COVID-19 recovery: tackling the 2-week wait colorectal pathway backlog by optimising CT colonography utilisation.

AIM: To review the indications for computed tomography colonography (CTC) performed on patients referred via the 2-week wait colorectal pathway (2WWCP). MATERIALS AND METHODS: A retrospective study was performed on all patients referred through the 2WWCP between October 2018 and September 2019. The referrals were audited against the National Institute for Health and Care Excellence (NICE) NG12/DG30 guidelines for referral to the 2WWCP, and against the Royal College of Radiologists (RCR) 2017 guidelines for CTC. RESULTS: Over the study period, there were 1,707 2WWCP referrals, and 362 (21.2%) of these patients underwent CTC. The median age was 66 years, and 55% were female. Forty-six patients did not meet the NICE NG12/DG30 guidelines for referral to the 2WWCP, and a further 268, although meeting the NICE guidelines, did not meet the RCR 2017 guidelines for CTC. In total, only 13% of CTCs performed complied with both guidelines. CONCLUSION: This audit demonstrated a significant opportunity to reallocate CTC resources in the recovery stage of the COVID-19 pandemic. To improve outcomes for colorectal cancer (CRC) in the UK, establishing a selective straight-to-test CTC 2WWCP should be considered. Documented consent detailing the risks and benefits of CTC versus colonoscopy should take place in order to assist the patient in making an informed choice.

Final results of a European, multicentre, prospective, observational study of Permacol™ collagen paste injection for the treatment of anal fistula.

AIM: Permacol™ collagen paste (Permacol™ paste) is an acellular cross-linked porcine dermal collagen matrix suspension for use in soft-tissue repair. The use of Permacol™ paste in the filling of anorectal fistula tract is a new sphincter-preserving method for fistula repair. The MASERATI100 study was a prospective, observational clinical study with the objective to assess the efficacy of Permacol™ collagen paste for anal fistula repair in 100 patients. METHOD: Patients (n = 100) with anal fistula were treated, at 10 European surgical sites, with a sphincter-preserving technique using Permacol™ paste. Fistula healing was assessed at 1, 3, 6 and 12 months post-treatment, with the primary end-point being healing at 6 months. Faecal continence and patient satisfaction were surveyed at each follow-up; adverse events (AEs) were monitored throughout the follow-up. RESULTS: At 6 months postsurgery, 56.7% of patients were healed and the percentage healed was largely maintained, with 53.5% healed at 12 months. Regarding AEs, 29.0% of patients had at least one AE, and 16.0% of patients had one or more procedure-related AE. Most AEs reported were minor and similar to those commonly observed after fistula treatment, and the incidence of serious adverse events was low (4.0% of patients). Regardless of treatment outcome, 73.0% of patients were satisfied or very satisfied with the procedure. CONCLUSION: Permacol™ paste is a promising sphincter-preserving treatment for anal fistulae and has minimal adverse side-effects.

Elderly patients have more infectious complications following laparoscopic colorectal cancer surgery.

AIM: Elderly patients may be at higher risk of postoperative complications, particularly infective, than younger patients. METHOD: We prospectively followed 163 consecutive patients undergoing elective laparoscopic resection for cancer. We compared patients < 65, 65-80 and > 80 years of age at the time of surgery. RESULTS: Seventy (42.9%) patients had no complication; 93 (57.1%) had at least one complication following surgery and in 20 (12.3%) this was major. There was no difference in major complications between the groups (P = 0.47). Patients over 65 years of age were more likely to have a complication of any severity [< 65 years, 39.3%; 65-80 years, 69.3%; and > 80 years, 63.0% (P = 0.002)]. The frequency of gastrointestinal complications (30.1%) was similar in the groups (P = 0.29), as was wound infection (25.2%) (P = 0.65). There was an increase in the frequency of infectious complications, especially chest infection, with age, from 14.8% in patients < 65 years, to 22.7% in patients 65-80 years, to 44.4% in patients > 80 years (P = 0.01). Multivariate analysis showed no increase in overall complications in elderly patients, but Stage II or Stage III cancer (OR = 2.59, P = 0.04) and increasing body mass index (BMI) (OR = 1.07 for each unit increase in BMI, P = 0.04) were related to complications. Age remained the only predictor of an infective complication on multivariate analysis. Patients > 80 years of age had 4.21 times the OR of an infective complication (P = 0.03). CONCLUSION: Older patients are more susceptible to infective complications postoperatively, particularly chest complications. Surgeons should alter their practice to reduce morbidity, such as adopting protocols requiring early physiotherapy.

A prospective multicentre observational study of Permacol collagen paste for anorectal fistula: preliminary results.

