Colon cancer survival in the elderly without curative surgery

INTRODUCTION

The aim of this study was to chart the natural history of elderly patients with colon cancer who are managed nonoperatively, with the primary outcome being life expectancy from diagnosis to death.

METHODS

This was a retrospective analysis of patients aged 80 years and above diagnosed with colon cancer in a tertiary care referral hospital in England between 1 January 2012 and 31 December 2017.

RESULTS

Thirty-two patients were diagnosed with non-metastatic colon cancer and managed non-operatively. The median age of patients in this study was 86 years. The group had a median Charlson Comorbidity Index of 7 (range 6-12) and the median frailty score was 6 (range 3-8). Progression to metastatic disease was identified in two patients; two further patients showed locoregional progression of cancer and therefore required palliative surgical intervention. Survival of these patients ranged from 105 to 1,782 days with a median life expectancy of 586 days. Place of death was identified in 15/31 patients: 4 (27%) died in hospital, 12 (38%) died at home and 15 (47%) died in a nursing or residential home; data were missing for 1 patient (3%).

CONCLUSIONS

Nonoperative management of elderly patients with colon cancer yields reasonable life expectancy and a low risk of life-threatening local complications.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Minimally invasive organ-preserving approaches in the management of mesh erosion after laparoscopic ventral mesh rectopexy

AIM

This is a systematic approach for minimally invasive methods in the management of mesh erosion after laparoscopic ventral mesh rectopexy.

METHODS

All patients managed with organ-preserving techniques for mesh erosion were identified from a prospective database and clinical records were reviewed. Each patient was contacted via telephone and a structured questionnaire was applied. A Likert score was used to assess patient symptoms and overall satisfaction with management. One or more of the following techniques were used: (i) transanal or transvaginal trimming/excision of exposed mesh and sutures, with or without using transanal endoscopic micro surgery or transanal minimally invasive surgery; (ii) laparoscopic pelvic assessment and detachment of mesh from the sacral promontory.

RESULTS

Eleven patients were managed for mesh erosion with organ-preserving techniques. All were women with a median age of 60 years [interquartile range (IQR) 53.5-68.5]. Vaginal, rectal, perineal erosion and recto-vaginal fistulation occurred in five, four, one and one patient respectively. Vaginal erosions presented at a median of 51 months (IQR 36-56) after index laparoscopic ventral mesh rectopexy compared to 17.5 months (IQR 14.5-27.25) for the rectal erosions. Median follow-up time was 24 months (IQR 19-49). Four of the meshes (36%) were removed completely whereas seven (63%) were partially removed. Vaginal erosions required a median of two procedures to achieve resolution as opposed to five for rectal. Out of 11 patients, eight were satisfied with the outcome of their management, whereas two were not and one remained ambivalent.

CONCLUSION

An organ-sparing minimally invasive approach is feasible in managing mesh erosions but requires multiple procedures and months to complete.

Multicentre phase II trial of near-infrared imaging in elective colorectal surgery

BACKGROUND

Decreasing anastomotic leak rates remain a major goal in colorectal surgery. Assessing intraoperative perfusion by indocyanine green (ICG) with near-infrared (NIR) visualization may assist in selection of intestinal transection level and subsequent anastomotic vascular sufficiency. This study examined the use of NIR-ICG imaging in colorectal surgery.

METHODS

This was a prospective phase II study (NCT02459405) of non-selected patients undergoing any elective colorectal operation with anastomosis over a 3-year interval in three tertiary hospitals. A standard protocol was followed to assess NIR-ICG perfusion before and after anastomosis construction in comparison with standard operator visual assessment alone.

RESULTS

Five hundred and four patients (median age 64 years, 279 men) having surgery for neoplastic (330) and benign (174) pathology were studied. Some 425 operations (85·3 per cent) were started laparoscopically, with a conversion rate of 5·9 per cent. In all, 220 patients (43·7 per cent) underwent high anterior resection or reversal of Hartmann's operation, and 90 (17·9 per cent) low anterior resection. ICG angiography was achieved in every patient, with a median interval of 29 s to visualization of the signal after injection. NIR-ICG assessment resulted in a change in the site of bowel division in 29 patients (5·8 per cent) with no subsequent leaks in these patients. Leak rates were 2·4 per cent overall (12 of 504), 2·6 per cent for colorectal anastomoses and 3 per cent for low anterior resection. When NIR-ICG imaging was used, the anastomotic leak rates were lower than those in the participating centres from over 1000 similar operations performed with identical technique but without NIR-ICG technology.

CONCLUSION

Routine NIR-ICG assessment in patients undergoing elective colorectal surgery is feasible. NIR-ICG use may change intraoperative decisions, which may lead to a reduction in anastomotic leak rates.

Pregnancy after laparoscopic ventral mesh rectopexy: implications and outcomes

AIM

Surgical management of rectal prolapse varies considerably. Most surgeons are reluctant to use ventral mesh rectopexy in young women until they have completed their family. The aim of the present study was to review outcomes of pregnancy following laparoscopic ventral mesh rectopexy from a tertiary referral centre over a 10-year period (2006-2016) and to review the impact on pelvic floor symptoms.

METHOD

We undertook a retrospective review of a prospectively compiled database of patients who had undergone laparoscopic ventral rectopexy in a single centre over a 10-year period. Pelvic floor symptom scores (Vaizey for incontinence and Longo for obstructive defaecation) were collected at initial presentation (pre-intervention), post-intervention and after child birth.

RESULTS

In all, 954 rectopexies were performed over this 10-year period. 225 (24%) patients were women and under 45 years of age (taken as an arbitrary cut-off for decreased likelihood of pregnancy). Eight (4%) of these patients became pregnant following rectopexy. The interval between rectopexy and delivery was 42 months (21-50). Six patients delivered live babies by elective lower segment caesarean section and two by spontaneous vaginal delivery. Six were first babies and two were second. No mesh related adverse outcome was reported. No difference in pelvic floor symptoms was demonstrated on comparison of post-rectopexy and post-delivery scores.

CONCLUSION

This study provides the first description in the English language literature of safe delivery by elective lower segment caesarean section or spontaneous vaginal delivery following laparoscopic ventral mesh rectopexy. No adverse impact on pelvic floor related quality of life was detected.

Rectal axis and enterocele on proctogram may predict laparoscopic ventral mesh rectopexy outcomes for rectal intussusception

BACKGROUND

Laparoscopic ventral mesh rectopexy (LVMR) has become a well-established treatment for symptomatic high-grade internal rectal prolapse. The aim of this study was to identify proctographic criteria predictive of a successful outcome.

