Prospective randomised trial comparing ayurvedic cutting seton and fistulotomy for low fistula-in-ano

The aim of this study was to evaluate the role of ayurvedic setons in the treatment of low fistula-in-ano. One hundred and eight patients were randomised into either conventional fistulotomy (F) or ayurvedic cutting seton insertion (C). Endpoints investigated included time to wound healing and complications of surgery. Post-operative pain scores were measured daily using a visual analog scale. Anal function was compared using a continence score. Pre- and postoperative manometry and ultrasound were also performed. After exclusions, there were 54 patients in group F and 46 in group C. There were no differences in age, sex or follow-up duration between the two groups. Healing time was similar between the groups. Group C reported more pain following operation and on the first 2-4 postoperative days, but both groups experienced the same amount of pain subsequently. In conclusion, chemical seton was more painful than conventional fistulotomy in the first few days following surgery. However, there was no difference in time to wound healing, complications or functional outcome.

External beam radiation therapy for inoperable hepatocellular carcinoma with portal vein thrombosis

Portal vein thrombosis (PVT) in patients with hepatocellular carcinoma (HCC) has a poor impact on prognosis. Many of these tumors may cause intrahepatic and extrahepatic metastases. From January 1991 to December 1996, 41 unresectable HCC patients with PVT underwent transcatheter arterial chemoembolization (TACE) and external beam radiation therapy (EBRT) to the portion of PVT. The irradiated field, with a mean equivalent field size of 6.6 x 7.1 cm2, was localized and simulated by abdominal sonography, angiography and computed tomography. Radiation dose ranged from 36 to 66 Gy (mean dose: 51.4 Gy), in a daily fraction of 1.8 to 2 Gy. The response of EBRT was evaluated by abdominal sonography within 3 months of completion of EBRT. The response rates of the PVT after treatment were 39% for complete response (CR), 41% for partial response (PR), and 19% for no response (NR), respectively. The median overall survival time from start of radiotherapy was 10 months for all patients, 17 months for CR patients, 8 months for PR patients and 4 months for NR patients. By multivariate analysis, response of PVT resulted in a significant improvement in survival. (P = 0.001) There was no occurrence of severe complication of radiation-induced liver disease. The results obtained with combined treatment modality of EBRT and TACE in the treatment of HCC patients with PVT are encouraging.

Primary colorectal signet-ring cell carcinoma in Singapore

BACKGROUND

Primary colorectal signet-ring cell carcinoma is a rare but distinctive tumour of the colon and rectum. The clinicopathological features are still controversial. The aim of this study is to review the clinicopathological features and management of this type of tumour in our hospital.

METHODS

The clinicopathological features and survival data of all cases of primary colorectal signet-ring cell carcinoma were reviewed retrospectively.

RESULTS

There were nine cases of primary colorectal signet-ring cell carcinoma in 3000 consecutive colorectal carcinoma patients seen from 1989 to 1999. There were seven male and two female patients with a mean age of 54.7 years. Three patients were younger than 40 years. The common presenting symptoms were rectal bleeding (33%) and small bowel obstruction (33%). Two (22%) patients required emergency surgery due to acute small bowel obstruction. The most common tumour location was the right colon (44%) followed by the rectum (33%). All nine patients presented at a very late stage of disease. A majority (77%) had Dukes' C disease while two (22%) had Dukes' D disease with distant dissemination. Peritoneal spread (33%) was the most frequent way of dissemination. There was no patient with liver metastases at the time of diagnosis and initial presentation. The mean survival time was 30 (range 5-108) months. The 5-year survival rate was 12%.

CONCLUSIONS

Primary colorectal signet-ring cell carcinoma is frequently diagnosed late with a very poor prognosis. A high incidence of peritoneal seeding and low incidence of liver metastases appears to be a characteristic of signet-ring cell carcinoma of the colon and rectum.

Randomized trial assessing anal sphincter injuries after stapled haemorrhoidectomy

BACKGROUND

Conventional stapled haemorrhoidectomy involves the use of a large circular anal dilator (DL technique), which may cause anal sphincter injuries. This study compared whether the procedure can be effectively performed without this dilator (ND technique), with better sphincter preservation.

