The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Human factors in pelvic exenteration: themes in high-performing teams

AIM

The aim of this study was to investigate the role of human factors in pelvic exenteration and how team performance is optimized in the preoperative, intraoperative and postoperative phases.

METHOD

Qualitative analysis of focus groups was used to capture authentic human interactions that reflect real-world multiprofessional performance. Theatre teams were treated as clusters, with a particular focus group containing participants who worked together regularly.

RESULTS

Three focus groups were conducted. Four themes emerged - driving force, technical skills, nontechnical skills and operational aspects - with a total of 16 subthemes. Saturation was reached by group 2, with no new subthemes emerging after this. There was some interaction between the themes and the subthemes. Broadly speaking, driving force led to the development of specialised technical skills and nontechnical skills, which were operationalized into successful service through operational aspects.

CONCLUSION

This study of teams performing pelvic exenteration is the first in the field using this methodology. It has generated rich qualitative data with authentic insights into the pragmatic aspects of developing and delivering a service. In addition, it shows how the themes are connected or 'coupled' in a network, for example technical and non-technical skills. In a complex system, 'tight coupling' leads to both high performance and adverse events. In this paper, we report the qualitative aspects of high performance by pelvic exenteration teams in a complex sociotechnical system, which depends on tight coupling of several themes.

Assessing Guidelines on the Need for Colonoscopy After Initial Flexible Sigmoidoscopy in Young Patients With Outlet-Type Rectal Bleeding

BACKGROUND

Although young-age-of-onset colorectal cancer is increasing in incidence, lack of screening leads to symptomatic presentation, often with rectal bleeding. Because most cancers in patients younger than 50 years are left-sided, flexible sigmoidoscopy is a reasonable way of investigating bleeding in these patients.

OBJECTIVE

To predict which patients undergoing flexible sigmoidoscopy for outlet-type rectal bleeding need a full colonoscopy.

DESIGN

Findings at colonoscopy were compared with published indications for colonoscopy after flexible sigmoidoscopy, which were as follows: 1) any number of advanced adenomas defined as a tubular adenoma of >9 mm diameter, a tubulovillous or villous adenoma of any size, or any adenoma with high-grade dysplasia; 2) 3 or more tubular adenomas of any size or histology; 3) any sessile serrated lesion; and 4) 20 or more hyperplastic polyps.

SETTING

Charity Hospital with volunteer specialists.

PATIENTS

Patients were included if they were younger than 57 years, had outlet-type rectal bleeding, and underwent flexible sigmoidoscopy at least to the descending colon followed by colonoscopy with biopsy of all resected lesions.

INTERVENTIONS

Flexible sigmoidoscopy and colonoscopy with excision of all removable lesions.

MAIN OUTCOME MEASURES

Findings at colonoscopy.

RESULTS

There were 66 patients who had a colonoscopy between 5 and 811 days after sigmoidoscopy and also had complete data. There were 43 men and 23 women with a mean age of 39.5 years. Analysis of flexible sigmoidoscopy criteria for finding proximal high-risk lesions on colonoscopy showed a sensitivity of 76.9%, a specificity of 67.9%, a positive predictive value of 37%, a negative predictive value of 92.3%, and an accuracy of 69.7%.

LIMITATIONS

A large number of exclusions for inadequate colonoscopy or inadequate data resulted in a reduced patient number in the study.

CONCLUSIONS

Our criteria for follow-up colonoscopy based on the findings at initial flexible sigmoidoscopy in young patients with outlet-type rectal bleeding are reliable enough to be used in routine clinical practice, provided this is audited. See Video Abstract.

GUA DE EVALUACIN PARA LA NECESIDAD DE COLONOSCOPIA DESPUS DE UNA SIGMOIDOSCOPIA FLEXIBLE INICIAL EN PACIENTES JVENES CON RECTORRAGIA

ANTECEDENTES:Si bien la edad de aparición temprana del cáncer colorrectal está aumentando en incidencia, la falta de pruebas de detección conduce a una presentación sintomática, a menudo con sangrado rectal. Debido a que la mayoría de los cánceres en pacientes menores de 50 años son del lado izquierdo, la sigmoidoscopia flexible es una forma razonable de investigar el sangrado en estos pacientes.OBJETIVO:Predecir qué pacientes sometidos a sigmoidoscopia flexible por rectorragia necesitan una colonoscopia completa.DISEÑO:Los resultados de la colonoscopia se compararon con las indicaciones publicadas para la colonoscopia después de una sigmoidoscopia flexible. Estos fueron: 1. Cualquier número de adenomas avanzados, definidos como un adenoma tubular > 9 mm, un adenoma tubulovelloso o velloso de cualquier tamaño, o cualquier adenoma con displasia de alto grado. 2. Tres o más adenomas tubulares de cualquier tamaño o histología. 3. Cualquier lesión serrada sésil. 4. Veinte o más pólipos hiperplásicos.ENTORNO CLINICO:Hospital de Caridad con especialistas voluntarios.PACIENTES:Menores de 57 años, con rectorragia, sometidos a sigmoidoscopia flexible al menos hasta el colon descendente, seguida de colonoscopia con biopsia de todas las lesiones resecadas.INTERVENCIONES:sigmoidoscopia flexible y colonoscopia con escisión de todas las lesiones removibles.PRINCIPALES MEDIDAS DE VALORACIÓN:Hallazgos en la colonoscopia.RESULTADOS:66 casos a los que se les realizó una colonoscopia entre 5 y 811 días después de la sigmoidoscopia, que también tenían datos completos. 43 hombres y 23 mujeres con una edad media de 39,5 años. El análisis de los criterios de sigmoidoscopia flexible para encontrar lesiones proximales de alto riesgo en la colonoscopia mostró una sensibilidad del 76,9 %, una especificidad del 67,9 %, un valor predictivo positivo del 37 %, un valor predictivo negativo del 92,3 % y una precisión del 69,7 %.LIMITACIONES:Gran número de exclusiones por colonoscopia inadecuada o datos inadecuados que causan un número reducido de pacientes en el estudio.CONCLUSIÓN:Nuestros criterios para la colonoscopia de seguimiento basados en los hallazgos de la sigmoidoscopia flexible inicial en pacientes jóvenes con rectorragia son lo suficientemente confiables para ser utilizados en la práctica clínica habitual, siempre que se audite. (Traducción- Dr. Ingrid Melo ).

