Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer.

BACKGROUND: Abdominal perineal excision (APE) was originally described with levator ani removal for rectal cancer. An even wider, more aggressive extralevator resection for APE has been proposed. Although some surgeons are performing a very wide 'extralevator APE (ELAPE)', there are few data to recommend it routinely. This multicentre study aimed to compare outcomes of APE and ELAPE. METHODS: A multicentre propensity case-matched analysis comparing two surgical approaches (APE and ELAPE) was performed. All patients who underwent abdominoperineal resection of a rectal tumour were considered for the analysis. Tumour height was defined by magnetic resonance imaging measurement and patients with stage II-III tumours had neoadjuvant radiochemotherapy. Involvement of the circumferential resection margin (CRM) and intraoperative tumour perforation were the main outcome measures. A logistic regression model was used to study the relationship between the surgical approaches and outcomes. RESULTS: From January 2008 to March 2013 a total of 1909 consecutive patients underwent APE or ELAPE, of whom 914 matched patients (457 in each group) formed the cohort for analysis. Intraoperative tumour perforation occurred in 7.9 and 7.7 per cent of patients during APE and ELAPE respectively (P = 0.902), and there was CRM involvement in 13.1 and 13.6 per cent (P = 0.846). There were no differences between APE and ELAPE in terms of postoperative complication rates (52.3 versus 48.1 per cent; P = 0.209), need for reoperation (7.7 versus 7.0 per cent; P = 0.703), perineal wound problems (26.0 versus 21.9 per cent; P = 0.141), mortality rate (2.0 versus 2.0 per cent; P = 1.000) and local recurrence rate at 2 years (2.7 versus 5.6 per cent; P = 0.664). CONCLUSION: ELAPE does not improve rates of CRM involvement, intraoperative tumour perforation, local recurrence or mortality.

Sacral nerve stimulation for the treatment of faecal incontinence following low anterior resection for rectal cancer.

AIM: The aim of this study was to assess the effectiveness of sacral nerve stimulation (SNS) in the management of faecal incontinence following neoadjuvant therapy and low anterior resection (LAR) for rectal cancer. METHOD: In a prospective single-centre study, 15 patients (12 men, median age 72 years) were enrolled between 2005 and 2008. All had severe incontinence after total mesorectal excision, and 14 had received preoperative full-course chemoradiotherapy. The patients were followed up for a median of 50 (range: 24-144) months. There was no recurrence (local or distal). Incontinence was evaluated using the Cleveland Clinic Florida Fecal Incontinence (CCF-FI) scoring system. Quality of life (QoL) was evaluated using the Fecal Incontinence Quality of Life (FIQL) questionnaire. SNS was performed in three stages. RESULTS: During percutaneous nerve evaluation (PNE), a good response was observed in seven patients, all of whom received a permanent implant. The median follow up was 12 (range: 1-44) months. The mean CCF-FI score was reduced from 19.2 [standard deviation (SD) 1.2] to 6.2 (SD 1.7) (P < 0.01). The mean number of days per week with an incontinent episode decreased from 7 (SD 0) to 0.2 (SD 0.3) (P < 0.01), and the mean number of defaecations per week decreased from 42.5 (SD 13.7) to 13.2 (SD 7.4) (P < 0.01). In the five patients with a permanent implant who were followed up for longer than 6 months, all FIQL scores improved. An increase in the mean resting and squeeze pressures was seen in four patients with a permanent implant. CONCLUSIONS: SNS is a treatment option for faecal incontinence after LAR for rectal cancer.

Randomized clinical trial of anal fistula plug versus endorectal advancement flap for the treatment of high cryptoglandular fistula in ano.

BACKGROUND: The aim of this randomized study was to compare the results of anal fistula plug and endorectal advancement flap in the treatment of high fistula in ano of cryptoglandular origin. METHODS: Consecutive patients with high trans-sphincteric fistula in ano of cryptoglandular aetiology were randomized to treatment with either an anal fistula plug or endorectal advancement flap. Patients agreed to participate in a follow-up programme, which included scheduled visits at 2, 4, 8, 12 and 24 weeks and at 1 year after surgery. The primary endpoint was effectiveness in fistula healing. Recurrence was defined as the presence of an abscess arising in the same area, or obvious evidence of fistulation. RESULTS: A large number of recurrences in the fistula plug group led to premature closure of the trial. After 1 year, fistula recurrence was noted in 12 of 15 patients treated with an anal fistula plug compared with two of 16 treated with an endorectal advancement flap (relative risk 6.40 (95 per cent confidence interval 1.70 to 23.97); P < 0.001). CONCLUSION: Contrary to other published studies, an anal fistula plug was associated with a low rate of fistula healing, particularly in patients with a history of fistula surgery.