METHODS

Fifty-eight patients with symptomatic prolapsed irreducible haemorrhoids were randomized to DL (n = 29) and ND (n = 29) groups. Preoperative continence scoring, anorectal manometry and endoanal ultrasonography were performed. These were repeated at up to 14 weeks after operation, with additional pain scores, analgesic requirements and quality of life assessments.

RESULTS

DL haemorrhoidectomy took significantly longer to perform (P = 0.02). However, there were fewer residual skin tags (P = 0.044) and less perianal pruritus (P = 0.007) at 2 weeks, although such symptoms subsided to an equivalent level in both groups afterwards. Internal anal sphincter fragmentation persisting to at least 14 weeks was found in four patients after DL, but not after ND haemorrhoidectomy (P = 0.038). However, these were asymptomatic and no differences were found in continence scores and anal pressures. The pain scores, satisfaction scores, quality of life assessments and time off work were similar.

CONCLUSION

The large circular anal dilator used for stapled haemorrhoidectomy increased the risk of anal sphincter injuries, which may become problematic with ageing.

Head-column field-amplified sample stacking in capillary electrophoresis for the determination of cimetidine, famotidine, nizatidine, and ranitidine-HCl in plasma

In this study, low concentrations of histamine2-receptor (H2-)antagonists were effected across a water plug, with separation taking place in a binary buffer comprising ethylene glycol and NaH2PO4 (pH 5.0), and detection at 214 nm. Liquid-liquid extraction with ethyl acetate- isopropanol is shown to provide extracts that are sufficiently clean. The calibration curves were linear over a concentration range of 0.1-2.00 microg/mL cimetidine, 0.2-5.0 microg/mL ranitidine-HCl, 0.3-5.0 microg/mL nizatidine, and 0.1-3.0 microg/mL famotidine. Mean recoveries were > 82%, while the intra- and interday relative standard deviations (RSDs) and relative errors (REs) were all < 13%. The method is sensitive with a detection limit of 3 ng/mL cimetidine, 30 ng/mL ranitidine HCl, 50 ng/mL nizatidine and 10 ng/mL famotidine (S/N = 3, electric-driven injection 90 s). This newly developed capillary electrophoresis (CE) method was applied for the determination of analytes extracted from plasma taken from a volunteer dosing a cimetidine, ranitidine, and nizatidine tablet simultaneously. These three H2-antagonists can be detected in real samples by this method, excluding the low dosing of famotidine tablet.

Simultaneous determination of cimetidine, famotidine, nizatidine, and ranitidine in tablets by capillary zone electrophoresis

A simple capillary zone electrophoresis (CZE) method is described for the simultaneous determination of cimetidine (CIM), famotidine (FAM), nizatidine (NIZ), and ranitidine (RAN). The analysis of these drugs was performed in a 100 mM phosphate buffer, pH 3.5. Several parameters were studied, including wavelength for detection, concentration and pH of phosphate buffer, and separation voltage. The quantitative ranges were 100-1,000 microM for each analyte. The intra- and interday relative standard deviations (n = 5) were all less than 4%. The detection limits were found to be about 10 microM for CIM, 20 microM for RAN, 20 microM for NIZ, and 10 microM for FAM (S/N = 3, injection 1 s) at 214 nm. All recoveries were greater than 92%. Applications of the method to the assay of these drugs in tablets proved to be feasible.

Postanal sphincter repair for anterior resection anal sphincter injuries: report of three cases

Treatment options are limited for intractable excessive stool frequency and incontinence after low anterior resection for rectal cancer. Fortunately, this is quite rare, but three such patients were reported. The patients did not respond to two years of expectant treatment, including medications and anorectal biofeedback. Anorectal physiologic tests and endoanal ultrasound findings were consistent with internal anal sphincter injuries, which are known to occur with transanal insertion of stapling instruments. After postanal sphincter repair, stool frequency was reduced from 5.7 (standard error of the mean, 1.3) to 1.7 (0.3) stools per day. Fecal incontinence requiring pads in all patients was reduced to full continence in two patients and gas incontinence in one. Continence score improved from 13.7 (2.2) to 1.3 (0.3). Mean follow-up was 3.2 (0.5) years. Postanal sphincter repair could be considered when persistent bowel dysfunction after anterior resection is caused by internal sphincter injury.