Bacterial lipopolysaccharide modulates immune response in the colorectal tumor microenvironment

Immune responses can have opposing effects in colorectal cancer (CRC), the balance of which may determine whether a cancer regresses, progresses, or potentially metastasizes. These effects are evident in CRC consensus molecular subtypes (CMS) where both CMS1 and CMS4 contain immune infiltrates yet have opposing prognoses. The microbiome has previously been associated with CRC and immune response in CRC but has largely been ignored in the CRC subtype discussion. We used CMS subtyping on surgical resections from patients and aimed to determine the contributions of the microbiome to the pleiotropic effects evident in immune-infiltrated subtypes. We integrated host gene-expression and meta-transcriptomic data to determine the link between immune characteristics and microbiome contributions in these subtypes and identified lipopolysaccharide (LPS) binding as a potential functional mechanism. We identified candidate bacteria with LPS properties that could affect immune response, and tested the effects of their LPS on cytokine production of peripheral blood mononuclear cells (PBMCs). We focused on Fusobacterium periodonticum and Bacteroides fragilis in CMS1, and Porphyromonas asaccharolytica in CMS4. Treatment of PBMCs with LPS isolated from these bacteria showed that F. periodonticum stimulates cytokine production in PBMCs while both B. fragilis and P. asaccharolytica had an inhibitory effect. Furthermore, LPS from the latter two species can inhibit the immunogenic properties of F. periodonticum LPS when co-incubated with PBMCs. We propose that different microbes in the CRC tumor microenvironment can alter the local immune activity, with important implications for prognosis and treatment response.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

AIM

Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery.

METHOD

A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres.

RESULTS

In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001).

CONCLUSION

Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.

Detection of the Bacteroides fragilis toxin gene in sheep with and without small intestinal adenocarcinoma

Aims: To determine if presence of the Bacteroides fragilis toxin (bft) gene, a molecular marker of colonic carriage of entertoxigenic Bacteroides fragilis (ETBF) in humans, was associated with a finding of small intestinal adenocarcinomas (SIA) in sheep in New Zealand. Methods: Samples of jejunal tissue were collected from the site of tumours and from grossly normal adjacent tissue in 20 sheep, in different consignments, diagnosed with SIA based on gross examination of viscera following slaughter. Two jejunal samples were also collected from a control sheep in the same consignment that had no gross evidence of SIA. A PCR assay was used to detect the presence of the bft gene in the samples. Results: Of the sheep with SIA, the bft gene was amplified from one or both samples from 7/20 (35%) sheep, and in sheep that had no gross evidence of SIA the bft gene was amplified from at least one sample in 11/20 (55%) sheep (RR 0.61; 95% CI = 0.30-1.25; p = 0.34). Of 11 positive samples analysed, ETBF subtype bft-1 was detected in one, bft-2 was detected in 10, and none were bft-3. Conclusions and Clinical Relevance: There was a high prevalence of detection of the bft gene in both SIA-affected and non-affected sheep, but there was no apparent association between carriage of ETBF, evidenced by detection of the bft gene, and the presence of SIA. ETBF are increasingly implicated in the aetiology of human colorectal cancer, raising the possibility that sheep may provide a zoonotic reservoir of this potentially carcinogenic bacterium. Abbreviation: Bft: Bacteroides fragilis toxin; ETBF: Enterotoxigenic Bacteroides fragilis; SIA: Small intestinal adenocarcinoma.

Prognostic factors and patterns of failure after surgery for T4 rectal cancer in the beyond total mesorectal excision era

BACKGROUND

Despite advances in the rates of total mesorectal excision (TME) for rectal cancer surgery, decreased local recurrence rates and increased 5-year survival, there still exists large variation in the quality of treatment received. Up to 30 per cent of rectal cancers are locally advanced at presentation and approximately 5-10 per cent still breach the mesorectal plane and invade adjacent structures despite neoadjuvant therapy. With the evolution of extended resections for rectal cancers beyond the TME plane, proponents advocate that these resections should be performed only in specialist centres. The aim was to assess the prognostic factors and patterns of failure after beyond TME surgery for T4 rectal cancers.

METHODS

Data were collected from prospective databases at three high-volume institutions specializing in beyond TME surgery for T4 rectal cancers between 1990 and 2013. The primary outcome measures were overall survival, local recurrence and patterns of first failure.

RESULTS

Three hundred and sixty patients were identified. The negative resection margin (R0) rate was 82·8 per cent (298 patients) and the local recurrence rate was 12·5 per cent (45 patients). The type of surgical procedure (Hartmann's: hazard ratio (HR) 4·49, 95 per cent c.i. 1·99 to 10·14; P = 0·002) and lymphovascular invasion (HR 2·02, 1·08 to 3·77; P = 0·032) were independent predictors of local recurrence. The 5-year overall survival rate for all patients was 61 (95 per cent c.i. 55 to 67) per cent. The 5-year cumulative incidence of first failure was 8 per cent for local recurrence, 6 per cent for local and distant disease, and 18 per cent for distant disease.

CONCLUSION

This study has demonstrated that a coordinated approach in specialist centres for beyond TME surgery can offer good oncological and long-term survival in patients with T4 rectal cancers.

Influence of the level of sacrectomy on survival in patients with locally advanced and recurrent rectal cancer

BACKGROUND

Exenterative surgery for locally advanced rectal cancer may involve partial sacrectomy to achieve complete resection. High sacrectomy is technically challenging, and can be associated with high morbidity and mortality rates. The aim of this study was to determine the influence of the level of sacrectomy on the survival of patients with locally advanced rectal cancer.

METHODS

This was an international multicentre retrospective analysis of patients undergoing exenterative abdominosacrectomy between July 2006 and June 2016. High sacrectomy was defined as resection at or above the junction of S2-S3; low sacrectomy was below the S2-S3 junction. Kaplan-Meier survival analysis was used to assess overall survival and cancer-specific survival. Predictive factors were determined using Cox regression analysis.

RESULTS

A total of 345 patients were identified, of whom 91 underwent high sacrectomy and 254 low sacrectomy. There was no difference in 5-year overall survival (53 versus 44·1 per cent; P = 0·216) or cancer-specific survival (60 versus 56·1 per cent; P = 0·526) between high and low sacrectomy. Negative margin rates were similar for primary and recurrent disease: 65 of 90 (72 per cent) versus 97 of 153 (63·4 per cent) (P = 0·143). Level of sacrectomy was not a significant predictor of mortality (P = 0·053). Positive resection margin and advancing age were the only significant predictors for death, with hazard ratios of 2·78 (P < 0·001) and 1·02 (P = 0·020) respectively.

CONCLUSION

There was no survival difference between patients who underwent high or low sacrectomy. In appropriately selected patients, high sacrectomy is feasible and safe.

Impact of restenting for recurrent colonic obstruction due to tumour ingrowth

Background

Endoscopic stenting is used to palliate malignant large bowel obstruction. A proportion of patients will develop recurrent obstruction due to tumour ingrowth and require reintervention. This study aimed to assess the outcome (clinical success and complication rates) of endoscopic reintervention compared with surgical intervention in patients with stent obstruction due to tumour ingrowth.

Methods

This was an observational study using data from a database of patients who underwent palliative colonic stenting between January 1998 and March 2017 at Christchurch Public Hospital.

