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.

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.

Extended vertical rectus abdominis myocutaneous flap for reconstruction of large pelviperineal defects following oncologic resection

BACKGROUND AND OBJECTIVES

Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection.

METHODS

A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space.

RESULTS

Forty-four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence.

CONCLUSIONS

The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.

Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study

AIM

The aim of the study was to compare the incidence of perineal hernia and the perineal wound morbidity following extralevator abdominoperineal excision (ELAPE) between two groups - primary perineal closure and reconstruction with a biological mesh.

METHOD

One hundred and forty-seven consecutive patients who underwent ELAPE for primary rectal cancer between January 2007 and December 2018 in two tertiary referral centres were retrospectively identified from prospective databases. Perineal closure was carried out via primary closure or with a biological mesh (porcine dermal collagen mesh). Outcome measures were perineal hernia and perineal wound morbidity (infection, dehiscence, persistent sinus and chronic pain).

RESULTS

A total of 139 patients were included in the study. A prophylactic mesh was used in 80 (57.5%) and primary closure was practised in 59 (42.4%) patients. The median follow-up was 30 (interquartile range 46.88) months. Thirty patients (21.6%) developed perineal hernia. No significant differences were found between prophylactic mesh and primary closure (16.3% vs 23.3%, P = 0.07). The median period between surgery and hernia diagnosis was 8 months in the primary closure group and 24 months in the mesh group (P < 0.01). Perineal wound morbidity was significantly higher in the prophylactic mesh group (55% vs 33.9%, P < 0.01).

CONCLUSION

In our study, the use of a biological mesh did not reduce the rate of perineal hernia, although it did delay its appearance. Perineal closure using a biological mesh may increase perineal morbidity, both acute and chronic.

Risk factors for leak, complications and mortality after ileocolic anastomosis: comparison of two anastomotic techniques

INTRODUCTION

There are no definitive data concerning the ideal configuration of ileocolic anastomosis. Aim of this study was to identify perioperative risk factors for anastomotic leak and for 60-day morbidity and mortality after ileocolic anastomoses (stapled vs handsewn).

MATERIALS AND METHODS

This is a STROBE-compliant study. Demographic and surgical data were gathered from patients with an ileocolic anastomosis performed between November 2010 and September 2016 at a tertiary hospital. Anastomoses were performed using standardised techniques. Independent risk factors for anastomotic leak, complications and mortality were assessed.

RESULTS

We included 477 patients: 53.7% of the anastomoses were hand sewn and 46.3% stapled. Laterolateral anastomosis was the most common configuration (93.3%). Anastomotic leak was diagnosed in 8.8% of patients and 36 were classified as major anastomotic leak (7.5%). In the multivariate analysis, male sex (P = 0.014, odds ratio, OR, 2.9), arterial hypertension (P = 0.048, OR 2.29) and perioperative transfusions (P < 0.001, OR 2.4 per litre) were independent risk factors for major anastomotic leak. The overall 60-day complication rate was 27.3%. Male sex (31.3% vs female 22.3%, P = 0.02, OR 1.7), diabetes (P = 0.03 OR 2.0), smoking habit (P = 0.04, OR 1.8) and perioperative transfusions (P < 0.001, OR 3.3 per litre) were independent risk factors for postoperative morbidity. The 60-day-mortality rate was 3.1% and no significant risk factors were identified.

CONCLUSION

Anastomotic leak after ileocolic anastomosis is a relevant problem. Male sex, arterial hypertension and perioperative transfusions were associated with major anastomotic leak. Conversion to open surgery was more frequently associated with perioperative death.

Use of a linear stapler for the treatment of ileocolic fistula in Crohn's disease

AIM

The study reports an easy technique for surgical management of some forms of ileocolic fistula in Crohn's disease.

METHOD

Five patients with Crohn's disease with ileocolic fistula (2011-2014) have been managed by the application of linear stapler devices.

RESULTS

Postoperative course was satisfactory in all patients. At 1 year there was no evidence of stricture or fistula formation and no patient had required reoperation.

CONCLUSION

The technique is easy and effective and can be used in open and laparoscopic surgery.

Anastomotic leakage after colon cancer resection: does the individual surgeon matter?

AIM

Anastomotic leakage is one of the most feared complications after colonic resection. Many risk factors for anastomotic leakage have been reported, but the impact of an individual surgeon as a risk factor has scarcely been reported. The aim of this study was to assess if the individual surgeon is an independent risk factor for anastomotic leakage in colonic cancer surgery.

METHOD

This was a retrospective analysis of prospectively collected data from patients who underwent elective resection for colon cancer with anastomosis at a specialized colorectal unit from January 1993 to December 2010. Anastomotic leaks were diagnosed according to standardized criteria. Patient and tumour characteristics, surgical procedure and operating surgeons were analysed. A logistic regression model was used to discriminate statistical variation and identify risk factors for anastomotic leakage.