Regulation of herpes simplex virus type 1 replication in Vero cells by Psychotria serpens: relationship to gene expression, DNA replication, and protein synthesis

Inhibitory effects of ethanolic extracts from seven Chinese herbs on herpes simplex virus type 1 (HSV-1) replication were investigated. From a bioassay-guided fractionation procedure, PS-A-6 was isolated from Psychotria serpens (P. serpens), which suppressed HSV-1 multiplication in Vero cells without apparent cytotoxicity. Time-of-addition experiments suggested that the inhibitory action of PS-A-6 on HSV-1 replication was not through blocking of virus adsorption. In an attempt to further localize the point in the HSV-1 replication cycle where arrest occurred, a set of key regulatory events leading to viral multiplication was examined, including viral gene expression, DNA replication, and structural protein synthesis. The results indicated that gB mRNA and protein expression in Vero cells were impeded by PS-A-6. Southern blot analysis showed that HSV-1 DNA replication in Vero cells was arrested by PS-A-6. In addition, PS-A-6 decreased thymidine kinase (tk) and ICP27 mRNA expression in the cells. The mechanisms of antiviral action of PS-A-6 seem to be mediated, at least in part, through inhibition of early transcripts of HSV-1, such as tk and ICP27 mRNAs, arresting HSV-1 DNA synthesis and gB gene expression in Vero cells. Plans are underway for the isolation of pure compounds from PS-A-6 and elucidation of their mechanism of action.

Total colectomy with ileorectal anastomosis leads to appreciable loss in quality of life irrespective of primary diagnosis

Total colectomy with ileorectal anastomosis (TC) is a well-accepted procedure for many colonic pathologies but data on faecal incontinence and related quality of life after TC are lacking. The aims of this study were to assess the long-term bowel frequency, degree of incontinence and quality of life with respect to faecal incontinence and to compare them with the outcome for TC for different diagnostic groups. We identified 54 patients who had undergone TC at Singapore General Hospital and interviewed them using two questionnaires: the faecal incontinence quality of life (FIQL) scale and the Wexner faecal incontinence score (WS). The patients were allocated in 3 groups based on the primary diagnosis leading to operation, i. e. slow-transit constipation or megacolon (STC), colonic neoplasm (CA) and complicated pan-colonic diverticular disease (DD). Median bowel frequencies for STC and DD groups were 2.5/day; for CA, it was 3.5/day (p=0.042). There was no significant difference in the FIQL score and WS between the groups. Eleven patients had some degree of faecal incontinence based on WS. Many patients (20.4%) with perfect continence had fear of faecal leakage affecting their quality of life. In conclusion, patients with frequent stools do not need to have incontinence to suffer from the fear of it. The primary pathology leading to TC made no difference to the faecal incontinence or bowel urgency problems.

Tumor size is irrelevant in predicting malignant potential of carcinoid tumors of the rectum

The malignant potential and prognosis of rectal carcinoids are said to be related to tumor size. Our study assessed if size could predict the malignant potential and hence its management. All patients in the Department of Colorectal Surgery, Singapore General Hospital, who underwent surgery for rectal carcinoid tumors between February 1991 and September 2000 were analyzed. Twenty patients (11 men), median age 48 years (range, 33-77 years) were studied. Median follow-up was 40 months (range, 5-120 months). The median tumor diameter was 2.5 cm (range, 0.1-5.0 cm). Eleven patients underwent radical resection and 9 patients had local resection for a presumed benign tumor. Morbidity was 15% and postoperative death was 5%. Overall median survival was 24 months (range, 5-120 months). One patient had an anterior resection for rectal adenocarcinoma but had an incidental 0.1-cm carcinoid tumor near the resection margin which on histology was found to have carcinoid tumor metastasis to 2 out of 12 lymph nodes. In conclusion, tumor size cannot predict malignant potential as even small tumors (<1 cm) can be malignant. Accurate preoperative staging with radical surgery may be required.

Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial

The colonic J-pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra-low anterior resection, but there are few studies with long-term follow-up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2-year period. Forty-two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 +/- 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 +/- 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 +/- 2.8 vs. 49 +/- 1.4/week; p < 0.05) and less soiling at passing flatus (38% vs. 73.7%; p < 0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 +/- 0.4 vs. 8 +/- 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p < 0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J-pouch.

Stratifying risk factors for follow-up: a comparison of recurrent and nonrecurrent colorectal cancer

INTRODUCTION

The selection of patients for individualized follow-up and adjuvant therapy after curative resection of colorectal carcinoma depends on finding reliable prognostic criteria for recurrence. However, such criteria are not universally accepted, and follow-up is often standardized for all patients without regard for each individual's level of risk of recurrence. Such a system of follow-up is not cost-effective.

METHODS

A comparison of operative findings, pathologic features, and follow-up data of 1,731 cases of nonrecurrent colorectal cancer (821 colon, 910 rectum) with 357 cases of recurrent colorectal cancer (164 colon, 193 rectum) following potentially curative surgery was made, and results were analyzed to ascertain criteria for stratifying follow-up according to risk factors.

RESULTS

Single-factor analysis showed that Dukes staging and tumor invasion were significantly associated with recurrence in both rectal and colon carcinoma. Tumor fixation and grading were additional significant factors in rectal cancer. Recurrence rates, time to recurrence, site of recurrence (locoregional vs. distant), and pattern of metastatic spread were not significantly affected by original tumor site. Recurrence was not significantly affected by patient age and gender. Individual surgeon performance in this series had also no significant effects on tumor recurrence. With multivariate analysis only, Dukes staging and tumor invasion into adjacent tissues were found to be independent adverse prognostic factors for recurrence.

CONCLUSIONS

Dukes staging and tumor penetration into adjacent tissues are the only significant adverse prognostic factors for tumor recurrence of colonic and rectal carcinoma. Tumor grade and tumor fixation are additional adverse prognostic factors in rectal cancer. Guidelines for follow-up may be based on these factors and follow-up thus stratified according to risk of developing recurrence.

Biofeedback avoids surgery in patients with slow-transit constipation: report of four cases

Biofeedback is established treatment for intractable constipation in patients with an element of pelvic floor dysfunction. In those with intractable slow-transit constipation and normal pelvic floor function, colectomy is usually recommended. We report four patients with isolated slow-transit constipation who benefited from biofeedback and avoided surgery. All four patients were extensively investigated for pelvic floor dysfunction before undergoing a standard biofeedback course of four outpatient sessions. All improved in terms of bowel frequency, laxative use, bloating, straining, and lifestyle. Improvement has been maintained for a median of nine (range, 5-12) months without the requirement for further treatment. Biofeedback represents a safe and inexpensive treatment for these patients and may avoid surgery in a significant proportion.

A comparison between open versus laparoscopic assisted colonic pouches for rectal cancer

The aim of this prospective study was to compare the surgical outcomes in patients undergoing laparoscopic assisted vs. open ultralow anterior resection (ULAR) with the creation of a colonic pouch-anal anastomosis. Patients undergoing ULAR with creation of a colonic pouch and who either had conventional open (CO) or laparoscopic assisted (LA) surgery in colorectal cancer were studied and compared. There were 33 patients, 22 in CO group and 11 in LA group. The groups were comparable for age, sex, tumour and anastomotic heights from anal verge, stage of disease, length of specimen removed and duration of surgery. Incisions were significantly shorter in the LA group (median, 9 cm vs. 16 cm, p = 0.01). Less parenteral analgesia was required in the LA group (2 days vs. 3 days, p = 0.05), but there were no significant differences in the time to passage of flatus, commencement of oral fluids or solid foods and length of hospital stay. There was no difference in morbidity or mortality. With regards to patients with Dukes A to C disease only, at a median of 12 months of follow-up, there was no patient with local or port site recurrence in the LA group. In the CO group, there was one local recurrence and two with distal metastases. In conclusion, laparoscopic assisted ULAR with colonic J pouch anal anastomosis is feasible, easy to perform and safe. It s advantages include significantly shorter incision and lower analgesic requirements postoperatively. Return of bowel function and length of hospital stay, however, are comparable to those of conventional open surgery.