Results

A total of 190 patients underwent colonic stent insertion, for palliation in 182 cases. Reintervention was performed in 55 (30·2 per cent). Thirty-one patients (17·0 per cent) developed obstruction within the stent at a median of 4·6 (i.q.r. 2·3-7·7) months after the procedure. Of these, 21 had endoscopic restenting and ten underwent surgery. Restenting had technical and clinical success rates of 100 per cent, and involved a significantly shorter length of stay compared with surgery (median 2 (i.q.r. 1-4) versus 11 (6-19) days respectively; P = 0·006). Seven of the 21 patients in the restented group underwent a third palliative intervention. The overall stoma rate in the restented group was significantly lower than that in the surgical group (4 of 21 versus 10 of 10; P < 0·001). There was no difference in complications or survival between the two groups.

Conclusion

Among palliative patients who develop malignant stent obstruction, endoscopic restenting had a high chance of technical success. It resulted in a shorter hospital stay and lower stoma rate than those seen after surgery.

Meta-analysis of prophylactic mesh to prevent parastomal hernia

BACKGROUND

Rates of parastomal hernia following stoma formation remain high. Previous systematic reviews suggested that prophylactic mesh reduces the rate of parastomal hernia; however, a larger trial has recently called this into question. The aim was to determine whether mesh placed at the time of primary stoma creation prevents parastomal hernia.

METHODS

The Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL were searched using medical subject headings for parastomal hernia, mesh and prevention. Reference lists of identified studies, clinicaltrials.gov and the WHO International Clinical Trials Registry were also searched. All randomized clinical trials were included. Two authors extracted data from each study independently using a purpose-designed sheet. Risk of bias was assessed by a tool based on that developed by Cochrane.

RESULTS

Ten randomized trials were identified among 150 studies screened. In total 649 patients were included in the analysis (324 received mesh). Overall the rates of parastomal hernia were 53 of 324 (16·4 per cent) in the mesh group and 119 of 325 (36·6 per cent) in the non-mesh group (odds ratio 0·24, 95 per cent c.i. 0·12 to 0·50; P < 0·001). Mesh reduced the rate of parastomal hernia repair by 65 (95 per cent c.i. 28 to 85) per cent (P = 0·02). There were no differences in rates of parastomal infection, stomal stenosis or necrosis. Mesh type and position, and study quality did not have an independent effect on this relationship.

CONCLUSION

Mesh placed prophylactically at the time of stoma creation reduced the rate of parastomal hernia, without an increase in mesh-related complications.

Disability in Restorative Proctocolectomy Recipients Measured using the Inflammatory Bowel Disease Disability Index

BACKGROUND AND AIMS

The inflammatory bowel disease [IBD] disability index [IBD-DI], which measures IBD-associated disability, has been validated on IBD patients but not those who have had restorative proctocolectomy with ileal pouch-anal anastomosis [RP with IPAA]. This study aimed to utilize the IBD-DI in RP with IPAA recipients and compare ulcerative colitis [UC]-indicated RP with IPAA patients to medically treated UC patients.

METHODS

This study was population based. Demographic, indication, complication and direct cost data were collected via medical records while disability, quality of life [QoL] and indirect costs were measured using questionnaires and structured interviews. De-identified raw data about medically treated UC patients were provided by a previous study for comparison.

RESULTS

In total there were 136 RP with IPAA patients [mean 11.5 years of follow up]. Eighty-four completed the IBD-DI and 80 completed the IBD questionnaire [IBDQ]. The IBDQ and IBD-DI were highly correlated [r = 0.84, p < 0.01]. Worse QoL and disability were found in those who had their position affected at work [both p < 0.01] and those who had more than 100 days off work in the last year [p < 0.01 for QoL and p = 0.012 for disability]. Lower QoL and disability scores were associated with higher indirect and total costs [p < 0.01]. UC patients treated with RP with IPAA had less disability than medically treated UC patients [p = 0.04].

CONCLUSIONS

Disability in RP with IPAA recipients can be measured using the IBD-DI. Perioperative complications and high costs of care are associated with higher levels of disability. Disability of RP with IPAA recipients was lower than that of medically managed UC patients.

Progress in the management of retrorectal tumours

AIM

Tumours in the retrorectal space are rare and pathologically heterogeneous. The roles of imaging and preoperative biopsy, nonoperative management and the indications for surgical resection are controversial. This study investigated a series of retrorectal tumours treated in a single institution with the aim of producing a modern improved management algorithm.

METHOD

A retrospective analysis was conducted of the management of all retrorectal lesions identified between 1998 and 2013 from a radiology database search. Patient demographics, presenting symptoms, imaging, biopsy, management and the results were recorded. Descriptive statistics were used and Kaplan-Meier survival analysis was performed.

RESULTS

Sixty-nine patients with a confirmed retrorectal tumour were identified. The median age was 50 (36-67 interquartile range) and 42 (56%) were female. Twenty (29%) of the tumours were malignant: 4 of 41 cystic lesions were malignant (12.9%) vs. 16 of 28 solid (or heterogeneous) lesions (57.1%) (P < 0.0001). Imaging demonstrated a 95% sensitivity and 64% specificity for differentiating benign from malignant tumours. Magnetic resonance imaging (MRI) was significantly better at distinguishing between benign and malignant tumours than computed tomography (94% vs. 64%, P = 0.03). Percutaneous biopsy was performed in 16 patients and only 27 underwent resection. There was no evidence of local recurrence associated with biopsy. Solid lesions were associated with a nonsignificant decreased overall survival (P = 0.348).

CONCLUSION

This study demonstrated that MRI should be the investigation of choice for retrorectal lesions. Biopsy of solid lesions is safe and useful for guiding neoadjuvant and surgical therapy. Cystic lesions without suspicious radiological features can be followed by serial imaging without resection.

Malignancy and mesenteric panniculitis

AIM

Mesenteric panniculitis (MP) is a chronic inflammatory process of the small bowel mesentery that has been reported in conjunction with malignancy. The objectives of the present study were to identify the frequency and type of cancers that may coexist with MP and whether these can be seen on the initial diagnostic computerised tomography (CT).

METHOD

A prospective database was kept of patients diagnosed with MP in the Canterbury region of New Zealand between 1 January 2003 and 31 December 2014. CT scans were independently reviewed. Clinical records were reviewed and family doctors were contacted for additional information.

RESULTS

There were 302 patients with possible MP identified and 259 in whom it was confirmed on review. Seventy-eight patients had a diagnosis of malignancy, with 54 having a current cancer (59 total cancers), 33 a past cancer and nine both. Of the 59 current cancers the most common primary sites were colorectum (19), lymph nodes (17), kidney (six) and prostate (four). Fifty-four were at sites included on an abdominal CT scan. At all sites [except prostate (0/4)] there were high rates of detection on CT with 44/54 cancers visible including 20/23 gastrointestinal tract, 14/17 lymphomas and 9/9 non-prostate urogenital tract malignancies. Six people were subsequently diagnosed with cancer after the index CT.

