Trends in the treatment of rectal prolapse: a population analysis.

PURPOSE: Rectal prolapse is a common condition, with conflicting opinions on optimal surgical management. Existing literature is predominantly composed of case series, with a dearth of evidence demonstrating current, real-world practice. This study investigated recent national trends in management of rectal prolapse in the Republic of Ireland (ROI). METHODS: This population analysis used a national database to identify patients admitted in the ROI primarily for the management of rectal prolapse, as defined by the International Classification of Diseases, 10th Revision (ICD-10). Demographics, procedures, comorbidities, and outcomes were obtained for patients admitted from 2005 to 2015 inclusive. RESULTS: There were 2648 admissions with a primary diagnosis of rectal prolapse; 39.3% underwent surgical correction. The majority were treated with either a perineal resection (47.2%) or an abdominal rectopexy ± resection (45.1%). The population-adjusted rate of operative intervention increased over the study period, from 25 to 42 per million (p < 0.001), with no change in the mean age of patients over time (p = 0.229). The application of a laparoscopic approach increased over time (p = 0.001). Patients undergoing an abdominal rectopexy were younger than those undergoing a perineal procedure (64.1 ± 17.3 versus 75.2 ± 15.5 years, p < 0.001) despite having a similar Charlson Comorbidity Index (p = 0.097). The mortality rate for elective repair was 0.2%. CONCLUSIONS: Despite the popularization of ventral mesh rectopexy over the study period, perineal resection Delorme's procedure remains the most common procedure employed for the correction of rectal prolapse in the ROI, with specific approach determined by age.

Patient satisfaction with joint colorectal-urogynaecology pelvic floor surgery

Introduction Pelvic floor dysfunction is a global term used to describe conditions such as pelvic organ prolapse, and faecal or urinary incontinence. The Pelvic Floor Centre is a multi-disciplinary clinic for pelvic floor dysfunction. The aim of this study was to assess patient satisfaction following joint colorectal-urogynaecology surgery in the Pelvic Floor Centre. Methods All patients who underwent a joint procedure in the Pelvic Floor Centre from 1st October 2015 to 31st October 2016 were contacted via telephone. Patient satisfaction was assessed using the Surgical Satisfaction Questionnaire (SSQ-8). Results Fifteen patients underwent joint surgeries between 1st October 2015 and 31st October 2016. All patients consented to the questionnaire. Patients underwent a variety of combined procedures including vaginal repairs, anal sphincter repairs, mid-urethral slings, perineal injections, and stapled trans-rectal resection of the rectum. Discussion Thirteen (86.7%) patients were satisfied with their surgery, and would recommend it to other patients with a similar condition. All patients were satisfied that their pain was well controlled after discharge. Eleven (73.3%) patients were satisfied with the time taken to return to daily activities, work, and their usual exercise routine. There is a high level of satisfaction amongst patients undergoing joint colorectal-urogynaecology surgery at the Pelvic Floor Centre. Further investigation into patient satisfaction with the clinic itself and international comparison is warranted.

Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life.

BACKGROUND: Perioperative epidural analgesia provides continuous pain control and may have advantages over parenteral opiate administration. This study assessed the impact of epidural analgesia on quality of life (QOL) of patients undergoing major surgery. METHODS: Sixty patients undergoing thoracic or thoraco-abdominal surgery were studied prospectively. Patients were randomly assigned to receive either thoracic epidural analgesia or patient-controlled i.v. opiate analgesia (PCA) after operation. Visual analogue pain and sedation scores were recorded for the period of the study. QOL health surveys at 24 h (SF-8 acute form) and at 1 week (SF-36) were recorded. Results were examined by uni- and multivariate analyses corrected for the effect of multiple comparisons. RESULTS: Mean pain scores were significantly lower in the epidural group at most time points. Physical and mental scores in the epidural group were significantly better than the PCA group for both SF-8 and SF-36 QOL health surveys (P<0.001). CONCLUSIONS: Epidural analgesia with local anaesthetic and opioid improves QOL and delivers better analgesia compared with PCA in patients undergoing major thoraco-abdominal surgery.

Conservative management resulting in complete resolution of a double intussusception in an adult haemophiliac.

Acute abdominal pain in haemophiliacs should be approached as haemorrhage until proven otherwise. With advancements in factor repletion and coagulopathic management a conservative approach should be considered. We describe a case of double colo-colonic intussusception lead by an intramural haematoma occurring spontaneously and resolving with conservative management in a young haemophiliac. This demonstrates that intussusception in these cases may be transient, and does not require surgical intervention.