Total pelvic exenteration: results from a multispecialty team approach to complex cancer surgery

Total pelvic exenteration is often the only curative option for recurrent or locally advanced pelvic cancers, but it carries a high risk of mortality and morbidity. A dedicated multispecialty team operative approach may provide the expertise to perform this uncommon procedure with favorable outcomes. Data were analyzed from a prospectively collected computerized database. There were 14 patients (2 men; mean age, 54.6 +/- 3.6 years) with mainly cervical cancers, of which 71.4% were recurrent. Anesthetic time was 5 +/- 0.9 hours, intraoperative blood loss was 2.1 +/- 0.5 liters, and postoperative hospitalization was 22 +/- 9.9 days. An ileal conduit was performed in all patients, but intestinal continuity was restorable with colonic J-pouch in 71.4% of the patients. There was no mortality at 30 days or during hospitalization. Complication rates were 35.7%, accounting for reoperations in 28.6%. Recurrences were detected in 50% patients at a mean follow-up of 53.1 +/- 9.2 months. The mean time for cancer recurrence was 13.3 +/- 3.3 months. Fifty percent of those patients had otherwise survived to date. We conclude that a dedicated multispecialty team may perform total pelvic exenteration with minimum mortality and acceptable morbidity.

High preoperative serum carcinoembryonic antigen predicts metastatic recurrence in potentially curative colonic cancer: results of a five-year study

INTRODUCTION

Serum carcinoembryonic antigen is used mainly for tumor follow-up to detect recurrence of colonic cancer. However, raised preoperative carcinoembryonic antigen levels may be helpful for the identification of understaged cases and of patients meriting more intensive preoperative and postoperative diagnostic workup.

METHODS

From a prospectively collected database, the data on 261 patients who had curative colonic carcinoma with a minimal follow-up of five years and who had preoperative carcinoembryonic antigen levels assessed were retrieved and analyzed. Outcome parameters were local and/or distant recurrence and time to recurrence. These parameters were correlated with Dukes staging and preoperative carcinoembryonic antigen levels.

RESULTS

The cumulative disease-free survival of patients with a preoperative carcinoembryonic antigen level within the normal range was significantly better than that of those whose carcinoembryonic antigen was 5 ng/ml or more (P = 0.001). No patient with carcinoembryonic antigen levels less than 1 ng/ml developed metastatic recurrence. Twenty-three percent of all patients with a raised carcinoembryonic antigen above 5 ng/ml compared with 2.1 percent of patients with carcinoembryonic antigen below 5 ng/ml developed a metastasis at two years. At five years, these figures were 37.2 percent and 7.5 percent, respectively. Dukes staging and carcinoembryonic antigen levels were found to be directly correlated (P < 0.001) when all patients were included. Carcinoembryonic antigen of more of 15 ng/ml was found to be a significant adverse prognostic indicator for disease-free survival irrespective of Dukes staging (P < 0.02). Raised carcinoembryonic antigen levels predicted distant metastatic recurrence (P < 0.001) but did not predict local recurrence (P = 0.72).

CONCLUSIONS

High preoperative carcinoembryonic antigen levels above 15 ng/ml predicted an increased risk of metastatic recurrence in potentially curative colonic cancer and may indicate undetectable disseminated disease. Preoperative carcinoembryonic antigen levels predict understaging and the possibility of distant recurrence. Such patients may therefore be selected for adjuvant therapy where indicated. Therefore, carcinoembryonic antigen is complementary to conventional Dukes staging for the prediction of recurrence and survival.

Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months

PURPOSE

Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique.

METHODS

A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique = 62; stapled hemorrhoidectomy = 57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs.

RESULTS

Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9) vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4) vs. 2.6 (0.4); P < 0.005) at two weeks, and analgesic requirements were more for up to six weeks (P < 0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent) vs. 19 (33.3 percent); P < 0.05) and pruritus (27 (43.5 percent) vs. 9 (15.8 percent); P < 0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent) vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8) vs. 17.1 (1.9) days; P < 0.05), but the total costs incurred were less ($921.17 (16.85) vs. $1,283.09 (31.59); P < 0.005).