Length of follow-up after fistulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano.

BACKGROUND: The length of follow-up required after surgical repair of cryptoglandular fistula in ano has not been established. This prospective study determined the follow-up time needed to establish that an anal fistula has been cured after elective fistulotomy or fistulectomy associated with endorectal advancement flap (ERAF) repair. METHODS: Between January 2001 and June 2004, consecutive patients with anal fistula of cryptoglandular aetiology were included provided that they lived within the catchment area of the hospital and agreed to participate in a follow-up programme, which comprised scheduled visits every month until complete wound healing and annually thereafter. RESULTS: Some 206 of 219 eligible patients were evaluable; fistulotomy was performed in 115 and ERAF repair in 91. Median follow-up was 42 (range 24-65) months. Eighteen patients had recurrence of the fistula during follow-up, with a median time to relapse of 5.0 (range 1.0-11.7) months. There were no recurrences after 1 year. CONCLUSION: Recurrence of fistula in ano of cryptoglandular origin treated by means of fistulotomy or ERAF repair occurs within the first year of operation.

[Treatment of perianal Crohn's disease]. / Tratamiento de la enfermedad de Crohn perianal.

Perianal affectation due to Crohn's disease includes a wide spectrum of lesions involving different management and prognosis. A thorough exploration of the patient, under anaesthetic if necessary, a rectoscope to evaluate the possible affectation of the rectum by the disease, and on occasions evaluation through endoanal echography or magnetic resonance, are the bases for a correct diagnostic and therapeutic focus. Pharmacology and surgery must be complementary in the treatment of perianal Crohn's disease and must pursue a double aim: to alleviate the symptomology of the patient and prevent possible complications. Except in situations of emergency due to perianal sepsis, medical treatment is the first step in managing perianal Crohn's disease, and on many occasions it will control the disease, making surgery unnecessary. When surgery is required, with the aim of a definitive treatment of the perianal lesion, the risk of developing complications, especially incontinence, must be contrasted.

Quality of life assessment in patients with chronic anal fissure after lateral internal sphincterotomy.

BACKGROUND: The aim of this study was to compare quality of life of patients with chronic anal fissure before and after open lateral internal sphincterotomy. METHODS: A prospective study was undertaken of 108 consecutive patients with a history of chronic anal fissure who underwent lateral internal sphincterotomy. Quality of life was measured before and 6 months after operation with the Short-Form 36 (SF-36) Health Survey. RESULTS: Quality of life improved significantly in six of the eight scales of the SF-36 questionnaire: physical functioning, role physical, bodily pain, energy, social functioning and mental health. There were no significant differences between the 70 patients who had no change in continence after operation and the 38 patients with continence disturbances after sphincterotomy. However, there were significant improvements in four scales in patients without changes in continence compared with improvements in only two scales in those with continence disturbances. CONCLUSION: Patients with chronic anal fissure showed an improvement in quality of life 6 months after internal lateral sphincterotomy. Patients with postoperative continence disturbances showed improvement in fewer scales of the SF-36 questionnaire than those without changes in continence.

Randomized clinical trial of stapled haemorrhoidopexy versus conventional diathermy haemorrhoidectomy.

BACKGROUND: The aim of this study was to compare the results of stapled haemorrhoidopexy (commonly called stapled haemorrhoidectomy) with those of conventional diathermy haemorrhoidectomy. METHODS: Fifty-five patients with symptomatic third- and fourth-degree haemorrhoids were randomized to either stapled haemorrhoidopexy (n = 27) or conventional diathermy haemorrhoid ectomy (n = 28). Operating time, postoperative pain, time to return to work, postoperative complications and effectiveness of haemorrhoidal symptom control were recorded. The mean follow-up was 15.9 months in the stapled haemorrhoidopexy group and 15.2 months in the conventional haemorrhoidectomy group. RESULTS: Mean pain intensity was significantly less in the stapled group (P = 0.001). There were no significant differences in the total number of complications, the length of absence from work or control of symptoms. Seven patients in the stapled group re-presented with prolapse compared with none in the conventional haemorrhoidectomy group (P = 0.004). This difference was also observed in the subset of patients with fourth-degree haemorrhoids (P = 0.003). CONCLUSION: The stapled operation was significantly less painful than conventional haemorrhoidectomy. However, the rate of recurrent prolapse was higher after stapled haemorrhoidopexy than after conventional diathermy haemorrhoidectomy.

