Comparison of hazard of death following surgery for colon versus rectal cancer.

INTORDUCTION: Prognosis in cancer is usually assessed by use of Kaplan-Meier survival function estimate curves, which reflect survival, or the proportion of patients that will remain alive after a particular event at a given time. By contrast, hazard function represents the proportion expected to be deceased among those surviving at a given time after an event. Objectives To evaluate survival and hazard of death, in patients with colon cancer (CC) and rectal cancer (RC), as indices of prognosis. METHODS: Colon and rectal cancer patients who underwent surgical resection with curative intent from 1996 to 2011 were studied. The hazard of death and survival patterns were assessed with Weibull Hazard models and Kaplan- Meier survival function estimate curves. RESULTS: There were 119 CC and 250 RC patients included in the study. Median (Inter-quartile range: IQR) age of both groups was 58 (49 - 66.5) years. The median (IQR) followup time was 30 (12 - 72) months for CC and 30 (13 - 70) months for RC. Both groups were similar in comparison with regard to age (p=0.96), gender (p=0.56), tumour stage (p=0.33), vascular invasion (p=0.69), lymphatic invasion (p=0.33), perineural invasion (p=0.94), degree of tumour differentiation (p=0.38) and preoperative carcinoembryonic antigen levels (p=0.77). CC showed better overall survival compared to RC (p=0.03) with a 5-year survival rate of 72% versus 60% respectively. After curative resection, CC showed a 6% decrease in hazard of death with time compared with RC which showed a 1% increase in the hazard of death with time. CONCLUSIONS: Among patients who underwent resectional surgery, CC had a better prognosis than RC.

Uses of a familial adenomatous polyposis registry.

OBJECTIVES: To improve the prognosis of patients with familial adenomatous polyposis (FAP) by early diagnosis and prophylactic treatment through a coordinated FAP register. DESIGN: The establishment and descriptive analysis of the prospective database of the FAP registry. SETTING: University surgical unit, Colombo North Teaching Hospital Ragama, Sri Lanka. PATIENTS: Probands were identified by tracing all diagnosed FAP patients from 1996 to 2010 and their family members at risk. INTERVENTIONS: The establishment of a polyposis register included the following stages: ascertainment of probands (first contact symptomatic FAP patients), construction of pedigrees, counselling relatives and prophylactic screening of family members at risk, treatment and follow up. RESULTS: Twenty seven enrolled probands (12 male and 15 female, age 11-52 years, median age 34 years) were investigated. Pedigree analyses showed 206 relatives at risk. Twenty four family members at risk were screened of a total of 51 registered individuals. The rate of spontaneous mutations was 41%. Thirty five were diagnosed with FAP. Eight were screen detected (median age - 32 years) and 27 symptomatic (median age - 34 years). Concomitant colorectal cancer was detected in 17 (63%) symptomatic individuals and in 1 (13%) screen detected individual. Colectomy was performed in 27 (77%) patients while 8 (23%) are on chemoprophylaxis. Congenital hypertrophic retinal pigment epithelium was detected in 15. Desmoids tumours (6%) and other extraintestinal manifestations including osteomas, sebacious cysts and dental abnormalities (34%) were also detected. A thyroid gland malignancy was screen detected while retinoblastoma, hepatoblastoma and cerebral tumours were seen in pedigrees. CONCLUSIONS: A polyposis register may improve prognosis of FAP by early detection. It will help coordinate, optimise and streamline clinical management of patients with FAP and their relatives at risk.

Local recurrence of rectal cancer in patients not receiving neoadjuvant therapy - the importance of resection margins.

