Familial adenomatous polyposis complicated by an intrahepatic desmoid tumor: report of a case

Desmoids are uncommon proliferations of fibroblasts that occur with disproportionate frequency in patients with familial adenomatous polyposis. They do not metastasize and are histologically benign. Despite this, the unpredictable and often aggressive nature of familial adenomatous polyposis-associated desmoids and their tendency to occur in intra-abdominal sites means that they present a difficult management problem, and they are a leading cause of death in patients with familial adenomatous polyposis who have undergone colectomy. We report a case of a patient with familial adenomatous polyposis who had extensive and aggressive desmoid disease and whose management was further complicated by a large intrahepatic desmoid. There are no previous reports of desmoids occurring in the liver.

Experimental study of faecal continence and colostomy irrigation

BACKGROUND

Colostomy irrigation is a useful method of achieving faecal continence in selected conditions, but remains largely underutilized because it is time consuming. This study investigated the effect of modifying irrigation technique (route, infusion regimen and pharmacological manipulation) on colonic emptying time in a porcine model.

METHODS

An end-colostomy and caecostomy were fashioned in six pigs. Twenty markers were introduced into the caecum immediately before colonic irrigation. Irrigation route (antegrade or retrograde), infusion regimen (tap water, polyethylene glycol (PEG), 1.5 per cent glycine) and pharmacological agent (glyceryl trinitrate (GTN) 0.25 mg/kg, diltiazem 3.9 mg/kg, bisacodyl 0.25 mg/kg) were assigned to each animal at random. Colonic transit was assessed by quantifying cumulative expelled markers (CEM) and stool every hour for 12 h.

RESULTS

Mean CEM at 6 h for bisacodyl, GTN and diltiazem were 18.17, 12.17 and zero respectively; all pairwise differences in means were significant (P < 0.001). The difference at 12 h between the two routes (P = 0.001) and three fluids (tap water 6.75, glycine 14.83, PEG 16.33; P < 0. 001) was significant, but not for PEG versus glycine and bisacodyl versus GTN. Cumulative output was significantly more with the antegrade than retrograde route using PEG, but the difference in mean cumulative output for bisacodyl and GTN at 12 h was not significant.

CONCLUSION

Colonic emptying is more efficient with antegrade than retrograde irrigation. PEG and glycine enhance emptying similar to bisacodyl and GTN solution. These findings show promise for improved faecal continence by colostomy irrigation and may justify construction of a Malone conduit at the time of colostomy in selected patients who wish to irrigate. Presented in part to the British Society of Gastroenterology in Glasgow, UK, March 1999, and published in abstract form as Gut 1999; 44(Suppl 1): A135

The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis

BACKGROUND

Patients with familial adenomatous polyposis have a nearly 100 percent risk of colorectal cancer. In this disease, the chemopreventive effects of nonsteroidal antiinflammatory drugs may be related to their inhibition of cyclooxygenase-2.

METHODS

We studied the effect of celecoxib, a selective cyclooxygenase-2 inhibitor, on colorectal polyps in patients with familial adenomatous polyposis. In a double-blind, placebo-controlled study, we randomly assigned 77 patients to treatment with celecoxib (100 or 400 mg twice daily) or placebo for six months. Patients underwent endoscopy at the beginning and end of the study. We determined the number and size of polyps from photographs and videotapes; the response to treatment was expressed as the mean percent change from base line.

RESULTS

At base line, the mean (+/-SD) number of polyps in focal areas where polyps were counted was 15.5+/-13.4 in the 15 patients assigned to placebo, 11.5+/-8.5 in the 32 patients assigned to 100 mg of celecoxib twice a day, and 12.3+/-8.2 in the 30 patients assigned to 400 mg of celecoxib twice a day (P=0.66 for the comparison among groups). After six months, the patients receiving 400 mg of celecoxib twice a day had a 28.0 percent reduction in the mean number of colorectal polyps (P=0.003 for the comparison with placebo) and a 30.7 percent reduction in the polyp burden (the sum of polyp diameters) (P=0.001), as compared with reductions of 4.5 and 4.9 percent, respectively, in the placebo group. The improvement in the extent of colorectal polyposis in the group receiving 400 mg twice a day was confirmed by a panel of endoscopists who reviewed the videotapes. The reductions in the group receiving 100 mg of celecoxib twice a day were 11.9 percent (P=0.33 for the comparison with placebo) and 14.6 percent (P=0.09), respectively. The incidence of adverse events was similar among the groups.