METHODS

One hundred and twenty consecutive patients were evaluated from a prospectively maintained pelvic floor database. Pre- and post-operative functional results were assessed with the Wexner constipation score (WCS) and Fecal Incontinence Severity Index (FISI). Proctogram criteria were analyzed against functional results. These included grade of intussusception, presence of enterocele, rectocele, excessive perineal descent and the orientation of the rectal axis at rest (vertical vs. horizontal).

RESULTS

Ninety-one patients completed both pre- and post-operative follow-up questionnaires. Median pre-operative WCS was 14 (range 10-17), and median FISI was 20 (range 0-61), with 28 patients (31%) having a FISI above 30. The presence of an enterocele was associated with more frequent complete resolution of obstructed defecation (70 vs. 52%, p = 0.02) and fecal incontinence symptoms (71 vs. 38%, p = 0.01) after LVMR. Patients with a more horizontal rectum at rest pre-operatively had significantly less resolution of symptoms post-operatively (p = 0.03).

CONCLUSIONS

These data show that proctographic findings can help predict functional outcomes after LVMR. Presence of an enterocele and a vertical axis of the rectum at rest may be associated with a better resolution of symptoms.

No benefit of ultrasound-guided transversus abdominis plane blocks over wound infiltration with local anaesthetic in elective laparoscopic colonic surgery: results of a double-blind randomized controlled trial

AIM

Advances in laparoscopic techniques combined with enhanced recovery pathways have led to faster recuperation and discharge after colorectal surgery. Peripheral nerve blockade using transversus abdominis plane (TAP) blocks reduce opioid requirements and provide better analgesia for laparoscopic colectomies than do inactive controls. This double-blind randomized study was performed to compare TAP blocks using bupivacaine with standardized wound infiltration with local anaesthetic (LA).

METHOD

Seventy-one patients were randomized to receive either TAP block or wound infiltration. The TAP blocks were performed by experienced anaesthetists who used ultrasound guidance to deliver 40 ml of 0.25% bupivacaine post-induction into the transverse abdominis plane. In the control group, 40 ml of 0.25% bupivacaine was injected around the trocar and the extraction site by the surgeon. Both groups received patient-controlled analgesia (PCA) with intravenous morphine. Patients and nursing staff assessed pain scores 6, 12, 24 and 48 h after surgery. The primary outcome was overall morphine use in the first 48 h.

RESULTS

Of the 71 patients, 20 underwent a right hemicolectomy and 51 a high anterior resection. The modified intention-to-treat analysis showed no significant differences in overall morphine use [47.3 (36.2-58.5) mg vs 46.7 (36.2-57.3) mg; mean (95% CI), P = 0.8663] in the first 48 h. Pain scores were similar at 6, 12, 24 and 48 h. No differences were found regarding time to mobilization, resumption of diet and length of hospital stay.

CONCLUSION

In elective laparoscopic colectomies, standardized wound infiltration with LA has the same analgesic effect as TAP blocks post-induction using bupivacaine at 48 h.

The treatment of all MRI-defined low rectal cancers in a single expert centre over a 5-year period: is there room for improvement?

AIM

Outcomes following treatment for low rectal cancer still remain inferior to those for upper rectal cancer. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict anatomical definition.

METHOD

A low rectal cancer was defined as one with a lower border below the pelvic attachment of the levator muscles on sagittal MRI. One hundred and eighty consecutive patients with tumours defined by this criterion between 2006 and 2011 were identified from a prospectively managed departmental database.

RESULTS

One hundred and eighteen patients (66%) underwent curative resection and 12 (7%) palliative resection. Eleven patients (6%) were entered into a 'watch and wait' (W&W) protocol; 10 others (5%) were not fit to undergo any operation. Some 26 patients (14%) had nonresectable local or metastatic disease. An R0 resection was the most important factor influencing survival after curative surgery. R+ resections occurred in 12% of non-abdominoperineal excisions, 11% of abdominoperineal excisions and 47% of extended resections. Overall survival was similar in the curative resections compared with the W&W patients. In 23 of the 96 (24%) treated with neoadjuvant chemoradiotherapy there was a persistent clinical or a pathological complete response.

CONCLUSION

In curative resections, a clear margin is the most important determinant of survival. In 24% of the patients treated with neoadjuvant chemoradiotherapy, surgery could potentially have been avoided. There is scope for improvement in the treatment of locally advanced rectal cancers.

Sacral neuromodulation for persistent faecal incontinence after laparoscopic ventral rectopexy for high-grade internal rectal prolapse

AIM

Internal rectal prolapse is recognized as an aetiological factor in faecal incontinence. Patients found to have a high-grade internal rectal prolapse on routine proctography are offered a laparoscopic ventral rectopexy after failed maximum medical therapy. Despite adequate anatomical repair, faecal incontinence persists in a number of patients. The aim of this study was to evaluate the outcome of sacral neuromodulation in this group of patients.

METHOD

Between August 2009 and January 2012, 52 patients who underwent a laparoscopic ventral rectopexy for faecal incontinence associated with high-grade internal rectal prolapse had persistent symptoms of faecal incontinence and were offered sacral neuromodulation. Symptoms were evaluated before and after the procedure using the Fecal Incontinence Severity Index (FISI) and the Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

Temporary test stimulation was successful in 47 (94%) of the patients who then underwent implantation of a permanent pulse generator. The median FISI score 1 year after sacral neuromodulation was lower than the median score before [34 (28-59) vs. 19 (0-49); P < 0.01], indicating a significant improvement in faecal continence. Quality of life (GIQLI) was significantly better after starting sacral neuromodulation [78 (31-107) vs. 96 (55-129); P < 0.01].

CONCLUSION

Patients may benefit from sacral neuromodulation for persisting faecal incontinence after laparoscopic ventral rectopexy.

Trans-anal endoscopic microsurgery for internal rectal prolapse

Internal rectal prolapse can lead to obstructed defecation, faecal incontinence and pain. In treatment of frail or technically difficult patients, a perineal approach is often used, such as a Delorme’s or a STARR. However, in case of very high take-off prolapse, these procedures are challenging if not unsuitable. We present trans-anal endoscopic microsurgery as surgical option for management of this uncommon type of rectal prolapse in specific cases.

