EP.FRI.451 Laparotomy rates and factors influencing treatment modality for diverticulitis during the COVID-19 lockdown

Background

Infection control measures during the COVID-19 crisis modified diverticulitis treatment. Here we present the treatment applied in three large UK centres compared to the same timeframe in 2019. 

Methods

This was a multicentre, comparative study, whereby diverticulitis cases from March 23^rdto May 11^th2019 acted as historical controls for cases during lockdown. Severity at presentation (SD), comorbidities, treatment modality, Length of Stay (LOS), complications and COVID-19 status (CS) were recorded. Chi-squared, ANOVA, Mann-Whitney test and linear regression were used for analyses. 

Results

59 patients presented with diverticulitis in 2020 compared to 130 in 2019 (M:F 27/32, 56/74 and 64vs.62 y.o.). Laparotomy was performed in 6/59 and 12/130 respectively. Comparing 2019 to 2020, there was no statistical difference for severity (p = 0.643), treatment modality (0.946), comorbidities (0.313), LOS (0.602). Linear regression demonstrated statistically significant association between treatment employed (p < 0.001) and SD, while there was no association with age, comorbidities or CS. LOS was associated with severity only (p < 0.001), whilst CS, treatment, age and comorbidities yielded no statistical difference. 

Conclusion

Diverticulitis cases during 2020 lockdown reduced noticeably (59vs.130). There was no difference in severity, treatment, comorbidities or LOS between 2019 and 2020. Laparotomy was performed in 6/59 and 12/130 respectively. Decision about treatment and LOS in 2020 was associated with severity of disease only. There was no association with COVID status. These findings should be interpreted with caution due to small COVID positive numbers and not including ambulatory units, however, they are consistent with findings from our sister Spanish group.    

Sacral nerve stimulation versus the magnetic sphincter augmentation device for adult faecal incontinence: the SaFaRI RCT

BACKGROUND

Preliminary studies using the FENIX™ (Torax Medical, Minneapolis, MN, USA) magnetic sphincter augmentation device suggest that it is safe to use for the treatment of adult faecal incontinence, but efficacy data are limited.

OBJECTIVE

To compare FENIX with sacral nerve stimulation for the treatment of adult faecal incontinence in terms of safety, efficacy, quality of life and cost-effectiveness.

DESIGN, SETTING AND PARTICIPANTS

Multicentre, parallel-group, unblinded, randomised trial comparing FENIX with sacral nerve stimulation in participants suffering moderate to severe faecal incontinence.

INTERVENTIONS

Participants were randomised on an equal basis to either sacral nerve stimulation or FENIX. Follow-up occurred 2 weeks postoperatively and at 6, 12 and 18 months post randomisation.

MAIN OUTCOME AND MEASURE

The primary outcome was success, defined as device in use and ≥ 50% improvement in Cleveland Clinic Incontinence Score at 18 months post randomisation. Secondary outcomes included complication rates, quality of life and cost-effectiveness. Between 30 October 2014 and 23 March 2017, 99 participants were randomised across 18 NHS sites (50 participants to FENIX vs. 49 participants to sacral nerve stimulation). The median time from randomisation to FENIX implantation was 57.0 days (range 4.0-416.0 days), and the median time from randomisation to permanent sacral nerve stimulation was 371.0 days (range 86.0-918.0 days). A total of 45 out of 50 participants underwent FENIX implantation and 29 out of 49 participants continued to permanent sacral nerve stimulation. The following results are reported, excluding participants for whom the corresponding outcome was not evaluable. Overall, there was success for 10 out of 80 (12.5%) participants, with no statistically significant difference between the two groups [FENIX 6/41 (14.6%) participants vs. sacral nerve stimulation 4/39 (10.3%) participants]. At least one postoperative complication was experienced by 33 out of 45 (73.3%) participants in the FENIX group and 9 out of 40 (22.5%) participants in the sacral nerve stimulation group. A total of 15 out of 50 (30%) participants in the FENIX group ultimately had to have their device explanted. Slightly higher costs and quality-adjusted life-years (incremental = £305.50 and 0.005, respectively) were observed in the FENIX group than in the sacral nerve stimulation group. This was reversed over the lifetime horizon (incremental = -£1306 and -0.23 for costs and quality-adjusted life-years, respectively), when sacral nerve stimulation was the optimal option (net monetary benefit = -£3283), with only a 45% chance of FENIX being cost-effective.