CONCLUSIONS

In patients with familial adenomatous polyposis, six months of twice-daily treatment with 400 mg of celecoxib, a cyclooxygenase-2 inhibitor, leads to a significant reduction in the number of colorectal polyps.

Functional outcome after restorative panproctocolectomy for ulcerative colitis decreases an otherwise enhanced quality of life

BACKGROUND

Restorative panproctocolectomy is a favoured operation for ulcerative colitis, but altered bowel habit may adversely affect overall quality of life.

METHODS

Specific and generic quality of life questionnaires and an instrument to award money for continuing disability based on government guidelines were sent to 103 patients who had curative surgery for ulcerative colitis between 1995 and 1997. Seventy-one patients returned completed questionnaires: 30 with an ileostomy (representing incontinence and abnormal body image), 11 with a Koch pouch (representing continence and abnormal body image) and 30 with a pelvic pouch (representing continence and normal body image).

RESULTS

Patients valued the disability of having an ileostomy similar to that for a Koch pouch or a pelvic pouch: pound 40 000, pound 30 000 and pound 40 000 respectively (P = 0. 97). There was no sex difference. Body image measured with a visual analogue scale (least = 1, worst = 10) was worst with the ileostomy and Koch pouch (8 each) and best with a pelvic pouch (5) (P = 0.06). However, pelvic pouches scored significantly worse than an ileostomy with regard to altered bowel emptying (pelvic pouch, 8; Koch pouch, 7; ileostomy, 5) (P = 0.01).

CONCLUSION

Poor function after pelvic pouch surgery offsets any advantage in body image over an ileostomy. Thus, overall quality of life and perceived monetary damage were the same for the two operations. Improved pelvic pouch function is likely to be reflected in better quality of life after restorative panproctocolectomy.

Analysis of genetic and phenotypic heterogeneity in juvenile polyposis

BACKGROUND

Juvenile polyposis syndrome (JPS) is characterised by gastrointestinal (GI) hamartomatous polyposis and an increased risk of GI malignancy. Juvenile polyps also occur in the Cowden (CS), Bannayan-Ruvalcaba-Riley (BRRS) and Gorlin (GS) syndromes. Diagnosing JPS can be problematic because it relies on exclusion of CS, BRRS, and GS. Germline mutations in the PTCH, PTEN and DPC4 (SMAD4) genes can cause GS, CS/BRRS, and JPS, respectively.

AIMS

To examine the contribution of mutations in PTCH, PTEN, and DPC4 (SMAD4) to JPS.

METHODS

Forty seven individuals from 15 families and nine apparently sporadic cases with JPS were screened for germline mutations in DPC4, PTEN, and PTCH.

RESULTS

No patient had a mutation in PTEN or PTCH. Five different germline mutations were detected in DPC4; three of these were deletions, one a single base substitution creating a stop codon, and one a missense change. None of these patients had distinguishing clinical features.

CONCLUSIONS

Mutations in PTEN and PTCH are unlikely to cause juvenile polyposis in the absence of clinical features indicative of CS, BRRS, or GS. A proportion of JPS patients harbour DPC4 mutations (21% in this study) but there remains uncharacterized genetic heterogeneity in JPS.