Complications and functional outcome following artificial anal sphincter implantation.

BACKGROUND: The postoperative complications and functional outcome following 24 consecutive implantations of an artificial anal sphincter were assessed prospectively. METHODS: A total of 24 artificial anal sphincters (Acticon Neosphincter) were implanted in 22 patients (mean age 47 years). The mean follow-up period was 28 (range 6-48) months. Results were assessed prospectively by two independent observers at 4-month intervals. The cumulative probability of artificial anal sphincter removal was analysed by the Kaplan-Meier method. RESULTS: Five patients were free of complications. During the postoperative period, complications occurred in nine patients, two of whom required reoperation. During follow-up, complications developed in ten patients, nine of whom were reoperated. Definitive device explantation was necessary in seven patients. The cumulative probability of device explantation was 44 per cent at 48 months. The 15 patients with functioning implants were followed up for a mean of 26 (range 7-48) months. Continence grading improved from a mean of 18 (range 14-20) in the preoperative period to 4 (range 0-14) after operation (P < 0.001). Resting anal canal pressure in patients with a functioning implant increased from a mean of 35 (range 8-87) mmHg before operation to 54 (range 34-70) mmHg after implantation (P < 0.01). CONCLUSION: An artificial anal sphincter is a useful alternative for refractory faecal incontinence but the incidence of late postoperative complications is high.

[Detection of liver metastases in colorectal neoplasms: use of intraoperative echography]. / Detección de metástasis hepáticas por neoplasia colorrectal mediante ecografía intraoperatoria.

Fifty patients were consecutively operated on for colorectal cancer. Preoperative ultrasonography and intraoperative palpation were compared to intraoperative ultrasonography to determine their relative capacities in the detection of liver metastases. Preoperative ultrasonography detected metastases in three patients (6%), intraoperative palpation in four (8%) and intraoperative ultrasonography in 5 (10%). The number of metastases detected were 7, 19 and 19 respectively. The comparison failed to yield significant differences. From statistical viewpoint, both preoperative ultrasonography and intraoperative palpation were found to be as effective as intraoperative ultrasonography in detecting liver metastases.

Is early postoperative feeding feasible in elective colon and rectal surgery?

UNLABELLED: In reports on earlier non-prospectively randomized trials the authors have claimed that early oral postoperative feeding is a unique benefit of laparoscopic surgery. On the other hand, some authors have suggested that early feeding could be tolerated by the majority of patients after elective open surgery. AIM: This prospective randomized study was undertaken to assess the feasibility and safety of immediate oral feeding in patients subjected to elective open colorectal surgery. METHODS: This trial included 190 patients who underwent an elective colon or rectal operation. Patients were randomized after the operative procedure into one of two groups. Group I (n = 95): On the first evening after the operation, patients were allowed ab libitum intake of clear liquids; this continued until the first postoperative day at which time they progressed to a regular diet as desired. Group II (n = 95): In this group the nasogastric tube was removed when the surgeon considered that postoperative ileus had been resolved. RESULTS: Early oral intake was tolerated by 79.6% of the patients in the first 4 days in group I; there were no differences between the two groups from the 4th day on. The incidence of vomiting and nasogastric tube insertion (21.5%) was higher in patients in group I than in those in group II. The time until the first bowel movement was 4.3 days in group I and 4.7 days in group II. Complications appeared in 17.3% of the patients in group I and in 19.3% in group II. CONCLUSION: This study has objectively demonstrated that early oral feeding is feasible and safe in patients who have elective colorectal surgery.

Early postoperative feeding after elective colorectal surgery is not a benefit unique to laparoscopy-assisted procedures.

