Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery.

Introduction Rectus sheath catheters (RSCs) are increasingly being used to provide postoperative analgesia following laparotomy for colorectal surgery. Little is known about their efficacy in comparison with epidural infusion analgesia (EIA). They are potentially better as they avoid the recognised complications associated with EIA. This study compares these two methods of analgesia. Outcomes include average pain scores, time to mobilisation and length of stay. Methods This was a 33-month single centre observational study including all patients undergoing elective open or laparoscopic-converted-to-open colorectal resection for both benign and malignant disease. Patients received either EIA or RSCs. Data were collected prospectively and analysed retrospectively. Results A total of 95 patients were identified. Indications for surgery, operation and complications were recorded. The mean time to mobilisation was significantly shorter in patients who had RSCs compared with EIA patients (2.4 vs 3.5 days, p<0.05). There was no difference in postoperative pain scores or length of stay. Conclusions RSCs provide equivalent analgesia to EIA and avoid the recognised potential complications of EIA. They are associated with a shorter time to mobilisation. Their use should be adopted more widely.

Bezoar: an unusual palpable mass in the right iliac fossa.

A 64-year-old gentleman presented with a 12-h history of right iliac fossa pain. On examination, the patient had a tender 8 × 6 cm mass in the right iliac fossa with localised peritonitis. The working diagnosis at this time was an appendix mass or caecal cancer. A computed tomography scan revealed the characteristic 'bird's nest' appearance of a bezoar. On further questioning, the patient confessed to regularly 'binging' on grapes. The patient described passing the mass and his symptoms completely resolved. This appears to be the only documented case of a bezoar affecting the ascending colon.

Postanal repair--do the long-term results justify the procedure?

OBJECTIVE: Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long-term continence after PAR and relate this to patient satisfaction and quality of life. METHOD: Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life. RESULTS: One-hundred one patients from four surgeons were identified. Fifty-four patients were excluded because of loss to follow-up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow-up of 9.1 years (2.2-18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0-5), 26% moderate (CCS 6-12), and 48% (n = 27) severe incontinence (CCS 13-24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow-up, and being able to distinguish flatus and stool. CONCLUSIONS: In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long-term subjective outcome, despite the fact that many patients have a high incontinence score.

How do we manage early rectal cancer? A national questionnaire survey among members of the ACPGBI after the preliminary results of the MRC CR07/NCIC CO16 randomized trial.

OBJECTIVE: The role of neoadjuvant radiotherapy in the management of rectal cancers has not reached a consensus in colorectal surgical practice. In the light of the preliminary results of the CRO7 trial, we undertook a national questionnaire survey to assess the current pattern of practice in the UK. The aim of this study was to assess the correlation between CRO7 trial results and current practice amongst consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI). METHOD: A 14-item questionnaire was designed to inquire into the current management strategy of operable rectal cancers and the possible role of neoadjuvant radiotherapy. The postal questionnaire survey was sent to all the 400 active consultant surgical members of the ACPGBI. RESULTS: Of 400 questionnaires, 200 (50%) were returned fully completed. One hundred and sixty-six (83%) of surgeons did not routinely use neoadjuvant short course radiotherapy (NASCRT) in clinically operable rectal cancers (T1/T2) <15 cm from anal verge with no metastases (The CR07 eligible cohort). Sixty-four (32%) used NASCRT for T3 cancers routinely whereas 76 (38%) used neoadjuvant long course radiotherapy instead. One hundred and fifty-sixty (78%) of the surgeons felt the height of the tumour from the anal verge influenced their decision on NASCRT, while 104 (52%) felt position was important (Anterior/Posterior). Positive anticipated margins of excision on magnetic resonance imaging was a deciding factor for 185 (92.5%) of surgeons in favour of neoadjuvant therapy. Postoperatively in patients who have not had preoperative radiotherapy, 154 (77%) recommended radiotherapy and 155 (77.5%) recommended chemotherapy if the circumferential resection margin was +ve on final pathology. Seventy-eight (39%) of the surgeons have changed their practice after the preliminary results of the CRO7 by adopting NASCRT for treating early rectal cancers. CONCLUSION: Despite the evidence of the CRO7 trial supporting the use of NASCRT for operable rectal cancer, approximately two-third of consultant surgeons in the UK have yet to implement this treatment regime routinely. A change in practice in 39% of surgeons following the early dissemination of trial results indicate that colorectal surgeons practice is guided by scientific evidence. Because the mature trial data have yet to be published, a further survey of practice is warranted after that publication to determine the ultimate impact of this trial. This survey measures the baseline practice to compare changes over the next 2 years.

