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Colorectal papers


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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 colon.

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; 86:1341-1343. 

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:  1067-1070.

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 ineffective.

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;  345:  638-646. 

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 standardised TME.

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:  1054-1059.

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 adjuvant therapy.

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 studies. 

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;  89:  1108-1117.

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:  26-27.

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:  1573-1579.

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:  1187-1192.

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:  286-291. 

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:  1731-1740.

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:  2050-2059.

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 cancer. 

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 preoperative treatment.

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 effective option.

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 condition

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:  1207-1217. 

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:  811-820. 

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] 039, 95% CI 027058, p<00001), and an absolute difference at 3 years of 62% (95% CI 5371) (44% preoperative radiotherapy vs. 106% selective postoperative chemoradiotherapy). We recorded a relative improvement in disease-free survival of 24% for patients receiving preoperative radiotherapy (HR 076, 95% CI 062094, p=0013), and an absolute difference at 3 years of 60% (95% CI 5368) (775% vs. 715%). Overall survival did not differ between the groups (HR 091, 95% CI 073113, p=040).  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 cancer.

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;  96:  982-989. 

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 786 and 762 per cent of patients in the open and laparoscopic groups respectively. Blood loss was significantly greater for open surgery (P < 0001) and operating time was significantly greater for laparoscopic surgery (P = 0020), 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 1363 versus 1157; P = 0026). 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;  34:  140-146. 

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 24 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, 90285) in the laparoscopy group and 110 minutes (range, 70210) in the open group (P < 0.0001). The median delay between surgery and first bowel movement was 76 (range, 31163) hours in the laparoscopy group versus 105 (range, 53175) hours in the open group (P < 0.0001). The median score for maximal pain (assessed by a visual analogue scale) was 4 (range, 110) in the laparoscopy group and 5 (range, 110) in the open group (P = 0.05). Finally, the median duration of hospital stay was 5 days (range, 469) in the laparoscopy group versus 7 days (range, 517) 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.

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