Oral sodium phosphate solution is a superior colonoscopy preparation to polyethylene glycol with bisacodyl

PURPOSE

The aim of this study was to compare the efficacy and patient tolerance of two bowel preparations for colonoscopy.

METHODS

Three hundred twenty-three consecutive patients undergoing colonoscopy were randomly assigned to receive either oral sodium phosphate, or 2 liters of polyethylene glycol solution preceded by the stimulant laxative bisacodyl. Patients were asked to record the effects of the preparation, noting any vomiting, nausea, or abdominal pain, and to determine a discomfort rating on a scale of 1 to 5. One hundred sixty-nine patients were assigned to the oral sodium phosphate solution, and 154 to polyethylene glycol with bisacodyl. Surgeons were blinded to the preparation used and rated the quality of the bowel preparation on a scale of 1 to 5.

RESULTS

Ninety-nine percent of patients in the sodium phosphate group drank all of the solution as opposed to 91 percent of patients in the polyethylene glycol with bisacodyl group. Patients in the sodium phosphate group reported significantly less discomfort (P = 0.002). No significant difference was reported for vomiting, nausea, or abdominal pain associated with the preparations. The quality of bowel cleansing was considered by the colonoscopists significantly better for the sodium phosphate group than the polyethylene glycol with bisacodyl group (P < 0.000001).

CONCLUSIONS

Colonoscopy preparation with sodium phosphate solution is better tolerated and more effective than polyethylene glycol with bisacodyl.

Successful overlapping anal sphincter repair: relationship to patient age, neuropathy, and colostomy formation

BACKGROUND

Fecal incontinence from single anal sphincter defects are surgically remedial and commonly the result of obstetric injuries. Overlapping anal sphincter repair has previously been associated in small series with good results in 69 to 97 percent of patients.

OBJECTIVES

The aims of this study were to assess the results of overlapping anal sphincter repair in one institution and to assess the effects of age, presence of a neuropathy, and addition of a temporary colostomy on the success of surgery.

METHODS

A study of 57 overlapping anal sphincter repairs in 56 (54 females) patients at the Royal Prince Alfred Hospital during a six-year period was performed. All patients were investigated preoperatively with endoanal ultrasound and concentric needle electromyography. Patients have been assessed prospectively since 1994 with a questionnaire, including a four-point Likert scale of continence level, the St. Mark's incontinence scoring system (range, 0-13), the Pescatori incontinence scoring system (range, 0-6), and patient assessment of success or failure of the overlapping anal sphincter repair. A colostomy was selectively formed in conjunction with an overlapping anal sphincter repair in 21 patients (8 preoperatively, 13 simultaneously), and 18 patients had a concomitant neuropathy (3 unilateral, 15 bilateral).

RESULTS

After a median follow-up of 18 months, median continence scores overall had improved from St. Mark's incontinence scoring 13 to 3 (P < 0.0001) and Pescatori incontinence scoring 6 to 2 (P < 0.0001). Forty-nine of 57 (86 percent) repairs have been successful, and 8 are considered to be failures. Twenty-one of 27 (78 percent) repairs in patients younger than 40 years of age were successful, as were 28 of 30 (93 percent) repairs in patients older than 40 years of age (P = 0.10). Four of 18 (22 percent) repairs associated with a neuropathy failed compared with 4 of 39 (10 percent) without a neuropathy (P = 0.21). Improved or normal continence was achieved in 17 of 21 (81 percent) patients with a stoma and overlapping anal sphincter repair and in 32 of 36 (89 percent) patients with an overlapping anal sphincter repair alone (P = 0.32). The presence of a stoma did not improve the rate of wound healing by primary intention (62 percent for stoma vs. 64 percent for overlapping anal sphincter repair alone; P = 0.55).

CONCLUSIONS

Single anal sphincter defects can be successfully treated with an overlapping anal sphincter repair. There is no improvement in primary healing with selective stoma formation. Age of the patient and presence of a neuropathy should not detract from proceeding with overlapping anal sphincter repair when singular anal sphincter defects are detected on endoanal ultrasound in muscle that is still active.

Implications of delayed diagnosis in colorectal cancer

BACKGROUND

Delayed diagnosis of colorectal cancer (CRC) continues to produce anxiety and is associated with the assumption that disease stage and survival will be worse. The aims of the present study were to assess the prevalence and reasons for delay in the diagnosis of CRC, and the effects of delay, gender, age and tumour site on the stage of disease.

METHODS

A retrospective study of 100 patients presenting with CRC during a 1-year period was performed. Delay was defined to have occurred if more than a 3-month period had lapsed from the time when initial symptoms were clearly established to the time of operation. Data were collected on principal presenting symptoms, time to first presentation to a doctor, time to diagnosis and treatment, reasons for delay, diagnostic procedures, tumour site, operation, and Australian clinicopathological (ACP) stage of the tumour.

RESULTS

Thirty-four patients had a delay in diagnosis of their cancer. In 18 patients (53%) delay was attributable to patient reasons; in 13 patients (38%) delay was attributable to doctor-related delay and in three patients (9%) it was attributable to both. Male patients were more likely to have patient-related delay (31% for male patients vs 10% for female patients; P = 0.011). Patients with delay were less likely to have a stage A tumour (6% for delay group vs 21% for non-delay group; P = 0.04). Male patients were less likely to have a stage A tumour than female patients (8% for male patients vs 25% for female patients; P = 0.018), but the effect of delay on stage disappeared when gender and tumour site were controlled in a logistic regression model.

CONCLUSIONS

The present study suggests some areas where improvements may be made concerning early diagnosis and treatment of patients with CRC.

Defunctioning of the anorectum: historical controlled study of laparoscopic vs. open procedures

BACKGROUND

Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy.