Endoscopically assisted extralevator abdominoperineal excision

AIM

Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard abdominoperineal excision. However, there can be difficulties with ELAPE, particularly in identifying the anterior plane in male patients. Usually, the dissection is performed in the prone position, which can be hazardous, particularly in obese patients in whom wound problems are commonly encountered. We describe an endoscopically assisted approach for ELAPE in the lithotomy position.

METHOD

Three male patients with a rectal tumour located at the anorectal junction underwent an endoscopically assisted ELAPE in the lithotomy position after preoperative radiotherapy.

RESULTS

All the procedures were performed successfully with operation times of 180, 390 and 420 mins. There were no instances of intra-operative perforation or other complications. One patient developed postoperative intestinal obstruction which resolved on conservative management. There were no wound complications. Histopathological examination demonstrated clear margins and intact mesorectal planes in each patient.

CONCLUSION

We report a good outcome in three patients after endoscopically assisted ELAPE. This approach allows the patient to be operated on in the lithotomy position giving excellent views of the anterior dissection.

Expression of fibulin-5 in the skin of patients with rectal prolapse

AIM

Components of connective tissue other than collagen have been found to be involved in patients with rectal prolapse. The organization of elastic fibres differs between controls and subsets of patients with rectal prolapse, and their importance for maintaining the structural and functional integrity of the pelvic floor has been demonstrated in transgenic mice, with animals which have a null mutation in fibulin-5 (Fbln5(i/i)) developing prolapse. This study aimed to compare fibulin-5 expression in the skin of patients with and without rectal prolapse.

METHOD

Between January 2013 and February 2014, skin specimens were obtained during surgery from 20 patients with rectal prolapse and from 21 without prolapse undergoing surgery for other indications. Fibroblasts from the skin were cultured and the level of fibulin-5 expression was determined on cultured fibroblasts, isolated from these specimens by quantitative real-time polymerase chain reaction. Immunohistochemistry was performed on fixed tissue specimens to assess fibulin-5 expression.

RESULTS

Fibulin-5 mRNA expression and fibulin-5 staining intensity were significantly lower in young male patients with rectal prolapse compared with age-matched controls [fibulin-5 mean ± SD mRNA relative units, 1.1 ± 0.41 vs 0.53 ± 0.22, P = 0.001; intensity score, median (range), 2 (0-3) vs 1 (0-3), P = 0.05]. There were no significant differences in the expression of fibulin-5 in women with rectal prolapse compared with controls.

CONCLUSION

Fibulin-5 may be implicated in the aetiology of rectal prolapse in a subgroup of young male patients.

Laparoscopic rectopexy is feasible and safe in the emergency admission setting

AIM

External rectal prolapse may require emergency admission in the elderly and comorbid population. We report the safety and efficacy of laparoscopic ventral rectopexy in patients having an emergency admission with external rectal prolapse.

METHOD

A retrospective analysis was performed of a prospective database of all rectopexies performed from 2006. Outcome and follow-up data were assessed.

RESULTS

Of 812 rectopexies performed, 28 were included for analysis. The mean length of hospital stay was 13.0 days. All operations were completed successfully and without intra-operative complications. Four patients developed a postoperative complication. Two patients developed a recurrence of prolapse.

CONCLUSION

Laparoscopic correction of rectal prolapse following emergency admission is both feasible and safe. It can be considered for both recurring cases and cases with multiple comorbidities.

Is group pelvic floor retraining as effective as individual treatment?

AIM

Traditionally, pelvic floor retraining for faecal incontinence or obstructed defaecation has been delivered to patients through individual sessions with a specialist pelvic floor nurse, a resource-intensive practice. This study aimed to assess whether a similar outcome can be achieved by delivering retraining to patients in small groups, allowing considerable savings in the use of resources.

METHOD

Data were collected prospectively in a pelvic floor database. Patients received pelvic floor retraining either individually or in a small group setting and completed baseline and follow-up questionnaires. Two hundred and fifteen patients were treated, 119 individually and 96 in a small group setting. Scores before and after treatment for the two settings were compared for the Gastrointestinal Quality of Life Index, the Fecal Incontinence Severity Index and the Patient Assessment of Constipation Symptoms. Additionally patients receiving group treatment completed a short questionnaire on their experience.

RESULTS

The median change in Gastrointestinal Quality of Life Index score was 5 (range -62 to 73) for individual treatment and 4 (range -41 to 47) for group treatment, both showing statistically significant improvement. However, there was no significant difference between the settings. Similar results were obtained with the Fecal Incontinence Severity Index and Patient Assessment of Constipation Symptoms scores for the faecal incontinence and obstructed defaecation subgroups respectively.

CONCLUSION

The majority of patients experienced symptomatic improvement following pelvic floor retraining and there was no significant difference in the resulting improvement according to treatment setting. As treatment costs are considerably less in a group setting, group pelvic floor retraining is more cost-effective than individual treatment.

Single incision glove port laparoscopic colorectal cancer resection

INTRODUCTION

The advantages of single port surgery remain controversial. This study was designed to evaluate the safety and feasibility of single incision glove port colon resections using a diathermy hook, reusable ports and standard laparoscopic straight instrumentation.

METHODS

Between June 2012 and February 2014, 70 consecutive patients (30 women) underwent a colonic resection using a wound retractor and glove port. Forty patients underwent a right hemicolectomy through the umbilicus and thirty underwent attempted single port resection via an incision in the right rectus sheath (14 high anterior resection, 13 low anterior resection, 3 abdominoperineal resection).

RESULTS

Sixty-two procedures (89%) were completed without conversion to open or multiport techniques. Four procedures had to be converted and additional ports were needed in four other patients. The postoperative mortality rate was 0%. Complications occurred in six patients (9%). Two cases were R1 while the remainder were R0 with a median nodal harvest of 20 (range: 9-48). The median length of hospital stay was 5 days (range: 3-25 days) (right hemicolectomy: 5 days (range: 3-12 days), left sided resection: 6 days (range: 4-25 days). At a median follow-up of 14 months, no port site hernias were observed.

CONCLUSIONS

Single incision glove port surgery is an appropriate technique for different colorectal cancer resections and has the advantage of being less expensive than surgery with commercial single incision ports.

Evaluation of quality of life and function at 1 year after transanal endoscopic microsurgery

AIM

Transanal endoscopic microsurgery (TEM) enables organ preservation after rectal tumour surgery. Its application is being expanded using adjuvant and neoadjuvant treatments. Our objective was to evaluate the changes over time in anorectal function, urinary symptoms and quality of life (QoL) in patients who had TEM surgery for a rectal tumour.

