 75 and over (n = 247). After exclusion of postoperative deaths and controlling for unrelated causes of death, 5-year survival rates were similar in the three age-groups (70%, 71% and 75%, respectively). Local recurrence rates, however, decreased with age from 23% to 18% and 14%, respectively. In multivariate analysis, the hazard ratios were 1, 0.84 and 0.66, respectively. These results suggest that local recurrence occurs less frequently in the elderly, which needs confirmation from prospective studies and warrants consideration in decisions about the use of adjuvant treatment.

Emergency large bowel surgery : a 15-year audit

Abstract: Object: To evaluate the management of patients presenting with colorectal emergencies. Method: Computerized audit of patients undergoing urgent/semi-urgent surgery in the Colorectal Service, University Department of Surgery, Wellington School of Medicine, NZ. Results: 246 patients underwent major emergency or semi-emergency operations. Consultants performed 144 operations. The complications of cancer and diverticular disease were the commonest indications for surgery. Patients with inflammatory processes required significant perioperative nutrition. The disease site varied with the pathology. Overall the sigmoid colon was the commonest. Resection and anastomosis was generally performed for right-sided lesions whereas Hartmann's operation was the commonest procedure for more distally situated non neoplastic lesions. A loop diverting stoma was used most commonly in patients with obstructing cancer. The most frequent post-operative complication was urinary tract infection. Four patients developed pulmonary embolism, 2 ARDS, 4 myocardial infarction and 1 CVA. Persistent intra-abdominal sepsis requiring drainage occurred in five patients. There were 6 anastomotic leaks. 3 patients were re-operated upon to relieve post-operative small bowel obstruction. The overall post-operative mortality rate was 6.9%. Conclusion: A cautious policy of resecting right sided lesions and either diversion or resection without anastomosis for patients presenting acutely with left-sided colonic lesions resulted in a low overall mortality rate.

Chronic pelvic pain in women--gastroenterological, gynaecological or psychological?

Abstract: Women with chronic pelvic pain form a substantial part of the workload of gynaecologists, gastroenterologists and surgeons. Each investigates with their own diagnostic bias but the source of pain often remains obscure, with a lack of abnormal findings or failure of symptom resolution despite treatment of identified pathology. The patient's physical and social disability may become compounded by diagnostic confusion, and by prolonged and ineffective treatments including surgery. The end result is often a sense of helplessness in both the patient and the physician.