Neostigmine for the treatment of acute
colonic pseudo-obstruction. Ponec R J, Saunders M D, Kimmey M B.
N Eng J Med 1999; 341: 137-141.
Acute colonic pseudo-obstruction consists of dilatation of
the colon in the absence of mechanical obstruction. It can develop in a
wide variety of medical and surgical conditions. Most cases respond to
conservative management but perforation is not unknown and is associated
with a high mortality rate. It has been suggested that intravenous
administration of neostigmine, an acetylcholinesterase inhibitor, can
produce rapid colonic decompression in patients with pseudo-obstruction
who fail to respond to conservative management. The aim of this study was
to assess the efficacy of neostigmine in the treatment of acute colonic
pseudo-obstruction. Twenty one patients with abdominal distension and
radiographic evidence of colonic dilatation and with a caecal diameter of
at least 10 cm, that had not improved with conservative management over a
24 hour period, were randomised to received an intravenous bolus of either
2 mg neostigmine or saline. The patient's response was assessed by a
clinician blinded to the treatment given. Ten of 11 patients given
neostigmine had prompt colonic decompression as compared to none of those
given saline (p<0.001). The median time to response was 4 minutes.
Two patients who had an initial response to neostigmine required
colonoscopic decompression and one eventually required a subtotal
colectomy. It was concluded that in patients with acute colonic
pseudo-obstruction who fail to respond to conservative management,
treatment with neostigmine is safe and it can rapidly decompress the
Randomised controlled trial shows that
glyceryl trinitrate heals anal fissure, high doses are not more effective
and there is a high recurrence rate. Carapeti E A, Kamm M A, McDonald P J
et al. Gut 1999; 44: 727-730.
Anal fissures present with severe perianal discomfort and
rectal bleeding and are associated with a high resting anal pressure. This
can cause localised ischaemia that perpetuates ulceration and can prevent
healing. Lateral anal sphincterotomy decreases the resting anal pressure
and is the traditional surgical treatment for a chronic anal fissure. It
is, however, associate with significant morbidity including incontinence
to both flatus and faeces. Nitric oxide (NO) appears to be the most
important inhibitory neurotransmitter in the internal anal sphincter.
Glyceryl trinitrate (GTN) is a NO donor that can produce reversible
relaxation of the sphincter. Topical application GTN ointment has been
shown to heal chronic anal fissures and provided an alternative to the
traditional first line treatment of sphincterotomy. The aim of this study
was to determine the most effective dose of GTN for the treatment of
chronic anal fissures and to assess the long term results. Seventy
consecutive patients with chronic anal fissures were randomly allocated to
eight weeks treatment with either placebo or two doses of GTN. After eight
weeks, fissures had healed in 67% of patients given GTN but only 32% given
placebo (p=0.008). Headaches were reported in 72% of those given
GTN compared to 27% on placebo (p<0.001). Maximal anal sphincter
pressure was reduced by GTN. Of fissure healed on placebo 43% recurred,
compared with 33% of those healed with 0.2% GTN and 25% healed with an
escalating dose of GTN. It was concluded that GTN is a good first line
treatment for two thirds of patients with chronic anal fissures.
Significant recurrence of symptomatic fissures and a high incidence of
headaches are the limitations of this treatment.
Prospective study of primary anastomosis
without colonic lavage for patients with an obstructed left colon.
Naraynsingh V, Rampaul R, Maharaj D et al. Br J Surg 1999;
Left-sided colonic obstruction has traditionally been
treated in a staged fashion with an initial defunctioning colostomy
followed by resection, anastomosis and eventual colostomy closure. There
is now growing acceptance that a one-staged procedure consisting of
resection and on-table colonic lavage with primary anastomosis is safe,
even in elderly patients. The role of lavage or simple colonic
decompression has not been extensively investigated. This paper describes
a series of 58 unselected consecutive patients admitted to the Department
of Surgery at the University of West Indies between 1989 and 1998 with
malignant left-sided colonic obstruction (55% sigmoid, 28% descending
colon, 10% distal transverse colon, 7% splenic flexure). All underwent
resection and primary anastomosis without colonic irrigation. Colonic
decompression was achieved by passing a 36 Fr chest drain through a
purse-string suture proximal to the obstruction and aspirating gas and
liquid faeces. The purse-string suture was included in the eventual
resection specimen. One anastomotic leak was detected on clinical grounds.
One post-operative death occurred due to a myocardial infarct. It was
concluded that emergency surgery for obstructing left sided colonic
lesions is safe with decompression alone and no on-table colonic lavage.
Rectal cancer: The Basingstoke experience
of total mesorectal excision 1978 - 1997. Heald R J, Moran B J,
Ryall R D H, Sexton R, MacFarlane J K. Arch Surg
1998; 133: 894-899.
Throughout this century the standard surgical treatment of
rectal cancer has been by abdomino-perineal (AP) or anterior resection
(AR). In most reported series local recurrence rates have been
disappointing and the overall survival has been poor. This has lead to the
adjuvant use of both chemotherapy and radiotherapy. In an effort to
reduce the local recurrence rate, in the 1970s, the concept of total
mesorectal excision (TME) was proposed by surgeons in Basingstoke.
This involves a precise dissection, from above, of the lympho-vascular
fatty tissue surrounding the rectum (the mesorectum). It was
postulated that mesorectal excision would remove residual tumour and
minimise the local recurrence rate. In this paper the authors review
their experiences with 519 consecutive patients with rectal adenocarcinoma
treated between 1978 and 1997. Patients underwent AR with low
stapled anastomosis (n = 465; 407 TME), AP resection (n=37), Hartmann's
procedure (n=10), local excisions (n=4) and laparotomy alone (n=3).
Preoperative radiotherapy was used in 49 patients. The main outcome
measures were local recurrence and cancer-specific survival. The
cancer-specific survival rates of all surgically treated patients was 68%
at 5 years and 66% at 10 years. The local recurrence rate was 6% at
5 years and 8% at 10 years. Local recurrence rates were even lower
in patients undergoing a 'curative' resection. An analysis of the
risk factors for local recurrence indicated that only Duke's stage,
extramural vascular invasion and tumour differentiation were important
variables. It was concluded that rectal cancer can be cured by
surgery alone in two-thirds of patients. Total mesorectal excision
is an important surgical strategy in reducing local recurrence rates and
this surgical technique should be incorporated in the protocols of trials
of adjuvant chemotherapy and radiotherapy.
Bascom's operation in the day-surgical
management of symptomatic pilonidal sinus. Senapati A, Cripps
N P J, Thompson M R. Br J Surg 2000; 87:
Many surgical procedures have been described for the
management of pilonidal sinus, none of which is perfect. All are
associated with failure of wound healing and the risk of recurrence.
Most procedures require extensive surgical intervention and are followed
by a period of prolonged wound healing. Day-case surgical techniques
that are effective and offer the prospect of early return to work are
desirable. Bascom's procedure fulfils these requirements. This
paper described one hospital's experiences with this operative procedure
in 218 patients treated as day cases mainly under local anaesthesia.
The mean duration of symptoms was 2.4 years and 68% percent of patients
had complex disease with more than one midline pit or a lateral
discharging sinus. The operative technique involved excision of the
pilonidal pits, a lateral drainage incision approximately 2 cm from the
midline, raising and suturing of a subcutaneous flap deep to the midline
pits and closure of the midline wounds. The lateral drainage wound
was left open. In total, 95% of patients were followed up for a mean of
12.1 months. All except one midline wound healed. Lateral
wounds healed after a mean of 4 weeks. Postoperative complications
were few and included bleeding (4%) and abscess formation treated by
reopening the lateral incision (6%). Recurrence requiring further
surgery was seen in 10% of patients. It was concluded that Bascom's
procedure is simple and results in minimal morbidity, social disruption
and an early return to work. Recurrent disease is no more frequent
than after other forms of treatment.
Randomised clinical trial of sutured
versus stapled closed haemorrhoidectomy. Khalil K H, O'Bichere
A, Sellu D. Br J Surg 2000; 87: 1352-1355.
Ferguson's closed haemorrhoidectomy is practiced widely in
the USA but is rarely used in the United Kingdom due to concerns that the
preliminary dissection exposes the wounds to faecal contamination and
increases the risk of wound infection. Recent studies have shown
that a stapled haemorrhoidectomy offers a simple, safe and effective
method of performing a closed haemorrhoidectomy through simultaneous
excision and wound closure without dissection. The aim of this study
was to compare the clinical outcome of closed haemorrhoidectomy with
(sutured) and without (stapled) preliminary dissection. Forty
patients with prolapsed symptomatic haemorrhoids were randomly assigned to
either a sutured (n=20) or stapled (n=20) haemorrhoidectomy.
Preoperative assessment was by proctoscopy, sigmoidoscopy and anal
manometry. Stapled and diathermy haemorrhoidectomies with wound
suture were performed and the excised tissue submitted for histological
examination. Pain scores, complications, wound healing and patient
satisfaction were recorded. Anal manometry was repeated at 3 and 6
months after surgery. Post-operative resting and squeeze anal
pressures were reduced by the stapled method at 3 month but had returned
to baseline by 6 months. Stapled haemorrhoidectomy was quicker.
Isolated muscle fibres were identified equally in both groups but
incontinence did not occur. The stapled technique resulted in less
post-operative pain, a greater degree of patient satisfaction and faster
wound healing. There was no difference in the complication rate.