METHOD

Between September 2009 and October 2012, a consecutive series of 102 patients underwent TEM at a single institution. Patients were asked to fill out standardized questionnaires at baseline and then at 6, 12, 26 and 52 weeks after surgery. The QoL among these patients was assessed using one generic (EQ-5D) and two disease-specific [European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR29] questionnaires. Anorectal and urinary symptoms were studied using the COlo-REctal Functional Outcome (COREFO) and the International Prostate Symptom Score (I-PSS) questionnaires, respectively.

RESULTS

The response rate was 90% (92/102 patients). Postoperative complications occurred in 14% (13/92) of patients. The general QoL (as assessed using the EQ-5D) was lower 6 and 12 weeks after TEM compared with baseline QoL (P < 0.05) but returned towards baseline after 26 weeks. Anorectal function (determined using the COREFO) was worse 6 weeks postoperatively (P < 0.01) but had normalized by 12 weeks. Urinary function (determined using the I-PSS) was not affected at any time point after surgery. The total COREFO score and the American Society of Anesthesiologists (ASA) score were correlated with the deterioration in QoL.

CONCLUSION

The study demonstrates that TEM has a temporary and reversible impact on QoL and anorectal function. Intensive interrogation of QoL and function using appropriate questionnaires will help to define the role of organ-preserving surgery for rectal cancer before and after chemoradiotherapy.

Addition of transversus abdominis plane block to patient controlled analgesia for laparoscopic high anterior resection improves analgesia, reduces opioid requirement and expedites recovery of bowel function

INTRODUCTION

Opioid sparing in postoperative pain management appears key in colorectal enhanced recovery. Transversus abdominis plane (TAP) blocks offer such an effect. This study aimed to quantify this effect on pain, opioid use and recovery of bowel function after laparoscopic high anterior resection.

METHODS

This was a retrospective analysis of prospective data on 68 patients. Patients received an epidural (n=24), intravenous morphine patient controlled analgesia (PCA, n=22) or TAP blocks plus PCA (n=22) determined by anaesthetist preference. Outcome measures were numerical pain scores (0-3), cumulative intravenous morphine dose and time to recovery of bowel function (passage of flatus or stool).

RESULTS

There were no differences in patient characteristics, complications or extraction site. The TAP block group had lower pain scores (0.7 vs 1.36, p<0.001) and morphine requirements (8 mg vs 15 mg, p=0.01) than the group receiving PCA alone at 12 hours and 24 hours. Earlier passage of flatus (2.0 vs 2.7 vs 3.4 days, p=0.002), stool (3.1 vs 4.1 vs 5.5 days, p=0.04) and earlier discharge (4 vs 5 vs 6 days, p=0.02) were also seen.

CONCLUSIONS

Use of TAP blocks was found to reduce pain and morphine use compared with PCA, expedite recovery of bowel function compared with PCA and epidural, and expedite hospital discharge compared with epidural.

Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome

AIM

Patients with unfavourable pathology after transanal endoscopic microsurgery (TEM) should be offered completion surgery (CS) if appropriate. The aim of this retrospective cohort study was to assess the short-term outcome and long-term oncological results of CS and identify factors compromising the quality of resection specimens.

METHOD

Data were retrieved and analysed on patients who underwent CS from a comprehensive national TEM database (1992-2008) and the institutional prospective database from the Oxford University Hospitals (2008-2011).

RESULTS

There were 36 patients eligible for analysis. Postoperative complications occurred in 19 and were minor (grade I-II) in 13 and major (grade III-V) in six patients. The quality of the resected specimen was graded as good in 23 (64%), moderate in six (16.6%) and poor in seven (19.4%). Full-thickness excision by TEM (P = 0.03), an interval to CS greater than 7 weeks (P = 0.05) and distally located lesions (P = 0.04) were associated with increased risk for an inferior surgical specimen. Overall survival after CS was 91% at 1 year and 83% at 5 years. Patients with a 'good' TME specimen had significantly improved disease-free survival compared with patients with an 'inferior' specimen (100 vs 51%, P = 0.001).

CONCLUSION

Patients having full-thickness TEM excision, distally placed lesions and a long interval (> 7 weeks) to CS were likely to have an inferior TME specimen. The results confirm that CS after TEM does not negatively influence local recurrence and survival, but the reduced disease-free survival in patients with an inferior specimen is of concern.

How useful is endorectal ultrasound in the management of early rectal carcinoma?

INTRODUCTION

Endorectal ultrasonography (EUS) is used to T stage early rectal tumours and select patients to whom transanal endoscopic microsurgery (TEM) could be offered. Published papers have shown that EUS can have good accuracy, but there is little literature on how EUS influences patient management. The study aim is to ascertain the value of EUS in the management of early rectal tumours.

METHODS

Patients with adenomas/early rectal carcinoma being considered for TEM were prospectively studied. Each patient underwent EUS. The surgeon recorded the expected T stage, confidence level of the T stage and management plan for each patient on a proforma before and after the ultrasound result was revealed. Comparison was made between the ultrasound stage and final pathological stage where available.

RESULTS

Ninety-six patients were referred over 2 years. Nine were out of reach of the rigid probe and were excluded. Proformas were completed on 53/87 patients (age range 28-87 years, mean age 66 years, 30 males/23 females). Forty-eight patients had a pathological report to compare with the EUS T stage. Ultrasound agreed with the pathological T staging in 43 patients (90%). Patient management was changed in five patients. In 30% of (16/53) patients, EUS increased the confidence level for T staging.

CONCLUSION

Although EUS has a high accuracy in predicting the T stage of early rectal cancers, it never changes the management plan for lesions thought to be benign. It seldom changes the pre-operative selection process when clinical examination is considered with other imaging modalities (MRI/CT). EUS should be reserved for answering specific questions in difficult cases rather than for all patients.

Laparoscopic ventral rectopexy is effective for solitary rectal ulcer syndrome when associated with rectal prolapse

AIM

Solitary rectal ulcer syndrome (SRUS) is uncommon and its management is controversial. The aim of this study was to evaluate the outcome of patients with SRUS who underwent laparoscopic ventral rectopexy (LVR).

METHOD

A review was performed of a prospective database at the Oxford Pelvic Floor Centre to identify patients between 2004 and 2012 with a histological diagnosis of SRUS. All were initially treated conservatively and surgical treatment was indicated only for patients with significant symptoms after failed conservative management. The primary end-point was healing of the ulcer. Secondary end-points included changes in the Wexner Constipation Score and Faecal Incontinence Severity Index (FISI).