CONCLUSION

When MP occurs in association with malignancy, the commonest primary sites are large bowel, the lymph nodes and the urogenital tract. In those with MP on imaging, any cancer except prostate can usually be seen on the index CT. Further extensive investigation in asymptomatic patients is therefore likely to be of low yield.

Does Bowel Preparation for Colonoscopy Affect Cognitive Function?

Colonoscopy is a common procedure used in the diagnosis and treatment of a range of bowel disorders. Prior preparation involving potent laxatives is a necessary stage to ensure adequate visualization of the bowel wall. It is known that the sedatives given to most patients during the colonoscopy cause a temporary impairment in cognitive function; however, the potential for bowel preparation to affect cognitive function has not previously been investigated. To assess the effect of bowel preparation for colonoscopy on cognitive function. This was a prospective, nonrandomized controlled study of cognitive function in patients who had bowel preparation for colonoscopy compared with those having gastroscopy and therefore no bowel preparation. Cognitive function was assessed using the Modified Mini Mental State Examination (MMMSE) and selected tests from the Cambridge Neuropsychological Test Automated Battery. Individual test scores and changes between initial and subsequent tests were compared between the groups. Age, gender, and weight were also compared. Forty-three colonoscopy and 25 gastroscopy patients were recruited. The 2 groups were similar for age and gender; however, patients having gastroscopy were heavier. MMMSE scores for colonoscopy and gastroscopy groups, respectively, were 28.6 and 29.5 (P = 0.24) at baseline, 28.7 and 29.8 (P = 0.32) at test 2, 28.1 and 28.5 (P = 0.76) at test 3. Motor screening scores for colonoscopy and gastroscopy groups, respectively, were 349.3 and 354.1 (P = 0.97) at baseline, 307.5 and 199.7 (P = 0.06) at test 2, 212.0 and 183.2 (P = 0.33) at test 3. Spatial working memory scores for colonoscopy and gastroscopy groups, respectively, were 14.4 and 6.7 (P = 0.29) at baseline, 9.7 and 4.3 (P = 0.27) at test 2, 10 and 4.5 (P = 0.33) at test 3. Digit Symbol Substitution Test scores for colonoscopy and gastroscopy groups, respectively, were 36.3 and 37.8 (P = 0.84) at baseline, 36.4 and 40.0 (P = 0.59) at test 2, 38.6 and 40.8 (P = 0.76) at test 3.This study did not find evidence of cognitive impairment resulting from administration of bowel preparation before colonoscopy.

Predictors of outcome in palliative colonic stent placement for malignant obstruction

BACKGROUND

Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After initially promising results, concerns have been raised over complication rates for self-expandable metal stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique used at the authors' institution, and reports on success and complication rates, as well as identifying predictors of endoscopic reintervention or surgical treatment.

METHODS

Data were collected for a prospective cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of endoscopic reintervention and surgical treatment.

RESULTS

Palliative SEMS insertion was attempted in 146 patients. Primary colorectal cancer was the most common cause of obstruction (95.2 per cent). The majority of patients (77.4 per cent) were treated in an acute setting, with a high technical success rate of 97.3 per cent. The perforation rate was 4.8 per cent and the 30-day procedural mortality rate 2.7 per cent. No predictors of early complications were identified, although patients with metastases and those who received chemotherapy were more likely to have late complications. Some 30.8 per cent of patients required at least one further intervention, with 11.0 per cent of the cohort requiring a stoma. Endoscopic reintervention was largely successful.

CONCLUSION

SEMS offer a valid alternative to operative intervention in the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more likely to receive endoscopic reintervention, which is largely successful.

Pulmonary staging in colorectal cancer: a review

AIM

Assessment of the chest in colorectal cancer (CRC) staging is variable. The aim of this review was to look at different chest staging strategies and determine which has the greatest efficacy.

METHOD

A review of studies assessing chest staging modalities for patients with CRC was performed. Modalities included chest X-ray (CXR), CT and positron emission tomography (PET).

RESULTS

The majority of data consisted of case series. Two studies identified a low pick-up rate for CXR as a staging tool. Five studies showed increased detection rates of pulmonary metastases for chest CT vs CXR and abdominal CT. The clinical benefit of the increased detection rates was not clear. The incidence of indeterminate lung lesions (ILL) on staging chest CT varied from 4 to 42%. The majority (≥ 70%) of ILLs did not have any clinical significance. On CT scans, the incidence of pulmonary metastases in patients with rectal cancer ranged from 10 to 18% and in patients with colon cancer the incidence of pulmonary metastases ranged from 5-6%. The incidence of synchronous liver and pulmonary metastases compared with the overall incidence of pulmonary metastases ranged from 45 to 70%. There was no evidence reporting the superiority of PET/CT vs CT for the detection of pulmonary metastases or characterization of ILL.

CONCLUSION

Studies show that chest CT scanning increases the detection rates for ILL and pulmonary metastases. The clinical benefit of the increased detection rates is not clear. There is a paucity of data assessing the optimal chest staging strategy for patients presenting with CRC.

The process and outcomes of a nurse-led colorectal cancer follow-up clinic

AIM

Evidence suggests that follow-up after colorectal cancer improves survival. Colorectal cancer is so common that patient follow-up can overwhelm a service, affecting the ability to see new referrals and reassess patients seen previously who have new symptoms. In order to cope with this demand a nurse-led follow-up service was started in 2004. We aimed to review the results of a nurse-led colorectal cancer follow-up clinic.

METHOD

Between 1 December 2004 and 31 January 2011, patients who underwent resection for colorectal cancer were followed up by a nurse specialist according to a protocol determined by the colorectal surgeons in the unit. All patient details were recorded prospectively in a purpose designed database.

RESULTS

Nine hundred and fifty patients were followed up over 7 years. Some 368 patients were discharged from the follow-up programme, 474 patients remain actively involved in the programme and 108 patients died. Of the patients discharged from the follow-up scheme 269 (73%) were discharged to their general practitioner free of disease after 5 years. Of the 108 who patients died, 98 were as a result of colorectal cancer. Twenty patients (2.1%) were identified with local (peri-anastomotic) disease recurrence and 93 patients (9.8%) were found to have developed distant metastatic disease. Of these, 65 patients (6.8%) were referred for palliative care and 28 (2.9%) had surgery for focal metastatic disease of whom 18 were still alive at the time of this analysis.

CONCLUSION

This paper shows that a nurse-led clinic for colorectal cancer follow-up can achieve satisfactory results with detection rates of recurrent or metastatic disease comparable to consultant follow-up. A nurse-led clinic provides the benefits of follow-up without overwhelming the consultant colorectal surgical clinic practice.

Colorectal complications of end-stage renal failure and renal transplantation: a review

AIM

End-stage renal failure (ESRF) and renal transplant recipients are thought to be associated with an increased risk of colorectal complications.

METHOD

A review of the literature was performed to assess the prevalence and outcome in both benign and malignant colorectal disease.