CONCLUSIONS

Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.

Postoperative intra-abdominal free gas after open colorectal resection

PURPOSE

An erect chest radiograph for subdiaphragmatic free gas can be a useful adjunct in detecting a defect in gastrointestinal continuity. The usefulness of this test after laparotomy has not been defined, because the period of persistence of free gas is unknown. We set out to determine the length of time for natural absorption of postlaparotomy pneumoperitoneum in a prospective cohort study.

METHOD

Plain erect chest radiographs were performed on the second and fourth postoperative day and daily thereafter until the disappearance of subdiaphragmatic free gas after laparotomy.

RESULTS

Seventy-five consecutive patients were studied after informed consent. The mean age was 62.1 (standard error of the mean, 1.7) years. On the fifth postoperative day, sixth postoperative day, and seventh postoperative day, 71.6, 80, and 89 percent of patients, respectively, had no visible subdiaphragmatic gas. Five patients had gas persisting beyond the tenth postoperative day. Two of these patients did not have an anastomosis. The use of drainage tubes did not affect significantly the mean time to disappearance of subdiaphragmatic free gas (4.5 vs. 4.9 days; P = 0.45: t-test). The duration of surgery, body mass index, and time to resume bowel function had no significant effect on gas disappearance. Two patients had a clinical leak on the fifth postoperative day. This was manifested as an increase in the collection of subdiaphragmatic gas during the course of a day.

CONCLUSION

By the sixth postoperative day 80 percent of patients had no subdiaphragmatic free gas on an erect chest radiograph regardless of the presence of a drainage tube. The erect chest radiograph may therefore be a simple and readily available adjunct in the evaluation of postoperative abdominal pain, especially after the sixth postoperative day when a similar prior examination is done routinely on the fourth postoperative day for comparison.

Ambulatory manometry in patients with colonic J-pouch and straight coloanal anastomoses: randomized, controlled trial

PURPOSE

Bowel function after ultralow anterior resection may be improved by a colonic J-pouch. The aim of this study was to compare the bowel function and ambulatory manometry in patients randomly assigned to straight coloanal anastomosis or colonic J-pouch.

METHODS

Forty-seven consecutive patients underwent ultralow anterior resection for adenocarcinoma. The colonic J-pouch was constructed with 6-cm limbs. A bowel function questionnaire was administered at one year after surgery. Ambulatory manometry was performed before and at one year after surgery.

RESULTS

Values are expressed below as mean and (standard error of the mean). Patients with colonic J-pouch were found to have less frequent stools (4.6 (0.3) vs. 7.1 (0.9) stools/day; P < 0.05) and stool clustering (35 vs. 63.2 percent; P < 0.05) and were less unlikely to soil when passing flatus (85 vs. 35.3 percent; P < 0.05). The ambulatory anorectal pressure gradient was better preserved in the colonic J-pouch group (30.3 (3.7) vs. 18 (2.6) mmHg; P < 0.05). Stool frequency was predicted by the mean rectal pressures (t = 3.368; P = 0.003). However, higher mean rectal pressures were tolerated by the colonic J-pouch for each daily bowel movement (6.7 (0.6) vs. 4.4 (0.5) mmHg/stool; P = 0.008). Anal sampling episodes and slow wave activity were impaired postoperatively in both groups. The minimal anal pressures were lower in patients unable pass flatus without soiling (12.4 (5.3) vs. 26 (2.3) mmHg; P = 0.004). Large contraction waves were not seen, and this may be related to the absence of severe defecation problems with 6-cm colonic J-pouches.

CONCLUSIONS

A colonic J-pouch resulted in better bowel function and more favorable ambulatory manometric findings at one year of follow-up.

Pilonidal disease in Singapore: clinical features and management

BACKGROUND

Pilonidal disease has not been well documented in Asian people. The aims of the present study were to investigate any variations in the clinical features and effectiveness of various surgical treatments in such a population.