Desmoids in familial adenomatous polyposis are monoclonal proliferations

Desmoids are poorly-understood, locally aggressive, non-metastasizing fibromatoses that occur with disproportionate frequency in patients with familial adenomatous polyposis (FAP). Their nature is controversial with arguments for and against a neoplastic origin. Neoplastic proliferations are by definition monoclonal, whereas reactive processes originate from a polyclonal background. We examined clonality of 25 samples of desmoid tissue from 11 female FAP patients by assessing patterns of X-chromosome inactivation to calculate a clonality ratio. Polymerase chain reaction (PCR) amplification of a polymorphic CAG short tandem repeat (STR) sequence adjacent to a methylation-sensitive restriction enzyme site within the human androgen receptor (HUMARA) gene using fluorescent-labelled primers enabled analysis of PCR products by Applied Biosystems Genescan II software. Twenty-one samples from nine patients were informative for the assay. Samples from all informative cases comprised a median of 66% (range 0-75%) clonal cells but from the six patients with a clonality ratio < or =0.5 comprised a median of 71% (65-75%) clonal cells. FAP-associated desmoid tumours are true neoplasms. This may have implications in the development of improved treatment protocols for patients with these aggressive tumours.

Randomized controlled trial of topical phenylephrine in the treatment of faecal incontinence

BACKGROUND

Anal incontinence due to internal sphincter dysfunction is not amenable to simple surgical repair. The alpha-adrenergic agonist phenylephrine produces contraction of the internal sphincter and raises resting pressure when applied topically in healthy volunteers. The effect of topical phenylephrine in the treatment of faecal incontinence due to internal sphincter dysfunction was investigated.

METHODS

Thirty-six patients (22 women) aged 28-81 (mean 58) years with faecal incontinence and ultrasonographically structurally normal anal sphincter muscles were treated with topical 10 per cent phenylephrine and placebo gels, allocated in random order in a double-blind crossover study. Maximum resting anal sphincter pressure and anodermal blood flow were measured. A symptom questionnaire was completed and incontinence score determined using a validated scale.

RESULTS

There were no significant differences in incontinence score, resting anal pressure and anodermal blood flow between the active and placebo treatments. Six patients on active treatment and two on placebo experienced more than 75 per cent subjective improvement. Three patients developed allergic dermatitis to phenylephrine.

CONCLUSION

This is the first study of the use of a topical pharmacological agent to treat faecal incontinence. This concentration of topical phenylephrine did not produce a significant improvement in symptoms or function. A subgroup of patients may respond. Further studies are required with increased concentrations.

Topical diltiazem and bethanechol decrease anal sphincter pressure without side effects

BACKGROUND

Topical nitrates lower anal sphincter pressure and heal anal fissures, but a majority of patients experience headache. The internal anal sphincter has a calcium dependent mechanism to maintain tone, and also receives an inhibitory extrinsic cholinergic innervation. It may therefore be possible to lower anal sphincter pressure using calcium channel blockers and cholinergic agonists without side effects.

AIMS

To investigate the effect of oral and topical calcium channel blockade and a topical cholinomimetic on anal sphincter pressure.

METHODS

Three studies were conducted, each involving 10 healthy volunteers. In the first study subjects were given oral 60 mg diltiazem or placebo on separate occasions. They were then given diltiazem once or twice daily for four days. In the second and third studies diltiazem and bethanechol gels of increasing concentration were applied topically to lower anal pressure.

RESULTS

A single dose of 60 mg diltiazem lowered the maximum resting anal sphincter pressure (MRP) by a mean of 21%. Once daily diltiazem produced a clinically insignificant effect but a twice daily regimen reduced anal pressure by a mean of 17%. Diltiazem and bethanechol gel produced a dose dependent reduction of the anal pressure; 2% diltiazem produced a maximal 28% reduction, and 0.1% bethanechol a maximal 24% reduction, the effect lasting three to five hours.

CONCLUSIONS

Topical diltiazem and bethanechol substantially reduce anal sphincter pressure for a prolonged period, and represent potential low side effect alternatives to topical nitrates for the treatment of anal fissures.

Desmoid tumours complicating familial adenomatous polyposis

BACKGROUND

Desmoid tumours are one of the most important and intriguing extracolonic manifestations of familial adenomatous polyposis (FAP). They have been studied only in small numbers of patients.

METHODS

Patients with FAP who also had desmoid tumour were identified from a polyposis registry database and their hospital notes were reviewed.