It was concluded that despite higher cost and difficult access, stapled
haemorrhoidectomy resulted in less postoperative pain, faster wound
healing and greater patient satisfaction than the open sutured technique.
Midline or transverse abdominal incision
for right-sided colon cancer - a randomised trial. Lindgren P G,
Nordgren S R, Oresland T, Hulten L. Colorectal
Disease 2001; 3: 46-50.
Both the midline and transverse incisions are commonly
used in abdominal surgery and a number of studies have been published
evaluating the effects of either incision on the postoperative course.
It has been suggested that a transverse incision is associated with less
pain, improved post-operative respiratory function and a lower incidence
of other complications. The use of a transverse incision in patients
undergoing large bowel cancer surgery has not been extensively
investigated. The aim of this study was to compare the two types of
incision in patients undergoing scheduled operations for caecal or
ascending colon surgery with a right hemicolectomy. Overall, 53
patients were randomised to either a median vertical or transverse
incision. Only 40 patients completed the study (23 in the median and
17 in the transverse group). Pain at rest and after physical
activity was assessed using a visual analogue scale. Respiratory
function was evaluated using pre- and post-operative spirometry.
Pain after activity was significantly reduced in patients with a
transverse incision. This group also had a reduced analgesic
requirement. Both vital capacity (VC) and forced expiratory volume
in 1 second (FEV1) were reduced after surgery in both groups.
Respiratory function improved quicker in patients undergoing surgery
through a transverse incision. No problem with access to the
operative field was identified in either group. It was concluded
that a transverse incision is preferable to a midline incision in patients
undergoing right hemicolectomy. This incision reduced postoperative
pain on exercise, interferes less with respiratory function and may reduce
the risk of postoperative pulmonary complications.
Topical diltiazem ointment in the
treatment of chronic anal fissure. Knight J S, Birks M, Farouk R. Br J
Surg 2001; 88: 553-556.
Anal fissures are a common perianal condition,
characterised by spasm of the internal anal sphincter and a reduction in
mucosal blood flow. The aim of treatment is to relieve ischaemia by
reducing resting anal pressure and improving mucosal perfusion. This can
be achieved surgically by either anal dilatation or internal
sphincterotomy. Both are however associated with a significant risk of
faecal incontinence. Chemical sphincterotomy has been attempted using a
range of agents including glyceryl trinitrate (GTN), calcium channel
blockers and botulinum toxin. Although initially promising results were
achieved with GTN ointment, its use is associated with side effects (e.g.
headaches) and a significant recurrence rate. The aim of this study was to
evaluate the use of topical 2% diltiazem as an alternative method of
chemical sphincterotomy in patients with chronic anal fissure. A
prospective assessment of 71 patients treated with a median duration of 9
(2-16) weeks was performed. Overall, 51 (75%) experienced healing of the
fissure after 2-3 months. Four patients experienced perianal dermatitis
and only one patient experienced headaches. After a median follow-up of 32
(14-67) weeks following completion of treatment, 27 of 41 patients
available for assessment remained symptom free. Six of 7 patients with
recurrent fissures were treated successfully by repeat chemical
sphincterotomy. It was concluded that the use of 2% diltiazem ointment in
the treatment of chronic anal fissure results in good healing rates
without a significant side-effect profile. Prospective randomised trials
are required to evaluate it in comparison to topical GTN.
Comparison of fluorouracil with
additional levamisole, higher-dose folinic acid or both as adjuvant
chemotherapy for colorectal cancer: a randomised trial. QUASAR
Collaborative Group. Lancet 2000; 355: 1588-1596.
Primary surgical treatment of colorectal cancer is
possible in about 70% of patients but approximately half of them will
eventually develop incurable recurrent disease. Cytotoxic
chemotherapy after apparently complete resection can lower the risk of
recurrence. Such adjuvant chemotherapy commonly consists of 6 months
treatment with fluorouracil-containing regimens, but uncertainty remains
as to the optimal combination. Combination chemotherapy is well
established for patients with node-positive (Duke's C) tumours however the
role of levamisole and the appropriate dose of folinic acid remains to be
determined. The QUASAR (Quick and Simple and Reliable) trial was
designed to provide large-scale randomised evidence on the value of
different therapeutic regimens in different groups of patients. It
has two parts. The part reported in this paper compared various
different fluorouracil-based regimes with or without additional levamisole
and high-dose folinic acid. Patients with colorectal cancer and
without evidence of residual disease were randomised (in a 2x2 design) to
low or high-dose folinic acid and either levamisole or placebo. The
primary endpoint was mortality from any cause. Analyses were by
intention to treat. Between 1994 and 1997, 4927 patients were
enrolled, 1776 had recurrences and 1576 died. Survival was similar
in the high and low-dose folinic acid groups (70% vs 71% at 3 years.
p=0.43). Recurrence rates were similar (36% vs. 36%. p=0.94).
Survival was worse with levamisole than placebo (69% vs. 71% at 3 years.
p=0.06). It was concluded that addition of levamisole to
chemotherapy regimes for colorectal cancer does not delay recurrence or
improve survival. High-dose folinic acid provides no additional
benefit. Trials of chemotherapy versus no chemotherapy will show
whether these four treatments are equally effective or equally
Prospective study of primary anastomosis
following sigmoid resection for suspected acute complicated diverticular
disease. Gooszen A W, Tollenaar A E M, Geelkerken R H et
al. Br J Surg 2001; 88: 693-697.
Two-stage resection and subsequent anastomosis is widely
practiced in the management of complicated diverticular disease. The
segment of bowel is resected and a left iliac fossa end-colostomy
fashioned with oversewing of the distal colonic or rectal stump
(Hartmann's procedure). The use of this technique is believed to reduce
the incidence of septic complications related to anastomotic leak and
intra-abdominal collections. However, a Hartmann's procedure has
significant disadvantages. In particular, there is a need for
a stoma followed by a further, often demanding, operation in order to
restore colonic continuity. Restoration of bowel continuity is not
completed in between 25 and 75% of patients. These disadvantages
have encouraged resection with primary anastomosis as an alternative
option. This prospective study was undertaken to evaluate the safety
of primary resection and anastomosis in patients presenting with
complicated diverticular disease. Between 1995 and 1997, 45
consecutive patients were recruited. Acute physiology and chronic
health evaluation (APACHE) II score, Mannheim peritonitis index and
Hughes' peritonitis index were used to classify patients and to detect
factors predictive of postoperative outcome. Death, anastomotic leak
and septic complications were the main outcome measures. Neither
anastomotic leak (4 of 45 patients) nor death (3 of 45 patients) were
related to higher MPI, APACHE II or Hughes' scores. Most
postoperative complications were seen in patients with a high MPI.
Death, anastomotic leak and the need for re-intervention were seen more
often in patients who presented with intestinal obstruction than in those
with abscess formation or perforation. It was concluded that primary
anastomosis is safe and effective in non-obstructed cases of complicated
diverticular disease and that colonic obstruction seemed to be a risk
factor for the development of postoperative complications.
Randomised clinical trial of stapled
versus Milligan-Morgan haemorrhoidectomy. Shalaby R, Desoky A.
Br J Surg 2001; 88: 1049-1053.
The treatment of third and fourth-degree haemorrhoids is
usually surgical with several techniques described. The
Milligan-Morgan haemorrhoidectomy has remained the most popular but has a
reputation for being a painful procedure with a prolonged convalescent
period. The introduction of a stapling technique for the treatment
of prolapsing haemorrhoids has the potential for less postoperative pain,
a shorter operating time and an early return to full activity. The aim of
this study was to to compare the outcome of stapled haemorrhoidectomy with
that of a current standard surgical technique in a randomised, controlled
trial. in total, 200 patients were randomised to either staple
haemorrhoidectomy (n=100) or a Milligan-Morgan haemorrhoidectomy (n=100).
Each patient received a standardized postoperative analgesic and laxative
regime and completed a visual analogue pain score very 6 hours during the
first day after the operation, after the first motion and daily until the
end of the first week. Operating time, postoperative analgesia
intake, hospital stay, time to return of normal activity and postoperative
complications were recorded. The mean ages in the two groups were
similar (44.1 vs 49.1 yrs). The stapled group had a shorter
operating time, less frequent postoperative analgesia intake, shorter
hospital stay and earlier return to normal activity. Early and late
complications and functional outcome were better in the stapled group.
It was concluded that the use of a circular stapler in the treatment of
haemorrhoidal disease was safe and was associated with fewer complications
than conventional haemorrhoidectomy.
Colonic J-pouch function at six months
versus straight coloanal anastomosis at two years: randomized
controlled trial. Ho Y-H, Seow-Choen F, Tan M. World J Surg
2001; 25: 876-881.
Ultra-low anterior resection with coloanal anastomosis has
gained wide acceptance for the treatment of middle and lower third rectal
carcinomas. However, direct end-to-end straight anastomosis of the
proximal colon to the anorectal junction often results in poor bowel
function. Although bowel continuity is restored, the normal
reservoir function of the excised rectum is not adequately replaced. It
has been demonstrated that, in the early postoperative period ,a straight
colorectal anastomosis less than 4 cm above the anal verge results in
poorer bowel function than a colonic J-pouch. The long-term results
are unknown. The aim of this study was to conduct a randomised
controlled trial to compare clinical outcome, bowel function, anal
manometry and rectal barostat findings in patients undergoing ultra-low
anterior resection and reconstructed with either a straight coloanal
anastomosis (straight group) or colonic J-pouch (pouch group) and followed
up for 2 years. Overall, 42 consecutive patients were recruited, 19
in the straight group and 17 in the pouch group. Four patients died
from metastatic disease and 2 emigrated. There was no surgical
morbidity or local recurrence. At 6 months, the pouch group had
significantly less stool frequency and faecal soiling than those in the
straight group. These had improved at 2 years with no significant
difference between the 2 groups. Anal squeeze pressure was
significantly reduced in both groups. There was no difference in
rectal compliance between the 2 groups. Rectal sensory testing on
the barostat phasic program showed impairment at 6 months and recovery at
2 years in both groups. It was concluded that stool frequency and
incontinence was less in the pouch group at 6 months but after adaptation
at 2 years, the straight group yielded similar results.