RESULTS

Thirty-six patients with SRUS were identified (31 women), with a median age of 44 (15–81) years. The commonest symptoms were rectal bleeding (75%) and obstructed defaecation (64%). The underlying anatomical diagnosis was internal rectal prolapse (n = 20), external rectal prolapse (n = 14) or anismus (n = 2). Twenty-nine patients underwent LVR and one a stapled transanal rectal resection (STARR) procedure. Nine (30%) required a further operation, six required posterior STARR for persistent SRUS and two a per-anal stricturoplasty for a narrowing at the healed SRUS site. Healing of the SRU was seen in 27 (90%) of the 30 patients and was associated with significant improvements in Wexner and FISI scores at a 3-year follow-up.

CONCLUSION

Almost all cases of SRUS in the present series were associated with rectal prolapse. LVR resulted in successful healing of the SRUS with good function in almost all patients, but a significant number will require further surgery such as STARR for persistent obstructed defaecation.

Local recurrence after stenting for obstructing left-sided colonic cancer

BACKGROUND

Self-expanding metallic stents (SEMS) may be used in acute obstructing left-sided colonic cancers to avoid high-risk emergency surgery. However, oncological safety remains uncertain. This study evaluated the long-term oncological outcome of SEMS as a bridge to elective curative surgery versus emergency resection.

METHODS

A consecutive prospective cohort of patients admitted with obstructing left-sided colonic cancer between 2006 and 2012 was analysed. The decision to stent as a bridge to surgery or to perform emergency surgery was made by the on-call consultant colorectal surgeon in conjunction with a consultant interventional radiologist; when appropriate, they performed the stent procedure together. Primary outcomes were local and distant recurrence, and overall survival. Secondary outcomes were postoperative complications, in-hospital mortality, proportion of procedures undertaken laparoscopically, and anastomosis and stoma rates.

RESULTS

In total, 105 patients with obstructing left-sided colonic cancer were treated with curative intent; 62 were treated with SEMS as a bridge to surgery and 43 had emergency resection. In patients aged 75 years or less, stenting and delayed surgery was associated with a higher local recurrence rate compared with emergency surgery at the end of follow-up (32 versus 8 per cent; P = 0·038). This did not translate into a significant difference in overall survival.

CONCLUSION

SEMS was associated with an increased local recurrence rate.

Impact of slow transit constipation on the outcome of laparoscopic ventral rectopexy for obstructed defaecation associated with high grade internal rectal prolapse

AIM

Limited literature exists on whether slow colonic transit adversely influences the results of outlet obstruction surgery. We compared the functional results of laparoscopic ventral rectopexy (LVR) for obstructed defaecation secondary to high grade internal rectal prolapse in patients with normal and slow colonic transit.

METHOD

Consecutive patients suffering from obstructed defaecation associated with an internal rectal prolapse, who underwent an LVR between 2007 and 2011, were identified from a prospective database. All patients underwent preoperative defaecating proctography, anorectal manometry and colonic transit studies. Symptoms were assessed preoperatively and at 12 months after operation using a standardized questionnaire incorporating the Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire, the Fecal Incontinence Severity Index (FISI), the Patient Assessment of Constipation Quality of Life (PAC-QOL) scale and the Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

In all, 151 patients underwent LVR, 109 with normal and 42 with slow colonic transit. Preoperatively there was no significant difference between the two groups in age, sex, PAC-SYM score or FISI score. The PAC-SYM and FISI scores were significantly reduced in both groups at 12 months (P < 0.001). When comparing the change from baseline of PAC-SYM between patients with and without slow transit constipation, a significant difference was observed (P = 0.030) with changes of 58% and 40%. Quality of life (GIQLI and PAC-QOL) was equally improved in both groups. Quality of life improvement was less in patients with right colonic stasis.

CONCLUSION

Slow colonic transit has no adverse impact on function and quality of life after LVR for obstructed defaecation due to high grade internal rectal prolapse.

Does the presence of a high grade internal rectal prolapse affect the outcome of pelvic floor retraining in patients with faecal incontinence or obstructed defaecation?

AIM

Pelvic floor retraining is considered first-line treatment for patients with faecal incontinence or obstructed defaecation. There are at present no data on the effect of a high grade internal rectal prolapse on outcomes of pelvic floor retraining. The current study aimed to assess this influence.

METHOD

In all, 120 consecutive patients were offered pelvic floor retraining. The predominant symptom was faecal incontinence in 56 patients (47%) and obstructed defaecation in 64 patients (53%). Patients were assessed before and after therapy using the Fecal Incontinence Severity Index (FISI), the Patient Assessment of Constipation Symptoms (PAC-SYM) score and the Gastrointestinal Quality of Life Index (GIQLI). Defaecography and anorectal manometry were performed in all patients before pelvic floor retraining.

RESULTS

A high grade internal rectal prolapse was observed in 42 patients (35%). In patients with faecal incontinence without a high grade internal rectal prolapse, the FISI score decreased from 36 to 27 (P < 0.01). The FISI score did not change (32 vs 32; P = 0.93) in patients with a high grade internal rectal prolapse. The PAC-SYM score improved significantly (24 vs 19; P = 0.01) in patients with obstructed defaecation without a high grade rectal prolapse compared with no significant change (26 vs 25; P = 0.21) in patients with a high grade rectal prolapse. Quality of life (GIQLI) improved only in patients without a high grade internal rectal prolapse.

CONCLUSION

Pelvic floor retraining may be useful in patients with defaecation disorders not associated with a high grade internal rectal prolapse. Patients with a high grade internal rectal prolapse may be considered for surgery from the outset.

What are the symptoms of internal rectal prolapse?

AIM

Although high-grade internal rectal prolapse is believed to cause functional symptoms such as obstructed defaecation, little has been published on the exact distribution and frequency of symptoms. The aim of this study was to identify the most common symptoms of patients with high-grade internal rectal prolapse.

METHOD

Patients were diagnosed with high-grade prolapse (grade 3 and 4) on proctography using the Oxford Rectal Prolapse Grade. Information from a prospectively collected database was supplemented by a retrospective case note review.

RESULTS

Eighty eight patients (94% of them women) were included for analysis. Faecal incontinence (56%) was the most common symptom at presentation. Symptoms related to obstructed defaecation syndrome were the next most common, including incomplete evacuation (45%), straining (34%), digital assistance (34%) and repetitive toilet visits (33%).