RESULTS

No prospective randomized studies assessing colorectal complications in ESRF or renal transplant were identified. Case series and case reports have described the incidence and management of benign colorectal complications. Complications included diverticulitis,infective colitis, colonic bleeding and colonic perforation. There was insufficient evidence to associated iverticular disease with adult polycystic kidney disease.Three population-based studies have shown up to a twofold increased incidence of colonic cancer but not rectal cancer for renal transplant recipients. Bowel cancer screening (as per the general population) by faecal occult blood testing appears justified for renal transplant patients; however, evidence suggests that consideration of starting screening at a younger age may be worthwhile because of an increased risk of developing colonic cancer.Two population-based studies have shown a threefold and 10-fold increased incidence of anal cancer for renal transplant recipients. A single case–control study demonstrated significant increased prevalence of anal human papilloma virus (HPV) and intraepithelial neoplasia (AIN)in patients with established renal transplants.

CONCLUSIONS

Despite the lack of high-level evidence,ESRF and renal transplantation were associated with colorectal complications that could result in major morbidity and mortality. Bowel cancer screening in this patient group appears justified. The effectiveness of screening for HPV, AIN and anal cancer in renal transplant recipients remains unclear.

Routine colonoscopy following acute uncomplicated diverticulitis

BACKGROUND

The evidence supporting current recommendations that the colon should be evaluated following an initial episode of acute diverticulitis is poor. The aim of this study was to clarify whether acute uncomplicated diverticulitis is a valid indication for subsequent colonoscopy/computed tomography (CT) colonography.

METHODS

This was a retrospective longitudinal study of patients with an initial presentation of acute uncomplicated diverticulitis on the basis of CT criteria, at a single institution between January 2004 and December 2008.

RESULTS

A radiological diagnosis of acute uncomplicated diverticulitis was made in 292 patients. Some 205 patients underwent subsequent colonic evaluation or had undergone colonoscopy/CT colonography within the preceding 2 years. Colorectal polyps were present in 50 patients (24·4 per cent). Twenty patients (9·8 per cent) had hyperplastic polyps and 19 (9·3 per cent) had adenomas. Eleven patients (5·4 per cent) had advanced colonic neoplasia, including one (0·5 per cent) with a colorectal cancer. One patient had inflammatory bowel disease (IBD). The patients with colorectal cancer and IBD had clinical indicators that independently warranted colonoscopy. None of the 87 patients who did not undergo colonic evaluation had a diagnosis of colorectal cancer registered with the New Zealand Cancer Registry.

CONCLUSION

The yield of advanced colonic neoplasia in this cohort was equivalent to, or less than that detected on screening asymptomatic average-risk individuals. In the absence of other indications, subsequent evaluation of the colon may not be required to confirm the diagnosis of diverticulitis.

Folic acid supplementation and colorectal cancer risk: a meta-analysis

AIM

This meta-analysis aims to determine the effect of folic acid supplementation on colorectal cancer risk.

METHOD

A structured search of the MEDLINE, EMBASE, Cochrane and CINAHL databases was undertaken in July 2008. All published full text English language articles were searched that included a randomized or pseudo-randomized comparison of subjects who received folate vs subjects who did not in relation to their risk of adenoma or advanced adenomatous lesions, including colorectal cancer. A weighted treatment effect (using fixed effects) was calculated across trials.

RESULTS

Overall, the risk of an adenomatous lesion was not increased (odds ratio 1.09, 95% confidence interval 0.93-1.28) among patients who received folate supplementation for up to 3 years; however, for those who received folate for over 3 years, the risk of an adenomatous lesion was increased (odds ratio 1.35, 95% confidence interval 1.06-1.70). The risk associated with treatment was the highest for the occurrence of an advanced lesion (odds ratio 1.50, 95% confidence interval 1.06-2.10). There was no significant statistical heterogeneity in the analyses.

CONCLUSION

At the 3-year colonoscopic follow up, folate supplementation had no effect on adenoma recurrence overall. While colonic surveillance beyond 3 years revealed an increased risk of colorectal adenoma, especially advanced adenoma, among those participants randomized to the folate group. This meta-analysis challenges the results from epidemiological studies that folate status is inversely related to the risk of developing colorectal cancer.

Computed tomographic colonography in the diagnosis of colorectal cancer

BACKGROUND

This study aimed to determine the sensitivity of computed tomographic colonography (CTC) in diagnosing colorectal cancer and to explore the reasons why these cancers are missed on CTC.

METHODS

Patients who underwent CTC in the 56-month period from 1 January 2004 to 1 September 2008, and all cases of colorectal cancer recorded in the National Cancer Registry database from 1 January 2004 to 1 December 2008, were identified. Cases from the two data sets were then matched to identify all patients in whom CTC had been performed more than 6 weeks before a histological report was available. CTC reports and patients' records were reviewed to determine the cancer site, and images were reviewed.

RESULTS

A total of 3888 patients underwent CTC over a 56-month interval. After matching with the National Cancer Registry database, colorectal cancer was identified in 131 patients, whereas it had been suspected on CTC in 123 patients. One of the patients with missed cancer was excluded, leaving seven (5.3 per cent) missed cancers, four of which were located in the caecum. Five cancers were missed because of technical limitations of CTC and two were due to perceptive errors. Systems errors and severe patient co-morbidity contributed to three of the cases. The sensitivity of CTC for colorectal cancer was 95 (95 per cent confidence interval 89 to 98) per cent.

CONCLUSION

The sensitivity of 95 per cent for CTC in the diagnosis of colorectal cancer compares favourably with that of double-contrast barium enema (92 per cent) and colonoscopy (94 per cent).

Influence of general health and degree of surgical insult on long-term survival

BACKGROUND

This study investigated the relationship of American Society of Anesthesiologists Physical Status (ASA-PS) grade and degree of surgical insult to long-term postoperative survival.

METHODS

National death records to June 2007 were matched against records of patients undergoing elective surgery between January 1997 and December 2001. Stratified survival analysis was performed to allow baseline hazard functions to vary among four patient groups (15-64 years with no malignancy, at least 65 years with no malignancy, 15-64 years with malignancy and at least 65 years with malignancy).

RESULTS

Of 8134 patients, 6185 (76.0 per cent) were alive after a median follow-up of 7.1 (range 0-10.5) years. The overall mortality rate was 3.62 (95 per cent confidence interval (c.i.) 3.46 to 3.78) per 100 person-years. The 10-year probability of survival was significantly higher in ASA-PS I or II for minor or intermediate surgery (90.7 (89.1 to 92.1) per cent) than in ASA-PS I or II for major or complex major surgery (79.6 (77.5 to 81.6) per cent), ASA-PS III or IV for minor or intermediate surgery (41.2 (36.2 to 46.7) per cent) and ASA-PS III or IV for major or complex major surgery (44.6 (41.4 to 47.7) per cent) (P < 0.001). Priority of admission modified survival probabilities. Adjusted survival probabilities were lowest in the elderly with malignancy.