Life-threatening gastrointestinal haemorrhage in Von Recklinghausen's disease.

Neurofibromatosis Type I (NF-1), also known as Von Recklinghausen's disease, is a common disorder, but gastrointestinal manifestations are rare and can be associated with severe complications and malignancy. We describe a case of multiple intestinal tumours, which presented as major per-rectal bleeding and was diagnosed by laparotomy. Presenting symptoms of this condition are usually non-specific, but the risk of malignancy and perforation should allow for a high index of suspicion in patients with NF-1 presenting with gastrointestinal symptoms. We present this case as a reminder that blood loss from the bowel in Von Recklinghausen's disease may be life-threatening, requiring immediate surgery to control haemorrhage.

Does anal sphincter injury preclude subsequent vaginal delivery?

OBJECTIVE: To assess continence and anal sphincter integrity during a subsequent pregnancy and delivery in women known to have a previous anal sphincter injury. DESIGN: Prospective observational study. SETTING: The National Maternity Hospital, Dublin, Ireland. POPULATION: Antenatal patients with a documented obstetric anal sphincter injury at a previous delivery. METHODS: Women underwent symptom scoring, endoanal ultrasound and manometry. MAIN OUTCOME MEASURES: Recommended and actual mode of delivery, continence scores and endoanal ultrasound findings after index delivery. RESULTS: 557 women were studied. 293 (53%) had no symptoms of faecal incontinence, 189 (34%) had mild symptoms and 75 (13%) moderate or severe symptoms. 408 (73%) had an endoanal ultrasound. 383(94%) had a normal or small (<1 quadrant) defect in the internal anal sphincter and 390 (96%) had a scar or small (<1e quadrant) defect in the external anal sphincter. 393 (70%) delivered vaginally. 164 (30%) were delivered by caesarean section. 197/557 (35%) returned for follow-up. There was no significant change in continence following either vaginal or caesarean delivery. 20 (5.1%) women had a recognised second anal sphincter tear during vaginal delivery. CONCLUSIONS: The majority of women who sustain a third degree tear have minimal or no symptoms of faecal incontinence when assessed antenatally in a subsequent pregnancy. 70% go on to have a vaginal delivery, with little impact on faecal continence. These findings provide reassurance for patients and clinicians about the safety of vaginal delivery following anal sphincter injury in appropriately selected patients.

Thrombomodulin: tumour biology and prognostic implications.

BACKGROUND: Thrombomodulin (TM) is an endothelial receptor that exerts anti-coagulant, anti-fibrinolytic, and anti-inflammatory activity by inhibiting thrombin and cellular adhesion. There is growing evidence that TM plays a role in tumour behaviour. METHODS: The electronic literature (1966-2004) was reviewed with a specific focus on tumour biology. RESULTS: TM is expressed on both the endothelium and tumour cells in several cancers. Loss of expression denotes a more malignant profile with poorer prognosis. Loss of TM is mediated by hypoxia, endotoxin, and various cytokines, while up-regulation can be achieved by pharmacological manipulation (e.g. pentoxyfylline and statins). CONCLUSION: Originally described as an endothelial anticoagulant, TM plays a key role in tumour biology and prognostics, and provides a potential therapeutic target in impeding cancer spread.

Open versus laparoscopic abdominal rectopexy: an examination of early postoperative outcomes.

BACKGROUND: Abdominal rectopexy is used to treat full thickness rectal prolapse and obstructed defecation syndrome, with good outcomes. Use of a laparoscopic approach may reduce morbidity. The current study assessed short-term operative outcomes for patients undergoing laparoscopic or open rectopexy. METHODS: Rectopexy cases were identified from theater logs in two tertiary referral centers. Patient demographics, intra-operative details and early postoperative outcomes were examined. RESULTS: There were 62 patients included over 10 years, a third of whom underwent laparoscopic rectopexy. Laparoscopy was associated with a longer operative time (195.9 versus 129.6 min, p = 0.003), but this did not affect postoperative outcomes, with no significant differences found for complication rates and length of stay between the two groups. Univariable analysis found no influence of laparoscopic approach on the likelihood of postoperative complications, and no factor achieved significance with multivariable analysis. This study included the first laparoscopic cases performed in the involved institutions, and a "learning curve" existed as seen with a decreasing operative duration per case over time (p = 0.002). CONCLUSIONS: Laparoscopic rectopexy has similar short-term outcomes to open rectopexy.