Preoperative radiotherapy combined with
total mesorectal excision for resectable rectal cancer. Kapiteijn E,
Marijnen C A M, Nagtegall I D et al. N Eng J Med 2001;
Locally-recurrent rectal carcinoma causes disabling
symptoms and is difficult to treat. The incidence of local recurrence
after surgery involving blunt dissection of the rectal fascia is very
variable and is believed to be due to failure to remove all of the tumour
bearing tissue. In an attempt to improve local control and survival
after such conventional surgery either pre- or postoperative radiotherapy
has be administered. Improved local control of disease can also be
achieved by resection of the entire mesorectum by the technique of total
mesorectal excision (TME). In previous studies of radiotherapy,
surgery for rectal cancer was not standardised. Since surgical
technique is key factor in the success of tumour control, standardisation
and quality with respect to surgery are indispensable for evaluating the
effects of adjuvant therapy. The aim of this study was to perform a
prospective randomised of preoperative radiotherapy in combination with
total mesorectal excision in patients with rectal cancer to see whether
radiotherapy increased the benefit from surgery. Overall 1861
patients with resectable rectal cancer were randomised to either
preoperative radiotherapy (5Gy per day for 5 days) followed by TME (n=924)
or TME alone (n=937). The trial was conducted with use of
standardisation and quality control measures to ensure consistency of
radiotherapy, surgery and pathological techniques. The overall
2-year survival was 82% in the radiotherapy group and 81.8% in the
surgery-alone group (p=0.84). Amongst the 1748 patients who
underwent macroscopically complete resection, the rate of local recurrence
at 2 years was 5.3%. The rate of local recurrence was 2.4% in the
radiotherapy group and 8.2% in the surgery-alone group (p<0.001). It
was concluded that short-term preoperative radiotherapy reduces the risk
of local recurrence in patients with rectal cancer who undergo a
Resection large numbers of hepatic
colorectal metastases. Moroz P, Salama P R, Gray B N.
Aust NZ J Surg 2002; 72: 5-10.
The development of surgical resection as a treatment for
hepatic colorectal metastases has had a major impact on the survival of
patients with this disease, with 5-year survival rates of 20-40% and
median survival of 25-40 months being common place. Furthermore, the
surgical mortality of hepatic resection is low. Despite the
increasing use of surgical resection, the criteria for selecting patients
for resection remain controversial. In particular, there is
disagreement about the value of resecting more than 3 or 4 metastases.
The aim of this study was to determine if resection of large numbers of
metastases affected patient survival. The survival of 123
consecutive patients who underwent curative hepatic resection for
colorectal metastases between 1989 and 1999 were retrospectively analysed.
Kaplan-Meier survival statistics and Cox regression were used to determine
the factors that affected survival and logistic regression was used to
determine the factors that affected the risk of local recurrence.
The median survival of the whole group was 38 months with 1,3 and 5-year
survival rates of 88%, 53% and 31% respectively. The survival rate
of patients undergoing resection of 4-7 metastases (n=22; 5-year survival
= 39%) was no different to that of patients undergoing resection of 1-3
metastases (n=91: 5-year survival = 30%). Age, sex, primary cancer
site, hepatic disease distribution, resection margins and adjuvant hepatic
intra-arterial chemotherapy did not affect survival. Local invasion
of the hepatic metastases (RR=2.9, p=0.001) and hepatic disease
recurrence (RR=2.1, p=0.007) were the only factors that
independently affected survival. Local invasion of the hepatic
metastases was the only factor associated with an increased risk of
hepatic recurrence (RR=2.8, p=0.03). It was concluded that
surgical resection of up to seven colorectal liver metastases can result
in significant survival benefit.
Primary chemoprevention of familial
adenomatous polyposis with sulindac. Giardiello F M, Yang V W,
Hylind L M et al. N Eng J Med 2002; 346:
Familial adenomatous polyposis (FAP) is an autosomal
dominant syndrome caused by a germ-line mutation of the adenomatous
polyposis coli (APC) gene located at chromosome 5q21. The disorder
is characterised by the development of hundreds of colorectal adenomas
during adolescence and the inevitable development of colorectal cancer in
adult life if prophylactic colectomy is not performed. Regression of
established adenomatous polyps in patients with FAP has been described in
patients taking NSAIDs. The aim of this study was to evaluate
whether a NSAID (sulindac) would prevent adenoma formation in patients
with genetic mutation but who were phenotypically normal. A
randomised, double-blind placebo controlled trial was conducted in 41
patients (age range 8-25 years). The subjects received either 75 or
150 mg of sulindac orally twice daily or placebo for 48 months. The
number and size of new adenomas and side effects of therapy were evaluated
every four months for four years. Levels of five major
prostaglandins were measured in biopsy specimens of normal appearing
colonic mucosa. After four years of treatment, the average rate of
compliance exceeded 76% in the sulindac group and mucosal prostaglandin
levels were lower in the sulindac group. During the course of the
study, adenomas developed in 9 of 21 subjects (43%) in the sulindac group
and 11 of 20 subjects (55%) in the placebo group (p=0.54).
There was no significant differences in the mean number or size of the
polyps between the two groups. Sulindac did not slow the development
of adenomas, according to an evaluation involving linear longitudinal
methods. It was concluded that standard doses of sulindac did not
prevent the development of adenomas in subjects with the germ-line
mutation for FAP.
Prognostic significance of the
circumferential resection margin following total mesorectal excision for
rectal cancer. Wibe A, Rendedal P R, Svensson E et al.
Br J Surg 2002; 89: 327-334.
Histopathological reporting of rectal cancer traditionally
includes information on resection margins, usually of the proximal and
distal bowel. Tumour involvement of the proximal margin is unusual
and distal intramural tumour extension more than 2 cm from the primary
lesion is uncommon. The circumferential margin status has less
frequently been reported, but involvement of this margin appears to be a
strong predictor for local recurrence and hence survival. The aim of
this study was to examine the prognostic impact of the circumferential
resection margin on local recurrence, distant metastases and survival.
A national population-based cancer registry included all 3319 patients
diagnosed with rectal cancer in Norway between 1993 and 1997. Some
686 patients underwent total mesorectal excision (TME) with a known
circumferential margin. The closest radial resection margin was
measure in fixed specimens. None of the patients received adjuvant
radiotherapy. Following potentially curative resection and after a
median follow-up of 29 (range 14-60) months, the overall local recurrence
was identified in 46 (7%) patients. Local recurrence was seen in 22%
patients with a positive resection margin and 5% of those with a negative
resection margin. Overall, 40% patients with a positive resection
margin developed distant metastases, compared with 12% of those with a
negative resection margin. With decreasing circumferential margin, there
was an exponential increase in the rates of local recurrence, metastases
and death. It was concluded that circumferential margin status had a
significant and major prognostic impact on the rates of local recurrence,
distant metastases and survival. Information on circumferential
margin status is important in the selection of patients for postoperative
Impact on survival of intensive follow
up after curative resection for colorectal cancer: systematic review
and meta-analysis of randomised trials. Renehan A G, Egger M,
Saunders M P, O'Dwyer S T. Br Med J 2002; 324: 1-8.
Colorectal cancer is the second most common malignancy in
Western societies and the second leading cause of death related to cancer.
At the time of diagnosis, about 60% of patients undergo resection with
curative intent, but 30-50% of these patients will relapse and die of the
disease. It has been suggested that intensive follow-up should lead
to the early detection of recurrent disease or metachronous tumours and
thus possibly improve survival. Several randomised controlled trials have
addressed this issue but none have had sufficient statistical power.
Thus, the aim of this study was to carry out a systematic review and
meta-analysis of randomised clinical trials to determine whether there is
any benefit of intensive follow-up strategies after curative resection for
colorectal cancer. Five trials that recruited 1342 patients were
included. The primary outcome measure was all-cause mortality at
five years of follow-up. Secondary outcome measures were local and
distant recurrence rates and the incidence of metachronous tumours.
Intensive follow-up was associated with a reduction in all cause mortality
(RR 0.81; 95% CI 0.70-0.94. p=0.007). The effect was most
pronounced in the extramural detection trials that used CT and frequent
measurement of CEA levels (RR=0.73; 95% CI 0.60-0.89. p=0.002).
Intensive follow-up was associated with an earlier detection of all
recurrences and an increased detection rate for isolated local recurrence
(RR=1.61; 95% CI 1.12-2.32. p=0.011). It was concluded
that intensive follow-up after curative resection for colorectal cancer
improves survival. Large trials are required to identify which
components of intensive follow-up are most beneficial.
Randomised clinical trial comparing loop
ileostomy and loop transverse colostomy for faecal diversion following
total mesorectal excision. Law W L, Chu K W, Choi H K.
Br J Surg 2002; 89: 704-708.
Anastomotic leak is a serious postoperative complication
following colorectal surgery. The incidence is particularly high
when an anastomosis involves the distal rectum or anal canal.