LIMITATIONS

The SaFaRI study was terminated in 2017, having recruited 99 participants of the target sample size of 350 participants. The study is, therefore, substantially underpowered to detect differences between the treatment groups, with significant uncertainty in the cost-effectiveness analysis.

CONCLUSIONS

The SaFaRI study revealed inefficiencies in the treatment pathways for faecal incontinence, particularly for sacral nerve stimulation. The success of both FENIX and sacral nerve stimulation was much lower than previously reported, with high postoperative morbidity in the FENIX group.

FUTURE WORK

Further research is needed to clarify the treatment pathways for sacral nerve stimulation and to determine its true clinical and cost-effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16077538.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 18. See the NIHR Journals Library website for further project information.

A new technique of extreme lateral positioning for laparoscopic splenic flexure mobilization

AIM

This aim of this study was to describe a novel positioning technique that assists in the expeditious mobilization of the splenic flexure without the need for redraping or compromise of port placement.

METHOD

A prospective case series was studied to evaluate the technique and its ability to facilitate splenic flexure mobilization.

RESULTS

The technique was used in 12 patients. There were no adverse intra- or postoperative events. The median time (interquartile range) for laparoscopic splenic flexure mobilisation was 10 (9-11.25).

CONCLUSION

This novel positioning technique is safe and feasible. We include a detailed video that describes and demonstrates the requisites for its safe conduct. We also include intra-operative footage demonstrating the benefits of the patient's position.

Systematic review of anorectal varices

AIM

Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise.

METHOD

A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices.

RESULTS

Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure.

CONCLUSION

As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.

Outcome of surgical resection of second-time locally recurrent rectal cancer

BACKGROUND

Locally recurrent rectal cancer relapses in the pelvis in up to 60 per cent of patients following resection. This study assessed the surgical and oncological outcomes of patients who underwent surgery for re-recurrent rectal cancer.

METHODS

Patients who underwent second-time resection of locally recurrent rectal cancer between 2001 and 2010 were eligible for inclusion. Data were collected on demographics, presentation of disease, preoperative staging imaging, adjuvant therapy, operative detail, histopathology and follow-up status (clinical and imaging) for the primary tumour, and first and second recurrences.

RESULTS

Thirty patients (of 56 discussed at the multidisciplinary meeting) underwent resection of re-recurrent rectal cancer. Postoperative morbidity occurred in nine patients but none died within 30 days. Negative resection margins (R0) were achieved in ten patients, microscopic margin positivity (R1) was evident in 15 and macroscopic involvement (R2) was found in five. Although no patient had distant metastatic disease, 22 had involvement of the pelvic side wall. One- and 3-year overall survival rates were 77 and 27 per cent respectively, with a median overall survival of 23 (range 3-78) months. An R0 resection conferred a survival benefit (median survival 32 (11-78) months versus 19 (6-33) months after R1 and 7 (3-10) months after R2 resection).

CONCLUSION

Surgical resection of re-recurrent rectal cancer had comparable surgical and oncological outcomes to initial recurrences in well selected patients.

Synchronous resection of colorectal cancer and liver metastases: comparative views of colorectal and liver surgeons

AIM

The optimal management of patients presenting with colorectal cancer and synchronous liver metastases is controversial. This survey was intended to summarize the opinions of UK colorectal and liver surgeons on the specific issues pertaining to synchronous resection.

METHOD

A validated electronic survey was sent to the consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Association of Upper Gastrointestinal Surgeons (AUGIS). The questions were structured to allow direct comparison between the two groups of the responses obtained.