RESULTS

A total of 1045 patients underwent elective colon cancer resection with primary anastomosis. Anastomotic leakage occurred in 6.4% of patients. Ileocolic anastomosis had an anastomotic leakage rate of 7.2%, colo-colonic/colorectal anastomosis 5.2% and ileorectal anastomosis 12.7%, with intersurgeon variability. The independent risk factors associated with anastomotic leakage were the use of perioperative blood transfusion (OR 2.83, CI 1.59-5.06, P < 0.0001) and the individual surgeon performing the procedure (OR up to 8.44, P < 0.0001).

CONCLUSION

In addition to perioperative blood transfusion, the individual surgeon was identified as an important risk factor for anastomotic leakage. Efforts should be made to reduce performance variability amongst surgeons.

Insertion of self-expanding metal stent for treatment of malignant obstruction in a pregnant woman

Colorectal cancer (CRC) is the second most frequent cancer both in incidence and mortality in women, especially in those over 60 years of age. Diagnosis in women at gestational age is rare, so its incidence during pregnancy is low. However, an increase in its diagnosis is expected during the next years because of the raise in the average age of pregnancy.In most cases, the diagnosis is delayed because symptoms related to CRC can be attributed to pregnancy itself. Up to 30 % of CRC cases may present as an intestinal obstruction. In this situation, the main objective is to solve the clinical emergency in the safest way for mother and fetus, together with performing an accurate diagnostic approach to offer the best possible therapeutic management knowing the limitations and difficulties related to pregnancy. The self-expanding metallic stent (SEMS) can be particularly useful in colon obstruction in a pregnant patient with CRC because it allows solving the acute condition providing time to perform a more accurate staging study and to prepare the patient for surgery, thus reducing both post-surgical morbidity and mortality.We report on the case of a patient who early in the second trimester of pregnancy presented with an acute colonic obstruction due to CRC which was successfully managed with the placement of a self-expanding metal stent.

Tumours of the retrorectal space: management and outcome of a heterogeneous group of diseases

AIM

Retrorectal tumours are a rare and complex entity in adults and children. They present a varied symptomatology and their treatment is very different according to their histology. We aimed to evaluate our experience of tumours of the retrorectal space.

METHOD

Forty patients with retrorectal tumours were divided into two groups according to age. The variables analysed were sex, signs and symptoms, complementary examinations, surgical approaches, adjuvant therapies, pathological analyses, recurrence and survival.

RESULTS

Symptoms across the 30 adults varied--back pain (18) was the most common. Surgical intervention was performed on 20 patients; the rest were candidates for other treatments: five metastatic disease, two lymphomas and two Ewing tumour. The most common surgical approach was posterior, with 10 cases (50%). In all, 70% of adult tumours were malignant, with chordoma (30%) and metastases (20%) being the most common lesions. The most frequent benign lesion was hamartoma (10%). The 1- and 5-year mortality rates were 23.8% and 38.1%, respectively. In the paediatric group, three patients were diagnosed in utero. The symptoms among children varied and all were operated upon. The most frequent tumour was teratoma. Overall mortality was 20%.

CONCLUSIONS

Given their complexity, these tumours should be addressed by experts and all treatment options must be contemplated. They continue to present a challenge, above all in malignant tumours where the tumour cannot be controlled at a locoregional level.

Prospective evaluation of intraoperative peripheral nerve injury in colorectal surgery

AIM

Intraoperative peripheral nerve injury can have permanent neurological consequences. Its incidence is not known and varies according to the location and the surgical specialty. This study was a prospective analysis of intraoperative peripheral nerve injury as a complication of abdominal colorectal surgery.

METHOD

All patients who underwent major colorectal abdominal surgery in our Colorectal Unit between 1996 and 2009 were analyzed. Data on nerve injury were prospectively collected.

RESULTS

There were 2304 patients, of whom eight (0.3%) experienced intraoperative peripheral nerve injury. This occurred in 5/2211 (0.2%) open procedures and in 3/93 (3%) laparoscopic procedures. There was no association between intraoperative peripheral nerve injury and age, gender, body mass index, surgeon, operation time, American Society of Anesthesiology (ASA) score and urgent surgery. The use of Allen-type stirrups and a vacuum bag (in laparoscopic surgery) seemed to be protective for nerve injury in the lower and upper limbs respectively.

CONCLUSION

Adequate positioning and the use of pressure-free positioning devices may prevent intraoperative peripheral nerve injury, particularly during laparoscopy.