Proximal faecal diversion reduces the incidence of clinical anastomotic
leakage following low anterior resection with total mesorectal excision
(TME). Although the use of proximal faecal diversion to prevent
leakage at rectal anastomoses remains controversial, most authors agree
that a defunctioning stoma can reduce the risk of sepsis resulting from
anastomotic leakage. Proximal faecal diversion can be achieved by
either a loop colostomy or loop ileostomy but which is the optimal method
is unclear. The aim of this study was to compare loop ileostomy and
loop transverse colostomy as the preferred method of faecal diversion
following low anterior resection with TME for rectal cancer.
Patients who required proximal diversion after low anterior resection and
TME were randomised to either a loop colostomy or loop transverse
colostomy. Postoperative morbidity, stoma-related problems and
morbidity following closure were compared. Between April 1999 and
November 2000, 42 patients had a loop ileostomy and 38 had a loop
transverse colostomy fashioned. Post-operative intestinal
obstruction and prolonged ileus occurred more commonly in patients with an
ileostomy (p=0.037). There was no difference in the time to
resumption of diet, length of hospital stay following stoma closure and
incidence of stoma-related complications after discharge from hospital.
A total of 7 patients had intestinal obstruction from the time of stoma
creation to stoma closure (6 following ileostomy and one following
colostomy. p=0.01). It was concluded that intestinal
obstruction and ileus are more common after loop ileostomy than loop
colostomy. Loop transverse colostomy should be recommended as the
preferred method of proximal faecal diversion.
Investigative modalities for massive
lower gastrointestinal bleeding. Al-Qahtani A R, Satin R, Stern J,
Gordon P H. World J Surg 2002; 26: 620-625.
Lower gastrointestinal bleeding is common and is
potentially life-threatening. It is defined as gastrointestinal
haemorrhage occurring from a source distal to the ligament of Treitz.
Although most bleeding of this nature stops spontaneously, approximately
10% patients require an urgent operation. The reported mortality
rates vary from 5% to 20%. The localisation of an acute lower
gastrointestinal bleed can be difficult. The reasons for this
include the various possible sites, the often intermittent nature of the
bleeding and the lack of a standardised diagnostic approach. The aim
of this study was to evaluate the clinical course, the relative value of
various diagnostic approaches, the therapeutic measures and the results in
patients with acute lower gastrointestinal haemorrhage. The notes of all
patients admitted to a large university teaching hospital over a 25-year
period were reviewed. Overall, 136 patients underwent 202
admissions. The mean age was 70 (range 16-95) years. At least
one significant co-morbid disease was present in 93% of patients.
Overall, 20% were on aspirin and 5% were on anticoagulants at the time of
diagnosis. Rigid or flexible sigmoidoscopy was performed in 68 and
18 patients respectively with a definitive diagnosis made in 3% and 11%
respectively. Colonoscopy was performed in 152 cases, 20 of which were
incomplete. A specific diagnosis was made in 53 (45%) of patients.
A red blood cell or colloid scan was performed on 53 patients with
extravasation noted in 13 (25%) and a localised site of bleeding
identified in 9 (17%) cases. Angiography was performed on 31
patients with bleeding sites localised in 6 (19%). Barium enema was
completed in 85 of 92 patients and the presumptive cause of bleeding was
identified in 72% of complete examinations. The commonest causes of
bleeding were diverticular disease (n=52) and angiodysplasia (n=14).
A cause of bleeding was not detected in in 48 (35%) of patients. Bleeding
stopped spontaneously in most patients and in only 7 patients was an
operation required. The average number of units transfused was three
(range 0-26). It was concluded that scintigraphy and angiography
were less efficacious then colonoscopy for localising the site and
etiology of the bleeding. Despite the combined use of the various
diagnostic modalities, a definitive diagnosis was not made in 35%.
The need for operative intervention was lower than in most previous
Randomised clinical trial comparing
quality of life after straight and pouch coloanal reconstruction.
Sailer M, Fuchs K-H, Fein M, Thiede A. Br J Surg 2002;
Sphincter-saving procedure have become standard treatment
in the surgical approach to most cancers of the middle and occasionally
lower third of the rectum. However, functional results following low
anterior resection with straight coloanal anastomosis are often poor.
To compensate for the loss of reservoir function the coloanal J pouch has
been developed and randomised trials comparing the pouch with straight
reconstruction have shown the pouch to be superior, especially in the
early months after surgery. Better functional results are not
necessarily associated with improved quality of life. The aim of
this study was to assess quality of life longitudinally as a primary end
point in patients undergoing rectal resection with different
reconstructive techniques, with a special emphasis on the early
postoperative phase. Overall, 64 patients were randomised to either
straight (n=32) or coloanal J pouch (n=32) anastomosis. Patients
were studied before operation, at the time of stoma reversal and at
3-monthly intervals for one year. Quality of life was measured using
two generic and one disease-specific instruments. Functional results
using a standardised score as well as manometric variables were recorded.
Thirty-nine patients (19 with a pouch and 20 with a straight anastomosis)
completed the trial. There was a marked difference between the two
groups with regard to quality of life profile. Patients with a pouch
reconstruction had a significantly better quality of life, particularly in
the early postoperative period. It was concluded that patients
undergoing low anterior resection and coloanal J pouch reconstruction may
expect not only better functional results but also an improved quality of
life in the early months after surgery compared with patients who receive
a straight coloanal anastomosis.
A randomized, double-blind trial of the
effect of metronidazole on pain after closed haemorrhoidectomy.
Balfour L, Stojkovic S G, Botterill I D et al. Dis
Colon Rectum 2002; 45: 1186-1191.
Haemorrhoidectomy has long been regarded by patients as an
inherently painful procedure. Reduction of pain after this operation
is an important goal with the ultimate aim being a reduction in the length
of inpatient stay. In order for this to be effective patients must
be selected appropriately and require regular laxative and
non-constipating analgesia. Metronidazole has been shown to reduce
postoperative pain after open haemorrhoidectomy. The aim of this
study was to evaluate the effect of metronidazole after closed
haemorrhoidectomy, an operation shown to be associated with less
discomfort than the open procedure. Overall, 28 patients undergoing
closed haemorrhoidectomy were randomised to receive metronidazole (400 mg;
n=18) or placebo (n=20) three times daily for seven postoperative days.
All patients received a stool softener and analgesics perioperatively.
Linear analogue scales were used to assess expected pain, actual pain and
patient satisfaction. Time to first bowel movement, return to normal
activity, complications and the use of additional analgesia was also
recorded. Both groups experienced less pain than expected.
Patients in the metronidazole group required less additional analgesia (6%
vs. 26%). Satisfaction scores were higher in the placebo group.
These differences were not statistically significant. There was no
difference in pain actually experienced, time to first bowel movement or
return to normal activity. It was concluded that closed
haemorrhoidectomy results in high patient satisfaction and low pain
scores. The use of metronidazole did not reduce postoperative pain.
Should 'doughnut histology be routinely
performed following anterior resection for rectal cancer. Speak W J,
Abercrombie J F. Ann R Coll Surg Eng 2003; 85:
The double-stapled technique of anterior resection of the
rectum for adenocarcinoma has enabled low anastomoses to be fashioned with
safety and efficiency. The staple-gun cuts two circular 'doughnuts'
of tissue from the inside of the anastomosis, one proximal and one distal.
It is customary for the doughnuts to be examined for completeness by the
operating surgeon since macroscopic defects in a doughnut increases the
risk of perioperative anastomotic leak. Doughnuts are invariably
submitted for histological examination but there is little evidence that
useful information is gained from the histopathological assessment.
The minimum dataset for colorectal cancer histopathology reports states
that it is not necessary to examine doughnuts histologically if the tumour
is more than 30 mm from the cut end. This paper reports on a
consecutive series of anterior resection doughnuts from 125 patients.
A retrospective review was undertaken to assess the impact of doughnut
histology on patient management. Only four of the doughnuts had a
histological abnormality reported and in none of the patients did it alter
the patients treatment. It was concluded that routine histological
examination of 'doughnuts' was not required in patients undergoing surgery
for rectal adenocarcinoma.
Symptoms and anal sphincter morphology
following primary repair of third-degree tears. Davis K, Kumar
D, Stanton S L et al. Br J Surg 2003; 90:
Childbirth injury is the main aetiological factor for
faecal incontinence in women. Vaginal delivery carries inherent
risks to the perineum, whereas structural damage to the anal sphincter
complex during first delivery predisposes a significant number of women to
the development of faecal incontinence. Third-degree tears involve
rupture of the anal sphincter complex without involvement of the rectal
mucosa. Such sphincter injuries are a serious complication of 0.6 to
9% of vaginal deliveries. The precise impact of these injuries on
future pelvic floor function remains unknown. The aim of this study
was to define the extent of structural and physiological damage to the
anal sphincter and to investigate anorectal function in women who
sustained a third-degree tears during vaginal delivery. Overall, 56
women who sustained a third degree tear were investigated prospectively.
All patients had a primary repair of the anal sphincter complex and were
assessed by anorectal physiology and endoanal ultrasonography at a mean of
4 months. Symptoms were assessed by direct personal interview and
also by a self-completed questionnaire. Some 44 patients had a
persistent anal sphincter defect on ultrasonography. The mean
resting and squeeze anal canal pressures were significantly lower in
patients with a combined defect than in those in whom the repair was
intact (p = 0.036 and p = 0.005 respectively). At
direct interview three patients volunteered current symptoms of faecal
and/or urinary incontinence whereas 32 reported bothersome symptoms on the
questionnaire. It was concluded that anatomical and physiological
damage during third-degree tears appears to be much greater than is
generally appreciated. Primary repair does nor provide lasting
integrity. A self-administered questionnaire appears to be more
accurate in defining the symptomatology.