OBJECTIVES: Local recurrence of rectal cancer reduces quality of life and survival. A multi-factorial linear logistic model was used to analyse risk factors for local recurrence in rectal cancer in patients not receiving preoperative chemo-radiation. METHODS: A case-control study of patients with rectal cancer having surgery with curative intent, between 1996 and 2008. Eighteen putative risk factors for local recurrence were subjected to uni-variate analysis. Significant factors were selected for multi-factorial analysis. RESULTS: Twenty-one patients with local recurrence (cases) and 78 controls were selected. Uni-variate analysis showed significant associations with recurrence for nodal stage (N) (p=0.027), metastasis (M) (p=0.009), adjuvant chemotherapy (p=0.039), positive resection margin (R) (p=0.018) and American Joint Committee for Cancer (AJCC) tumours above stage II (p=0.043). Significant uni-variate odds ratios (OR) were obtained for the same factors. Two linear logistic models were fitted as (1) N, M, R1 status and adjuvant chemotherapy and (2) AJCC stage, R1 status and adjuvant chemotherapy. From both models, the only factor significantly associated (p ≤ 0.01) with local recurrence was found to be a positive resection margin (OR 4.81 and 5.51 respectively). CONCLUSIONS: A positive resection margin is the single factor affecting local recurrence of rectal cancer in patients not receiving neo-adjuvant therapy.

Modified dynamic gracilis neosphincter for fecal incontinence: an analysis of functional outcome at a single institution.

BACKGROUND: We undertook a prospective longitudinal study of patients with end-stage fecal incontinence who were undergoing transposition of the gracilis muscle as a neo-anal sphincter with external low-frequency electrical stimulation of the nerve to the gracilis combined with biofeedback. METHODS: A total of 31 patients (21 male, 10 female: median age: 22 years; range: 4-77 years) underwent this procedure for treatment of traumatic disruption (11 patients, 35%), congenital atresia (11 patients, 35%), iatrogenic injury (6-20%), and perineal sepsis (3 patients, 10%). The gracilis muscle was transposed at operation in an alpha or gamma configuration. Low-frequency (7 Hz) transcutaneous electrical stimulation commenced 2 weeks after operation and was continued for up to 12 weeks. Biofeedback therapy, which consisted of supervised neosphincter squeeze exercises, commenced simultaneously and continued for up to 28 weeks. Outcome was assessed by clinical examination, anal manometry, the Cleveland Clinic Florida continence score (CCFS), and the Rockwood quality of life scale (FIQL). Successful outcome was defined by improvement in clinical outcome, patient satisfaction, a positive result on anal manometry, and/or CCFS < 9, or FIQL > or = 4. RESULTS: At median follow-up of 67 months, overall improvement was seen in 22 (71%). Maximum resting pressure (MRP) and maximum squeeze pressure (MSP) improved significantly after operation [MRP pre versus post, mean (SD), cm water-13.8 (9.6) versus 20.9 (11.3); P = 0.01; and MSP 36.6 (22.4) versus 95.4 (71.2), P = 0.001]. In a subset of 18 patients who showed improvement after operation, the CCFS score (mean, SD) improved from 19.2 (3.4) to 5.2 (5.6); P = 0.0001. FIQL (mean, SD) showed significant improvement in all four domains in 14 patients who reported improvement since the year 2000. CONCLUSIONS: A modified dynamic gracilis neoanal sphincter for end-stage fecal incontinence helps restore and sustain continence with improvement in quality of life in the majority of patients. The procedure was most effective as augmentation in those who had suffered a traumatic injury, when compared with patients with congenital atresia and sepsis that had resulted in loss of the native anal sphincter.

Young patients with colorectal cancer have poor survival in the first twenty months after operation and predictable survival in the medium and long-term: analysis of survival and prognostic markers.

OBJECTIVES: This study compares clinico-pathological features in young (<40 years) and older patients (>50 years) with colorectal cancer, survival in the young and the influence of pre-operative clinical and histological factors on survival. MATERIALS AND METHODS: A twelve year prospective database of colorectal cancer was analysed. Fifty-three young patients were compared with forty seven consecutive older patients over fifty years old. An analysis of survival was undertaken in young patients using Kaplan Meier graphs, non parametric methods, Cox's Proportional Hazard Ratios and Weibull Hazard models. RESULTS: Young patients comprised 13.4 percent of 397 with colorectal cancer. Duration of symptoms and presentation in the young was similar to older patients (median, range; young patients; 6 months, 2 weeks to 2 years, older patients; 4 months, 4 weeks to 3 years, p > 0.05). In both groups, the majority presented without bowel obstruction (young--81%, older--94%). Cancer proximal to the splenic flexure was present more in young than in older patients. Synchronous cancers were found exclusively in the young. Mucinous tumours were seen in 16% of young and 4% of older patients (p < 0.05). Ninety four percent of young cancer deaths were within 20 months of operation. At median follow up of 50 months in the young, overall survival was 70% and disease free survival 66%. American Joint Committee on Cancer (AJCC) stage 4 and use of pre-operative chemoradiation in rectal cancer was associated with poor survival in the young. CONCLUSION: If patients, who are less than 40 years old with colorectal cancer, survive twenty months after operation, the prognosis improves and their survival becomes predictable.