UNLABELLED: Previous analyses of non-prospectively randomized trials have suggested that early oral postoperative feeding might be a benefit unique to laparoscopic surgery. However, some authors have indicated that early feeding can be tolerated by the majority of patients after elective open surgery. AIM: This prospective randomized study was undertaken to assess whether the time prior to oral intake of food after laparoscopy-assisted surgery is shorter than that after standard laparotomy. METHODS: This trial included 40 patients who were divided randomly into two groups before operation. Group I included 20 patients (mean age, 52 years; range, 15-77 years) who underwent a laparoscopy-assisted colon or rectal procedure (LAP). Group II consisted of 20 patients (mean age, 56 years, range, 41-74 years) who underwent surgery with a standard midline incision (SMI). On the evening after surgery, patients were allowed clear liquids ab libitum. This regimen was continued until the first postoperative day at which time they could elect to start eating a regular diet. If a patient had two episodes of vomiting, a nasogastric tube was inserted. RESULTS: Five laparoscopic procedures were converted to SMI because of adhesions (25%) and an equal number of patients was excluded from the group that was treated in the traditional manner. Therefore, only 30 patients were included in the analysis. There were no deaths in this trial. Complications appeared in four of the patients in the LAP group and in two of the patients in the SMI group (no significant difference). There were no statistically significant differences between the two groups in terms of the ability to tolerate the early oral intake of food, in the frequency of vomiting or in the incidence of insertion of a nasogastric tube. The time to the first bowel movement was 5.4 days in LAP and 5.5 days in SMI, and the difference was not significant. CONCLUSION: This study invalidates the claim by laparoscopic surgeons that earlier oral intake of food is tolerated by their patients than by patients who undergo standard procedures.

[Anal incontinence in patients with rectal neoplasms previous to surgical intervention]. / Incontinencia anal en pacientes con neoplasia de recto previamente a la intervención quirúrgica.

HYPOTHESIS: Patients with rectal carcinoma may have anal continence disorders before the operation, in relation to age. AIM: To evaluate the anorectal function in a consecutive sample of patients with rectal carcinoma before the operation. MATERIAL AND METHODS: 56 consecutive patients with rectal carcinoma were studied and classified into two groups according to anal continence: continent and incontinent. Anorectal function were evaluated in all patients: Perineometry (perineal measurements at rest and during a straining effort), Anal manometry (anal pressures and rectal capacity), Pudendal nerve terminal motor latency. STATISTICAL ANALYSIS: quantitative data: -test (confidence interval), qualitative data: Fischer exact test. RESULTS: Anal continence: continent 41, incontinent 15. All patients with anal incontinence were more than 60 years old (p<0.01). Mean age: continent 61.3 +/- 12.4, incontinent 74.3 +/- 6 (p<0.01, CI 8.02-17.98). Perineal measurement: at rest: continent 2.97 +/- 0.69. incontinent 2.54 +/- 0.56 (p<0.05, CI 0.03-0.83), with straining effort: continent 1.37 +/- 0.86, incontinent 0.81 +/- 0.92 (p < 0.05, CI 0.03 - 1.86). Pudendal latency: continent 1.9 +/- 0.3, incontinent 2.3 +/- 0.5 (p<0.01, CI 0.11-0.69). There was no significant difference in the manometric data. CONCLUSION: Patients with rectal carcinoma have preoperative anal continence alterations, in relation to pelvic disorders and age.

Anterior resection: do the patients perceive any clinical benefit?

