Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries.

AIM: Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV). METHOD: A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria. RESULTS: There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores. CONCLUSION: OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.

Perforated jejunal diverticula in a young woman: A case report.

INTRODUCTION AND IMPORTANCE: Small bowel diverticulosis is a rare condition. It usually remains asymptomatic and undiscovered, until potentially severe complications such as diverticulitis or even perforation occur. We present an unusual case and discuss the pathophysiology, diagnostics strategies, and possible surgical intervention. CASE PRESENTATION: A young woman was referred to our emergency department suffering from acute abdominal pain. A computed tomography scan showed signs of small bowel perforation of unknown origin. Exploratory laparotomy revealed multiple perforated jejunal diverticula (JD). The patient underwent segmental resection of the affected jejunum followed by primary anastomosis. Pathological examination confirmed the diagnosis of perforated JD. CONCLUSIONS: Due to its rarity and variable clinical presentation, it can sometimes be challenging to diagnose this potentially life-threatening condition. If the bowel is suspected from perforation; segmental resection is the treatment of choice, preferably followed by direct restoration of the bowel continuity.

Outcome of rectal cancer after radiotherapy with a long or short waiting period before surgery, a descriptive clinical study.

BACKGROUND: Radiotherapy and surgery have shown to improve local control and survival in rectal cancer. There are two applied schedules; radiotherapy with a long or short waiting period before surgery. The effect on survival and recurrence of both schedules was studied. METHODS: All consecutive patients with rectal cancer in the period 2002-2008 were included. Data were gathered on survival, tumour stage, co-morbidity score, and cause of death. The patients were divided in three groups: group 1 patients undergoing surgery without neo-adjuvant radiotherapy; group 2 patients undergoing radiotherapy followed by immediate surgery; and group 3 patients treated with (chemo) radiotherapy followed by a longer waiting period. RESULTS: A total of 113 patients with rectal cancer underwent surgery. Twenty two patients in group 1, 71 patients in group 2, and 20 in group 3. There was no difference in gender, time to recurrence, co-morbidity score, or causes of death. Fifty percent of patients died due to non-cancer related causes. Mean age in patients of group 3 was significantly lower than in groups 1 and 2 (P=0.02). There was a trend towards a lower tumour stage in the patients of group 3. Overall five year survival was 32% in group 1, 48% in group 2, and 35% in group 3. CONCLUSIONS: Neo-adjuvant radiotherapy seems to be of benefit in daily practice in patients with rectal cancer. A longer waiting period results in down-staging. Clinicians have to be aware that many patients will die due to other causes than those related to the rectal cancer.

Thirty days post-operative mortality after surgery for colorectal cancer: a descriptive study.

BACKGROUND: The goal of surgery for colorectal cancer is cure. Unfortunately post-operative mortality occurs. This study aims to identify co-morbidity and causes of mortality in the post-operative period in relation to direct technical complications of surgery. METHODS: All consecutive patients who underwent surgery for colorectal cancer were included. Co-morbidity was determined via the Charlson co-morbidity score. The post-operative course was studied and cause of death within 30 days was determined. Patients were divided in two groups: group 1 died within 30 days after surgery and group 2 survived for longer than 30 days. RESULTS: Twenty three out of 333 patients (6.9%) with colon cancer and 6 out of 112 (5.3%) with rectal cancer died in the post-operative period. Patients in group 1 were significantly older than patients in group 2 (P<0.001). Patients in group 1 with colon cancer also significantly had more often a higher stage of cancer (P=0.03). The Charlson co-morbidity score for patients with colon cancer in group 1 was mean 5.17 (SD 1.57, range, 1-8), and for rectal cancer mean 4.83 (SD 2.32, range, 2-7). There was no difference in Charlson co-morbidity score when patients from groups 1 and 2 were compared. In group 1, 13 (44%) died as a direct consequence of technical surgical complications. Sixteen patients died due to complications because of pre-existing co-morbidity. CONCLUSIONS: Post-operative mortality very often is the direct result of pre-existing co-morbidity and not always the direct result of the surgical procedure.

The PRECious trial PREdiction of Complications, a step-up approach, CRP first followed by CT-scan imaging to ensure quality control after major abdominal surgery: study protocol for a stepped-wedge trial.