Prognostic implications of circumferential location of distal rectal cancer

AIM

This study evaluated the prognostic importance of circumferential tumour position of mid and low rectal cancers.

METHOD

All uT2, uT3 and uT4 tumours of the middle and lower rectum that underwent total mesorectal excision (TME) with curative intent between 1996 and 2006 were included. The predominant circumferential tumour position (anterior, posterior or circumferential) was defined on preoperative endorectal ultrasound examination (ERUS). The relationships between tumour position and other characteristics and recurrence were explored.

RESULTS

Two hundred and five patients with distal rectal cancer were operated on for a uT2-T4 tumour. Median follow up was 49 months. The location of the tumour was predominantly anterior, posterior or circumferential in 128, 49 and 27 patients, respectively. Anterior tumours were more likely to receive neoadjuvant therapy (P = 0.016) and perioperative blood transfusion (P = 0.012). No significant differences were observed between circumferential position and pT or pN stage, circumferential resection margin involvement or mesorectal excision quality. Sixty-three (30.7%) patients developed recurrence, which was local only in 16 (7.8%). Although tumours involving 360° of the rectal wall had a higher risk of local recurrence (P = 0.048), those with a predominant anterior or posterior position were not related to a higher risk of local or overall recurrence.

CONCLUSION

Anterior rectal tumours do not differ in pathological characteristics from posterior tumours, and their prognosis is no worse when circumferential resection is complete.

Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas

OBJECTIVE

Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques.

METHOD

We retrospectively analysed a prospectively entered database composed of 146 patients (112 M; 34 F), undergoing operations for CF of cryptoglandular origin. The patients were divided in two groups: Group A: (EAF); n = 71 patients; Group B: (ISR); n = 75 patients.

RESULTS

Forty-two fistulas (28.7%) were recurrent, 98 trans-sphincteric (TS) and 37 suprasphincteric (SS). Twenty-six (17.7%) patients had some degree of preoperative continence disturbances, 11 in Group A vs 15 in Group B (P = 0.47). After a mean follow up of 13 months (12-60), fistula persisted or recurred in 13 (18.3%) patients in Group A vs eight (10.6%) in Group B (P = 0.19) irrespective of the fistula type (TS or SS). Thirty-one (43.6%) patients in Group A vs 16 (21.3%) in Group B presented postoperative continence disturbances (P < 0.001). No changes were observed with the Faecal Incontinence Quality of Life Scale (FIQLS). Group A patients had a significant reduction of maximal rest pressure after surgery. After ISR, no significant changes in pressures were observed.

CONCLUSION

Immediate sphincter repair can be a therapeutic option in selected cases of CF, mainly when associated with incontinence or increased risk factors.

Risk factors for recurrence and incontinence after anal fistula surgery

OBJECTIVE

Fistula-in-ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors.

METHOD

We analysed a series of 279 patients who had undergone anal fistula surgery with long-term follow-up.

RESULTS

42.7% of the fistulae were considered complex and 46% had been referred from other institutions. There was delayed healing or recurrence in 7.2% patients, which appeared at a median of 4 months. The factors associated with recurrence were the type of fistula (extrasphincteric/suprasphincteric), nonidentification of internal opening (IO), recurrent or complex fistulae (CF), and associated chronic abscess. Only CF and nonidentification of IO were statistically significant in the multivariate analysis. Preoperative incontinence was a risk factor for postoperative incontinence, as were suprasphincteric, recurrent and CF. The age and gender of the patient did not influence postoperative continence, nor did the surgeon or surgical technique appear as a risk factor, although after excluding preoperative incontinent patients, fistulotomy was the technique that showed a higher risk of incontinence. Multivariate analysis only confirmed previous incontinence as a RF.

CONCLUSION

The overall recurrence rate is acceptable, but high fistulae continue to be difficult to treat. IO identification is also essential for obtaining good results. It is important to identify the patients with preoperative incontinence as they are at a greater risk of deterioration after surgery.

Risk factors for recurrence and incontinence after anal fistula surgery

OBJECTIVE

Fistula-in-ano continues to raise problems that require important therapeutic decisions. Our aim was to evaluate its recurrence and incontinence risk factors.

METHOD

We analysed a series of 279 patients who had undergone anal fistula surgery with long-term follow-up.

RESULTS

42.7% of the fistulae were considered complex and 46% had been referred from other institutions. There was delayed healing or recurrence in 7.2% patients, which appeared at a median of 4 months. The factors associated with recurrence were the type of fistula (extrasphincteric/suprasphincteric), nonidentification of internal opening (IO), recurrent or complex fistulae (CF), and associated chronic abscess. Only CF and nonidentification of IO were statistically significant in the multivariate analysis. Preoperative incontinence was a risk factor for postoperative incontinence, as were suprasphincteric, recurrent and CF. The age and gender of the patient did not influence postoperative continence, nor did the surgeon or surgical technique appear as a risk factor, although after excluding preoperative incontinent patients, fistulotomy was the technique that showed a higher risk of incontinence. Multivariate analysis only confirmed previous incontinence as a RF.