Patients with rectal cancer having neoadjuvant chemoradiation do not have increased complications of ileostomy closure.

OBJECTIVES: It is conceivable that reversal of an ileostomy after low anterior resection following neoadjuvant therapy (NAT) may involve anastomosis of small bowel exposed to irradiation. The aim was to evaluate peri-operative complications of ileostomy closure and to compare the histology of ileal mucosa in excised stomas in patients who received NAT with those without NAT. METHODS: Twenty patients who underwent rectal excision following NAT for cancer, were compared with 20 control patients who underwent rectal excision without NAT. All patients received a diverting loop ileostomy which was subsequently reversed with excision of the ileostomy. The clinical outcome and histopathological features after reversal were evaluated. RESULTS: There was no significant difference with regard to peri-operative complications such as post-operative deaths related to ileostomy closure, anastomotic leakage, retraction of stoma or small bowel fistulae. Resection margins revealed no significant difference in crypt distortion, depletion of mucin, acute inflammation, chronic inflammation and infiltration of eosinophils following NAT compared with controls. CONCLUSIONS: Neoadjuvant therapy for rectal cancer does not result in higher morbidity following closure of diverting loop ileostomy or result in significant inflammatory changes in the ileum. Therefore ileostomy closure is as safe in those with preoperative radiotherapy as in those without neoadjuvant therapy.

Detection of micrometastases in lymph nodes using reverse transcription polymerase chain reaction (RT-PCR) for cytokeratin 20 (CK-20)--a pilot study.

OBJECTIVES: The aim of the study was to detect micrometastases in lymph nodes in patients with rectal cancer following neoadjuvant therapy, staged node negative by routine histology. PATIENTS AND SETTING: Mesenteric lymph nodes from patients who have undergone neoadjuvant therapy for rectal cancer were harvested during surgery. Nodes were bisected and one half was sent for haematoxylin and eosin (H&E) staining and evaluated by a single pathologist. The other half was examined for CK20 by RT-PCR. The technique was validated by testing mesenteric lymph nodes with known metastases and nodes from patients without cancer. Twenty one lymph nodes from 6 patients (median age 46 years, range 25-55) which were negative for tumour deposits by H & E stain were assessed for micro-metastases. RESULTS: All 21 nodes which were histologically negative for metastases were positive for micrometastases. Two nodes with known metastases were positive for CK20 and 3 nodes from non cancer patients were negative for CK20. CONCLUSIONS: Detection of CK20 is accurate in identification of rectal cancer micro-metastasing to lymph nodes. Assessment of nodes by H & E histology risks under staging.

Gracilis muscle as neoanal sphincter for faecal incontinence.

Faecal incontinence is a debilitating chronic clinical condition which may affect the patient and care givers. Modality of treatment is based on severity of the symptoms as well as the anatomical defect itself, availability of resources and expertise. We describe a modified technique of dynamic graciloplasty as neoanal sphincter for the treatment severe faecal incontinence who has failed previous over lapping sphincteroplasty. In our modified version, instead of using implanted intramuscular electrodes and subcutaneous neurostimulator to provide continuous stimulation, the patient will undergo an external stimulation on the nerve of transplanted gracilis periodically and concurrent biofeedback therapy. We believe the technique is relatively easy to learn and very cost effective without any electrodes or neurostimulator related complications.

Histopathology reporting in colorectal cancer: a proforma improves quality.

