Colonic transit before and after resection rectopexy for full-thickness rectal prolapse.

BACKGROUND: The objective of this study was to measure the change in colonic transit time after resection rectopexy for complete rectal prolapse. METHODS: We prospectively carried out isotope colonic transit studies before resection rectopexy in 38 patients with full-thickness complete rectal prolapse and invited them to attend for a postoperative transit study at least 1 year after resection rectopexy. RESULTS: Preoperatively, 27 (70 %) patients had abnormally prolonged colonic transit times, while 11 had normal colonic transit. Twenty-two (61 %) patients agreed to attend for a three-day colonic transit study. Resection rectopexy failed to correct delayed colonic transit in all patients with abnormal preoperative tests, while 4 patients developed new delayed transit and 2 with normal transit were unchanged. CONCLUSIONS: The study suggests that most prolapse patients have a pan-colonic motility disorder that is not corrected by rectopexy and resection of most of the left colon. If resection rectopexy fails to correct abnormal transit, this study questions the rationale for continuing to offer resection and supports less invasive surgical procedures such as ventral rectopexy.

Subspecialist emergency management of diverticulitis is associated with reduced mortality and fewer stomas.

AIM: The aim of the study was to compare outcomes for emergency management of diverticulitis before and after the creation of a regional subspecialist colorectal unit. METHOD: We retrieved data on all emergency admissions for diverticulitis from the regional surgical audit database and compared results before (January 1998 to August 2002) and after (August 2002 to December 2008) establishment of the subspecialist colorectal surgery unit in August 2002. Additional data were retrieved from electronic patient records. The primary outcome measures were mortality and rate of primary anastomosis following resection. RESULTS: There were 879 patients before and 1280 patients after subspecialization. Nonoperative management was undertaken in approximately 80% of cases. Total mortality fell from 3.3 to 1.5% (P = 0.008), attributable to reduced operative mortality (9.6 to 4.2%; P = 0.019). The primary anastomosis rate for all left colon resections increased from 50.3 to 77.9%; P < 0.0001. Stoma formation of any type fell from 46.6 to 27.7%; P < 0001). CONCLUSION: Emergency management of diverticulitis by subspecialist colorectal surgeons is associated with low overall and operative mortality whilst safely achieving high rates of primary anastomosis.

Outcomes of the rectal remnant following colectomy for ulcerative colitis.

OBJECTIVE: Controversy surrounds the optimal surgical management of the distal rectal remnant during colectomy for ulcerative colitis (UC) and the potential benefit from the placement of a rectal catheter for remnant drainage. This study reviews the clinical outcomes of patients who have undergone colectomy for UC with intra-peritoneal closure of the rectal remnant. METHOD: Analysis of prospective data lodged on Lothian Surgical Audit databases from patients treated in a tertiary coloproctology unit over 11 years. RESULTS: One hundred and fifty-nine patients were identified, the mean age was 41.9 years, 63% were men. Failure of maximal medical therapy necessitated surgery for 78.1% patients, while 12.6% had acute perforation and 11.9% had toxic megacolon. Complications included five (3.1%) stump dehiscences, eight (5.0%) intra-abdominal/pelvic collections, four (2.5%) significant wound infections, three (1.9%) small bowel obstructions and three (1.9%) deaths. Within the follow-up period, 62.3% patients had an ileo-pouch anal anastomosis (IPAA), 7.5% patients had a completion proctectomy, 10.1% patients within the series had a retained rectal remnant after 1 year follow up, the remaining patients had less than 1 year follow up. CONCLUSION: The intra-peritoneal rectal stump following colectomy for UC is associated with low rates of pelvic sepsis and a high proportion of patients successfully proceeding to IPAA.

Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection.

OBJECTIVE: Preoperative conditioning with oral fluid and carbohydrate (CHO) loading allows the patient to undergo surgery in the fed state and is associated with reduced postoperative insulin resistance. Further benefit may accrue from oral nutritional supplements (ONS) to counteract the fasting associated with mechanical bowel preparation (MBP). In this study we assess the ability to prescribe, dispense and have patients comply with a protocol combining preoperative ONS and CHO/fluid loading during MBP. METHOD: One hundred and forty-seven patients undergoing elective left colonic or rectal resection were recruited to an Enhanced Recovery after Surgery (ERAS) programme. All patients were prescribed MBP (2 sachets Picolax). On the daytime prior to surgery, eligible patients were prescribed 2 x 200 ml of ONS (Fortijuice, Nutricia) and in the evening 800 ml oral CHO/fluid loading (Preop(R), Nutricia,). Patients were prescribed a further 400 ml of oral/CHO/fluid on the morning of surgery 2 h prior to induction of anaesthesia. Protocol compliance was audited prospectively. RESULTS: One hundred and forty-seven patients received MBP. Twenty-three patients were ineligible for oral CHO/fluid loading [diabetes (n = 22), allergy to lemon flavoured drinks (n = 1)]. Fourteen patients did not receive the preoperative CHO drinks due to failure to prescribe (n = 8) or dispense (n = 6). One hundred and ten patients were dispensed the combined ONS and CHO/fluid loading regimen, compliance rates were 83% with ONS, 80% with CHO/fluid loading and 74% with both. CONCLUSION: Approximately 74% of patients undergoing MBP can comply with preoperative conditioning with ONS and CHO/fluid loading. Prescription and dispensing requires close attention to detail.