RESULTS

Four hundred and twenty-four specialist colorectal surgeons and 52 specialist hepatobiliary surgeons were identified from the register of their respective associations. Responses were obtained from 133 (31%) colorectal and 22 (42%) liver surgeons. A majority of both groups of surgeons felt that synchronous resection was a valid therapeutic option. A majority of both groups believed that synchronous resection was justified despite the options of laparoscopic surgery and enhanced recovery programmes for each discipline. Agreed possible advantages of synchronous resections were: a decrease in the overall length of hospital stay, cost and patient anxiety. The major concern about synchronous resections was an excessive overall physiological insult. Specific scenarios indicated that synchronous resection was favoured for major/complex major colorectal resection with minor liver resection or most colorectal resections not involving an anastomosis with either a minor or major liver resection.

CONCLUSION

Although significant concerns relating to synchronous resection remain amongst colorectal and liver surgeons, a majority of them felt that synchronous resections could be offered to appropriately selected patients.

Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol

AIM

Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes).

METHOD

One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 μg/ml and then allowed to self-administer a bolus of propofol (200 μg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer's Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure.

RESULTS

The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference -0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability.

CONCLUSION

Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.

Artificial neural networks to predict presence of significant pathology in patients presenting to routine colorectal clinics

AIM

Artificial neural networks (ANNs) are computer programs used to identify complex relations within data. Routine predictions of presence of colorectal pathology based on population statistics have little meaning for individual patient. This results in large number of unnecessary lower gastrointestinal endoscopies (LGEs - colonoscopies and flexible sigmoidoscopies). We aimed to develop a neural network algorithm that can accurately predict presence of significant pathology in patients attending routine outpatient clinics for gastrointestinal symptoms.

METHOD

Ethics approval was obtained and the study was monitored according to International Committee on Harmonisation - Good Clinical Practice (ICH-GCP) standards. Three-hundred patients undergoing LGE prospectively completed a specifically developed questionnaire, which included 40 variables based on clinical symptoms, signs, past- and family history. Complete data sets of 100 patients were used to train the ANN; the remaining data was used for internal validation. The primary output used was positive finding on LGE, including polyps, cancer, diverticular disease or colitis. For external validation, the ANN was applied to data from 50 patients in primary care and also compared with the predictions of four clinicians.

RESULTS

Clear correlation between actual data value and ANN predictions were found (r = 0.931; P = 0.0001). The predictive accuracy of ANN was 95% in training group and 90% (95% CI 84-96) in the internal validation set and this was significantly higher than the clinical accuracy (75%). ANN also showed high accuracy in the external validation group (89%).

CONCLUSION

Artificial neural networks offer the possibility of personal prediction of outcome for individual patients presenting in clinics with colorectal symptoms, making it possible to make more appropriate requests for lower gastrointestinal endoscopy.

Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists

AIM

Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction.

METHOD

Consecutive patients undergoing LGE answered specially developed patient satisfaction questionnaire at discharge and 24 h thereafter. This questionnaire was a modification of m-Group Health Association of America questionnaire. Construct and face validity of questionnaire were tested by an expert group. Demographic and clinical data was prospectively collected. Multivariate regression analysis was performed to determine factors influencing patient satisfaction.

RESULTS

Some 503 patients were surveyed after LGE. Examinations were performed by nurse (n = 105), doctor (n = 191), or NMEs (n = 155). There were no differences between three groups in terms of completion rates/complications. No differences were detected between endoscopists in patient rating for overall satisfaction (P = 0.6), technical skills (P = 0.58), communication skills (P = 0.61) or interpersonal skills (0.59). Multivariate regression analysis showed that higher preprocedure anxiety, history of pelvic operations/hysterectomy and higher pain scores were associated with adverse patient satisfaction and preprocedure anxiety, history of hysterectomy and female gender were associated with higher pain scores.

CONCLUSION

This study has shown that there are no differences in patient satisfaction with LGE performed by nurse, doctor or NME. The most important factor affecting patient satisfaction is degree of discomfort/pain experienced by patient.

Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists

AIM

Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction.

METHOD

Consecutive patients undergoing LGE answered specially developed patient satisfaction questionnaire at discharge and 24 h thereafter. This questionnaire was a modification of m-Group Health Association of America questionnaire. Construct and face validity of questionnaire were tested by an expert group. Demographic and clinical data was prospectively collected. Multivariate regression analysis was performed to determine factors influencing patient satisfaction.