Antegrade continence enema in the treatment of obstructed defaecation with or without faecal incontinence.

BACKGROUND: Obstructed defaecation and faecal incontinence are complex functional disorders that pose management challenges. In recent times, the antegrade continence enema (ACE) has been tried both as a primary procedure and as a final resort to avoid a colostomy in patients with a variety of functional problems. The purpose of this study was to evaluate the role of the ACE procedure as a treatment option for adult patients suffering from obstructed defaecation with or without faecal incontinence, some of whom also had slow transit constipation. METHODS: Twenty female patients underwent ACE as an appendicostomy (65%) or caecostomy (35%). The median age was 44 years (range, 20-65 years). The indications were obstructed defaecation with faecal incontinence (65%) and obstructed defaecation alone (35%). Fifteen of these patients were followed for 3-51 months (median, 6 months). Cleveland continence score, bowel score and quality of life score were recorded pre- and postoperatively along with post-procedure complications. RESULTS: Thirteen (65%) patients were satisfied with the outcome and recorded improvement in their scores while two (10%) remained the same and one (5%) was worse. This latter woman and another patient stopped using their ACE, whilst follow-up data was unavailable for three patients. Minor wound infections were noted in nine patients (45%), of whom one needed drainage of an abscess; the rest settled with antibiotics and dressings. Bowel and Cleveland continence scores improved postoperatively (p<0.001 and p=0.001, respectively) but SF36 scores did not. To date, no patient has had a colostomy following an ACE procedure. CONCLUSIONS: Colostomies can be avoided in patients with obstructed defaecation. There is, however, a need to minimise wound infections which seem to be the most troublesome complication.

The impact of low technology lead hazard reduction activities among children with mildly elevated blood lead levels.

This prospective environmental intervention study was conducted to determine the impact of low-technology lead hazard reduction activities among children with mildly elevated blood lead levels. Children whose homes had severe lead hazards were automatically assigned to the intervention group. Children whose homes had lesser hazards were randomly assigned to the intervention group or comparison group. The one-time intervention focused mainly on cleaning and repainting window areas and educating caregivers to maintain effective housekeeping techniques. Changes in blood lead and dust lead loading levels were observed following the interventions. Analysis of covariance was used to adjust comparisons of postintervention levels for preintervention levels and other variables. The lead hazard reduction activities were associated with a modest decline in blood lead levels among children with severe hazards. The magnitude of the decline depended on the confounder that was controlled; the majority ranged from-1.1. to-1.6 microgram/dL. A moderate reduction in window well dust lead loading levels was also observed. While low-technology lead hazard reduction measures appeared to be an effective secondary prevention strategy among children with severe household lead hazards, larger studies are needed to confirm these results.

The most frequent aminoglycoside resistance mechanisms--changes with time and geographic area: a reflection of aminoglycoside usage patterns? Aminoglycoside Resistance Study Groups.

The aminoglycoside resistance mechanisms revealed by two surveys in Europe and other countries have been compared to those revealed in earlier studies. Mechanisms have become more complex in all bacterial groups. In Providencia, Serratia, Pseudomonas, Acinetobacter, and Staphylococcus species isolates, genus-specific mechanisms were very common, and it was not possible to see differences between different geographic areas. In other Enterobacteriaceae, the increasing complexity of mechanisms was most often caused by combinations of gentamicin-modifying enzymes with AAC(6')-I, which acetylates amikacin but not gentamicin. The occurrence of these combinations varied by geographical region and among hospitals. The frequency of these combinations correlated with aminoglycoside usage in either the geographical regions or in individual hospitals. These broad-spectrum combinations occurred most frequently in Citrobacter, Enterobacter, and Klebsiella species but also occurred in Escherichia, Morganella, Proteus, Salmonella, and Shigella species. Often the only clinically available aminoglycoside that retained its normal activity was isepamicin.