AIM: The histopathology report is vital to determine the need for adjuvant therapy and prognosis in colorectal cancer (CRC). Completeness of those in text format is inadequate. This study evaluated the improvement of quality of histopathology reports following the introduction of a template proforma, based on standards set by the Royal College of Pathologists (RCP), UK. METHOD: Sixty-eight consecutive histopathology reports based on 19 items for rectal cancer (RC) and 15 items for colon cancer (CC) using the proforma were prospectively analysed and compared with results of a previous audit of 82 consecutive histopathology reports in text format. The percentage of reports containing a statement for each data item for both series was compared using the Normal test for difference between two proportions. Completeness of each report was assessed and a percentage score (percentage completeness) was given. Mean percentage completeness was calculated for each format and compared using the two sample t-test. RESULTS: Except for comments on the presence of 'histologically confirmed liver metastases' in CC and RC, 'distance from dentate line' and 'distance to circumferential margin' in RC, all other items were commented in more than 90% of reports, where 71% of the items based on the minimum data set were present in all reports. Compared to prose format, the mean percentage completeness (SD) improved from 74% (8) to 91% (4) (P < 0.0001) and from 81% (5) to 99% (1) (P < 0.0001) for RC and CC respectively in template proforma format. CONCLUSION: A template proforma and surgeon's contribution in relation to operative findings improves the quality of the histopathology report in CRC.

A new technique for suture rectopexy without resection for rectal prolapse.

BACKGROUND: We surmised that if rectopexy was performed without dissection of the lateral rectal stalks in patients with full-thickness rectal prolapse and normal preoperative transit, sigmoid resection may not be required. This study evaluated a new approach to abdominal suture rectopexy for rectal prolapse. METHODS: A total of 81 patients (57 male, 24 female; median age 37 years, range 5-82 years) with rectal prolapse were assessed by clinical examination, anal manometry (maximum resting pressure, MRP, and squeeze pressure, MSP) and radioopaque marker transit studies. Of the 81 patients, 70 with normal preoperative transit underwent suture fixation alone, without resection, performed under spinal anaesthesia, through a 7-cm transverse left lower quadrant incision gaining access to the presacral space via a left pararectal "window", preserving the lateral stalks. RESULTS: Average surgical time was 50 min, mortality was zero, and morbidity was 9% (three patients with wound infection, four with urinary retention). Anal incontinence improved in 43 of 53 patients (81%, p=0.001). MRP and MSP had improved at 3 months after surgery: MRP from a mean of 27.6+/-1.4 mmHg (range 2-30 mmHg) before surgery to 32.5+/-2.21 mmHg (2-60 mmHg) after surgery (p=0.008); MSP from 69.25+/-6.4 mmHg (8-153 mmHg) before surgery to 79+/-4.77 mmHg (35-157 mmHg) after surgery (p=0.001).. Transit was unchanged in 18 of 20 patients (90%) who were evaluated before and after surgery; none was constipated after surgery. At 56 months, prolapse had recurred in five patients (7%). CONCLUSION: Abdominal suture rectopexy with a left pararectal approach without sigmoid resection in those with normal preoperative transit resulted in an improvement in anal incontinence and satisfactory long-term control of prolapse. The operation did not alter transit and did not result in significant constipation.

Consideration of the blood supply of the ileocecal segment in valve preserving right hemicolectomy.

The ileocecal valve (ICV) is known to control the flow of chyme and to prevent bacterial colonization of the small intestine. Preservation of this segment during right hemicolectomy is likely to prevent loss of its function. This study aimed at evaluating the arterial supply of the ICV to help preserve the valve during right hemicolectomy. Fifty-four fresh human cadavers (37 male, 17 female; median age: 54 years, range: 18-90 years) were studied after relatives gave written, informed consent. At postmortem, 20 cm of terminal ileum with the ileocecal segment and up to 20 cm of ascending colon were removed en bloc with its mesentery and blood supply. The ileocolic artery was cannulated and injected with 10 ml of water-soluble red dye under pressure. The arterial supply was dissected to demonstrate a pattern. In all, the ICV was supplied by the ileocolic artery, a branch of the superior mesenteric, which divided into an anterior and a posterior cecal artery. A marginal branch of the right colic was noted to contribute to ICV blood supply in only two (4%). Furthermore, study of the anastomosis at the ICV showed that the anterior cecal artery was present in all (100%), posterior cecal in 48 (89%), and recurrent ileal artery in 53 (98%). A rich anastomosis between vessels at the ICV; small "windows," short tributaries, were seen in 38 (70%), whereas a poor anastomotic network at the ICV; large "windows," long tributaries, between these vessels were seen in 12 (22%). In four (8%), we were unable to clearly determine between rich and poor anastomotic networks. Other variants included, absent posterior cecal artery in six (11%) and absent recurrent ileal artery in one (2%). The ICV has a predictable blood supply in the majority of patients. Preservation of the anterior cecal artery would ensure a vascularized ICV in right hemicolectomy.