AIM: Permacol collagen paste (Permacol paste) is a new option for the treatment of anorectal fistula. It functions by filling the fistula tract with an acellular crosslinked porcine dermal collagen matrix suspension. The MASERATI 100 study group was set up to evaluate the clinical outcome of Permacol paste in the treatment of anorectal fistula. This paper reports the results from the initial 30 patients enrolled in the MASERATI 100 prospective, observational clinical trial. METHOD: Patients (N = 30) with anal fistula presenting to 10 European academic surgical units were treated with a sphincter-preserving technique using Permacol paste. Fistula healing was assessed at 1, 3, 6 and 12 months after treatment, with the primary end-point of fistula healing at 6 months post-surgery. Faecal continence and patient satisfaction were recorded at each follow-up visit and adverse events were monitored throughout the follow-up. RESULTS: Of the 28 patients with data at 6 months post-surgery, 15 (54%) were healed, and the healing rate was maintained at 12 months. Healing after treatment with Permacol paste was similar for intersphincteric to transsphincteric fistulae and primary or recurrent fistulae. Only one patient exhibited an adverse event (perianal abscess) that was possibly related to the treatment. At the last outpatient visit, over 60% of patients were satisfied or very satisfied with the operation. CONCLUSION: Permacol paste is shown to be effective in treating primary and recurrent cryptoglandular anorectal fistula with minimal unwanted side effects.

A systematic review of stercoral perforation.

AIM: Stercoral perforation is a rarely suspected life-threatening condition. Early diagnosis is difficult but essential. A comprehensive systematic review was performed to evaluate its presentation, diagnosis and treatment. METHOD: A systematic review was carried out of Embase, MEDLINE, PubMed and Cochrane databases for all articles published between 1998 and 2011. Only studies describing stercoral perforation were included. RESULTS: Twenty-four relevant articles were found including 137 patients (median age = 62 years) with stercoral perforation, of whom 81% had chronic constipation. Stercoral perforation was diagnosed by CT scan in 90% of 31 patients, with the commonest findings being a combination of faecal impaction (84%) and subphrenic (90%) or extraluminal air (61%). The commonest site of perforation was the sigmoid colon (50%) followed by the rectosigmoid junction (24%). The overall mortality was 34%. CONCLUSION: Stercoral perforation should be suspected in elderly and chronically constipated patients with unexplained abdominal pain and investigated appropriately with a CT scan to allow timely and optimal treatment.

Laparoscopic rectopexy.

Abdominal rectopexy has been advocated as the treatment of choice for complete rectal prolapse. Recurrence rates are low raging from 0-12% and fecal continence has been documented to improve in 3-75% of patients. As most patients are elderly and not always fit enough to undergo abdominal procedure, various perineal approaches have been advocated. Depending on the type and extent of the operation, these procedures have a recurrence of up to 38%. Laparoscopic rectopexy represents the latest development in the evolution of surgical treatment of rectal prolapse. This technique aims to combine the good functional outcome of the open abdominal procedure with the low postoperative morbidity of minimal invasive surgery. We present a laparoscopic rectopexy on 72-year-old lady with a 10-year history of fecal incontinence and mucosal rectal prolapse. Electronic supplementary material is available for this article at http://dx.doi.org/10.1007/s00464-006-0136-y.

Loop ileostomy: modification of technique.

INTRODUCTION: A loop ileostomy is a suitable procedure for faecal diversion. A number of technical improvements and advancement in stoma management have made its creation a suitable alternative to a loop colostomy. We describe an alternative technique for securing a loop ileostomy and perform a retrospective review of this technique. PATIENTS & METHOD: 40 patients who had a loop ileostomy performed as part of an abdominal procedure were reviewed. The loop of ileum was secured to the stoma site with a novel 'suture bridge' technique. RESULTS: 32 patients had the stoma formed to protect a distal anastomosis, 6 to palliate bowel obstruction, 1 to control faecal incontinence and another for colonic Crohn's disease. There were no incidences of paralytic ileus, mechanical obstruction, prolapse, retraction or bleeding after the loop ileostomies were formed. Thirty patients had their ileostomies closed. In 27 patients this was performed by excising the muco-cutaneous edge and anterior closure. Three patients had their stomas resected and an end-to-end bowel anastomoses. Following closure there were two complications in separate patients--self-limiting paralytic ileus and small bowel obstruction at the site of the stomal closure that required a second operation. There were no incidences of anastomotic leaks or bleeding in patients who had their ileostomy closed. No mortalities were attributed to either stoma formation or closure. CONCLUSION: We have described a safe alternative technique for securing a loop ileostomy with negligible complications in construction and closure as demonstrated in our results.

An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting.

Acute ischemia of the hand developed after coronary artery bypass grafting with a radial artery conduit. Perioperative tests established that there was good perfusion to the hand via the collateral vessels. Angiographic examination showed an absence of the ulnar artery. Circulation was restored with a vein graft. I briefly review noninvasive investigations available and suggest that color Doppler scanning should be routinely performed before the use of the radial artery as a conduit.