CONCLUSION

ASA-PS grade has a more significant and persistent effect on long-term survival than degree of surgical insult.

Patterns of recurrence in patients with acute diverticulitis

Background

The natural history of acute diverticulitis remains unclear, with the role of prophylactic surgery following conservatively managed diverticulitis increasingly controversial. This study investigated recurrence rates, patterns and complications after conservatively managed diverticulitis.

Methods

This was a retrospective chart review of all patients admitted with diverticulitis between June 1997 and June 2002. Demographic data, management, recurrence rates, complications and subsequent surgery were recorded.

Results

Some 502 patients were identified, 337 with uncomplicated and 165 with complicated diverticulitis. Median follow-up was 101 (range 60–124) months. Of 320 patients with uncomplicated diverticulitis managed conservatively, 60 (18·8 per cent) had one episode of recurrence, whereas 15 (4·7 per cent) had two or more episodes. After an initial attack of uncomplicated diverticulitis, only 5·0 per cent developed complicated disease. Complicated disease recurred in 24 per cent, compared with a recurrence rate of 23·4 per cent in those with uncomplicated diverticulitis (P = 0·622). When recurrence occurred, it usually did so within 12 months of the initial episode.

Conclusion

Acute diverticulitis has a low recurrence rate and rarely progresses to complications. Any recurrence is usually early, in a pattern more consistent with failure of the index episode to settle. Subsequent elective surgery to prevent recurrence and the development of complications should be used sparingly.

Helicobacter species in the human colon

OBJECTIVE

To determine the prevalence, frequency and colonization patterns of Helicobacter species throughout the colon.

METHOD

Patients having initial colonoscopy for nonspecific gastrointestinal disturbance had colonic biopsies taken from up to four sites during colonoscopy and examined for evidence of the Helicobacteraceae family using a group-specific PCR. Serum was also collected and examined for IgG reactivity to Helicobacter pylori.

RESULTS

100 patients had colonoscopy of whom 35 were found to have DNA evidence of Helicobacter species throughout the colon, with 22 having H. pylori. Fifteen patients had a demonstrable serum IgG response to H. pylori that was not always associated with molecular evidence of H. pylori DNA in colon biopsies and vice versa. No specific association with colon disease was found in patients with H. pylori infection.

CONCLUSION

We found evidence of Helicobacter infection in a significant number of patients presenting for colonoscopy but no specific association between the presence of these bacteria and colon disease. Our finding of disparity between molecular and serological techniques to detect Helicobacter species suggests that future studies should not rely on serology alone to detect these bacteria in the human colon.

Australasian Laparoscopic Colon Cancer Study shows that elderly patients may benefit from lower postoperative complication rates following laparoscopic versus open resection

BACKGROUND

A retrospective analysis of age-related postoperative morbidity in the Australia and New Zealand prospective randomized controlled trial comparing laparoscopic and open resection for right- and left-sided colonic cancer is presented.

METHODS

A total of 592 eligible patients were entered and studied from 1998 to 2005.

RESULTS

Data from 294 patients who underwent laparoscopic and 298 who had open colonic resection were analysed; 266 patients were aged less than 70 years and 326 were 70 years or older (mean(s.d.) 70.3(11.0) years). Forty-three laparoscopic operations (14.6 per cent) were converted to an open procedure. Fewer complications were reported for intention-to-treat laparoscopic resections compared with open procedures (P = 0.002), owing primarily to a lower rate in patients aged 70 years or more (P = 0.002). Fewer patients in the laparoscopic group experienced any complication (P = 0.035), especially patients aged 70 years or above (P = 0.019).

CONCLUSION

Treatment choices for colonic cancer depend principally upon disease-free survival; however, patients aged 70 years or over should have rigorous preoperative investigation to avoid conversion and should be considered for laparoscopic colonic resection.

REGISTRATION NUMBER

NCT00202111 (http://www.clinicaltrials.gov).

Review of 120 anal cancer patients

OBJECTIVE

Chemoradiotherapy is the mainstay of treatment for the majority of patients with anal cancer, with abdominoperineal resection reserved for salvage. The purpose of this study was to evaluate our results after radiotherapy with or without chemotherapy, and/or surgery in terms of overall survival and colostomy free survival in patients with anal cancer.

METHOD

A review of patients diagnosed with anal cancer between 1991 and 2004 was performed. The principle end-points of the study were overall and colostomy-free survival.

RESULTS

One hundred and twenty patients were identified. The T stage distribution was T1 32, T2 44, T3 19, T4 17 and TX 8. Eighteen patients had clinically involved regional nodes. Eighty patients received radiotherapy as a component of their treatment. Twenty-four of the 80 patients had a colostomy. The most common late toxicity was faecal incontinence. The overall survival and colostomy-free survival rates for all 120 patients were 58% and 79% at 5 years, respectively. For the 80 patients who received radiotherapy, the corresponding figures were 66% and 82% at 5 years, respectively.

CONCLUSION

Chemoradiation is effective organ preserving treatment for anal cancer. Grade 1 and 2 faecal incontinence is a relatively common late toxicity experienced by patients.

Immunomodulation does not alter histology in resected Crohn's disease

BACKGROUND

The use of immunomodulators (Azathioprine, 6-Mercaptopurine and Methotrexate) and biological agents (Infliximab and adalimumab) for the treatment of Crohn's disease (CD) has increased in the recent years with the aim of treating the inflammatory component of the disease and hoping to change the natural history of the disease. The aim of this study was to determine if the use of immunomodulators or biological agents in the 2 years prior to resection affects the histopathological characteristics of the patient's disease.

METHODS

A retrospective review was conducted over a 10-year period (1996-2005) of patients who underwent resection for CD. Clinical case notes and histology specimens were reviewed. Patients treated with Azathioprine, 6-Mercaptopurine, Methotrexate or Infliximab for more than 3 months within the 2 years preceding surgery were deemed to have been immunomodulated. The results were also analysed by Montreal phenotype.

RESULTS

A total of 165 patients were identified. 52 patients had been treated with either immunomodulator or biological agent. Of 20 histological features examined, only muscular hypertrophy approached significance (P = 0.05), Montreal A and Montreal L phenotypes were the same regardless on immunomodulators, however, there was a significant difference (P = 0.03) with regard to Montreal B in patients with stricturing disease being more likely to have received an immunomodulator.

CONCLUSIONS

In this cohort of patients requiring resection for CD, those with stricturing disease were more likely to receive immunomodulators or biologics than those without stricturing disease. However, there were no significant histological differences in the resected specimens between those who did and those who did not receive these drugs.

Intradermal injection of methylene blue for the treatment of refractory pruritus ani

OBJECTIVE

Idiopathic pruritus ani is a common perianal condition that can be refractory to diligent perineal care. We wished to evaluate the efficacy and side effects of intradermal methylene blue for the treatment of refractory pruritus ani.