RESULTS

Some 503 patients were surveyed after LGE. Examinations were performed by nurse (n = 105), doctor (n = 191), or NMEs (n = 155). There were no differences between three groups in terms of completion rates/complications. No differences were detected between endoscopists in patient rating for overall satisfaction (P = 0.6), technical skills (P = 0.58), communication skills (P = 0.61) or interpersonal skills (0.59). Multivariate regression analysis showed that higher preprocedure anxiety, history of pelvic operations/hysterectomy and higher pain scores were associated with adverse patient satisfaction and preprocedure anxiety, history of hysterectomy and female gender were associated with higher pain scores.

CONCLUSION

This study has shown that there are no differences in patient satisfaction with LGE performed by nurse, doctor or NME. The most important factor affecting patient satisfaction is degree of discomfort/pain experienced by patient.

Quality assurance in colonoscopy: role of endomucosal clips

OBJECTIVE

Quality assurance in colonoscopy is important, and subjective assessment of completion based on endoscopic signs can be inaccurate leading to missed lesions. We aimed to determine the technique of endomucosal clips with follow-up X-rays in objectively documenting completion and correlation with pathology miss rates.

METHOD

A total of 82 patients undergoing colonoscopy by trained colonoscopists had an endomucosal clip applied to the most proximal bowel reached. A plain abdominal X-ray was performed while there was still a pneumocolon, and the clip position was assessed by a blinded radiologist to determine objective completion rates. Repeat colonoscopies were performed in patients with incomplete procedures. Pathology and endoscopy database were also reviewed to identify missed lesions at a median follow-up of 6 years. These were correlated with colonoscopy completions.

RESULTS

The clip was found in caecum of 76 (93%), ascending-colon in three (3.6%), hepatic flexure in one (1.2%) and splenic flexure in two (2.4%) patients. The endoscopist opinion was incorrect in six incomplete colonoscopies. A total of 33 patients underwent repeat colonoscopies over the median 6-year follow-up. Three adenomas and one carcinoma were missed in the incomplete group and were subsequently picked up in repeat endoscopies. Only one adenoma was truly missed in complete colonoscopies, providing an overall miss rate of 1.3%.

CONCLUSION

Use of endomucosal clips with follow-on abdominal X-ray is a safe and effective method of determining completion of colonoscopy. This technique is also an excellent objective measure of quality assurance of completion and miss rates in colonoscopy, especially when combined with an audit to determine the missed lesions at two years postprocedure.

Quality assurance in flexible sigmoidoscopy: medical and nonmedical endoscopists

PURPOSE

The clinical assessment of position in colon and hence completion during flexible sigmoidoscopy (FS) is believed to be inaccurate. The technique of applying endomucosal clips with follow-up X-ray has previously been used for establishing completion in colonoscopy. Furthermore, we have now trained non-healthcare professionals (non-medical endoscopists, NME) to perform FS, but there is no data on assessment of their performance of FS. We performed this study with the aims of determining accuracy of endoscopists' clinical impression regarding actual position of endoscope in colon during FS, comparing medical (ME) and NME in terms of clinical accuracy, and to determine role of endomucosal clips with follow-up X-rays in documenting completion and hence quality assurance.

METHODS

All patients undergoing elective FS, except those with surgical resection, were included, after ethics approval. During FS, endoscopist applied an endomucosal clip at most proximal bowel reached and endoscopists recorded their independent opinion about position of clip. Post procedure, all patients underwent an abdominal X-ray, reported by consultant radiologist, blinded to outcome of FS. X-ray results were compared with endoscopist findings. Complete FS was defined as one where descending colon was reached.

RESULTS

Fifty-one patients, with median age of 55 years, participated in study. The endoscopists were accurate in their assessment of position in colon in 38 patients (75%). The attending nurse was accurate in only 31% of cases. The crude and corrected completion rates were 73% and 84%, respectively. There was no correlation between length of endoscope and its position in colon. There were no differences between NME and ME in terms of clinical accuracy.