A retrospective evaluation of rectal irrigation in the treatment of disorders of faecal continence.

OBJECTIVES: The aim of this study was, firstly, to evaluate the efficacy and acceptability of rectal irrigation in the treatment of patients with disorders of faecal continence that have not responded to other treatment modalities. Secondly, to see if standard anorectal physiology measures can identify patients who might have successful treatment with rectal irrigation. PATIENTS AND METHODS: All patients who had been treated with rectal irrigation, between 1998 and 2000, were sent a postal questionnaire. Patients were asked to quantify their symptoms (before and after rectal irrigation) using a visual analogue scale to determine the efficacy of rectal irrigation. An increase of 10 (10 mm) in this score was regarded as successful treatment and incontinence scores obtained. The acceptability of rectal irrigation was determined using a Quality of Life questionnaire. Data regarding presenting symptoms, previous therapies, pretreatment anorectal physiology measurements were obtained from a retrospective case note and database review. RESULTS: Completed questionnaires were obtained from 48 (52%) of 92 patients, 39 patients had had previous medical and/or surgical treatment before trying rectal irrigation. At the time of the questionnaire 44 of 48 patients were still using rectal irrigation. Using the linear analogue scores 24 of 48 (50%) reported an improvement in their symptoms using rectal irrigation. Most patients found the treatment acceptable. Incontinence scores and anorectal physiology measures did not predict those patients who responded successfully to rectal irrigation. CONCLUSION: Rectal irrigation can offer symptomatic improvement to patients with faecal evacuatory disorders where other therapies have failed. Most patients find the treatment acceptable. Standard anorectal physiology measures and incontinence scores do not predict those patients likely to have successful treatment.

Safety of primary anastomosis in emergency colo-rectal surgery.

BACKGROUND: The surgical management of left-sided large bowel emergency patients remains controversial. There has been an increasing trend towards primary reconstructive surgery. The main dilemma remains appropriate patient selection for primary anastomosis. METHODS: The records of 323 patients who presented as acute emergencies and underwent surgery between January 1990 and December 2000 for left-sided colorectal cancer and diverticular disease were reviewed, to compare the outcome of resection and primary anastomosis with Hartmann's procedure. Patients were stratified into 3 groups according to whether the presentation was with localized or generalized peritonitis, or with obstruction. RESULTS: Resection and anastomosis was carried out in 176 (55.7%) patients with a 30-day mortality of 5.7%. Anastomotic dehiscence occurred in 9 (5.1%) patients, with no difference between the three groups. Wound sepsis occurred in 8 (4.5%) patients, and the median hospital stay was 13 days. Hartmann's resection was associated with a higher incidence of systemic and surgical morbidity (39.5% and 24.3%, respectively). The mortality rates in those selected for primary anastomosis (5.7%) compared favourably with those undergoing Hartmann's resections (20.4%) (P < 0.001). CONCLUSION: Emergency primary anastomosis in left-sided disease can be performed with a low morbidity and mortality in selected patients, even in the presence of a free perforation with diffuse peritonitis. Patients selected for staged resection, were those with major comorbid disease.

Assessment of ileoanal pouch inflammation by interleukin 1beta and interleukin 8 concentrations in the gut lumen.

PURPOSE: The cytokines interleukin 1beta and interleukin 8 have previously been shown to be present in mucosal biopsy specimens from inflamed ileoanal pouches. Our aim was to use the method of whole gut lavage fluid to measure cytokine concentrations and relate these to disease activity. METHODS: Forty-two patients with ulcerative colitis were recruited (23 males). Their ages ranged from 20 to 73 years (median 39). A questionnaire was completed and whole gut lavage, pouchoscopy, and biopsy were performed. RESULTS: Both interleukin 1beta and interleukin 8 were present in the whole gut lavage fluid of ileoanal pouches, with concentrations ranging from 4 to 143 pg/ml (median 6.3 pg/ml) for whole gut lavage fluid interleukin 1beta and from 18 to 1000 pg/ml (median 53.7 pg/ml) for whole gut lavage fluid interleukin 8. Whole gut lavage fluid interleukin 1beta and interleukin 8 were simultaneously detectable in 24 patients. These included the five patients with pouchitis, who had higher levels of interleukin 1beta (75 pg/ml vs. 8 pg/ml, P < 0.005) and interleukin 8 (668 pg/ml vs. 106 pg/ml, P < 0.005) compared with the rest of the patients with detectable cytokines (n = 19). The sensitivity of whole gut lavage fluid interleukin 8 (>200 pg/ml) in the diagnosis of pouchitis was 1, and the specificity was 0.86. There was a significant positive correlation of both whole gut lavage fluid interleukin 1beta and interleukin 8 with all the gut protein loss markers (immunoglobulin G, albumin, alpha1-antitrypsin). CONCLUSION: Cytokine interleukin 1beta and interleukin 8 concentrations, along with other parameters of inflammation, are raised in pouchitis in the whole gut lavage. The results also suggest a spectrum of severity of "pouchitis," with clinical pouchitis fulfilling Moskowitz criteria at the severe end of the spectrum.