CONCLUSION

The overall recurrence rate is acceptable, but high fistulae continue to be difficult to treat. IO identification is also essential for obtaining good results. It is important to identify the patients with preoperative incontinence as they are at a greater risk of deterioration after surgery.

The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy

OBJECTIVE

To evaluate the relationship between extent of internal sphincter division following open and closed sphincterotomy, as assessed by anal endosonography, with fissure persistence/recurrence and faecal incontinence.

METHOD

A total of 140 consecutive patients undergoing lateral internal sphincterotomy (LIS) for idiopathic chronic anal fissure were prospectively studied. Preoperative clinical assessment was performed together with a postoperative clinical and endosonographic examination. Three zones of the internal sphincter, identifiable by endosonography, were used to describe the uppermost extent of LIS. Primary end-points were fissure persistence/recurrence and faecal incontinence.

RESULTS

A total of 140 patients, median age 49.5 years (IQR: 38-56 years) were included. Seventy-five (53.6%) and 65(46.4%) patients underwent percutaneous LIS (PLIS) and open LIS (OLIS) respectively. Median follow-up was 21 months (IQR: 14-29 months). Persistence and recurrence rates were 2.9% (4/140) and 5.7% (8/140) respectively. 7.9% (11/140) patients scored > 3 on the Jorge and Wexner Faecal Incontinence scale. PLIS was associated with a trend towards higher fissure persistence/recurrence rates than OLIS (12.0%vs 4.6%, P = 0.141). OLIS was significantly associated with a higher proportion of complete sphincterotomies (CS) than PLIS (56/65 vs 48/75, P = 0.003). A CS was associated with a lower fissure persistence or recurrence rate (1/104 vs 11/36, P < 0.001) but higher incontinence scores (11/104 vs 0/36 cases with Wexner scores > 3, P = 0.042) than following incomplete sphincterotomy. There was a strongly significant increase in incontinence scores (P < 0.001) and decrease in recurrence rates (P < 0.001) with increasing length of sphincterotomy.

CONCLUSION

We recommend a short and CS using either PLIS or OLIS for the treatment of idiopathic anal fissure.

Relaxation of the isolated human internal anal sphincter by sildenafil

BACKGROUND

Hypertonicity of the internal anal sphincter (IAS) appears to be involved in the pathogenesis of anal fissure. The relaxant effects of sildenafil, a selective phosphodiesterase 5 (PDE5) inhibitor, on isolated human IAS were investigated.

METHODS

The efficacy (maximal effect, E(max)) and potency (-log IC(50), where IC(50) is half-maximal inhibitory concentration) of the PDE5 inhibitors, sildenafil and zaprinast, and of nitric oxide donors, sodium nitroprusside and glyceryl trinitrate, as relaxants of histamine (0.1 mmol/l)-induced tone were examined in IAS strips under isometric contraction. The presence of PDE5 isoenzymes and changes in intracellular calcium and cyclic nucleotide levels in IAS muscle were tested by real-time reverse transcriptase-polymerase chain reaction, epifluorescence microscopy and enzyme immunoassay respectively.

RESULTS

Sildenafil produced a concentration-related inhibition of the mean(s.e.m.) histamine-induced tone (E(max) 83(2) per cent, - log IC(50) 7.04(0.05); n = 12). Zaprinast produced relaxation to similar degree, but with lower potency. Nitric oxide donors also relaxed IAS. Sildenafil (1 micromol/l) produced a 1.8-fold increase in guanosine 3',5'-cyclic monophosphate content, with no change in adenosine 3',5'-cyclic monophosphate levels. Sildenafil markedly depressed the peak intracellular calcium increase evoked by histamine. PDE5A1, PDE5A2 and PDE5A3 transcripts were expressed in IAS muscle.

CONCLUSION

Sildenafil relaxes the augmented tone of human IAS in vitro. These results support the potential use of this PDE5 inhibitor in the treatment of chronic anal fissure.

[Early use of CT in the management of acute diverticulitis of the colon]

OBJECTIVE

To assess the early use of CT for the diagnosis, staging, and management of acute diverticulitis.

MATERIAL AND METHODS

A prospective study of 102 patients with a clinical diagnosis of acute diverticulitis of the left colon. Acute diverticulitis was initially divided into 3 clinical stages. Patients were restaged according to CT findings into stages I, IIa, IIb, and III. Diagnosis was subsequently confirmed intraoperatively or by colonoscopy or barium studies.