BACKGROUND: After major abdominal surgery (MAS), 20% of patients endure major complications, which require invasive treatment and are associated with increased morbidity and mortality. A quality control algorithm after major abdominal surgery aimed at early identification of patients at risk of developing major complications can decrease associated morbidity and mortality. Literature studies show promising results for C-reactive protein (CRP) as an early marker for postoperative complications, however clinical significance has yet to be determined. METHODS: A multicenter, stepped wedge, prospective clinical trial including all adult patients planned to undergo elective MAS. The first period consists of standard postoperative monitoring, which entails on demand additional examinations. This is followed by a period with implementation of postoperative control according to the PRECious protocol, which implicates standardized measurement of CRP levels. If CRP levels exceed 140 mg/L on postoperative day 3,4 or 5, an enhanced CT-scan is performed. Primary outcome in this study is a combined primary outcome, entailing all morbidity and mortality due to postoperative complications. Complications are graded according to the Clavien-Dindo classification. Secondary outcomes are hospital length of stay, patients reported outcome measures (PROMs) and cost-effectiveness. Data will be collected during admission, three months and one year postoperatively. Approval by the medical ethics committee of the VU University Medical Center was obtained (ID 2015.114). DISCUSSION: the PRECious trial is a stepped-wedge, multicenter, open label, prospective clinical trial to determine the effect of a standardized postoperative quality control algorithm on postoperative morbidity and mortality, and cost-effectiveness. TRIAL REGISTRATION: www.ClinicalTrials.gov, NCT02102217. Registered 5 February 2015.

Healing of segmental bone defects with granular porous hydroxyapatite augmented with recombinant human osteogenic protein-1 or autologous bone marrow.

Hydroxyapatite is a synthetic bone graft, which is used for the treatment of bone defects and nonunions. However, it is a rather inert material with no or little intrinsic osteoinductive activity. Recombinant human osteogenic protein-1 (rhOP-1) is a very potent biological agent, that enhances osteogenesis during bone repair. Bone marrow contains mesenchymal stem cells, which are capable of new bone formation. Biosynthetic bone grafts were created by the addition of rhOP-1 or bone marrow to granular porous hydroxyapatite. The performance of these grafts was tested in a sheep model and compared to the results of autograft, which is clinically the standard treatment of bone defects and nonunions. A 3 cm segmental bone defect was made in the tibia and fixed with an interlocking intramedullary nail. There were five treatment groups: no implant (n=6), autograft (n=8), hydroxyapatite alone (n=8), hydroxyapatite loaded with rhOP-1 (n=8), and hydroxyapatite loaded with autologous bone marrow (n=8). At 12 weeks, healing of the defect was evaluated with radiographs, a torsional test to failure, and histological examination of longitudinal sections through the defect. Torsional strength and stiffness of the healing tibiae were about two to three times higher for autograft and hydroxyapatite plus rhOP-1 or bone marrow compared to hydroxyapatite alone and empty defects. The mean values of both combination groups were comparable to those of autograft. There were more unions in defects with hydroxyapatite plus rhOP-1 than in defects with hydroxyapatite alone. Although the differences were not significant, histological examination revealed that there was more often bony bridging of the defect in both combination groups and the autograft group than in the group with hydroxyapatite alone. Healing of bone defects, treated with porous hydroxyapatite, can be enhanced by the addition of rhOP-1 or autologous bone marrow. The results of these composite biosynthetic grafts are equivalent to those of autograft.

The localisation of cancer in the sigmoid, rectum or rectosigmoid junction using endoscopy or radiology-What is the most accurate method?

INTRODUCTION: There is a difference in approach between colon and rectal cancer. AIM: EVALUATE THE METHODS OF LOCALISATION: endoscopy and radiology. MATERIALS AND METHODS: Patients with cancer in the sigmoid or rectum diagnosed with endoscopy, were included. Patients underwent additional radiological examinations. The resection specimen served as the gold standard. A tumour surrounded by serosa was considered a sigmoid cancer, surrounded by perirectal fat, than it was rectal cancer. If the frontal edge of the tumour showed serosa and the dorsal plane perirectal fat than the tumour was located in the "rectosigmoid". RESULTS: A total of 182 cancers were diagnosed. Of the 128 cancers with gold standard, endoscopy had the correct localisation in 112 (87.5%), and radiology in 114 (90.5%) cases. Concordance between both techniques was present in 80%. In 28 cases there was discordance. Radiology located 10 sigmoidal cancers wrongly in the rectum. One rectal cancer was placed in the sigmoid. In 16 cases the endoscopic localisation wrongly was the sigmoid. Sensitivity and specificity for endoscopy in sigmoidal cancer is 100% and 77% respectively, for rectal cancer 77% and 100%. Sensitivity of radiology for cancer in the sigmoid and rectum are 80% and 98% respectively. Specificity for both cancers is 98% and 80% respectively. CONCLUSIONS: The endoscopist and the radiologist should not be too overconfident with localisation of the tumour in cases of high rectal or low sigmoidal cancer.