CONCLUSION

A variety of symptoms may be caused by high-grade internal rectal prolapse Although symptoms of obstructed defaecation were frequent, urge faecal incontinence was the most common.

Evaluation and surgical treatment of rectal prolapse: an international survey

AIM

Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP.

METHOD

A 36-question questionnaire in English about the evaluation, treatment and follow-up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e-mail.

RESULTS

In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients.

CONCLUSION

The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.

Long-term follow-up after anterior sphincter repair: influence of age on functional outcome

AIM

Anterior sphincter repair has been advocated for women with anterior sphincter defects and faecal incontinence. There have been a number of reports of deterioration in functional outcome from anal sphincter repair over the long-term and of inferior outcomes in older patients. This study set out to examine these issues in a specialist tertiary referral unit.

METHOD

Patients having a sphincter repair were identified from a prospectively collected database. The information within the database was expanded by the use of a postal questionnaire and structured review of the case notes. The questionnaire incorporated commonly used validated scoring systems as well as subjective questions.

RESULTS

One hundred and thirteen patients were identified, of whom 66 (58%) responded. Of these patients, four had incomplete medical notes, leaving 62 (55%) with both returned questionnaires and complete medical notes. Forty-eight (72%) patients reported subjective initial improvement in their symptoms, though only 37 (56%) believed themselves improved at long-term follow-up (median 8.8 years; range 1.1-13.6 years). Incontinence and quality of life scores mirrored these patients' subjective responses. The median age of those patients reporting a subjective improvement at long-term follow-up was 38, compared with 56 in those who thought they were not improved (P < 0.001).

CONCLUSIONS

Outcome from anal sphincter repair deteriorates with time. Subjective outcome is worse in older patients who additionally tend to have worse incontinence scores and quality of life measures.

A critical appraisal of endorectal ultrasound and transanal endoscopic microsurgery and decision-making in early rectal cancer

AIM

Transanal endoscopic microsurgery (TEM) for early rectal cancer (ERC) gives results similar to major surgery in selected cases. Endorectal ultrasound (ERUS) is an important part of the preoperative selection process. This study reports its accuracy and impact for patients entered on the UK TEM database.

METHOD

The UK TEM database comprises prospectively collected data on 494 patients. This data set was used to determine the prevalence of ERUS in preoperative staging and its accuracy by comparing preoperative T-stage with definitive pathological staging following TEM.

RESULTS

ERUS was performed in 165 of 494 patients who underwent TEM for rectal cancer. It inaccurately staged rectal cancer in 44.8% of tumours: 32.7% were understaged and 12.1% were overstaged. There was no significant difference in the depth of TEM excision or R1 rate between the patients who underwent ERUS before TEM and those who did not (P = 0.73).

CONCLUSION

The data show that ERUS is employed in a minority of patients with rectal cancers undergoing TEM in the UK and its accuracy in this 'Real World' practice is disappointing.

Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus ('pseudoanismus') is excluded

AIM

Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus.

METHOD

Botulinum toxin was administered, under local anaesthetic, into the puborectalis/external sphincter of patients with proctographic anismus. Responders (resolution followed by recurrence of obstructed defecation over a 1- to 2-month period) underwent repeat injection. Nonresponders underwent rectal examination under anaesthetic (EUA). EUA-diagnosed rectal prolapse was graded using the Oxford Prolapse Grade 1-5.

RESULTS

Fifty-six patients were treated with botulinum toxin. Twenty-two (39%) responded initially and 21/22 (95%) underwent repeat treatment. At a median follow up of 19.2 (range, 7.0-30.4) months, 20/21 (95%) had a sustained response and required no further treatment. Isolated obstructed defecation symptoms (OR = 7.8, P = 0.008), but not proctographic or physiological factors, predicted response on logistic regression analysis. In 33 (97%) of 34 nonresponders, significant abnormalities were demonstrated at EUA: 31 (94%) had a grade 3-5 rectal prolapse, one had internal anal sphincter myopathy and one had a fissure. Exclusion of these alternative diagnoses revised the initial response rate to 96%.

CONCLUSION

Simple proctographic criteria overdiagnose anismus and underdiagnose rectal prolapse. This explains the published variable response to botulinum toxin. Failure to respond should prompt EUA seeking undiagnosed rectal prolapse. A response to an initial dose of botulinum toxin might be considered a more reliable diagnosis of anismus than proctography.

Isolated colonic inertia is not usually the cause of chronic constipation

AIM

Chronic constipation is classified as outlet obstruction, colonic inertia or both. We aimed to determine the incidence of isolated colonic inertia in chronic constipation and to study symptom pattern in those with prolonged colonic transit time.

METHODS

Chronic constipation patients were classified radiologically by surgeon-reported defaecating proctography and transit study into four groups: isolated outlet obstruction, isolated colonic inertia, outlet obstruction plus colonic inertia, or normal. Symptom patterns were defined as stool infrequency (twice weekly or less) or frequent unsuccessful evacuations (more than twice weekly).

RESULTS

Of 541 patients with chronic constipation, 289 (53%) were classified as isolated outlet obstruction, 26 (5%) as isolated colonic inertia, 159 (29%) as outlet obstruction plus colonic inertia and 67 (12%) as normal. Of 448 patients (83%) with outlet obstruction, 35% had additional colonic inertia. Only 14% of those with prolonged colonic transit time had isolated colonic inertia. Frequent unsuccessful evacuations rather than stool infrequency was the commonest symptom pattern in all three disease groups (isolated outlet obstruction 86%, isolated colonic inertia 54% and outlet obstruction plus colonic inertia 63%).

CONCLUSION

Isolated colonic inertia is an unusual cause of chronic constipation. Most patients with colonic inertia have associated outlet obstruction. These data question the clinical significance of isolated colonic inertia.

What causes chronic idiopathic perineal pain?

AIM

Chronic idiopathic perineal pain is poorly understood. Underlying structural abnormalities have been clinically suspected but rarely demonstrated objectively. The condition has been frequently considered to be a psychological disorder. We aimed to evaluate how commonly a structural explanation for such pain symptoms is present.

METHOD

Patients seen in a pelvic floor clinic with severe chronic functional anorectal pain that was classified as chronic idiopathic perineal pain (study group) were prospectively registered in a pelvic floor database and underwent pelvic floor work up (defaecating proctography, anorectal physiology and anal ultrasound +/- rectal examination under anaesthetic). A control group was formed by patients with obstructed defaecation, with or without faecal incontinence, with advanced posterior compartment prolapse.