RESULTS

102 patients (52 females and 50 males, mean age of 59.4 (SD + 14.96 years)) were included; 84 (82.35%) patients with a clinical diagnosis of acute diverticulitis were confirmed to suffer this disease for a diagnostic error of 17.65% (n=18). Acute diverticulitis was diagnosed by CT in 84.3% (n=86). CT had a sensitivity of 100% and a specificity of 88.9%. CT changed clinical stage for 38% of patients because of understaging in 13% and of overstaging in 25%. When stages II and III were analyzed separately, 60 and 50% were overstaged, respectively. The reclassification of patients according to CT results had a significant impact on treatment.

CONCLUSIONS

Early clinical staging with CT avoids diagnostic clinical errors in 17.65% of patients. CT changes the initial clinical staging of acute episodes in 38% of cases, thus avoiding unnecessary delays in surgery for severe cases, and unnecessary surgeries for mild cases.

Management of intersphincteric abscesses

OBJECTIVE

Intersphincteric abscesses are relatively rare, and in some cases of upward extensions in the supralevator plane, can be difficult to manage. The aim of this study was to analyse the type of treatment used in these abscesses.

METHODS

Twenty-one intersphincteric abscesses treated by endoanal drainage in our colorectal unit between 1992 and 2004 were reviewed from our database; location and extension of the abscess, type of treatment and recurrence rates and the use of endoanal ultrasound were studied.

RESULTS

Ninety per cent of patients were male; 10 had a previous history of surgery for perianal abscess and suppuration (48%); 16 (76%) had a posterior location and five were anterolateral. Twelve patients had low intersphincteric abscesses and were treated by laying open the abscess and dividing the internal sphincter. Nine were found to have high extensions into the intermuscular planes and were treated by staged procedures: a temporary transanal mushroom catheter was used in seven patients. Endoanal ultrasound was used initially in seven patients (33.3%) and for the evaluation of definitive treatment in 11 (52%).

CONCLUSIONS

Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.

Randomized clinical trial to evaluate the effects of perioperative supplemental oxygen administration on the colorectal anastomosis

Background

Perioperative supplemental oxygen therapy may have beneficial effects on wound healing following colorectal surgery. The aim of this study was to evaluate the effects of such therapy on colorectal anastomotic pH and partial pressure of carbon dioxide (Pco2) gap.

Methods

Forty-five patients undergoing anterior resection for rectal or sigmoid cancer were randomized to receive 30 or 80 per cent perioperative oxygen. Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. Intragastric and anastomotic tonometric catheters were placed in each patient and intramucosal pH (pHi) was measured immediately after operation, and 6 and 24 h later. Gastric and anastomotic pHi and Pco2 gap in each group were compared.

Results

There was a significantly lower anastomotic pHi and wider Pco2 gap for gastric readings in the 30 per cent O2 group, both 30 min (pHi, P = 0·006; Pco2 gap, P = 0·006) and 6 h (pHi, P = 0·024; Pco2 gap, P = 0·036) after surgery. There were no differences 24 h after surgery while breathing room air (pHi, P = 0·131; Pco2 gap P = 0·139). No difference was found between gastric and anastomotic readings at any time point in the 80 per cent O2 group.

Conclusion

Perioperative administration of 80 per cent O2 both during surgery and for 6 hours afterwards is associated with an improvement in relative anastomotic hypoperfusion as assessed by the measurement of pHi and Pco2 gap.

A prospective audit of the complications of loop ileostomy construction and takedown

AIM

A prospective review of the complications of ileostomy construction and takedown.

MATERIALS AND METHODS

One hundred twenty-seven consecutive patients undergoing construction of a loop ileostomy were included in a prospective nonrandomized computer database. Complications of the loop ileostomy were assessed prior to and after closure. Three closure techniques were performed [enterotomy suture (25.7%), resection and hand sewn (31.2%) or stapled anastomosis (43.1%)] and compared.

RESULTS

One hundred twenty-seven (73 male, 54 female) patients, mean age 54 years were included from 1992 to 2002. Seventy-two patients underwent anterior resection for low rectal carcinoma, 30 an ileoanal pouch for ulcerative colitis and 25 for miscellaneous conditions. Fifty-nine pre-takedown complications occurred in 50 (39.4%) patients. The most common were dermatitis (12.6%) and erythema (7.1%). The most severe were dehydration in 1 patient and stomal prolapse in 4 patients. Closure was associated with a complication rate of 33.1% and a mortality rate of 0.9%. Wound infection occurred in 18.3% and small bowel obstruction in 4.6%. Anastomotic leak requiring reanastomosis occurred in 2.8% and enterocutaneous fistula treated conservatively in 5.5%. There were no statistically significant differences in morbidity between closure techniques (p = 0.892). There were no statistically significant differences in complications (p = 0.516) between patients with ulcerative colitis and those with neoplasia (39.29% vs. 32.2%).