PURPOSE: Functional results following anterior resection of the rectum have been sparsely reported. Results concerning stool frequency and continence vary widely. These variations may represent several areas of bias, but one of the main concerns is study design. Many studies are focused on physiological results and even when a control population is included in the study design, it is not used to compare the clinical functional outcome. the aims of this prospective study were: (1) to study serially before and 1 year after low anterior resection for carcinoma the changes in clinical function; and (2) to study if these changes could be attributable to the characteristics of the population, comparing the results with sex-matched and age-matched controls. MATERIAL AND METHODS: Sample size was previously established according the prevalence of continence disorders fund in two previous studies carried out in our country, 36% for anterior resection, and 6% among general population in our community. Thirty-eight consecutive patients (mean age 63.9 years, range 41-77 years) with a diagnosis of rectal carcinoma were invited to participate in the study. The lower margin of the tumor was located between 4 and 15 cm from the anal margin (median of level tumor 6.0 cm). A control group of 25 volunteers matched for sex and age with patients who were questioned 1 year after the anterior resection were also studied. Median level of anastomosis was 6.2 +/- 2.7 cm (range 2-11) above the anal margin. In six patients with an anastomosis less than 4 cm from the anal margin, a loop ileostomy was constructed and closed 3 months later. Patients were interviewed by a research assistant before and 1 year after operation or 1 year after closure of the temporary defunctioning loop ileostomy. Patients were questioned about bowel frequency over 24 h, urgency, tenesmus, erratic defecatory patterns, discrimination of bowel content and continence. RESULTS: Clinical function of patients before and after operation. Compared with pre-operative, bowel frequency of 3.9/day (range 0.3-14) did not differ significantly 1 year after operation at 2.3/day (range 0.5-6). Frequency of erratic defecatory patterns (44%), urgency (40%) and obstructed defecation (20%) did not differ between the preoperative and postoperative period. Forty-eight percent of patients suffered tenesmus and 20% were unable to discriminate between flatus and feces before operation, whereas these troublesome symptoms were present in 24% and 16%, respectively, after the operation. Before the operation 32% of patients reported fecal leaks while in the postoperative period 52% patients complained of this alteration. Clinical function of patients compared with controls. Patients had a mean stool frequency per day of 2.3 (range 0.5-6) and controls 1.3 (range 0.3-5). Forty-four percent of patients had erratic defecatory patterns, 24% suffered tenesmus and 40% urgency, whereas these troublesome symptoms were present in 12% in the control population. Moreover, obstructed defecation was present in 20% and 4%, respectively. All controls and 84% of patients maintained discrimination of flatus, liquid and solid feces. Fifty-two percent of patients and 8% of controls suffered from altered continence. CONCLUSIONS: One year after low anterior resection patients had poor bowel function when compared with a control population of the same age and sex. A distinct anterior resection syndrome exists consisting of increased bowel frequency, erratic defecatory patterns, urgency, tenesmus, obstructed defecation, and minor fecal leakage. Furthermore, these disturbances in defecatory function did not differ significantly from symptoms produced by the rectal carcinoma, and patients experienced no major benefit from surgery from a functional point of view.

Coloanal anastomosis: are functional results better with a pouch?

PURPOSE: Different studies have shown that low colorectal and coloanal anastomosis often yield poor functional results. The aim of the present study was to investigate whether a colonic reservoir is able to improve functional results. METHODS: Thirty-eight consecutive patients subjected to low anterior resection were randomized following rectal excision in two groups. One (n = 19) had a stapled straight coloanal anastomosis, and the other (n = 19) had a 10-cm stapled colonic pouch low rectal anastomosis. Median anastomotic distance above the anal verge was 3.38 +/- 0.56 cm and 2.14 +/- 0.36 cm in both groups, respectively. Continence alterations, urgency, tenesmus, defecatory frequency, anal resting and maximum voluntary squeezing pressures, and maximum tolerable volume were evaluated one year later. RESULTS: One patient died of pulmonary embolism, and seven presented with a recurrence and were excluded from the study. Stool frequency was greater than three movements per day in 33.3 percent of cases with a reservoir and in 73.3 percent of those with a straight coloanal anastomosis (P < 0.05). Maximum tolerable volume was significantly greater in patients with a reservoir (335 +/- 195) than in those without (148 +/- 38) (P < 0.05). There were no significant differences in other variables studied. CONCLUSIONS: This study shows that some aspects of defecatory function after rectal excision could improve with a colonic reservoir.

Does the frequency of paracolostomy hernias depend on the position of the colostomy in the abdominal wall?

The aim of this study was to determine the rate of paracolostomy hernia in relation to transrectal or pararectal position of a colostomy. Fifty-four consecutive patients who had undergone an abdomino-perineal excision for rectal neoplasia were studied. The location of the colostomy was assessed by physical examination. Computerised Tomography (CT) scanning was used in the cases where its anatomical position remained in doubt. The colostomy was in a pararectal position in 29 (54%), while in 25 (46%) it was transrectal. CT was necessary to determine the location of the colostomies in 9 cases (16%), eight of which had a parastomal hernia. The colostomy was pararectal in 15 (52%) of the 26 patients who had a paracolostomy hernia, and in 14 (48%) of the 28 patients without a paracolostomy hernia. No statistically significant correlation was found between the presence of a parastomal hernia and the position of the stoma in the abdominal wall.