RESULTS

Of 59 patients with chronic idiopathic perineal pain [80% women; mean age 53 (range, 22-84) years], representing 5% of all pelvic floor presentations, 33 (56%) had chronic idiopathic perineal pain alone and 26 (44%) had chronic idiopathic perineal pain with obstructed defaecation. Thirty-five (59%) had an underlying high-grade internal rectal prolapse (73% with chronic idiopathic perineal pain + obstructed defaecation vs 48% with chronic idiopathic perineal pain alone; P < 0.05). Anorectal pain was present in 50% of 543 controls with advanced posterior compartment prolapse.

CONCLUSION

High-grade internal rectal prolapse commonly underlies chronic idiopathic perineal pain, particularly when obstructed defaecation is present. Chronic anorectal pain is a common, under-recognized subsidiary symptom in patients with advanced posterior compartment prolapse presenting primarily with obstructed defaecation or faecal incontinence.

A contraction response of the internal anal sphincter to Botulinum toxin: does low-pressure chronic anal fissure have a different pathophysiology?

AIM

A subset of low-pressure fissures is not associated with typical internal anal sphincter hypertonia and may involve a different pathophysiological mechanism. We aimed to assess the manometric response of the internal anal sphincter to botulinum toxin in low-pressure fissures compared to high-pressure fissures.

METHOD

Twenty five units of botulinum toxin (Botox(TM)) were injected directly into the internal anal sphincter. Maximum resting pressure (MRP) and maximum squeeze increment (MSI) were documented at baseline and four weeks after injection.

RESULTS

Nine (31%) of 29 patients had a low-pressure fissure. Those with an anterior fissure had a significantly lower median baseline MRP than those with a posterior fissure (66 vs 83 mmHg, P = 0.009). Significantly more patients with low-pressure fissures developed a contraction or no response (78%vs 30%, difference 48%, 95% CI 14-82%, P = 0.006). Those developing a contraction response had a lower mean baseline MRP than those developing a relaxation response (56 vs 86 mmHg, difference 30 mmHg, 95% CI 17-43%, P < 0.001).

CONCLUSION

Botulinum toxin appears to have an atypical contraction effect on the internal anal sphincter in low-pressure (usually anterior) fissures. This may be accounted for by blockade of acetylcholine released at parasympathetic nerve terminals and the sympathetic ganglion (relaxation). Low pressure fissures may be physiologically different from high-pressure fissures.

Changes in the management and outcome of rectal cancer over a 10-year period in Oxford

AIM

The changes in the management and outcome of rectal cancer in Oxford were studied over a 10-year period.

METHOD

Rectal cancer data using a prospectively collected data base were divided into curative (global) and palliative groups. The global curative group was further divided into those with and without (selected group) the following features: emergency cases, local excision, salvage surgery for recurrence or incomplete local excision, metastatic disease, perioperative death, hereditary cancer, inflammatory bowel disease-related cancer, and synchronous cancer.

RESULTS

Between 1994 and 2003, 709 cases of rectal cancer were treated, 532 for cure and a selected group of 393 after removing patients with the aforementioned exclusions. For the selected group, the average follow-up was 51.2 months, overall survival 65.4% and cancer-specific survival 75.3%. There was no 2-year survival difference between each of the 10-year periods of study. Two-year local recurrence was 5.6% for the first 5-year period and 2.3% for the second (P = 0.11). MRI staging increased during the 10 years (0% in 1994; 66.7% in 2003) as did use of definitive chemoradiotherapy (dCRT) (0% in 1994; 64.7% in 2003). The anastomotic leakage rate was significantly higher in the second 5-year period (2.6%vs 9.6%; P = 0.01).

CONCLUSION

Despite increasing use of MRI and dCRT, 2-year survival and local recurrence were not significantly different within the 10 years studied.

The relationship between internal rectal prolapse and internal anal sphincter function

AIM

Faecal incontinence is commonly seen in patients with internal rectal prolapse (IRP), although the mechanism is not clear. This study assessed the relationship between IRP and anal sphincter function.

METHOD

Patients both with IRP diagnosed on proctography and those with external rectal prolapse (ERP) were identified from a prospective database generated from a tertiary referral pelvic floor clinic. The results of anorectal manometry were analysed, and the relationship between sphincter pressure and grade of prolapse was assessed.

RESULTS

A total of 515 patients were identified with clinical evidence of ERP or proctographic evidence of internal and external prolapse. There were 88 with grade 5 or external prolapse [mean maximal resting pressure (MRP) 28.5 (standard error 2.1) mmHg], 156 with grade 4 prolapse [44.0 (1.8) mmHg], 153 with grade 3 prolapse [49.2 (1.6) mmHg], 88 with grade 2 prolapse [56.2 (2.1) mmHg] and 29 patients with grade 1 rectal prolapse [56.8 (4.5) mmHg]. There was a significant reduction in the mean MRP with increasing grade of prolapse from grade 2 to 5. By contrast, there was no relationship between prolapse grade and mean maximal squeeze pressure, except in patients with ERP, in whom the squeeze pressure was significantly lower compared with patients with IRP.

CONCLUSION

This is the first large-scale study to show the relationship between internal prolapse and MRP. The observation that squeeze pressure is unchanged suggests that the effect of internal prolapse on continence occurs mainly through a reduction in internal anal sphincter tone.

Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete?

AIM

Perineal approaches are considered to be the 'gold standard' in treating elderly patients with external rectal prolapse (ERP) because morbidity and mortality with perineal approaches are lower compared with transabdominal approaches. Higher recurrence rates and poorer function are tolerated as a compromise. The aim of the present study was to assess the safety of laparoscopic ventral rectopexy (LVR) in elderly patients, compared with perineal approaches.

METHOD

The prospectively collected databases from two tertiary referral pelvic floor units were interrogated to identify outcome in patients of 80 years of age and older with full-thickness ERP treated by LVR. The primary end-points were age, American Society of Anesthesiology (ASA) grade, mortality, and major and minor morbidity. Secondary end-points were length of stay (LOS) and recurrence.

RESULTS

Between January 2002 and December 2008, 80 [median age 84 (80-97) years] patients underwent rectopexy. The mean ± standard deviation ASA grade was 2.44 (± 0.57) (two patients were ASA grade I, 42 patients were ASA grade II, 35 patients were ASA grade III and one patient was ASA grade IV). The median LOS was 3 (range 1-37) days. There was no mortality, and 10 (13%) patients had complications (one major and nine minor). At a median follow-up of 23 (2-82) months, two (3%) patients had developed a recurrent full-thickness prolapse.