CONCLUSIONS

Loop ileostomy construction and takedown is associated with considerable morbidity, mostly minor. No differences exist between technique used for closure or the baseline pathology of the patient.

Multiple idiopathic small bowel strictures: report of three cases

Multiple strictures of the small bowel are relatively rare. In many cases, a distinct cause can be defined, but some strictures are unexplainable by any specific mechanism and have been termed 'idiopathic' small bowel strictures. We present 3 cases of multiple small bowel strictures in which the affected segments were studied with perioperative photoplethysmography, in vivo specimen angiography and pathology. Neither photoplethysmographic alterations nor structural vascular lesions were found.

Impact of surgeon organization and specialization in rectal cancer outcome

PURPOSE

The present study was designed to assess the differences in the outcome of patients with rectal cancer treated by a group of surgeons before and after being organized as a Coloproctology Unit at the same University Department of Surgery.

METHODS

Comparison of two periods of rectal cancer surgery: I (1986-91) and II (1992-95). Period I: 94 patients were operated on by 14 general surgeons. Period II: 108 patients were operated on by only 4 surgeons of the same group organized as a Colorectal Surgery Unit after visiting referral centres abroad, adopting techniques such as total mesorectal excision (TME) for middle and low rectal cancer and washout of rectal stump. Mean follow-up during periods I and II was 69.1 and 42.0 months, respectively. A prospective data base analysis was used. Survival and local recurrence rates were calculated by the actuarial method. For comparison between groups the log rank method was used.

RESULTS

The two groups were comparable with respect to mean age, gender, TNM and rectal tumour location. A significant increase in radical resectability and a decrease of the Abdominoperineal resection (APR)/Low anterior resection (LAR) ratio were observed in the second period. The overall pelvic recurrence rate was 25% in the first period and 11 in the second (P < 0.01). Significant differences were also found when the patients with LAR were compared between both periods, 30% vs 9% (P < 0.01) and specially when the 10 cm anal verge distance was considered to divide the LAR groups. No differences were found regarding the APR procedures in both periods. There was improved cancer-specific survival for the LAR group in the second period (P=0.03).

CONCLUSION

Specialization and centralization influence the quality of rectal cancer surgery, mainly local recurrence rates and survival after low anterior resection.

Simple technique for the intraoperative detection of Crohn's strictures with a calibration sphere

Several methods have been used to detect and evaluate small-bowel strictures in Crohn's disease. We describe a simple technique for the calibration of strictures using a 2.5-cm medical plastic sphere. This method provides an aseptic, safe, and effective calibration of the entire small bowel.

Lumbar osteomyelitis and epidural abscess complicating recurrent pilonidal cyst: report of a case

PURPOSE

This study was conducted to report the rare presentation of lumbar osteomyelitis and epidural abscess as a complication of a pilonidal cyst.

METHODS

A case report is presented.

RESULTS

We describe the rare case of a male patient with diabetes with a recurring pilonidal cyst who developed a lumbar osteomyelitis and epidural abscess three weeks after pilonidal cyst excision with epidural anesthesia, with a fatal outcome despite emergency treatment.

CONCLUSIONS

Life-threatening complications should be kept in mind in high-risk patients with repetitive surgery and neurologic involvement.

Therapeutic effects of different doses of botulinum toxin in chronic anal fissure

PURPOSE

The aim of this study was to evaluate the clinical and manometric results of three different doses of botulinum toxin and two methods of injection for the treatment of chronic idiopathic anal fissure.

METHODS

Sixty-nine patients with chronic anal fissure were included in a non-randomized, prospective trial of intrasphincteric injection of botulinum toxin. All patients reported postdefecatory anal pain lasting more than two months. Scoring systems were developed for anal pain, bleeding, and defecatory difficulty. Maximum resting and squeeze anal pressures were determined before and one month after treatment. Twenty-three patients undergoing a 5-U injection of diluted botulinum toxin A (BOTOX) on each side of the anal sphincter (total dose, 10 U) constituted the first group. In a second group 27 patients were injected as previously described, with an additional 5-U injection below the fissure (total dose, 15 U). The 19 patients constituting the third group received a 7-U injection on each side of the anus and below the fissure (total dose, 21 U). All patients were followed up for at least six months.