RESULTS

There were 166 desmoids in 88 patients (median age 32 (interquartile range 22-38) years; 51 (58 per cent) female); 83 tumours (50 per cent) were within the abdomen and 80 (48 per cent) were in the abdominal wall. All but 16 individuals (18 per cent) had already undergone abdominal surgery, which was significantly more recent in women (P = 0.01, Mann-Whitney U test). Intra-abdominal desmoids caused small bowel and ureteric obstruction and resulted in ten deaths; survival was significantly poorer than in patients with abdominal wall desmoid alone (chi2 = 3. 93, 1 d.f., P = 0.047, log rank test), and eight of 22 patients who underwent resection of intra-abdominal desmoid died in the perioperative period.

CONCLUSION

Abdominal wall desmoids caused no deaths or significant morbidity; although recurrence was common after excision, the treatment was safe. Intra-abdominal desmoids can cause serious complications and treatment is often unsuccessful; in particular, surgery for desmoids at this site is hazardous.

Preventative strategies for periampullary tumours in FAP

Almost all patients with familial adenomatous polyposis develop duodenal polyps most of which occur in a cluster around the ampulla of Vater. Between 5 and 10% of FAP patients will die from upper gastrointestinal cancer, usually periampullary in origin. In an attempt to prevent cancer a screening programme has been developed using a well defined staging system to detect those patients most at risk of developing the disease. Treatment options are limited, with endoscopic clearance being contraindicated in most cases. The only certain method of preventing duodenal cancer is prophylactic radical surgery which has its own associated morbidity and mortality. Future developments may include new drug treatments or even gene therapy. Until then patients with FAP should all be considered for clinical trials as research continues.

Attenuated adenomatous polyposis coli: the role of ascertainment bias through failure to dye-spray at colonoscopy

PURPOSE

The aim of this study is to show that the diagnosis of attenuated adenomatous polyposis coli must be made with caution and certainly only after adequate colonic examination with dye-spray.

METHODS

Four patients thought to have attenuated adenomatous polyposis coli on the basis of family history and the identification of fewer than 100 polyps on simple colonoscopy underwent colonoscopy with dye-spray.

RESULTS

All four individuals were found to have more than 100 polyps when dye-spray was used, confirming a diagnosis of classical familial adenomatous polyposis.

CONCLUSIONS

The diagnosis of familial adenomatous polyposis may be missed altogether or incorrectly assigned as attenuated adenomatous polyposis coli if dye-spray is not used at colonoscopy. Patients with a family history of familial adenomatous polyposis or colorectal cancer should be considered for dye-spray before the diagnosis of familial adenomatous polyposis is excluded or one of attenuated adenomatous polyposis coli is made.

Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate

BACKGROUND

Topical application of glyceryl trinitrate (GTN) ointment heals chronic anal fissures, providing an alternative to the traditional first line treatment of surgical sphincterotomy.

AIMS

To determine the most effective dose of topical GTN for treatment of chronic anal fissures and to assess long term results.

METHODS

Seventy consecutive patients with chronic anal fissure, were randomly allocated to eight weeks treatment with placebo, 0.2% GTN three times daily, or GTN starting at 0.2% with weekly 0.1% increments to a maximum of 0.6%, in a double blind study.

RESULTS

After eight weeks fissure had healed in 67% of patients treated with GTN compared with 32% with placebo (p=0.008). No significant difference was seen between the two active treatments. Headaches were reported by 72% of patients on GTN compared with 27% on placebo (p<0.001). Maximum anal sphincter pressure reduced significantly from baseline by GTN treatment (p=0.02), but not placebo (p=0.8). Mean pain scores were lower after treatment with GTN compared with placebo (NS). Of fissures healed with placebo 43% recurred, compared with 33% of those healed with 0.2% GTN and 25% healed with escalating dose GTN (p=0.7).

CONCLUSIONS

GTN is a good first line treatment for two thirds of patients with anal fissure. An escalating dose of GTN does not result in earlier healing. Significant recurrence of symptomatic fissures and a high incidence of headaches are limitations of the treatment.

Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation

PURPOSE

The aim of this study was to determine the long-term symptomatic and anatomic results of rectocele repair for impaired defecation.

METHODS

All 26 females operated on during a five-year period in one hospital were reviewed in clinic. Follow-up was available on 22 patients after a median of 27 (range, 5-54) months. Interview, anorectal physiological testing, and evacuation proctography were performed preoperatively and postoperatively. Fifteen patients had a transperineal repair and seven patients had a transanal repair.

RESULTS

Sixteen (73 percent) patients felt improved. A feeling of incomplete emptying (19 vs. 10, preoperative vs. postoperative; P = 0.02) and the need to use digital assistance vaginally (13 vs. 6; P = 0.07) were both reduced by surgery, the former being improved significantly more often after transperineal repair. The rectocele width and area were reduced by both types of surgery; however, the rectocele diameter was greater than 2 cm in 16 patients preoperatively and 10 patients postoperatively. There was no significant difference between patients who did or did not feel improved by surgery in the percentage reduction in rectocele width (22 vs. 18 percent; P = 0.95), the percentage reduction in rectocele area (65 vs. 62 percent; P = 0.95), or a rectocele width of more than 2 cm (44 vs. 50 percent; P = 0.80), did vs. did not feel improved, respectively.

CONCLUSION

Operative repair symptomatically improves a majority of patients with impaired defecation associated with a large rectocele, but the improvement probably relates at least in part to factors other than the dimensions of the rectocele.

Topical phenylephrine increases anal sphincter resting pressure

BACKGROUND

Phenylephrine is an alpha1-adrenergic agonist which causes contraction of human internal anal sphincter muscle in vitro. Its intra-arterial administration in animals has been shown to increase resting sphincter pressure in vivo. In this study the effect of topical application of phenylephrine on resting anal pressure in healthy human volunteers was investigated.

METHODS

Twelve healthy volunteers had measurements of maximum resting sphincter pressure (MRP) and anodermal blood flow taken before and after topical application of increasing concentrations of phenylephrine gel to the anus. To determine the duration of effect of the agent, readings were taken throughout the day after a single application.

RESULTS

There was a dose-dependent rise in the resting anal sphincter pressure, with a small 8 per cent rise after 5 per cent phenylephrine (P = 0.012) and a larger 33 per cent rise with 10 per cent phenylephrine (mean(s.d.) MRP 85(12) cmH2O before versus 127(12) cmH2O after treatment, P < 0.0001). Thereafter no additional response was noted with higher concentrations of phenylephrine. The median duration of action of a single application of 10 per cent phenylephrine was 7 (range from 6 to more than 8) h.

CONCLUSION

Topical application of 10 per cent phenylephrine gel to the anus produces a significant rise in the resting anal sphincter pressure in healthy human volunteers. This represents a potential novel therapeutic approach to the treatment of passive faecal incontinence associated with a low resting anal sphincter pressure.

Cytogenetics and the surgeon: an invaluable tool in diagnosis, prognosis and counselling of patients with solid tumours

Role of magnetic resonance angiography for assessment of abdominal aortic aneurysm before endoluminal repair

P. Robless, N. Cheshire, G. Stansby, J. H. N. Wolfe, A. O. Mansfield, Department of Surgery, Leicester Royal Infirmary, Leicester LE2 7LX, UK

Authors' reply. A. Nasim, R. D. Sayers, P. R. F. Bell, Department of Surgery, Clinical Sciences Building, Leicester Royal Infirmary NHS Trust, Leicester LE2 7LX, UK

Cytogenetics and the surgeon: an invaluable tool in diagnosis, prognosis and counselling of patients with solid tumours

R. K. S. Phillips, S. K. Clark, The Polyposis Registry, St Mark's Hospital, Northwick Park, Harrow HA1 3UJ, UK

Venous insufficiency and perforating veins

A. D. B. Chant, Department of Surgery, Wessex Nuffield Hospital, Chandlers Ford SO53 2DW, UK

Arteriovenous fistula using transposed basilic vein

F. Torella, D. T. Reilly, Department of Vascular Surgery, Wirral Hospital Trust, Arrowe Park Hospital, Wirral L49 5PE, UK