METHOD

A prospective series of 49 patients with idiopathic pruritus ani, who had failed to improve with perineal care, were treated by a single surgeon. All patients received intradermal injections of methylene blue. Endpoints were patient symptom score, and complications (pain, dysaesthesia, skin necrosis, incontinence and anaphylaxis).

RESULTS

Symptoms improved in 96% and resolved in 57% of patients after one treatment. All four patients who had a second treatment became symptom-free. Seven patients noticed changes in continence, all resolved between 10 days and 6 weeks. Two patients were distressed by their decrease in their perianal sensation. There was no skin necrosis or anaphylaxis.

CONCLUSION

Treatment of refractory pruritus ani by intradermal injection of methylene blue is effective and generally well tolerated.

Sacrococcygeal pilonidal disease

BACKGROUND

Sacrococcygeal pilonidal is a common disease in active young adults. Many surgical methods have been proposed, although no clear consensus as to the optimal treatment has been reported. This review looks at the different surgical techniques available and examines the reported results of primary healing, recurrent disease and complications (including delayed healing).

METHOD

A literature search using the Medline database was performed to locate English language articles on surgery for pilonidal disease. Further articles were obtained from the references cited in the literature initially reviewed.

RESULTS

Management should be tailored according to the individual and whether the disease is acute or chronic. Treatment should take into consideration hospital stay and return to work. Simple excision, curettage, partial lateral wall excision, or marsupialisation, are simple techniques with good results. They can be used for the initial surgery but their use is not recommended for recurrent disease. The modified rhomboid flap for recurrent disease has consistently shown positive results in terms of complication rates and recurrence.

CONCLUSION

We would recommend tailored treatment with simple excision for initial presentation and the modified rhomboid flap for recurrent disease.

A randomized controlled trial comparing the efficacy and acceptability of phospo-soda buffered saline (Fleet) with sodium picosulphate/magnesium citrate (Picoprep) in the preparation of patients for colonoscopy

OBJECTIVE

Small-volume bowel preparations for colonoscopy has become increasingly popular due to improved tolerance by patients and equivalent efficacy compared with the larger volume preparations. Comparative studies, however, between small volume preparations are lacking. This randomized controlled trial aimed at comparing the efficacy and acceptability of phospo-soda buffered saline (Fleet) with sodium picosulphate/magnesium citrate (Picoprep) in the preparation of patients for colonoscopy.

METHOD

A randomized prospective trial designed to compare the efficacy and acceptability of Fleet with Picoprep in patients undergoing colonoscopy.

RESULTS

Seventy-three patients undergoing colonoscopy were randomized to receive either Fleet or Picoprep as bowel preparation. Patients were asked to score the acceptability and to comment specifically on adverse events, namely headache, nausea and vomiting. The efficacy of the preparation was also assessed. The results showed no difference in efficacy (P = 0.06, chi(2) test), but there was a significant difference in acceptability (P = 0.01, chi(2) test). and side effects of patients suffering nausea (P = 0.003, chi(2) test), in favour of Picoprep.

CONCLUSION

Whilst there was no difference in efficacy, there was a significant difference in acceptability and side effects in favour of Picoprep.

Mismatch repair protein expression in ovine intestinal adenocarcinomas

Sheep in New Zealand develop small intestinal adenocarcinomas more frequently than sheep elsewhere in the world. This high rate of neoplasm development could be due to a genetic predisposition or due to an environmental carcinogen. Differentiation between a genetic and an environmental factor is important as, if an environmental carcinogen is present, people could be exposed directly or by consuming sheep meat. In humans, germline defects in the mismatch repair (MMR) genes cause hereditary nonpolyposis colorectal cancer (HNPCC). Affected people are predisposed to neoplasm development, most commonly colonic adenocarcinomas. It was hypothesized that MMR defects are common within the New Zealand sheep flock, and these defects predispose New Zealand sheep to intestinal neoplasia. To investigate this, immunohistochemistry was used to evaluate the expression of the MMR proteins MSH2, MSH6, MLH1, and PMS2 within 49 ovine intestinal adenocarcinomas. Neoplastic cells within all sheep tumors expressed MSH2, MSH6, and MLH1. Expression of PMS2 could not be assessed, most likely because of insufficient affinity of the anti-human PMS2 antibody to ovine PMS2. The consistent expression of MSH2, MSH6, and MLH1 within the ovine intestinal adenocarcinomas does not support the hypothesis that defects in the MMR genes are common in New Zealand sheep.

The impact of splenectomy on outcome after resection for colorectal cancer: a multicenter, nested, paired cohort study

PURPOSE

This study was designed to determine whether incidental splenectomy for iatrogenic injury affects long-term cancer-specific survival in patients having resection of an adenocarcinoma of the sigmoid or rectum.

METHODS

A retrospective case-matched review of patients undergoing surgery for colorectal cancer with incidental splenectomy between January 1, 1990 and December 31, 1999 was undertaken. Data were analysed for age, American Society of Anesthesiologists physical status, gender, disease stage, operation type, and outcome. These cases were matched with patients from the same center, of the same age and gender, with the same stage of disease and operation, who did not require a splenectomy at the time of their surgery.

RESULTS

Fifty-five patients were identified who had an iatrogenic splenectomy. Matched gender, stage, and American Society of Anesthesiologists-matched controls were identified. Follow-up from time of surgery to death or last follow-up ranged from 2 to 205 (median, 43) months. A Kaplan-Meier survival analysis using the Cox proportional hazards model to define the statistical significance found a significant difference between the groups favoring those without splenectomy (hazard ratio, 1.8; 95 percent confidence interval (CI), 1-3.3; P=0.0399). Cancer-specific survival at five years was 70 vs. 47 percent and at ten years was 55 vs. 38 percent.

DISCUSSION

Patients with colorectal cancer who had splenectomy as a result of iatrogenic damage of the spleen while undergoing resection of the sigmoid or rectum for adenocarcinoma had a significantly worse prognosis.

The effect of epidural analgesia on postoperative outcome after colorectal surgery

OBJECTIVE

The aim of this review was to determine the effects of epidural analgesia as it relates to outcome after colorectal surgery.

METHOD

We searched and reviewed studies that included colorectal surgery and epidural method of analgesia listed on the Pubmed, Medline, Embase and the Cochrane library database.

RESULTS

The majority of data demonstrate a superior effect of epidural analgesia on pain control after colorectal surgery. Well designed randomized controlled trials (RCT's) have also shown that epidural analgesia reduces the duration of ileus after colorectal surgery. Limited data suggest the additional benefit may be minimal after laparoscopic surgery or when epidural analgesia is used as part of a multimodal regime. Data does not convincingly show either a clear harmful or beneficial effect of epidural analgesia on rates of anastomotic leakage. Epidural analgesia may have beneficial effects on postoperative lung function, however due to low numbers, the effects on cardiovascular and thromboembolic complications are indeterminate. Length of hospital stay has not been shown to be shortened by sole use of an epidural and, although epidural analgesia may be apparently more costly, alternatives may incur higher indirect costs and decreased patient satisfaction.