METHODS

A prospectively collected computerized database of 61 consecutive patients admitted to a specialist colorectal unit over a 9-year period was studied. The five methods of surgical treatment used during this period (incision and drainage; laying open; marsupialization; primary closure; and the flap procedure) were compared.

RESULTS

There were 38 men and 23 women with a mean age of 27+/-1.02 years. Pilonidal disease was significantly more common among the Indian people (52.5% of patients) than the other ethnic races in the Singaporean community (P < 0.001). Chronic discharging sinuses were the most common presentation (93.4%). There were no differences between the various surgical techniques employed with regard to the time required for wound healing (mean: 48+/-21 days) and recurrence rates (4/61, 6.6%). Wound dehiscence after primary wound closure (10%) and flap procedures (42%) meant that the overall healing rate was not faster than when the wound was just laid open. Furthermore, flap procedures required a longer hospitalization than other procedures (P = 0.005).

CONCLUSION

Pilonidal disease was more common among Indian people, the more hirsute among the Singaporean population. Primary closure and flap procedure did not improve overall wound healing because of dehiscence.

Anal sphincter injuries from stapling instruments introduced transanally: randomized, controlled study with endoanal ultrasound and anorectal manometry

PURPOSE

Injury sustained from the transanally introduced stapling technique was assessed by comparison with biofragmentable anastomotic ring anastomosis, which excluded anal manipulation.

METHODS

A randomized, controlled trial was conducted on consecutive patients undergoing sigmoid colectomy (where pelvic nerve injury was avoided). A bowel function questionnaire was administered six months after surgery. Anorectal manometry and endoanal ultrasonography were performed preoperatively and at six months postoperatively. The observers were blinded to the randomization.

RESULTS

There were 18 patients in the transanally introduced stapling technique group and 17 patients in the biofragmentable anastomotic ring group, with no differences in age, gender, Dukes staging, and follow-up. Three of the transanally introduced stapling technique patients had occasional liquid soiling, which was absent in biofragmentable anastomotic ring patients. Mean change in resting anal pressures was also significantly impaired when compared with patients with biofragmentable anastomotic ring (P = 0.007). Endosonographic internal sphincter fragmentation was found in five transanally introduced stapling technique patients but none after biofragmentable anastomotic ring anastomosis (P = 0.046). Internal sphincter fragmentation was associated with the impaired resting pressures (P = 0.007). External sphincter deficiencies were found after transanally introduced stapling technique in two patients (biofragmentable anastomotic ring = 0), and these were associated with the soiling (P = 0.005).

CONCLUSIONS

The transanally introduced stapling technique may result in anal sphincter defects and impaired anal pressures when assessed at six months of follow-up.

Micronized purified flavonidic fraction compared favorably with rubber band ligation and fiber alone in the management of bleeding hemorrhoids: randomized controlled trial

PURPOSE

The aim of this study was to assess the role of micronized purified flavonidic fraction in the management of bleeding nonprolapsed hemorrhoids.

METHODS

Patients were randomly assigned to receive ispaghula husk alone, rubber band ligation plus ispaghula husk, or micronized purified flavonidic fraction plus ispaghula husk. Other colorectal diseases were excluded by colonoscopy. Blinded observers noted the time for bleeding to stop completely, recurrences, and treatment complications.

RESULTS

A total of 162 patients were randomly assigned with no significant differences in the age and gender distributions among the groups. Hemorrhoidal bleeding was relieved most expediently in the micronized purified flavonidic fraction plus ispaghula husk group (ispaghula husk alone n = 66, mean (standard error of the mean) 10.6 (2.3) days; rubber band ligation plus ispaghula husk n = 57, 5.6 (1.1) days; micronized purified flavonidic fraction plus ispaghula husk n = 39, 3.9 (1.2) days; P = 0.03). However, there were no significant differences in the recurrences at six months of follow-up (ispaghula husk alone n = 8 (12 percent); rubber band ligation plus ispaghula husk n = 12 (21 percent); micronized purified flavonidic fraction plus ispaghula husk n = 2 (5.1 percent); P = 0.075). No complications or side-effects were noted.

CONCLUSIONS

micronized purified flavonidic fraction used with fiber supplements rapidly and safely relieved bleeding from nonprolapsed hemorrhoids.