Assessment of a scoring system for breast imaging

Letter 1 A. D. Spigelman, (formerly Director of St Mary's Hospital Breast Group), Division of Surgery, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, New South Wales 2310, Australia

Letter 2 B. J. Mander, G. C. Wishart, The Breast Unit, Princess Royal Hospital, Hayward's Heath RH16 4EX, UK.

Lack of telomerase in desmoids occurring sporadically and in association with familial adenomatous polyposis

BACKGROUND

Telomerase activity may be required for unlimited growth of cells and is repressed in most somatic tissues, but is detectable in immortal cell lines, germ cells, many malignancies and some benign lesions. Desmoids are proliferative, locally invasive, non-metastasizing fibromatous tumours which rarely regress. They occur frequently in familial adenomatous polyposis (FAP), causing significant morbidity and death. Telomerase activity was assayed in desmoids from patients with and without FAP to assess the role of telomerase in the development of these lesions, and its potential as a prognostic marker and possible target for treatment.

METHODS

Protein extracts from 11 desmoids from nine patients with FAP, and ten desmoids from ten patients without FAP, were analysed for telomerase activity by the telomeric repeat amplification protocol, a sensitive polymerase chain reaction-based assay. Six fibrosarcomas and a fibrosarcoma cell line were used as positive controls; all displayed telomerase activity.

RESULTS

No telomerase activity was detected in any of the 21 desmoids studied.

CONCLUSION

These results indicate that desmoid tumours are one of the intriguing exceptions to the emerging view that re-expression of telomerase activity accompanies the development of preneoplastic and neoplastic tissues, and suggest that alternative mechanisms may operate in these proliferative neoplasms.

Identification and progression of a desmoid precursor lesion in patients with familial adenomatous polyposis

BACKGROUND

Desmoid tumours occur in about 10 per cent of patients with familial adenomatous polyposis (FAP), and are an important cause of morbidity and death. The natural history of desmoids was investigated by documenting prospectively the prevalence and progression of possible precursor lesions.

METHODS

A group of patients with FAP and controls were examined at laparotomy. Another group, with FAP and no clinical evidence of desmoid, and a group of controls, underwent abdominopelvic computed tomography.

RESULTS

At laparotomy 13 of 42 patients with FAP had fibromatous mesenteric plaques; seven of these had not had surgery. Seven had more extensive mesenteric fibromatosis and had undergone significantly more laparotomies than the rest. Of 103 patients scanned, two had desmoid tumours and 22 (21 per cent) had mesenteric fibromatosis. On follow-up both desmoid tumours grew rapidly; mesenteric fibromatosis was unchanged in eight and resolved in four of the 12 patients rescanned.

CONCLUSION

A model of desmoid tumour development is suggested, analogous to the adenoma-carcinoma sequence, in which a less benign phenotype emerges as molecular genetic abnormalities accumulate: mesenteric plaque-like desmoid precursor lesions arise in many patients with FAP before surgery as a result of abnormal fibroblast function; some, perhaps stimulated by surgery, progress to mesenteric fibromatosis; these in turn can give rise to desmoid tumours.

Upper gastrointestinal disease in patients with familial adenomatous polyposis

BACKGROUND

Upper gastrointestinal disease has become an important aspect in the management of patients with familial adenomatous polyposis (FAP).

METHODS

A review of the literature was carried out using Medline. Epidemiology, pathology and treatment options are considered.

RESULTS AND CONCLUSION

Despite the fact that over 90 per cent of patients with FAP develop duodenal adenomas, only 5 per cent go on to develop cancer. In the absence of methods to detect who is at risk of cancer, all patients undergo regular endoscopic surveillance at present. Chemoprevention in the form of drug therapy may be the answer to controlling the disease.