Laparoscopic resection of rectosigmoid
carcinoma: prospective randomised trial. Leung K L, Kwok
S P Y, Lam S C W et al. Lancet 2004; 363:
Colorectal cancer is one of the commonest malignant
diseases worldwide, and laparoscopic resection of colorectal cancer has
been attempted since 1991. However, because of early port site
recurrences, concerns have been expressed about the adequacy of tumour
clearance and long-term survival after laparoscopic resection.
Laparoscopic resection has therefore been recommended for colorectal
cancer only as part of a randomised controlled clinical trial. The
aim of this study was to test the null hypothesis that there was no
difference in survival after laparoscopic and open resection for
rectosigmoid cancer. Between 1993 and 2002, 403 patients with
rectosigmoid carcinoma were randomised to receive either laparoscopic
assisted (n=203) or conventional open (n=200) resection of the tumour.
Survival and disease-free interval were the main endpoints. Patients
were last followed up in March 2003. Perioperative data was recorded
and direct costs of operation estimated. Data was analysed on an
intention to treat basis. The demographic details of the two groups
were similar. After curative resection, the probabilities of
survival at 5 years of the laparoscopic and open resection groups were 76%
and 73% respectively. The probabilities of being disease free at 5
years were 75% and 78% respectively. The operative time of the
laparoscopic group was significantly longer, whereas postoperative
recovery was significantly better than for the open resection group.
The distal margin, overall morbidity and operative mortality did not
differ between the groups. It was concluded that laparoscopic
resection of rectosigmoid carcinoma did not jeopardise survival and
disease control. The justification for adoption of laparoscopic
technique depends on the perceived value of its effectiveness in improving
short-term post-operative outcomes.
Emergency presentation of colorectal
cancer is associated with poor 5-year survival. McArdle C S,
Hole D J. Br J Surg 2004; 91: 605-609.
Colorectal cancer is the second commonest cause of cancer
in Western Europe and North America. Many patients have evidence of
locally advanced or metastatic disease at the time of initial presentation
and only half of those undergoing apparently curative resection survive 5
years. Approximately one-third of patients with colorectal cancer
present as an emergency. Previous studies have reported that
emergency presentation of colorectal cancer is associated with poor
outcome. Many of these studies were small and most were not adjusted
for case mix. The aim of this study was to establish, after
adjusting for case mix, the magnitude of the difference in postoperative
mortality and survival between patients undergoing elective surgery and
those presenting as an emergency. Overall, 3,200 patients who underwent
surgery for colorectal cancer between 1991 and 1994 were studied.
Five-year survival rates and adjusted hazard ratios were calculated.
Some 1603 (72%) of 2214 elective patients had a potentially curative
resection compared with 632 (64%) of 986 patients who presented as an
emergency (p<0.001). Following curative resection, the
postoperative mortality rate was 2.8% after elective and 8.2% after
emergency operation (p<0.001). Overall survival at 5-years
was 58% after elective and 39% after emergency curative surgery (p<0.001);
cancer-specific survival at 5 years was 71% and 53% respectively (p<0.001).
The adjusted hazard ratio for overall survival after emergency relative to
elective surgery was 1.68 (95% CI 1.49 - 1.90. p<0.001) and
that for cancer-specific survival was 1.90 (95% CI 1.62 - 2.22. p<0.001).
It was concluded that following apparently curative resection for
colorectal cancer, there was an excess of both cancer-related and
intercurrent deaths in patients who presented as an emergency.
FDG-PET for the pre-operative evaluation
of colorectal liver metastases. Arulampalam T H A, Francis D
L, Visvikis D et al. EJSO 2004; 30:
Some 50% of patients with colorectal cancer develop liver
metastases and die of their disease. Surgical resection of
colorectal liver metastases (CLM) improves 5-year survival between 25 and
40%. Surgical failure and recurrent disease may be due to inadequate
initial evaluation of metastatic disease. CT is a pre-operative
investigation for the presence of liver metastases but is a poor predictor
or resectability. It may fail to detect metastases and underestimate
the number of lobes involved. Spiral CT and CT arterial portography
have improved these figures. Positron emission tomography (PET)
targets cancer tissue through preferential accumulation of positron
labeled tracer in cells, using the fluorinated glucose analogue
fluorodeoxyglucose (FDG). Positron decay results in the emission of
high-energy photons that are detected by the scintillation crystals in the
PET scanner. The aim of this study was to assess the value of
FDG-PET in the management of patients with confirmed CLM referred for
hepatic resection. A prospective study of patients referred for
hepatic resection was undertaken. Patients were staged with FDG-PET
and spiral CT scanning. The results of these two imaging modalities
were considered independently. Overall, 28 patients had confirmed
CLM. Eleven patients had solitary CLM, 10 of whom were correctly
identified by both modalities. In the remaining 17 patients, 10 had
multiple CLM and 7 had extrahepatic disease. FDG-PET detected all lesions
(sensitivity 100%, specificity 91%). CT incorrectly diagnosed
solitary CLM in 5 patients and failed to identify extrahepatic disease in
4 patients (sensitivity 47%, specificity 91%). FDG-PET resulted in
altered management for 12 patients of whom 7 avoided inappropriate
surgery. It was concluded that FDG-PET is more sensitive and
specific for pre-operative staging of CLM. FDG-PET confers clinical
benefit through altered patient management.
Preoperative versus postoperative
chemoradiotherapy for rectal cancer. Sauer R, Becker H,
Hohenberger W et al. N Engl J Med 2004; 351:
Adjuvant radiotherapy with or without chemotherapy has
been used widely to improve outcomes in patients with rectal cancer.
For locally advanced disease, postoperative chemoradiotherapy
significantly improves both local control and overall survival as compared
with surgery alone or surgery plus irradiation. The aim of this
study was to compare preoperative chemoradiotherapy with postoperative
chemoradiotherapy for locally advanced rectal cancer. Patients with
clinical stage T3 or T4 or node-positive disease were randomly assigned to
either preoperative or postoperative chemoradiotherapy. The
preoperative treatment consisted of 5040 cGy delivered in fractions of 180
cGy per day, five days per week and fluorouracil given in a 120-hour
continuous infusion at a dose of 1000mg per square metre of BSA per day
during the first and fifth weeks of the radiotherapy. Surgery was
performed 6 weeks after completion of the chemoradiotherapy. One
month after surgery, four five-day cycles of fluorouracil (500mg per
square metre per day) were given. Chemoradiotherapy was identical in
the postoperative treatment group except for the delivery of a boost of
540 cGy. The primary endpoint was overall survival. Overall,
421 patients were randomly assigned to receive preoperative
chemoradiotherapy and 402 patients to receive postoperative
chemoradiotherapy. The overall survival rates were 76% and 74%
respectively (p=0.80). The five-year cumulative incidence of
local relapse was 6% for patients assigned preoperative chemoradiotherapy
and 13% in the postoperative-treatment group (p=0.006). Grade
3 or 4 acute toxic effects occurred in 27% of the patients in the
preoperative group as compared to 40% in the postoperative treatment group
(p=0.001). It was concluded that preoperative
chemoradiotherapy, as compared with postoperative chemoradiotherapy,
improved local control and was associated with reduced toxicity but did
not improve overall survival.
A comparison of laparoscopically
assisted and open colectomy for colon cancer. The Clinical Outcomes
of Surgery Therapy Study Group. N Engl J Med 2004; 350:
Minimally invasive, laparoscopically assisted surgery has
been considered for over a decade for patients undergoing colectomy for
colon cancer. Concern that this approach would compromise survival
by failing to achieve a proper oncologic resection or adequate staging or
by altering patterns of recurrence prompted a controlled trial evaluation.
A noninferiority trial was conducted at 48 institutions. Overall 872
patients with adenocarcinoma of the colon were randomly assigned to
undergo open or laparoscopically assisted colectomy. The median
follow-up was 4.4 years. The primary endpoint was the time to tumour
recurrence. At three years, the rates of recurrence were similar in
the two groups. They were 16% in the group that underwent
laparoscopically assisted surgery and 18% in the open colectomy group (HR
for recurrence 0.86, 95% CI 0.63-1.17). Recurrence rates in the
surgical wounds were less than 1% in both groups (p=0.50).
The overall survival rate at three year was also very similar in the two
groups. It was 86% in the laparoscopically assisted group and 85% in
the open colectomy group. There was no significant difference
between the groups in time to recurrence or overall survival for patients
with any stage of cancer. Perioperative recovery was faster in the
laparoscopic-surgery group than in the open colectomy group as reflected
by a shorter median hospital stay (five days vs. six days, p<0.001),
briefer use of parenteral opiates (three days vs. four days, p<0.001)
and oral analgesics (one day vs. two days, p<0.02). The rates
of intraoperative complications, 30-day postoperative mortality,
complications at discharge and 60 days, hospital readmission and
reoperation were very similar between the groups. It was concluded
that in this multi-institutional study, the rates of recurrent cancer were
similar after laparoscopically assisted colectomy and open colectomy,
suggesting that the laparoscopic approach is an acceptable alternative to
open surgery for colon cancer.
Quality of life and functional outcome
following anterior or abdominoperineal resection for rectal cancer.