Identification and comparative analysis of human colonocyte short-chain fatty acid response genes.

Short-chain fatty acids (SCFAs) butyrate, propionate, and acetate produced during fiber fermentation promote colonic differentiation and can reverse or suppress neoplastic progression. We sought to identify candidate genes responsible for SCFA activity on colonocytes and to compare the relative activities of independent SCFAs. cDNA was generated from polyA+ mRNA isolated from control Caco-2 cells and cells treated with equimolar butyrate, propionate, and acetate. GeneCalling, a restriction-based differential RNA expression platform linked to a DNA sequence database lookup, was applied. A total of 30,000 individual genetic sequences were analyzed for differential expression among the three SCFAs. Differentially expressed peaks corresponding to cancer-related genes were isolated, sequenced, and cross-referenced to the GenBank human database. Gene identities were independently confirmed by oligonucleotide poisoning. More than 1000 gene fragments were identified as being substantially modulated in expression by butyrate. Butyrate tended to have the most pronounced effects and acetate the least. Five fragments selected for further study were fully sequenced and proved 100% homologous with human sequences for clusterin, amyloid precursor-like protein 2, and caudal homeobox 2 protein, not previously known to be modulated by SCFAs. In each case, a similar order of potency for the three SCFAs studied was observed. The common SCFAs appear to exert different effects. This study suggests the diversity of the SCFA response at the molecular level and facilitates identifying genes important in the biologic activity of dietary fiber.

Prophylactic colectomy for hyperplastic polyposis.

BACKGROUND: Hyperplastic polyposis (HP) is important to recognise as it increases the risk of adenomata which may develop dysplastic change or frank adenocarcinoma. We present the case of a 58-year-old woman with HP. CASE: Following a diagnosis of HP in this patient, it was noted that the number of polyps were progressively increasing over time, becoming pancolic and extending into the rectum. Genetic testing for a familial polypotic syndrome was negative. Histological analysis demonstrated that the majority of polyps were hyperplastic, but there were also serrated and tubular adenomata with foci of low-grade dysplasia. Whilst there was no evidence of frank malignancy or high-grade dysplasia, following a risk-benefit discussion the patient underwent a laparoscopic total colectomy with an ileal pouch formation. CONCLUSION: This case highlights the complexity in the management of HP and that even in the absence of confirmed invasive disease, patients may elect to undergo prophylactic colonic resection.

Percutaneous cholecystostomy--a safe option in the management of acute biliary sepsis in the elderly.

Percutaneous cholecystostomy (PC) has been used in the management of acute cholecystitis and biliary sepsis in patients with severe comorbidities where emergency cholecystectomy or open cholecystostomy are considered to carry prohibitive risks of mortality. We reviewed three consecutive cases of elderly patients with biliary sepsis presenting acutely to our unit who were managed successfully with this approach, and present herein these cases and a review of the literature.

Thrombomodulin expression in colorectal carcinoma is protective and correlates with survival.

Thrombomodulin (TM) is an endothelial receptor that exhibits anticoagulant, antifibrinolytic and anti-inflammatory activity by inhibiting thrombin and cellular adhesion. In this study, the expression and significance of TM was examined in primary colorectal cancer and its prognostic implications explored. TM immunostaining was performed on formalin-fixed, paraffin-embedded tissue sections, from primary lesions of 200 patients with colorectal carcinoma. Institutional Ethical approval was granted and clinical data retrieved from patients' records. All normal colonic tissue expressed TM on endothelial cells. TM tumour cell expression was demonstrated in 53 (26.5%) cases and 147 (73.5%) showed no neoplastic cell staining. On univariate and multivariate analysis TM expression on tumour cells correlated significantly with tumour stage, differentiation, Jass score and 5 year survival. TM expression decreases as overall stage and tumour size increase (P=0.03). In all, 91% TM positive tumours were well differentiated and 85% of TM negative tumours were poorly differentiated (P<0.01). Five year survival rates of patients with positive and negative TM expression were 71 and 41%, respectively. Survival rate was poorer in those patients who were TM negative compared with those who were positive (P<0.01). A total of 101 (50.5%) of the cases were node negative. In this group, 5 year survival rates of patients with positive and negative TM expression were 87.5 and 37.8%, respectively, demonstrating a poorer survival rate for those who are node negative and TM negative at the time of surgery (P<0.001). This study demonstrates that loss of TM is a key indicator in tumour biology and prognosis.