Sexual and urinary dysfunction following rectal dissection compared with segmental colectomy.

INTRODUCTION: The aim of this study was to assess the impact of nerve sparing surgery and major abdominal surgery on sexual and urinary function in men and women with colorectal cancer undergoing rectal dissection and segmental colectomy. METHOD: Forty-eight patients (group A: 22 males, 26 females; median age 55 years) undergoing rectal dissection were compared with 24 having segmental colectomy (group B: 12 male, 12 female; median age 55 years). Preoperative data were also compared with age- and gender-matched controls (group C). RESULTS: More patients after rectal dissection vs segmental colectomy had urinary tract infections [15 (31%) vs 3 (17.5%), P = 0.04]. At 37 months, urinary dysfunction after rectal excision was seen in 29 (60%; 20 men) vs nine (37.5%; eight men) after segmental colectomy. Postoperative urinary symptoms were significant in group A, but not in group B (pre: vs post; groups A and B: poor stream--13%vs 38%, P = 0.001 and 21%vs 21%, P = NS; incontinence--4.2%vs 17%, P = 0.008 and 8%vs 8%, P = NS; hesitancy--13%vs 35%, P = 0.034 and 17%vs 21%, P = NS). Sexual health was worse after rectal excision compared with segmental colectomy (men--62.5%, women--25%vs 44% of men) respectively. Erectile dysfunction was the chief cause (rectal excision--50%vs segmental colectomy - 33%). After rectal excision, 6% of women had dyspareunia and 19% reported reduced orgasm but none after segmental colectomy. Conclusion More men than women had urinary and sexual impairment after rectal excision than after segmental colectomy. Its aetiology is multifactorial.

Complications of loop ileostomy and ileostomy closure and their implications for extended enterostomal therapy: a prospective clinical study.

INTRODUCTION: Patients who have a temporary loop ileostomy have impaired quality of life. Complications associated with a loop ileostomy or ileostomy closure will impair patients' quality of life further and require extended enterostomal therapy. We performed a prospective audit of loop ileostomy to ascertain the nature of the workload that may be created with ileostomy-related complications. PATIENTS AND METHODS: One hundred and forty patients (67 males, 73 females, median age 50 years, range 5-90 years) who received a temporary loop ileostomy were analysed after completion of proformas on a prospective basis between 1999 and 2006. RESULTS: Operation was performed for rectal cancer 100 (71%), familial adenomatous polyposis 14 (10%), ulcerative colitis 21 (15%) and for trauma or Hirchsprung's disease 5 (3%). Complications of loop ileostomy were: retraction 1 (0.7%), ileostomy flux 11 (8%), stomal prolapse 1 (0.7%), parastomal hernia 1 (0.7%), paraileostomy abscess 4 (3%) and severe skin excoriation 9 (6%). The loop ileostomy was reversed in 117 (83%) at a median (range) of 13 weeks (1-60). Ileostomy closure-related complications were: small bowel fistula 1 (0.9%), small bowel obstruction 5 (4.3%) and a stitch sinus in 1 (0.9%). Five women developed recto-vaginal fistula (n=3; 2.6%), pouch-vaginal fistula (n=1; 0.9%) and pouch-anal fistula (n=1; 0.9%) that required extended enterostomal therapy, after loop ileostomy reversal. CONCLUSION: Nineteen percent of patients following creation of a loop ileostomy and 10.5% of patients after reversal of the ileostomy required extended enterostomal care by a specialized enterostomal therapist, which supported resumption of a normal life.

Colorectal cancer burden and trends in a South Asian cohort: experience from a regional tertiary care center in Sri Lanka.