Guren M G, Eriksen M T, WiiG J N et al. EJSO
2005; 31: 735-742.
In patients with rectal cancer, the introduction of
stapling devices, the demonstration that shorter resection margins are
adequate and the introduction of total mesorectal excision, has resulted
in an increasing number of patients being treated with restorative
surgery. The trend has been that increasingly lower metastases are
performed. Whilst having a stoma may affect the patients quality of
life (QoL), low anastomoses may result un reduced anorectal function,
which may impact on QoL. The aims of this study were to investigate
QoL and functional outcome in patients undergoing anterior resection (AR)
and abdominoperineal resection (APR) and to assess whether these were
dependent on the level of the anastomosis. Patients who were without
recurrent or metastatic disease were identified from the Norwegian Cancer
Registry. QoL was assessed by the EORTC QLQ-C30 and QLQ-CR38
and rectal function by a short questionnaire. Of the 319 patients
studied, 229 had undergone AR and 90 APR. The median age was 73
years and the median time since surgery was 64 months. Mean QoL
scores for body image and male sexual problems were better following AR
than APR (p<0.01). Patients who had undergone AR had higher
mean scores for constipation (p<0.001) and more often used
anti-diarrhoeal medication (p=0.005) than patients how had
undergone APR. Patients with a low anastomosis (< 3 cm) had more
incontinence for gas and solid stools (p<0.05) and had more
incontinence (p=0.006) compared with patients with a high
anastomosis, but there was no difference in QoL. Subgroup analysis
showed that irradiated patients (n=34) had worse rectal function in terms
of frequency, urgency and incontinence (p<0.01). It was
concluded that although rectal function was impaired in patients with a
low anastomosis, patients who had undergone AR had better QoL than
patients who had undergone APR.
Randomized clinical trial comparing
primary closure with the Limberg flap in the treatment of primary
sacrococcygeal pilonidal disease. Akca T, Colak T,
Ustunsoy B et al. B J Surg 2005; 92: 1081-1084.
Sacrococcygeal pilonidal disease (SPD) is a common
condition that affects young people. It causes discomfort that may
interfere with education and employment. A number of surgical options
exist ranging from lying open, marsupialization, excision and primary
closure to rhomboid excision and the Limberg flap procedure. Simple
excisional techniques are associated with high morbidity and recurrence
rates due to the continuing presence of the natal cleft. Rhomboid
excision removes the natal cleft and may be associated with a lower
recurrence rate. The purpose of this study was to compare the
outcome of excision and primary closure with that of rhomboid excision and
the Limber flap procedure in patients with primary SPD. Overall, 200
consecutive patients with primary SPD were randomly allocated to undergo
either excision and primary closure (group 1, n=100) or rhomboid
excision (group 2, n=100). Duration of operation,
postoperative pain, time to first mobilisation, lengthy of hospital stay,
postoperative complications, time to resumption of work, recurrence and
time to recurrence in all patients were recorded. Duration of
operation was longer in group 2 than in group 1 (p=0.001).
However, postoperative pain was less (p<0.001), duration of
hospital stay shorter (p<0.001), time to resumption of work shorter
(p<0.001) and postoperative complications fewer (p<0.001) in
group 2. During a median follow-up of 28 months, no recurrences were
detected in group 2 versus 11 in patients in group 1 (p=0.001).
It was concluded that because of its low complication rate and acceptable
long-term results, rhomboid excision and the the Limberg flap procedure is
preferable to simple excision and primary closure in the treatment of SPD.
Experience of 3711 stapled
haemorrhoidectomy operations. Ng K-h, Ho K-S, Ooi B-S
et al. Br J Surg 2006; 93: 226-230
The use of stapled haemorrhoidectomy for the treatment of
third and fourth degree haemorrhoids was first introduced in Singapore in
late 1999. Since then, the Department of Colorectal Surgery, Singapore
General Hospital, has performed this procedure more than 3,700 times and
now does so routinely in an ambulatory setting. The aim of this
study was to review retrospectively the effectiveness and efficiency of
this procedure. A retrospective review was undertaken of all
patients who underwent stapled haemorrhoidectomy between 1999 and 2004.
The outcomes studied were patient profiles, priority of operation,
indications for surgery, length of operation, postoperative complications
and recurrences. A total of 3711 patients (51% women) had the
surgery. The median patient age was 50 (range 18-88) years.
The main indications were bleeding (81%), haemorrhoidal prolapse (60%) and
thrombosis (4%). The median duration of operation was 15 (range
5-45) min. Minor complications occurred in 12% of patients; acute
retention of urine (5%), bleeding (4%), significant post-operative pain
(2%), anorectal stricture (1%), perianal haematoma (<1%) and significant
residual skin tags (<1%). One patient developed a perianal abscess
after the operation. Anastomotic dehiscence occurred in 3 patients.
Overall, 12 (0.3%) patients had recurrence at a median of 16 (range 5-45)
months. It was concluded that considerable experience with stapled
haemorrhoidectomy confirms that it is a safe and effective procedure.
Is rectal washout necessary in anterior
resection for rectal cancer? A prospective clinical study.
Terzi C, Unek T, Sagol O et al. World J Surg
2006; 30: 233-241.
Implantation of exfoliated malignant cells has been
suggested as a possible mechanism of tumour recurrence following
colorectal anastomoses. There is experimental evidence that
colorectal cancer cells are shed into the lumen of the bowel, are viable
and may represent clones of cells capable of transplanting.
Implantation of these cells may be prevented by cytocidal washout.
The aim of this study was to assess whether malignant cells are likely to
be collected by a circular stapler introduced transanally to perform the
anastomosis and to observe local recurrence during follow up, with special
attention to the washout status of the patient. Between 1999 and
2004, 96 patients with carcinoma of the rectum or distal sigmoid colon
underwent anterior resection under the care of three surgeons. While
38 patients had rectal washout with 5% povidone-iodine before anastomosis,
58 patients did not. A circular stapler was used for the anastomosis
and the stapler was immediately washed in 100 ml saline. The fluid
was classified as acellular or containing benign or malignant cells.
Malignant cells were obtained from the stapler after use in 3 patients
(8%) on whom rectal washout was performed and in 2 patients (3%) who did
not have rectal washout. Three patients (8%) in the washout group
developed local recurrence and 2 patients (3%) in the no-washout group had
local recurrence. The median follow up was 23 (range 9-70) months.
It was concluded that although this was not a randomised trial, the
results do not offer support to the use of intraoperative rectal washout
when a circular stapler is used for an anterior resection for rectal
Randomised clinical trial of 0.2% GTN
ointment for wound healing and pain reduction after open diathermy
haemorrhoidectomy. Tam K-Y, Sng K K, Tay K-H et al.
Br J Surg 2006; 93: 1464-1468.
Haemorrhoidectomy is associated with considerable
postoperative pain and prolonged wound healing that may delay return to
work. Postoperative spasm of the internal anal sphincter may be a
contributory factor. Previous attempts to address this issue by
using internal anal sphincterotomy, anal dilatation or suppositories
failed to show a significant reduction in postoperative pain.
Topical GTN ointment reduces anal canal pressure, improves anodermal blood
flow and has a role in the treatment of chronic anal fissure.
Topical GTN after haemorrhoidectomy may reduce anal spasm and post
operative pain and accelerate wound healing. The aim of this study
was to assess whether GTN ointment promotes wound healing and reduces pain
after open haemorrhoidectomy. A randomised prospective double-blind
placebo controlled trial was conducted. Patients were randomised to
receive either 0.2% ointment of petroleum jelly as a placebo.
Patients were asked to complete a pain diary. Complete healing was
defined as complete epithelialisation. There 40 patients in the GTN
group and 42 in the placebo group. There was no statistically
significant difference in sex, weight, type of haemorrhoids, duration of
surgery, hospital stay and complication rate between the two groups.
Pain scores and analgesic use were not significantly different between the
two groups. By 3 weeks, 17 patients in the GTN group had completely
epithelialised wounds compared with eight patients in the placebo group (p=0.021).
Only one patient who received GTN experienced headache requiring
discontinuation of the ointment. It was concluded that 0.2% GTN
ointment improved wound healing rates but did not reduced pain in patients
undergoing open haemorrhoidectomy.
Diagnostic accuracy of preoperative
magnetic resonance imaging in predicting curative resection of rectal
cancer: prospective observational study. MERCURY Study Group.
BMJ 2006; 333: 779-785.
Colorectal cancer is a common malignancy and the second
commonest cause of cancer death in the Western world. Rectal cancer,
defined as a tumour with its lower edge with 15cm of the anal verge,
accounts for about a third of all colorectal malignancies. In total
mesorectal excision surgery, the plane of dissection is formed by the
mesorectal fascia, which encloses the fatty mesorectum that envelops the
rectum. This fascia forms the circumferential resection margin and
tumour within 1mm of the margin strongly predicts local recurrence and
poor survival. High resolution MRI consistently shows the mesorectal
fascia and can predict tumour at the potential circumferential resection
margin. The aim of this study was to assess the accuracy of
preoperative staging with MRI to predict surgical circumferential
resection margins. A prospective observational study was undertaken
of rectal cancers treated in 11 different units between January 2002 and
October 2003. Overall, 408 patients presenting with all stages of
rectal cancer underwent MRI before total mesorectal surgery and
histopathological assessment. The primary outcome measure was the
accuracy of MRI in predicting curative resection. 354 of the 408
patients (87%) has a clear circumferential resection margin. The
specificity for prediction of a clear margin by MRI was 92% (95% CI
90-95%). High resolution scans were technically satisfactory in 93%
of patients. Magnetic resonance imaging predicted clear margins in
349 patients. At surgery 327 patients had clear margins (94%.