RESULTS

Pain relief one month after treatment was more evident in the second and the third group (48 percent of patients in the first group, 74 percent in the second group, and 100 percent in the third group). A significant reduction of the mean resting pressure was demonstrated only in Groups II and III (P < 0.05), whereas the mean squeeze pressure significantly decreased in the three groups (P < 0.01 in Group I and P < 0.001 in Groups II and III). Fifty-two percent of the patients in the first group, 30 percent in the second group, and 37 percent in the third group were reinjected during the follow-up period, because of persistence of symptomatology or early relapse. The need for surgery was similar in the first and the second group (17 and 19 percent, respectively) and clearly lower in the last group (5 percent). No serious complications or incontinence attributable to this therapeutic modality developed in any patient.

CONCLUSIONS

Intrasphincteric injection of botulinum toxin is a reliable new option in the treatment of uncomplicated chronic anal fissure. The healing rate is related to the dose and probably to the number of puncture sites. No permanent damage to the continence mechanism was detected in these patients.

Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy

PURPOSE

The present study was undertaken to evaluate anal endosonographic results of the transverse and longitudinal extent of internal anal sphincter division after closed lateral subcutaneous sphincterotomy and its relationship to outcome with respect to anal fissure recurrence and postoperative anal incontinence.

METHODS

Ten patients selected for symptomatic anal fissure recurrence (mean follow-up, 10.9 months) and 41 asymptomatic control patients (mean follow-up, 15.5 months) were reviewed by anal endosonography after closed lateral subcutaneous sphincterotomy. Clinical evaluation was focused on anal fissure recurrence and postoperative anal incontinence. The anal endosonographic study involves serial radial images of the distal, proximal, and midanal canal.

RESULTS

In 32 patients in whom a complete internal sphincter defect was identified, 31 (75.6 percent) were from the control group and only 1 patient (10 percent) was from the recurrence group (P < 0.001). In 19 patients, an incomplete internal sphincter defect was identified; 10 (24.4 percent) were from the control group (residual median size, 1.8 mm; contralateral, 2.5 mm) and 9 patients (90 percent) were from the recurrence group (P = 0.001; residual median size, 1.4 mm; contralateral, 2.2 mm). Ten patients (19.6 percent) were incontinent for gas and three patients (5.9 percent) for liquid feces, without significant differences between groups.

CONCLUSIONS

Anal endosonography is a useful method for evaluating the anatomic effectiveness of closed lateral subcutaneous sphincterotomy. An incomplete sphincterotomy is associated with significant symptomatic anal fissure recurrence.

Evolutive study of the functional results after restorative proctocolectomy for ulcerative colitis

AIM

Evolutive study of the functional results after restorative proctocolectomy for ulcerative colitis.

PATIENTS AND METHODS

Prospective study in 24 patients with an ileoanal "J" pouch (n = 8: mucosectomy and hand-sewn anastomosis; n = 16: stapled anastomosis without mucosectomy). A clinical survey was carried out during two evolutive follow-ups of the functional pouch (medians: 14.5 and 39.0 months) as well as an anorectal manometry study during the preoperative period and in two follow-ups after the creation of the pouch (medians: 6.0 and 35.5 months).

RESULTS

The mean frequency of defecation per 24 hours and per night was significantly reduced in the first follow-up (5.5 [24 h]; p < 0.003 and 1.0 [per night]; p < 0.009) compared with the postoperative period (7.9 [24 h] and 1.4 [per night]), with no significant changes in the second follow-up (5.5 [24 h] and 0.9 [per night]). At the same time, it has been significantly lower in patients with stapled anastomosis in the different evolutive follow-ups. One patient (4.2%) had major fecal incontinence in the two evolutive follow-ups and 7 (29.2%) and 6 (25%) patients had minor incontinence in the first and second follow-up respectively. The mean maximum resting anal pressure in the first follow-up was significantly lower (p = 0.002) in patients with mucosectomy than the values observed in patients with stapled anastomosis (35.4 vs 68.0 mmHg). In the second follow-up increased significantly (p = 0.046) only in patients with mucosectomy (55.1 mmHg). Recto-anal inhibitory reflex was present in 2 (10%) and 9 (45%) patients in the first and second follow-up respectively.

CONCLUSIONS

The functional results improve significantly with the follow-up time, fundamentally during the first year of the functional pouch.

Effect of epidural anesthesia on colorectal anastomosis: a tonometric assessment

PURPOSE

Epidural anesthesia is believed to benefit colorectal anastomotic blood flow because of the sympathetic blockade it produces. Our purpose is to measure with tonometry the effect of epidural anesthesia on colorectal anastomotic oxygenation.

PATIENTS AND METHODS

Fifteen patients operated on for rectal cancer (radical anterior resection) were monitored postoperatively using tonometers placed in the stomach (celiac trunk), transverse colon (superior mesenteric artery), and the anastomotic area during the operation. An epidural catheter was placed at L1-2, and on the first postoperative day, 8 ml of bupivacaine (0.25 percent) was administered. The anesthetic effect extended up to T-4. Intramucosal pH (pHi) at the three locations was measured before, during, and after the epidural blockade.