CONCLUSION

LVR is a safe procedure for using to treat full-thickness ERP in elderly patients. Mortality, morbidity and hospital stay are comparable with published rates for perineal procedures, with a 10-fold lower recurrence.

Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete?

AIM

Perineal approaches are considered to be the 'gold standard' in treating elderly patients with external rectal prolapse (ERP) because morbidity and mortality with perineal approaches are lower compared with transabdominal approaches. Higher recurrence rates and poorer function are tolerated as a compromise. The aim of the present study was to assess the safety of laparoscopic ventral rectopexy (LVR) in elderly patients, compared with perineal approaches.

METHOD

The prospectively collected databases from two tertiary referral pelvic floor units were interrogated to identify outcome in patients of 80 years of age and older with full-thickness ERP treated by LVR. The primary end-points were age, American Society of Anesthesiology (ASA) grade, mortality, and major and minor morbidity. Secondary end-points were length of stay (LOS) and recurrence.

RESULTS

Between January 2002 and December 2008, 80 [median age 84 (80-97) years] patients underwent rectopexy. The mean ± standard deviation ASA grade was 2.44 (± 0.57) (two patients were ASA grade I, 42 patients were ASA grade II, 35 patients were ASA grade III and one patient was ASA grade IV). The median LOS was 3 (range 1-37) days. There was no mortality, and 10 (13%) patients had complications (one major and nine minor). At a median follow-up of 23 (2-82) months, two (3%) patients had developed a recurrent full-thickness prolapse.

CONCLUSION

LVR is a safe procedure for using to treat full-thickness ERP in elderly patients. Mortality, morbidity and hospital stay are comparable with published rates for perineal procedures, with a 10-fold lower recurrence.

Rectal hyposensitivity is uncommon and unlikely to be the central cause of obstructed defecation in patients with high-grade internal rectal prolapse

BACKGROUND

There are several causes of obstructed defecation one of which is thought to be internal rectal prolapse. Operations directed at internal prolapse, such as laparoscopic ventral rectopexy, may improve obstructed defecation symptoms significantly. It is not clear whether the obstructed defecation with internal prolapse is a mechanical phenomenon or whether it results changes in rectal sensitivity. This study aimed to evaluate rectal sensory function in patients with obstructed defecation and high-grade internal rectal prolapse.

METHODS

This study represents a retrospective review of a prospectively collected database of patients attending a tertiary referral pelvic floor unit. Patients with high-grade (recto-anal) intussusception formed the basis of this study. Rectal sensory function was determined by intrarectal balloon inflation. Three parameters (sensory threshold, urge to defecate and maximum tolerated volumes) were recorded. Abnormal sensitivity was defined as partial (one or two parameters abnormal) or total (all three abnormal).

KEY RESULTS

Four hundred and eight patients with high-grade internal rectal prolapse both with and without obstructed defecation symptoms were studied. Two hundred and forty one (59%) had normal sensation. Eighteen (4%) had total hyposensitivity and three (1%) total hypersensitivity. A further 96 (24%) had partial hyposensitivity whilst 50 (12%) had partial hypersensitivity. Neither hypersensitivity nor hyposensitivity differed between patients with and without symptoms of obstructed defecation.

CONCLUSIONS & INFERENCES

Rectal hyposensitivity is relatively uncommon in patients with high-grade internal rectal prolapse and obstructed defecation. Internal rectal prolapse may cause obstructed defecation through a mechanical process. It does not appear that rectal hyposensitivity plays a significant part in the pathological process.

Examination of outcome following abdominoperineal resection for adenocarcinoma in Oxford

AIM

Abdominoperineal resection (APR) has been shown to have poor outcomes compared with anterior resection (AR) in the treatment of rectal cancer. We compared APR outcomes with those for low AR.

METHOD

Lower third rectal cancers treated at the John Radcliffe Hospital with APR and low AR were examined using a prospectively collected database augmented with review of patient records. For all cases (APR and low AR), a range of patient, cancer and outcome data were collected. A selected group was created on the basis of exclusions. Outcomes for the global and selected APR and low AR groups were compared using the Kaplan-Meier method. CRM+ve and CRM-ve APR cases were compared.

RESULTS

Between 1994 and 2003, 70 APR and 93 low AR were performed. After exclusions, 42 APR and 81 low AR remained. Median follow-up was 4.8 years. Five year survival for the APR group was significantly worse than for the low AR group. The APR group showed significantly fewer T0 cancers and significantly more T3 cancers. CRM R1 involvement was significantly higher for the APR group. The CRM+ve APR group contained significantly more later stage cancers, more defective resection specimens, more abscesses and fistulas and was associated with more local recurrence.

CONCLUSIONS

These data showed that APR led to worse results than low AR in terms of overall survival and circumferential margin involvement, but that the cancers treated with APR tended to be more locally advanced.

Benchmarking circumferential resection margin (R1) resection rate for rectal cancer in the neoadjuvant era

AIM

Circumferential resection margin (CRM) involvement (R1) is used to audit rectal cancer surgical quality. However, when downsizing chemoradiation (dCRT) is used, CRM audits both dCRT and surgery, its use reflecting a high casemix of locally advanced tumours. We aimed to evaluate predictors of R1 and benchmark R1 rates in the dCRT era, and to assess the influence of failure of steps in the multidisciplinary team (MDT) process to CRM involvement.

METHOD

A retrospective analysis of prospectively collected rectal cancer data was undertaken. Patients were classified according to CRM status. Uni- and multivariate analysis was undertaken of risk factors for R1 resection. The contribution of the steps of the MDT process to CRM involvement was assessed.

RESULTS

Two hundred and ten rectal cancers were evaluated (68% T3 or T4 on preoperative staging). R1 (microscopic) and R2 (macroscopic) resections occurred in 20 (10%) and 6 patients (3%), respectively. Of several factors associated with R1 resections on univariate analysis, only total mesorectal excision (TME) specimen defects and threatened/involved CRM on preoperative imaging remained as independent predictors of R1 resections on multivariate analysis. Causes of R1 failure by MDT step classification found that less than half were associated with and only 15% solely attributable to a suboptimal TME specimen.

CONCLUSION

Total mesorectal excision specimen defects and staging-predicted threatened or involved CRM are independent strong predictors of R1 resections. In most R1 resections, the TME specimen was intact. It is important to remember the contribution of both the local staging casemix and dCRT failure when using R1 rates to assess purely surgical competence.