95% CI 91-96%). It was concluded that high resolution magnetic
resonance imaging accurately predicts whether the surgical resection
margins will be clear or affected by tumour. This technique can be
reproduced in multiple centres to predict curative resection and can warn
of potential surgical failure, thus enabling the selection of patients for
Randomised clinical trial comparing
botulinum toxin injections with 0.2 percent nitroglycerin ointment for
chronic anal fissure. Brisinda G, Cadeddu F, Brandara F
et al. Br J Surg 2007; 94: 162-167.
Treatment of chronic anal fissure has shifted in recent
years from surgical to medical. Primary medical therapy is an
inexpensive and convenient was of curing most chronic anal fissures.
With medication, it is possible to create the effect of a temporary and
reversible sphincterotomy, reducing anal sphincter pressure only until the
fissure has healed. Two such approaches - injection of botulinum
toxin and application of nitroglycerin ointment - have been used to treat
chronic anal fissure and avoid the risk of permanent injury to the
internal anal sphincter. The aim of this clinical trail was to
compare the clinical results of botulinum toxin injections with those of
0.2% nitroglycerin ointment for the treatment of chronic anal fissure.
Overall, 100 adult were randomly assigned to receive treatment with type A
botulinum toxin injected into the internal anal sphincter or 0.2%
nitroglycerin ointment applied three time daily for eight weeks.
After 2 months, the fissures were healed in 46 (92%) of 50 patients in the
toxin group and in 35 (70%) in the nitroglycerin group (p=0.009).
Three patients in the toxin group and 17 patients in the nitroglycerin
group reported adverse effects (p<0.001). Those treated with
botulinum toxin had mild incontinence to flatus that lasted 3 weeks after
treatment but disappeared spontaneously. Those in the nitroglycerin
group has transient moderate to severe headaches. Nineteen patients
who did not have a response to the assigned treatment crossed over to the
other therapy. It was concluded that although treatment with either
topical nitroglycerin or botulinum toxin is effective as an alternative to
surgery in patients with chronic anal fissure, botulinum toxin is the more
Randomized clinic trial comparing
day-care open haemorrhoidectomy under local versus general anaesthesia.
Kushwaha R, Hutchings W, Davies C et al. Br J Surg
2008, 95: 555-563.
Open haemorrhoidectomy is traditionally viewed as a
painful procedure. Most operations are performed under general or
regional anaesthesia. Day-care open haemorrhoidectomy under local
anaesthesia may be the most cost-effective approach to haemorrhoidectomy.
This prospective randomized clinical trial compared clinical outcome and
patients' evaluation of pain and satisfaction after day-care open
haemorrhoidectomy under general anaesthesia (GH) and local anaesthesia
(LH). Forty-one patients with third-degree haemorrhoids were
randomized to LH (n=19) or GH (n=22). Patient demographics were
comparable/ A single haemorrhoid was excised in 15 patients and two
and three haemorrhoids in 13 each. Independent nurse-led assessment
and clinical evaluation were carried out for 6 months. Outcome and
pain scores were assessed at 30, 60 and 90 mins, then daily for 10 days
and satisfaction scores at 10 days, 6 weeks and 6 months. Pain was
worse following LH than GH at 90 mins after surgery (p=0.028) but
pain scores on reaching home were similar. Maximum pain was
experienced on day 3 after LH and day 6 after GH. Mean pain over 10
days, expectation and satisfaction scores were similar in the two groups.
It was concluded that LH has a similar tolerance and clinical outcomes and
was associated with shorter journey times and lower costs
Randomized clinical trial of botulinum
toxin injection for pain relief in patients with thrombosed external
haemorrhoids. Patti R, Arcara M, Bonventre S et al.
Br J Surg 2008; 95: 1339-1343.
Thrombosed external haemorrhoids (TEH) are one of the most
frequently diagnoses anorectal emergencies. They commonly occur in young
adults of both sexes. They are associated with swelling and intense
pain. Internal sphincter hypertonicity plays a role in the aetiology
of the pain. Clinical studies have demonstrated that injection of
botulinum toxin into the anal sphincter can temporarily reduce maximum
anal resting pressure (MRP) in patients with chronic fissures and after
haemorrhoidectomy. The aim of this study was to assess the efficacy
and safety on intrasphinteric injection of botulinum toxin for pain relief
in patients with TEH. Thirty patients with thrombosed external
haemorrhoids who refused surgical operation were randomized into two
groups. Patients received an intrasphinteric injection of either 0.6
ml saline or 0.6 ml of a solution containing 30 units botulinum toxin.
Anorectal manometry was performed before treatment and after 5 days.
After 5 days of treatment, the MRP fell in both groups but was
significantly lower in the botulinum group (p=0.004). Pain
intensity was significantly reduced within 24 hours of botulinum toxin
treatment (p<0.001) but only after one week in the placebo group (p=0.019).
It was concluded that a single injection of botulinum toxin into the anal
sphincter seems to be effective in rapidly controlling the pain associated
with TEH and could represent an effective conservative treatment for this
Accuracy of CT colonography for the
detection of large adenomas and cancers. Johnson C D, Chen
m-H, Toledano A Y et al. N Engl J Med 2008; 359:
Colorectal cancer is the third most common cancer and the
second leading cause of death from cancer in USA. Mortality from
colorectal cancer can be reduced by regular screening bit despite if
effectiveness screening remains underused for many reasons drawbacks in
terms of the performance, comfort and availability of currently endorsed
test options. CT colonography uses advanced visualisation technology
that permits minimally invasive evaluation of the entire colorectum.
It has several potential benefits over other screening modalities.
However, its accuracy as a screening tool in asymptomatic adults has not
been well defined. In this study 2600 asymptomatic study
participants, 50 years of age or older underwent CT colonography after
standard bowel preparation. Radiologists trained in CT colonography
reported all lesions measuring more than 5 mm in diameter. Optical
colonoscopy and histological review were then performed. The primary
end point was the detection by CT colonography of histologically confirmed
large adenomas and carcinomas that had been detected by colonoscopy.
Complete data was available for 2531 participants (97%). For large
adenomas and cancers the mean per-patient estimate of sensitivity,
specificity, positive and negative predictive values for CT colonography
were 0.90, 0.86, 0.23 and 0.99. It was concluded that in this study,
in asymptomatic adults, CT colonographic screening identified 90% of
subjects with adenomas and cancers measuring 10mm or more in diameter.
These finding augment published date on the role of CT colonography in
screening patients with an average risk of colorectal cancer.
Preoperative radiotherapy versus
selective postoperative chemoradiotherapy in patients with rectal cancer;
a multicentre, randomise trial. Sebag-Montefiore D, Stephens R
J, Steele R et al. Lancet 2009; 373:
Preoperative and postoperative radiotherapy reduces the
risk of local recurrence in patients with operable rectal cancer.
However, improvements in surgery and histopathological assessment mean
that the role of radiotherapy needs to be reassessed. The aim of
this study was to compare short-course preoperative radiotherapy versus
initial surgery with selective postoperative chemoradiotherapy. A
randomised trial was undertaken in 80 centres in 4 countries.
Overall, 1350 patients with operable adenocarcinoma of the rectum were
randomly assigned, by a minimisation procedure, to short course
preoperative radiotherapy (25 Gy in five fractions: n=647) or to initial
surgery with selective postoperative chemoradiotherapy (45 Gy in 25
fractions with concurrent 5-flurouracil) restricted to patients with
involvement of the circumferential resection margin (n=676). The
primary outcome measure was local recurrence. Analysis was by
intention to treat. At the time of analysis, which included all
participants, 330 patients had died (157 preoperative radiotherapy group
vs. 173 selective postoperative chemoradiotherapy), and median follow-up
of surviving patients was 4 years. 99 patients had developed local
recurrence (27 preoperative radiotherapy vs 72 selective postoperative
chemoradiotherapy). We noted a reduction of 61% in the relative risk of
local recurrence for patients receiving preoperative radiotherapy (hazard
ratio [HR] 0·39, 95% CI 0·27—0·58, p<0·0001), and an absolute difference
at 3 years of 6·2% (95% CI 5·3—7·1) (4·4% preoperative radiotherapy vs.
10·6% selective postoperative chemoradiotherapy). We recorded a relative
improvement in disease-free survival of 24% for patients receiving
preoperative radiotherapy (HR 0·76, 95% CI 0·62—0·94, p=0·013), and an
absolute difference at 3 years of 6·0% (95% CI 5·3—6·8) (77·5% vs. 71·5%).
Overall survival did not differ between the groups (HR 0·91, 95% CI
0·73—1·13, p=0·40). It was concluded that this trial showed
convincing and consistent evidence that short-course preoperative
radiotherapy is an effective treatment for patients with operable rectal
Randomized clinical trial comparing
laparoscopic and open surgery in patients with rectal cancer.
Lujan J, Valero G, Hernandez Q et al. Br J Surg 2009;
The laparoscopic treatment of rectal cancer is
controversial. The aim of this to study was to compare surgical outcomes
after laparoscopic and open approaches for mid and low rectal cancers.