CONCLUSION

This study has shown that clinical impression of endoscopist during FS regarding position is not very accurate, implying need for regular quality assurance. The technique of applying endomucosal clips with follow-on abdominal X-ray is an excellent objective measure of quality assurance in FS. NME can perform FS with comparable completion rates and accuracy.

Randomized clinical trial of Entonox versus midazolam-fentanyl sedation for colonoscopy

BACKGROUND

Intravenous sedation for colonoscopy is associated with cardiorespiratory complications and delayed recovery. The aim of this randomized clinical trial was to compare the efficacy of Entonox (50 per cent nitrous oxide and 50 per cent oxygen) and intravenous sedation using midazolam-fentanyl for colonoscopy.

METHODS

Some 131 patients undergoing elective colonoscopy were included. Patients completed a Hospital Anxiety and Depression questionnaire, letter cancellation tests and pain scores on a 100-mm visual analogue scale before, immediately after the procedure and at discharge. They also completed a satisfaction survey at discharge and 24 h after the procedure.

RESULTS

Sixty-five patients were randomized to receive Entonox and 66 to midazolam-fentanyl. Completion rates were similar (94 versus 92 per cent respectively; P = 0.513). Patients receiving Entonox had a shorter time to discharge. They reported significantly less pain (mean score 16.7 versus 40.1; P < 0.001), and showed better recovery of psychomotor function immediately after the procedure and at discharge. Patient satisfaction was higher among patients who received Entonox (median score 96 versus 89; P = 0.001).

CONCLUSION

Entonox provides better pain relief and faster recovery than midazolam-fentanyl and so is more effective for colonoscopy.

Recent advances in the management of rectal cancer

Recently there have been significant advances in the management of patients with rectal cancer, attributed mainly to advances in surgical techniques and pre- and postoperative therapy. This review addresses some of these advances and their impact on the prognosis for rectal cancer patients.

Transanal endoscopic microsurgery in early rectal cancer: time for a trial?

OBJECTIVE

The optimal aim of oncological surgery is to balance cancer outcomes with preservation of function and quality of life. Radical resection (RR) offers the best curative procedure in colorectal cancer but at significant morbidity. Transanal endoscopic microsurgery (TEM) offers an alternative with less morbidity and better function. Its role remains unclear and needs to be established in the light of new emerging trends in rectal cancer. This review aims to evaluate the use of TEM and its limitations.

METHOD

PubMed and MEDLINE search was performed.

RESULTS

Strongest level of evidence (Level II) favoured TEM over RR and laparoscopic resection in term of mortality and morbidity. There was no difference in recurrence at follow-up of 41 and 56 months but neither study was adequately powered to detect a difference in recurrence/survival. Three retrospective case comparisons (Level III) also favoured TEM over RR but were subject to selection bias. Twenty eight published case series (Level IV) reported varying results due to different cancer stages, study population, full excision, adjuvant therapy and treatment indication. The oncological outcomes in TEM are similar to RR in highly selected cases but with far less mortality (near 0%), morbidity, blood loss, hospital stay and genitourinary/gastrointestinal dysfunction. TEM alone (+/- adjuvant therapy) appears sufficient for 'favourable' T1 tumours. 'Unfavourable' T1 or T2 tumours require adjuvant treatment. TEM should only be used for palliation in T3+ cancers. Seven functional studies reported significant transient dysfunction following TEM with full clinical recovery within a year. TEM is cost-effective providing sufficient cases are performed.

CONCLUSION

Significant heterogeneity limits conclusions from current literature. A trial is required. Alternate end-points to local recurrence may be required in assessing the optimal surgical approach, which balances disease control with quality of life, and probability of noncancer related death.

Cost analysis of transanal endoscopic microsurgery for rectal tumours

OBJECTIVE

Transanal endoscopic microsurgery (TEM) is considered to be a safe and effective treatment for selected rectal neoplasms. We demonstrate that in addition to the recognized clinical benefits of the less invasive TEM approach, there are substantial economic benefits.

METHOD

We reviewed our prospective database of patients undergoing TEM excision of a rectal lesion between July 1997 and December 2003. A cost analysis was undertaken, including procedural and related costs of TEM and compared with the relevant open procedures.