A survey of phenotypic features in juvenile polyposis

Solitary juvenile polyps are quite frequent in children, but juvenile polyposis (JP) is a rare autosomal dominant trait characterised by the occurrence of numerous polyps in the gastrointestinal tract. Extracolonic phenotypic abnormalities are well documented in patients with familial adenomatous polyposis and Peutz-Jeghers syndrome and can allow a clinical diagnosis to be made before the bowel pathology becomes available. Though described, characteristic extracolonic abnormalities have not been clearly defined in juvenile polyposis. We sought to determine whether there are consistent extracolonic phenotypic abnormalities in JP patients and how frequently this would allow diagnosis of one of the genetic syndromes known to be associated with juvenile polyposis. Twenty-two JP patients underwent clinical examination and data from one patient were obtained from case notes. Those consenting to further investigations had x rays of the skull, chest, and hands and an echocardiogram if clinically indicated. Significant extracolonic phenotypic abnormalities were present in 18 patients (14 male and four female), and included dermatological (13), skeletal (16), neurological (5), cardiopulmonary (4), gastrointestinal (3), genitourinary (4), and ocular (1) features. In five patients the diagnosis of a genetic syndrome was possible: two had Bannayan-Riley-Ruvalcaba syndrome, two had Gorlin syndrome, and one had hereditary haemorrhagic telangiectasia (HHT, also known as Osler-Rendu-Weber syndrome). Other patients had some features of these conditions and of Cowden and Simpson-Golabi-Behmel syndromes, but these were not sufficient to allow a definitive diagnosis.

Sphincteroplasty for incontinence after surgery for idiopathic fistula in ano

Between 1990 and 1992, external sphincter repair was performed in 20 patients rendered faecally incontinent after earlier fistula surgery. All were improved, 13 (65%) achieving Grade 1 or 2 continence. Postoperative ultrasound was useful in explaining the sub-optimal outcome of 3 patients who still had defects. Clinical outcome in female patients was better than in male patients. Clinical outcome was not related to the results of preoperative manometry, the site of external sphincter damage, the use of a stoma, or the occurrence of wound complications. External sphincter repair for faecal incontinence after fistula surgery achieves good results in the majority of patients.

Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy

BACKGROUND

Haemorrhoidectomy is commonly an inpatient procedure because patients and doctors worry about postoperative pain. Day-case haemorrhoidectomy (DCH) is possible if patient anxiety is addressed and postoperative pain and bowel function are managed. Pain sometimes increases a few days after haemorrhoidectomy, possibly because of secondary infection. We studied the effect of metronidazole on pain after DCH.

METHODS

We randomly assigned 40 consecutive patients admitted for DCH metronidazole 400 mg (n = 20) or placebo (n = 20) three times daily, both for 7 days. All patients received lactulose from 2 days before surgery for 2 weeks. Diathermy DCH was performed without pedicle ligature or anal-canal dressing, and a diclofenac suppository was administered at the end of the procedure. Patients were discharged on the same day with diclofenac, 0.2% glyceryl-trinitrate ointment, lactulose, a telephone number to call for queries in emergencies, and an outpatient appointment. Patients took paracetamol or Co-dydramol (dihydrocodeine and paracetamol) as required; they completed linear analogue charts every day and completed questionnaires on satisfaction at 1 and 6 weeks.

FINDINGS

34 patients had all three major piles excised, of whom seven had additional division and reconstruction of the posterior skin bridge. Overall, both groups of patients experienced less pain than expected, except on days 3 and 4. Patients in the metronidazole group had significantly less pain than those in the placebo group on days 5, 6, and 7 (p = 0.004, p = 0.02, and p = 0.006). Median time to return to work or normal activity was 15 days (range 12-28) in the metronidazole group and 18 days (7-34) in the placebo group (p = 0.009). The patient satisfaction score was higher in the metronidazole group than in the placebo group at 1 week (p = 0.005).

INTERPRETATION

Prophylactic metronidazole in diathermy DCH suppressed secondary pain around days 5-7 and increased patient satisfaction and earlier return to work.