Overall, 204 patients with mid and low rectal adenocarcinomas were
allocated randomly to open (103) or laparoscopic (101) surgery. The
surgical team was the same for both procedures. Most patients had stage II
or III disease, and received neoadjuvant therapy with oral capecitabine
and 50-54 Gy external beam radiotherapy. Sphincter-preserving surgery was
performed in 78·6 and 76·2 per cent of patients in the open and
laparoscopic groups respectively. Blood loss was significantly greater for
open surgery (P < 0·001) and operating time was significantly greater for
laparoscopic surgery (P = 0·020), and return to diet and hospital stay
were longer for open surgery. Complication rates, and involvement of
circumferential and radial margins were similar for both procedures, but
the number of isolated lymph nodes was greater in the laparoscopic group
(mean 13·63 versus 11·57; P = 0·026). There were no differences in local
recurrence, disease-free or overall survival. It was concluded that
laparoscopic surgery for rectal cancer has a similar complication rate to
open surgery, with less blood loss, rapid intestinal recovery, shorter
hospital stay, and no compromise of oncological outcomes.
Blinded randomized clinical trial of
botulinum toxin versus isosorbide dinitrate ointment for treatment of anal
fissure. Festen S, Gisbertz S S, van Schaagen F. Br J Surg
2009; 96: 1393-1399.
Nitric oxide donors such as
isosorbide dinitrate (ISDN) are considered the first choice of treatment
for anal fissure. After reports of the successful treatment of such
fissures with botulinum toxin, this randomized blinded trial compared
botulinum toxin with ISDN in the treatment of chronic anal fissure.
Patients were randomized to receive an injection of botulinum in the
internal anal sphincter and a placebo ointment, or a placebo injection and
ISDN ointment. The primary endpoint was macroscopic fissure healing after
4 months. After 4 months macroscopic healing of the fissures was noted in
14 of 37 patients in the botulinum group and 21 of 36 in the ISDN group.
Pain scores were lower among patients who received ISDN, although the
difference was not significant. Side-effects were similar in the two
groups. It was concluded that in contrast with previous reports on
botulinum toxin as a therapeutic agent for anal fissure, this study found
no advantage over treatment with a nitric oxide donor as regards fissure
healing and fissure-related pain
Increased serum levels of C-reactive
protein precede anastomotic leak in colorectal surgery. Woeste G,
Muller C, Beckstein W O et al. World J Surg 2010;
Anastomotic leakage (AL) is a severe complication
following colorectal surgery. C-reactive protein (CRP) is considered to be
an indicator of postoperative complications. Between August 2002 and
August 2005, 342 colorectal resections with primary anastomosis were
performed at the Department of General and Vascular Surgery. Johann
Wolfgang Goethe-University Frankfurt. For this retrospective study, serum
CRP was measured daily until postoperative day 7, and in cases of AL it
was excluded from statistical analysis beginning with the day on which the
AL was diagnosed. Twenty-six of 342 (7.6%) patients developed AL at a mean
of 8.7 days postoperatively. The in-hospital mortality was 3.5% for all
patients and was significantly higher in the AL group (11.5 versus 2.8%).
The CRP level in the two groups showed a peak on day 2.5 and day 2.2,
respectively. In case of postoperative AL the CRP level did not show a
marked decline during the next few days. Compared to the cases where AL
did not develop, there was a significantly higher increase in CRP from the
preoperative level to the levels measured on postoperative day 3, 5, 6 and
7. Higher CRP levels were observed in patients experiencing pneumonia or
urinary tract infection, but the decrease of CRP values was not as slow as
in cases of AL. It was concluded that serum CRP levels are a relevant
marker in detecting postoperative complications in colorectal surgery.
Prolonged elevation and a missing decline in CRP level precede the
occurrence of AL.
Five year follow‐up of the Medical
Research Council CLASICC trial of laparoscopically assisted versus open
surgery for colorectal cancer. Jayne D G, Thorpe H C, Copeland J
et al. Br J Surg 2010; 97: 1638-1645.
The UK Medical Research Council CLASICC trial assessed the safety and
efficacy of laparoscopically assisted surgery in comparison with open
surgery for colorectal cancer. The results of the five year follow‐up
analysis are presented in this paper. Outcomes were analysed and included
overall and disease‐free survival, and local, distant and wound/port‐site
recurrences. Two exploratory analyses were performed to evaluate the
effect of age (70 years or less, or more than 70 years) on overall
survival between the two groups, and the effect of the learning curve. No
differences were found between laparoscopically assisted and open surgery
in terms of overall survival, disease‐free survival, and local and distant
recurrence. Wound/port‐site recurrence rates in the laparoscopic arm
remained stable at 2·4 per cent. Conversion to open operation was
associated with significantly worse overall but not disease‐free survival,
which was most marked in the early follow‐up period. The effect of surgery
did not differ between the age groups, and surgical experience did not
impact on the 5‐year results. It was concluded that this study confirmed
the oncological safety of laparoscopic surgery for both colonic and rectal
cancer. The use of laparoscopic surgery to maximize short‐term outcomes
does not compromise the long‐term oncological results
A Prospective, randomized, single-blind
comparison of laparoscopic versus open sigmoid colectomy for
diverticulitis. Gervaz P, Inan I, Perneger T et al.
Ann Surg 2010; 252; 3-8
The aim of this study was to compare open and laparoscopic sigmoid
resection for diverticulitis with the patient and the nursing staff
blinded to the surgical approach. A total of 113 patients scheduled for an
elective sigmoid resection were randomized to receive either a
conventional open (54 patients) or a laparoscopic (59 patients) approach.
Postoperatively, an opaque wound dressing was applied and left in place
for 4 days, and patients from both groups were managed similarly. The
primary endpoints for analysis were postoperative pain, duration of
postoperative ileus and duration of hospital stay. The median
duration of procedure was 165 minutes (range, 90–285) in the laparoscopy
group and 110 minutes (range, 70–210) in the open group (P < 0.0001). The
median delay between surgery and first bowel movement was 76 (range,
31–163) hours in the laparoscopy group versus 105 (range, 53–175) hours in
the open group (P < 0.0001). The median score for maximal pain (assessed
by a visual analogue scale) was 4 (range, 1–10) in the laparoscopy group
and 5 (range, 1–10) in the open group (P = 0.05). Finally, the median
duration of hospital stay was 5 days (range, 4–69) in the laparoscopy
group versus 7 days (range, 5–17) in the open group (P < 0.0001). It was
concluded that laparoscopic sigmoid resection is associated with a 30%
reduction in duration of postoperative ileus and hospital stay. By
comparison, benefits in terms of postoperative pain appear less
impressive, when the patient is blinded to the surgical technique.
Randomized clinical trial of short-term
outcomes following purse-string versus conventional closure of ileostomy
wounds. Reid K, Pockney P, Pollitt T et al. Br
J Surg 2010; 97: 1151-1157.
Ileostomy closure is an operation with an underappreciated morbidity,
including surgical-site infection, small bowel obstruction and anastomotic
leakage. Surgical-site infections, in particular, are a frequent
occurrence following closure of contaminated wounds. This randomized
controlled trial compared a purse-string closure technique with
conventional linear closure. Sixty-one patients were randomized to
conventional or purse-string closure of ileostomy wounds. The primary
endpoint was the incidence of surgical-site infection, including
infections requiring hospital or community treatment. Purse-string closure
resulted in fewer surgical-site infections than conventional closure: two
of 30 versus 12 of 31 respectively (p = 0.005). It was concluded
that purse-string method results in a clinically relevant reduction in
surgical-site infections after ileostomy closure.
Computed tomographic colonography versus
colonoscopy for investigation of patients with symptoms suggestive of
colorectal cancer (SIGGAR): a multicentre randomised trial. Atkin W,
Dadswell E, Wooldrage K et al. Lancet 2013; 381:
Colonoscopy is the gold-standard test for investigation of symptoms
suggestive of colorectal cancer. Computed tomographic colonography
(CTC) is an alternative, less invasive test. However, additional
investigation after CTC is needed to confirm suspected colonic lesions,
and this is an important factor in establishing the feasibility of CTC as
an alternative to colonoscopy. the aim of this study was to compare rates
of additional colonic investigation after CTC or colonoscopy for detection
of colorectal cancer or large (≥10 mm) polyps in symptomatic patients in
clinical practice. A pragmatic multicentre randomised trial recruited
patients with symptoms suggestive of colorectal cancer from 21 UK
hospitals. Eligible patients were aged 55 years or older and regarded by
their referring clinician as suitable for colonoscopy. Patients were
randomly assigned (2:1) to colonoscopy or CTC by computer-generated random
numbers, in blocks of six, stratified by trial centre and sex. The
primary outcome measure was the rate of additional colonic
investigation—by intention to treat. Overall, 1610 patients were
randomly assigned to receive either colonoscopy (n=1072) or CTC (n=538).
30 patients withdrew consent, leaving for analysis 1047 assigned to
colonoscopy and 533 assigned to CTC. 160 (30·0%) patients in the CTC group
had additional colonic investigation compared with 86 (8·2%) in the
colonoscopy group (relative risk 3·65, 95% CI 2·87—4·65; p<0·0001). Almost
half the referrals after CTC were for small (<10 mm) polyps or clinical
uncertainty, with low predictive value for large polyps or cancer.
Detection rates of colorectal cancer or large polyps in the trial cohort
were 11% for both procedures. CTC missed 1 of 29 colorectal cancers and
colonoscopy missed none (of 55). Serious adverse events were rare. It was
concluded that guidelines are needed to reduce the referral rate after
CTC. For most patients, however, CTC provides a similarly sensitive, less
invasive alternative to colonoscopy.