RESULTS

124 patients (80 men, 44 women) with a median age of 71.5 years underwent TEM excision of rectal lesions (52 cancers and 72 adenomas). The morbidity rate was 8% and mortality was zero. A controlled case series of 52 patients undergoing open resection for early rectal cancers with similar characteristics as above was compared in terms of clinical outcome. The morbidity rate in these patients was 29.5%. The cost analysis comparison was undertaken using National Health Service mean reference costs for major large intestinal surgery, Intensive care unit/high dependency unit and hospital accommodation for each procedure. The average cost of open resection was 4135 pound, vs 567 pound for TEM excision. Our total saving over the series was 525,576 pound. Although the initial capital cost of the TEM equipment is high at approximately 40,000 pound given the massive cost savings, these initial equipment costs are recovered within a rapid time frame.

CONCLUSION

This study has shown that TEM is a safe and extremely cost-effective approach for excision of selected rectal tumours including rectal adenomas and early well differentiated rectal cancers (pTis & pT1).

Anterior anal sphincter repair for fecal incontinence: Good longterm results are possible

BACKGROUND

Anterior anal sphincter repair (ASR) is standard treatment for fecal incontinence resulting from an obstetrically damaged anal sphincter. Longterm results of repair have generally been shown to be poor. This review of single-unit series aimed to determine longterm outcomes of primary ASR for patients with fecal incontinence from obstetrically damaged anal sphincter.

STUDY DESIGN

This study included patients undergoing ASR from 1995 to 1999. We perform standard overlapping ASR, but external and internal sphincters are repaired separately. The internal sphincter is sutured by direct method and only if damaged. Telephone interview was conducted with all patients, after which questionnaires, including SF-36 survey, Fecal Incontinence Quality of Life Scale questions, and Wexner score-type questions, were sent at median followup of 7 years. Demographic data, anorectal physiology, and data on short-term followup (median 12 months) were prospectively collected.

RESULTS

Sixty-four of 72 patients returned questionnaires and the operation was considered a success in 80% of patients at median followup of 84 months. Six patients underwent additional procedures for incontinence and 58 patients were analyzed. Fourteen patients reported complete continence to stool and flatus (20%). Continence had improved from median Wexner score of 14 to 7 (p < 0.001). Ninety-five percent of patients were satisfied with their operation. There was substantial improvement in all aspects of Fecal Incontinence Quality of Life Scale questionnaire and SF-36. None of the anorectal physiology variables were of value in predicting outcomes.

CONCLUSIONS

We have shown that good longterm results can be achieved with anterior anal sphincter repair. The independent muscle repair technique could explain the improved outcomes.

Mesorectal grades predict recurrences after curative resection for rectal cancer

PURPOSE

Local recurrence after curative excision for rectal cancer is frequently regarded as a failure of surgery. The macroscopic quality of the excised mesorectum after total mesorectal excision has been proposed as a means of assessment of the adequacy of surgery. This study was designed to determine the utility of mesorectal grading in prediction of local and overall recurrence after curative surgery.

METHODS

All patients undergoing resection for primary adenocarcinoma of the rectum had a mesorectal grading prospectively applied to their resection specimens, according to the classification proposed by Quirke et al. (Grades 1-3; 3 is the best). The outcome of patients undergoing potentially curative surgery from 2001 to 2003 was reviewed. Prognostic significance of mesorectal grades was determined by multivariate regression analyses.

RESULTS

A total of 130 patients with a median follow-up of 26 (range, 17-42) months were studied. The local and overall recurrences were 8.4 and 15 percent, respectively. The mesorectum was reported as Grade 3 in 61 patients (47 percent), Grade 2 in 52 patients (40 percent), and Grade 1 in 17 patients (13 percent). Patients with Grade 1 mesorectum had 41 percent local recurrence and 59 percent overall recurrence, respectively. However, patients with Grade 2 and Grade 3 mesorectum had 5.7 and 1.6 percent local recurrences, respectively, and 17 and 1.6 percent overall recurrence, respectively. By Cox's regression analysis, grade of mesorectum independently influenced both local and overall recurrences.