CONCLUSION

Randomized controlled trials have shown a benefit for epidurals on postoperative pain relief, and ileus, and possibly respiratory complications. There is no proven benefit with regard to length of stay. There are a number of unresolved issues which further focussed RCT's may help clarify such as effects of epidural on complication rates after colorectal surgery.

Presacral tumours in adults

Presacral tumours represent a heterogeneous group of predominantly benign and occasionally malignant neoplasms. Due to the rarity of these tumours, their management is often performed in an ad hoc fashion and an algorithm for optimal treatment remains undefined. This review aims to present an overview of presacral tumours, focusing on their presentation, pathology, investigation and management.

Presacral tumours in adults

Presacral tumours represent a heterogeneous group of predominantly benign and occasionally malignant neoplasms. Due to the rarity of these tumours, their management is often performed in an ad hoc fashion and an algorithm for optimal treatment remains undefined. This review aims to present an overview of presacral tumours, focusing on their presentation, pathology, investigation and management.

The role of positron emission tomography in the management of recurrent colorectal cancer: a review

PURPOSE

Surgery remains the only option for potential cure in patients with recurrent colorectal cancer. Accurate staging modalities aid in the avoidance of futile surgery, which may result in considerable morbidity in patients with incurable disease. Current imaging techniques used in disease staging often are not sensitive enough to identify low-volume metastatic disease. This study reviews the role of positron emission tomography in the assessment of patients with suspected recurrent colorectal cancer.

METHODS

A literature search using the PubMed, MEDLINE, and Embase database was performed, locating English language articles on positron emission tomography, positron emission tomography, recurrent colon, and/or rectal cancer. The references of these papers were searched manually for further references.

RESULTS

Positron emission tomography is more sensitive and more specific than conventional diagnostic imaging for metastatic disease and local recurrence respectively. Studies confirm the superior ability of positron emission tomography scans compared with conventional diagnostic imaging in differentiating between scar tissue and invasive tumor. Positron emission tomography scanning is more sensitive and specific for the assessment of liver metastases (and probably in patients with lung metastasis) than conventional diagnostic imaging. Positron emission tomography is superior to conventional diagnostic imaging in the investigation of raised carcinoembryonic antigen in the postoperative patient and alters management in approximately 37 percent of patients with recurrent colorectal cancer. The limitations and cost effectiveness of positron emission tomography are discussed.

CONCLUSIONS

Positron emission tomography scanning is emerging as the imaging modality of choice for patients being considered for surgery for locally recurrent colorectal cancer. Positron emission tomography has the greatest impact by detecting unresectable disease and thereby averting inappropriate surgery. Despite the high set-up costs, its use seems to be cost effective.

Colorectal motility and defecation after spinal cord injury in humans

Following spinal cord injury, colorectal problems are a significant cause of morbidity, and chronic gastrointestinal problems remain common with increasing time after injury. Although many cord-injured patients achieve an adequate bowel frequency with drugs and manual stimulation, the risk and occurrence of fecal incontinence, difficulties with evacuation, and need for assistance remain significant problems. The underlying physiology of colorectal motility and defecation is reviewed, and consequences of spinal cord injury on defecation are reported. A discussion of present management techniques is undertaken and new directions in management and research are suggested. There is need for more intervention in regard to bowel function that could improve quality of life, but there is also a need for more research in this area.

Ileal pouch-anal anastomosis-vaginal fistula: a review

BACKGROUND

Fistula between an ileal pouch and the vagina is an uncommon complication of ileal pouch-anal anastomosis. Its optimal management has not been determined because of its low incidence.

METHODS

The literature describing such fistulas was reviewed to determine the incidence, cause, and appropriate investigation and repair of these lesions. A literature search was performed with the PubMed, MEDLINE, and EMBASE databases. Through this search we located English-language articles from 1970 to 2003 on pouch-vaginal fistulas following ileal pouch-anal anastomosis. References from these articles were searched manually for further references.

RESULTS AND CONCLUSION

Pouch-vaginal fistula occurs in 6.3 (range, 3.3-15.8) percent of female patients with an ileal pouch-anal anastomosis. Sepsis and technical factors are the most common contributors. It is the cause of considerable morbidity. Management depends on the level of the fistula, the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical treatment is suggested.

Elective surgery after acute diverticulitis

BACKGROUND

Diverticulitis is a common condition. Practice guidelines from many organizations recommend bowel resection after two attacks. The evidence for such a recommendation is reviewed.

METHODS

A Medline literature search was performed to locate English language articles on surgery for diverticular disease. Further articles were obtained from the references cited in the literature initially reviewed.

RESULTS

Most people with diverticulosis are asymptomatic. Diverticular disease occurs in over 25 per cent of the population, increasing with age. After one episode of diverticulitis one-third of patients have recurrent symptoms; after a second episode a further third have a subsequent episode. Perforation is commonest during the first episode of acute diverticulitis. After recovering from an episode of diverticulitis the risk of an individual requiring an urgent Hartmann's procedure is one in 2000 patient-years of follow-up. Surgery for diverticular disease has a high complication rate and 25 per cent of patients have ongoing symptoms after bowel resection.

CONCLUSION

There is no evidence to support the idea that elective surgery should follow two attacks of diverticulitis. Further prospective trials are required.

Hyponatremia and seizures after bowel preparation: report of three cases

Oral sodium phosphate and sodium picosulfates/magnesium citrate are commonly used to evacuate the colon and rectum before colonoscopy or colorectal surgery. These substances, however, are known to cause electrolyte abnormalities. Seizures caused by electrolyte abnormalities associated with bowel preparation have only rarely been reported. We report the cases of three patients with no prior history of seizures, who had their first seizure associated with hyponatremia following ingestion of sodium phosphate or sodium picosulfates/magnesium citrate combination. Care must be taken with patients with a low seizure threshold and those with possible chronic sodium depletion, such as patients on thiazide diuretics, who are undertaking bowel preparation with oral sodium phosphate or sodium picosulfates/magnesium citrate combination.

[Registration of clinical trials: a statement from the International Committee of Medical Journal Editors]

Altruistic motives and trust are central to scientific investigations involving people. These prompt volunteers to participate in clinical trials. However, publication bias and other causes of the failure to report trial results may lead to an overly positive view of medical interventions in the published evidence available. Registration of randomised controlled trials right from the start is therefore warranted. The International Committee of Medical Journal Editors has issued a statement to the effect that the 11 journals represented in the Committee will not consider publication of the results of trials that have not been registered in a publicly accessible register such as www.clinicaltrials.gov. Patients who voluntarily participate in clinical trials need to know that their contribution to better human healthcare is available for decision making in clinical practice.