OBJECTIVES

The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three-port technique (including one at the stoma site) and to compare initial results with a historical control group.

METHODS

Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented.

RESULTS

Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7 vs. 89.9 mg; P < 0.01), an earlier tolerance of both liquid (mean, 2.1 vs. 3.7 days; P < 0.01) and solid diets (mean, 3.6 vs. 5.5 days; P < 0.001), and an earlier time to passage of both flatus (mean, 2.2 vs. 3.6 days; P < 0.001) and feces (mean, 3.7 vs. 5.6 days; P < 0.001). Operating time was longer for the laparoscopic group (mean, 176 vs. 104 minutes; P < 0.001), whereas median time to discharge from hospital was shorter (median, 8 vs. 11 days; P = 0.014). Postoperative 30-day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients.

CONCLUSIONS

In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.

Evolution of the pelvic pouch procedure at one institution: the first 100 cases

BACKGROUND

Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series.

METHODS

Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation.

RESULTS

After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis.

CONCLUSIONS

Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.

A randomized controlled trial of four different regimes of biofeedback programme in the treatment of faecal incontinence

AIM

Biofeedback is an established, effective and non-invasive treatment for faecal incontinence (FI). The aim was to compare the effectiveness of four different biofeedback treatment regimes.

METHOD

This was a randomized control trial of patients with FI, stratified into two groups (metropolitan and rural) and then randomized into two subgroups (groups 1 and 2 within metropolitan, groups 3 and 4 within rural) with varying face-to-face and telephone biofeedback components. All patients received standardized counselling and education, dietary modification and the use of anti-diarrhoeal medications. Group 1 received four monthly face-to-face biofeedback treatments, groups 2 and 3 received one face-to-face biofeedback followed by telephone biofeedback and group 4 received a one-off face-to-face biofeedback treatment. Primary outcomes were patient-assessed severity of FI and quality of life as assessed by the 36-item Short Form Health Survey and direct questioning of objectives. Secondary outcomes included St Mark's incontinence score, anxiety, depression and anorectal physiology measures (resting, squeeze pressures; isotonic, isometric fatigue times).

RESULTS

Between 2006 and 2012, 351 patients were recruited. One patient died leaving 350 for analysis. 332 (95%) were women. Mean age was 60 (SD = 14). All groups had significant improvements in FI, quality of life, incontinence score and mental status (P < 0.001 each). There were no differences in improvements in FI between groups although patient satisfaction was less with reduced face-to-face contact. There were modest improvements in isotonic and isometric fatigue times suggesting improved sphincter endurance (both P < 0.001).

CONCLUSION

Biofeedback is effective for FI. Although face-to-face and telephone biofeedback is not necessary to improve FI, it is important for patient satisfaction.

Stenting large bowel obstruction avoids a stoma: consecutive series of 100 patients

AIM

Large bowel obstruction (LBO) is a surgical emergency that requires urgent operative intervention and often a stoma. The introduction of a self-expanding metallic stent provides an alternative for this group of patients. The aim of this study was to assess prospectively the results in the first 100 consecutive patients with LBO undergoing attempted self-expanding metallic stent insertion at the Royal Prince Alfred Hospital, Sydney, Australia.

METHOD

A prospective consecutive uncontrolled trial of 100 patients having an attempted self-expanding metallic stent insertion for LBO was performed after institutional ethical approval.

RESULTS

The mean age was 63.9 years (range 16-95). Primary colorectal cancer was the most common cause of LBO (61%). A self-expanding metallic stent was inserted with a palliative intent in 89% of patients. An initial technical success rate of 87% was achieved. Overall 30-day mortality was 7% (95% CI, 3.4-13.7%), with only one stent-related death within 30 days of stent insertion. Morbidity occurred in 20% of patients. Surgery was avoided in 69 patients and permanent stoma was avoided in 72 patients. The median follow up was 34.5 months (range 1-64 months).

CONCLUSION

In this uncontrolled study, self-expanding metallic stents had a low morbidity and a low procedure-related mortality. A randomized controlled trial has commenced in our institution, in which length of stay, quality of life, morbidity and mortality of patients with stents are compared with those of patients having open procedures during palliative care for LBO.

Randomized controlled trial of colonic stent insertion in non-curable large bowel obstruction: a post hoc cost analysis

AIM

In view of the increasing burden on the healthcare system, this study aims to perform a cost-effectiveness analysis of the management of incurable large bowel obstruction comparing the cost of a stent vs surgery.

METHOD

A prospective randomized controlled trial was conducted at two major teaching hospitals in Australia between September 2006 and November 2011. Fifty-six patients with malignant incurable large bowel obstruction were randomized to stent insertion or surgical decompression, of whom 52 were included in the final analysis. Data were collected at all points during the patient journey and quality of life data were obtained by patient surveys. All data points were analysed and a cost-effectiveness study was performed to compare the costs between the two treatment groups.

RESULTS

Stenting as a procedure was significantly more expensive than surgery (A$4462.50 vs A$3251.50; P < 0.001). Post-procedure stay for stented patients was significantly lower (median 7 vs 11 days; P = 0.03). Combined costs of stent group ward stay, multidisciplinary team discussion and complication management were significantly lower (P = 0.013). Overall cost difference between the two treatment groups was A$3902.44 (P = 0.101). European Quality of Life - 5 Dimensions (EQ-5D) scores for the first 4 weeks gave mean area under the curve adjusted weeks of 2.411 vs 2.271 for the stent and surgery groups respectively (P = 0.603). The incremental cost-effectiveness ratio between the surgery and the stent group was $22 955.53 in favour of stenting.

CONCLUSIONS

Treatment with stenting is cheaper than open surgery and provides quicker discharge from hospital.