CONCLUSIONS

The macroscopic quality of mesorectum after curative excision of rectal cancer is an important predictor of local and overall recurrences. The mesorectal grades may be of value in decisions regarding postoperative adjuvant therapy.

Transanal endoscopic microsurgery for carcinoma of the rectum

BACKGROUND

The authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM).

METHODS

This prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit.

RESULTS

For this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48-93 years). The median diameter of the lesions was 3.44 cm (range, 1.6-8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3-15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20-150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22-82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred.

CONCLUSIONS

The findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.

Do supervised colorectal trainees differ from consultants in terms of quality of TME surgery?

OBJECTIVE

The quality of surgical excision is held to be a major determinant of outcome following surgery for rectal cancer. Macroscopic examination of the excised mesorectum allows for reproducible assessment of the quality of surgery. We aimed to determine whether quality of excision undertaken by colorectal trainees under supervision was comparable with that performed by consultants, as measured using mesorectal grades.

METHOD

A total of 130 consecutive patients undergoing potentially curative resection for primary adenocarcinoma of the rectum in our centre from 2001 to 2003 were included in the study. The pathologists graded the excised mesorectum according to staged classification proposed by Quirke. The outcome (quality of mesorectal excision and secondary outcomes including local recurrence and overall recurrence) of operations performed by consultants was compared with that of trainees. Statistical significance was tested using Pearson chi(2) test.

RESULTS

Eighty-nine operations were performed by consultants and 41 by senior colorectal trainees with consultant supervision. Forty-four patients (49%) had good mesorectum when operated by consultants in comparison with 17 (41.5%) by the trainees. There was no statistically significant difference (P = 0.717) between the two groups in terms of quality of mesorectum excised after potentially curative resection. Furthermore, there were seven local recurrences in patients operated by consultants (7.8%) when compared with four in the trainee group (9.5%) and once again there was no statistical significance between the two groups (P = 0.719).

CONCLUSION

We conclude that the quality of rectal cancer excision, as defined by mesorectal grades, achieved by supervised colorectal trainees is comparable with that achieved by consultants.

Investigation and treatment of faecal incontinence

Faecal incontinence is a debilitating condition affecting people of all ages, and significantly impairs quality of life. Proper clinical assessment followed by conservative medical therapy leads to improvement in more than 50% of cases, including patients with severe symptoms. Patients with advanced incontinence or those resistant to initial treatment should be evaluated by anorectal physiology testing to establish the severity and type of incontinence. Several treatment options with promising results exist. Patients with gross sphincter defects should undergo surgical repair. Those who fail to respond to sphincteroplasty and those with no anatomical defects have the option of either sacral nerve stimulation or other advanced procedures. Stoma formation should be reserved for patients who do not respond to any of the above procedures.

Transanal endoscopic microsurgery: where are we now?

AIMS

This review of literature aimed to assess the role and establish the current status of transanal endoscopic microsurgery (TEM) in the management of benign and malignant rectal lesions.

METHODS

A review of the literature was undertaken through the Medline database and by cross-referencing previous publications, thus identifying 54 relevant publications on TEM in the management of rectal lesions. Aggregated results of various parameters were calculated but statistical comparisons deemed unsuitable due to heterogeneity of data.

RESULTS

The TEM procedure is associated with good functional results, morbidity of 4% and zero procedure-related mortality. The local recurrence rates after TEM excision is 4.5% (range 0-14) for benign rectal lesions, 6% (0-13) for T(1) cancers, 14% (range 0-50) for T(2) cancers and 20% (range 14-67%) for T(3) cancers. Local recurrences after TEM can be surgically salvaged with good disease free survival rates.

CONCLUSIONS

The TEM procedure clearly offers the benefits of good exposure of the operative field allowing extremely precise dissection and access to high rectal lesions unresectable by other methods. For pTis and low risk pT(1) lesions, the oncological results are comparable to the more traditional formal resection. The routine use of TEM for high-risk pT(1) and higher stage lesions is not an oncologically sound choice at the present moment.