OBJECTIVE: Colorectal cancer (CRC) burden is increasing in the south Asian region due to the changing socio-economic landscape and population demographics. There is a lack of robust high quality data from this region in order to evaluate the disease pattern and comparison. Using generalized linear models assuming Poisson distribution and model fitting, authors describe the variation in the landscape of CRC burden along time since 1997 at a regional tertiary care center in Sri Lanka. RESULTS: Analyzing 679 patients, it is observed that both colon and rectal cancers have significantly increased over time (pre 2000-61, 2000 to 2004-178, 2005 to 2009-190, 2010 to 2014-250; P < 0.05). Majority of the cancers were left sided (82%) while 77% were rectosigmoid. Over 25% of all CRC were diagnosed in patients less than 50 years and the median age at diagnosis is < 62 years. Increasing trend is seen in the stage at presentation while 33% of the rectal cancers received neoadjuvant chemoradiation. Left sided preponderance, younger age at presentation and advanced stage at presentation was observed. CRC disease pattern in the South Asian population may vary from that observed in the western population which has implications on disease surveillance and treatment.

Endosonographic characteristics of the anal sphincter complex in primigravid Sri Lankan women.

OBJECTIVE: To determine the endosonographic anatomy of the anal sphincter complex in primigravid Sri Lankan women. METHOD: This is an observational study of 95 primigravid women admitted to an antenatal ward. They were examined using anal endosonography and data from subjects without sphincter injury were analyzed to describe anal sphincter morphology. Individual anal canal components were measured at defined levels, and the relationship of individual measurements with age and body mass index was calculated. RESULTS: Ninety-three of 95 women had no anal sphincter damage. The puborectalis sling (mean 5.5 mm, S.D. 0.77) forms the upper most border of the sphincter complex. The mean width of the deep external sphincter was 4.3 mm (S.D. 0.61); that of the superficial external sphincter was 4.5 mm (S.D. 0.56); and that of the internal anal sphincter at the mid anal canal was 2.1 mm (S.D. 0.21). The intersphincteric space (mean 2.1 mm, S.D. 0.26) could be distinguished sonographically in all subjects. The mean width of the anterior ring of the subcutaneous component was 3.8 mm (S.D. 1.01). The perineal body was sonographically identified in 60%. CONCLUSION: A set of normal values for the anal sphincter components in Sri Lankan primigravid women was established.

Surgical management of left colon obstruction: the University of Minnesota experience.

BACKGROUND: Management of left-sided colonic obstruction is a surgical challenge. This study was performed to review our management of patients with left colon obstruction presenting to the University of Minnesota Hospitals over a 10-year period, 1985 to 1994. STUDY DESIGN: We did a retrospective chart review of 143 patients (48 male and 95 female; mean age 70 years). RESULTS: Sites of obstruction were rectosigmoid, 40%; sigmoid colon, 47%; descending colon, 5%; and splenic flexure, 8%. Fifty-two percent of patients had obstructing colorectal cancer. Two patients presented with generalized peritonitis secondary to colonic perforation. The majority (n = 121, 85%) of patients underwent resection (subtotal in 39 [32%], and segmental in 82 [68%]) and anastomosis in a single stage after appropriate resuscitation. Intraoperative colonic cleansing was undertaken in 40 patients (28%). Morbidity within 30 days of operation was 11%, including 1 anastomotic leak, and mortality was 3%. The 4 deaths occurred in patients over 75 years of age and were not from anastomotic complications. CONCLUSIONS: A single stage resection and an anastomosis facilitated by intraoperative colonic cleansing in one-third of cases was performed in 85% of patients presenting with left colon obstruction. One anastomotic leak occurred. Our current policy of strongly favoring a single stage, definitive operation for patients presenting with left colon obstruction appears reasonable on the basis of this retrospective review of our experience.

Saphenoperitoneal anastomosis for resistant ascites in patients with cirrhosis.