RESULTS

Gastric and transverse colon pHi increased during the epidural blockade from 7.35 +/- 0.01 to 7.41 +/- 0.01 and from 7.34 +/- 0.02 to 7.40 +/- 0.02, respectively. The anastomotic pHi decreased from 7.3 +/- 0.02 to 7.24 +/- 0.03 under the epidural and increased up to 7.34 +/- 0.02 after withdrawal of the effect on the following day. All pHi variations were statistically significant (P < 0.05, paired Student's t-test and Wilcoxon's test), because it was the comparison between gastric and transverse colon pHi with the anastomotic pHi during the epidural (P < 0.05, one-way analysis of variance and Kruskal-Wallis tests). None of the patients developed anastomotic or other complications.

CONCLUSIONS

Epidural anesthesia with bupivacaine causes a significant decrease in the oxygenation-perfusion state of colorectal anastomosis in comparison with the increase in other areas of the digestive tract. Further studies need to be done to see if other epidural anesthetic-analgesic protocols also worsen colorectal anastomotic blood flow.

Relationship of curative surgery on natural killer cell activity in colorectal cancer

PURPOSE

Aim of this study has been to evaluate natural killer (NK) activity in patients with colorectal tumors before and after curative surgery.

METHODS

Forty colorectal cancer patients without distant metastases were stratified according to American Joint Committee on Cancer/International Union Against Cancer staging system into three categories: Stage I (n = 12), Stage II (n = 15), and Stage III (n = 13). All of them underwent curative resection, and there were no major postoperative complications. Venous blood samples were obtained preoperatively, at surgical wound closure, and on the 1st, 7th, and 21st postoperative days. Mononuclear cells were isolated over Ficoll-Hypaque (Lymphoprep, Nycomed Pharma AS, Oslo, Norway) gradients, and NK activity was assayed by evaluation of cytotoxic response against K562 cells. Normal NK activity was achieved from 15 healthy donors. Percentage relative increments in relation to preoperative levels were calculated for every postoperative sample, and t-test was used for statistical evaluation.

RESULTS

Before surgery, Stages II and III patients had lower levels of NK activity than healthy people (P < 0.05 and P < 0.001, respectively). NK activity always fell after surgery (Stage I: -18.48 +/- 11.42; Stage II: -16.93 +/- 13.57; Stage III: -35.29 +/- 12.03, at day 1 postsurgery) and appeared to rise slightly by the 21st postoperative day in Stage I patients (+4.87 +/- 12.41). Stage II, and especially Stage III, patients did show a significant recovery by the 21st postoperative day (+23.63 +/- 9.36 and +43.19 +/- 13.34, respectively). At this time, NK activity in these two groups was not significantly lower than in normal subjects (P > 0.05).

CONCLUSION

NK activity is depressed in colorectal cancer patients in relation to progression of illness, even at locoregional stages. Curative resection of tumors at Stages II and III has promoted a recovery of NK activity in patients with uneventful postoperative courses.

Evaluation of residual vascularisation in oesophageal substitution gastroplasty by surface oximetry-capnography and photoplethysmography. An experimental study

OBJECTIVE

To evaluate residual vascularisation in gastroplasty and its possible relation to the development of anastomotic fistulas or dehiscences after oesophageal resection.

DESIGN

Experimental open study.

MATERIAL

Eleven mongrel dogs.

INTERVENTIONS

Gastric parietal blood flow was evaluated by photoplethysmography and measurement of surface oxygen and carbon dioxide tensions under basal conditions and after Akiyama's tubular gastroplasty. Temperature, heart rate, and electrocardiogram; arterial pressure, pulmonary arterial pressure, pulmonary capillary pressure, central venous pressure, cardiac output, venous oxygen saturation, and arterial blood gas tensions were monitored under stable haemodynamic conditions.

RESULTS

After gastroplasty, the mean serosal oxygen tension (pO2) of 8.6 mmHg and carbon dioxide tension (pCO2) of 99.5 mmHg and residual photoplethysmographic wave amplitude (8%) indicated considerable severe ischaemia at the fundus. There was relative ischaemia of the mid-stomach with residual mean values of 52.7 mmHg, 77.8 mmHg, and 57% for pO2; pCO2 and PPG wave amplitude, respectively.

CONCLUSIONS

Important devascularisation of the fundus, theoretically incompatible with healing, occurs after gastroplasty. Operative photoplethysmography and surface measurements of pO2 and pCO2 are good ways of evaluating the level and degree of ischaemia in gastric tubes for oesophageal replacement.