BACKGROUND: Restriction of salt intake and diuretics combined with repeated paracentesis has been the mainstay of managing longstanding ascites. Peritoneal-venous shunts have been employed in refractory ascites but are not without complication. We evaluated an autologous reversed segment of proximal long saphenous vein anastomosed to the peritoneum in management of patients with resistant ascites. METHODS: Eleven patients (8 male, median age 48 years, range 37 to 68) with tense refractory ascites associated with cirrhosis of the liver and portal hypertension underwent saphenous vein-peritoneal anastomosis by rotating the proximal vein cephalad which was anastomosed to peritoneum in the posterior wall of the inguinal canal. Ten of 11 procedures were performed under general anesthetic. RESULTS: Thirty-day mortality was 1 patient. Morbidity included transient hepatic encephalopathy in 4 (36%), minor wound hemorrhage in 3 (27%), fluid leakage in 7 (64%), and wound infection in 7 (64%). Hospital stay (median) was 16 days (range 11 to 23). In the short term (median of 9 months) significant reduction in body weight and abdominal girth was seen in 9 (90%), 6 (60%) were not on diuretics while 3 (30%) continued to remain on reduced doses of diuretic. Furthermore, 7 (70%) did not require paracentesis. At 2-year follow-up, 5 (45%) patients had died and 3 were lost to follow-up. The remaining 3 were all in active employment, 1 was off diuretics, and 2 were on reduced doses. All 3 patients maintained reduced body weights and abdominal girths compared with preoperative values. CONCLUSIONS: Saphenous-peritoneal anastomosis appears a simple, safe, and effective method of achieving long-term control of refractory ascites. The use of a biological shunt is an added advantage over prosthetic shunts for drainage of ascitic fluid.

Comparison of hydrogen peroxide instillation with Goodsall's rule for fistula-in-ano.

BACKGROUND: Identification of the internal opening is an essential step in the management of fistula-in-ano. The predictive accuracy of Goodsall's rule is compared with instillation of hydrogen peroxide for fistulas-in-ano. METHODS: Thirty-five patients (32 male, three female; median age 42 years; range: 6 months-70 years) were studied. Hydrogen peroxide solution was injected into the external opening of the fistula track and effervescence was observed at the internal opening within the anal canal. A fistula track was either excised or incised. Setons were placed within high fistulas. RESULTS: There were 24 simple fistulas, compared to 11 complex fistulas (horseshoe, n = 4; abscess, n = 4). Eighteen external openings were anterior and 17 were posterior. Thirty-four of 35 (97%) internal openings were identified. Only 20 internal openings were in accordance with Goodsall's rule (positive predictive value: 59%). Predictive accuracy was greater for anterior external openings (13 of 18 (72%)) versus posterior external openings (six of 17 (41%); P = 0.016). For recurrent fistulas, seven of 17 fistula tracks had an internal opening in accordance with Goodsall's rule, resulting in a positive predictive value of 41%. (Positive predictive value: anterior 67% vs posterior 12.5%; P = 0.0009.) CONCLUSION: The overall predictive accuracy of Goodsall's rule was poor chiefly because of poor predictive accuracy in posterior and recurrent fistulas. The use of Goodsall's rule alone in decision-making before surgical intervention is not recommended.

The internal jugular vein valve may have a significant role in the prevention of venous reflux: evidence from live and cadaveric human subjects.

INTRODUCTION: The internal jugular vein valve (IJVV), which is situated just above the termination of the internal jugular vein, is the only valve between the heart and the brain. This means that it plays a role in the prevention of cephalad flow of venous blood. If the IJVV is damaged or becomes incompetent, increase in intrapleural pressure could result in raised intracranial pressure. Additionally, the jugular venous pulse (JVP) is used clinically to estimate right atrial pressure, a functional IJVV may prevent accurate estimation of the JVP. OBJECTIVES: To describe the presence and the competence of the IJVV in post-mortem and live human subjects. DESIGN - setting and methods: The anatomical appearance of the IJVV from 30 cadavers was studied. Competence was checked by measuring maximum hydrostatic pressure before reflux occurred through the valve. The function of the valve was evaluated in 25 live subjects using colour duplex scanning. RESULTS: The IJVV was present in all cadavers just before its termination (60 IJVVs from 30 subjects). The valve was bicuspid in most cases (93%). The competence of 41 IJVVs was checked of which only three (7%) were found to be incompetent. All IJVVs in live subjects were found to be competent. CONCLUSION: This study confirms that a functional IJVV is present just above the termination of the internal jugular vein. The IJVV may therefore prevent reflux of venous blood from the right atrium into the internal jugular vein.