An experience with video-assisted anal fistula treatment (VAAFT) with new insights into the treatment of anal fistulae.

BACKGROUND: The aim of this retrospective study was to assess our experience of 41 patients with anal fistulae treated with video-assisted anal fistula treatment (VAAFT). METHODS: Forty-one consecutive patients with cryptoglandular anal fistulae were included. Patients with low intersphincteric anal fistulae or those with gross perineal abscess were excluded. Eleven (27 %) patients had undergone prior fistula surgery with 5 (12 %) having had three or more previous operations. RESULTS: All patients underwent the diagnostic phase as well as diathermy and curettage of the fistula tracts during VAAFT. Primary healing rate was 70.7 % at a median follow-up of 34 months. Twelve patients recurred or did not heal and underwent a repeat VAAFT procedure utilising various methods of dealing with the internal opening. There was a secondary healing rate of 83 % with two recurrences. Overall, stapling of the internal opening had a 22 % recurrence rate, while anorectal advancement flap had a 75 % failure rate. There was no recurrence seen in six cases after using the over-the-scope-clip (OTSC(®)) system to secure the internal opening. CONCLUSIONS: VAAFT is useful in the identification of fistula tracts and enables closure of the internal opening. Adequate closure is essential with the method used to close large or fibrotic internal openings being the determining factor for success or failure. The OTSC system delivered the most consistent result without leaving a substantial perianal wound. Ensuring thorough curettage and drainage of the tract during VAAFT is also important to facilitate healing. We believe that this understanding will bring about a decrease in the high recurrence rates currently seen in many series of anal fistulae.

A prospective randomized trial on the use of Coca-Cola Zero(®) vs water for polyethylene glycol bowel preparation before colonoscopy.

AIM: The study aimed to determine whether Coca-Cola (Coke) Zero is a safe and effective solvent for polyethylene glycol (PEG). METHOD: Between December 2013 and April 2014, 209 healthy adults (115 men, 95 women) scheduled for elective colonoscopy were randomized to use either Coke Zero (n = 100) or drinking water (n = 109) with PEG as bowel preparation. Each patient received two sachets of PEG to dissolve in 2 l of solvent, to be completed 6 h before colonoscopy. Serum electrolytes were measured before and after preparation. Bowel cleanliness and colonoscopy findings were recorded. Palatability of solution, adverse effects, time taken to complete and willingness to repeat the preparation were documented via questionnaire. RESULTS: Mean palatability scores in the Coke Zero group were significantly better compared with the control group (2.31 ± 0.61 vs 2.51 ± 0.63, P = 0.019), with a higher proportion willing to use the same preparation again (55% vs 43%). The mean time taken to complete the PEG + Coke Zero solution was significantly faster (74 ± 29 min vs 86 ± 31 min, P = 0.0035). The quality of bowel cleansing was also significantly better in the Coke Zero group (P = 0.0297). There was no difference in the frequency of adverse events (P = 0.759) or the polyp detection rate (32% vs 31.2%). Consumption of either preparation did not significantly affect electrolyte levels or hydration status. CONCLUSION: Coke Zero is a useful alternative solvent for PEG. It is well tolerated, more palatable, leads to quicker consumption of the bowel preparation and results in better quality cleansing.

Sigmoid volvulus treated by mini-incision.

Definitive surgical management of sigmoid volvulus is usually via a midline laparotomy or laparoscopy. We report our experience with a series of five consecutive cases over a 10-year period. All patients had definitive surgery via a left iliac fossa mini-incision after prior decompression. For four patients, it was the first episode of sigmoid volvulus and one patient had a recurrent sigmoid volvulus after previous sigmoid colectomy. The latter patient had pan colonic megacolon diagnosed at initial surgery. All five cases were surgically treated successfully via a mini-incision on the left iliac fossa. There were no instances of recurrence at a median follow-up duration of 95 months (range 7-132 months). A left iliac fossa mini-incision is sufficient for the definitive management of non-perforated sigmoid volvulus. Larger studies are warranted to draw definitive conclusions.

LARG at chromosome 11q23 has functional characteristics of a tumor suppressor in human breast and colorectal cancer.

Deletion of 11q23-q24 is frequent in a diverse variety of malignancies, including breast and colorectal carcinoma, implicating the presence of a tumor suppressor gene at that chromosomal region. We examined a 6-Mb region on 11q23 by high-resolution deletion mapping, using both loss of heterozygosity analysis and customized microarray comparative genomic hybridization. LARG (leukemia-associated Rho guanine-nucleotide exchange factor) (also called ARHGEF12), identified from the analysed region, is frequently underexpressed in breast and colorectal carcinomas with a reduced expression observed in all breast cancer cell lines (n=11), in 12 of 38 (32%) primary breast cancers, 5 of 10 (50%) colorectal cell lines and in 20 of 37 (54%) primary colorectal cancers. Underexpression of the LARG transcript was significantly associated with genomic loss (P=0.00334). Hypermethylation of the LARG promoter was not detected in either breast or colorectal cancer, and treatment of four breast and four colorectal cancer cell lines with 5-aza-2'-deoxycytidine and/or trichostatin A did not result in a reactivation of LARG. Enforced expression of LARG in breast and colorectal cancer cells by stable transfection resulted in reduced cell proliferation and colony formation, as well as in a markedly slower cell migration rate in colorectal cancer cells, providing functional evidence for LARG as a candidate tumor suppressor gene.

Ultra-low anterior resection for low rectal cancer: five key tips to make it easy.

The primary treatment for rectal cancer is still surgery. Surgery however, may be either preceded or followed by chemotherapy and radiotherapy as and when needed. Good surgery on its own when applied appropriately is associated with a very low rate of local recurrence. Bad surgery however, is associated with a high risk of local and systemic recurrence. The well-performed ultra-low anterior resection with total mesorectal clearance has been shown to be the most important step in the treatment of a low rectal cancer. The author details five key tips to make the performance of an ultra-low anterior resection easy. These five key tips are: tip 1 Decide on the best approach for your particular patient before surgery; tip 2 The inferior mesenteric artery is crucial in obtaining the right dissection plane; tip 3 The sigmoid colon should be used for construction of the J-pouch whenever possible; tip 4 Use of a good light source is the key to obtaining a good idea of where to operate and to keeping to the right planes; tip 5 The last key to making surgery easier is to have a good head and good hands. Surgeons must know precisely the reasons why they do what they do in the way they do. Surgery which is difficult may be expected to carry with it more risks and therefore poorer results. Surgery which goes smoothly and is easy is usually rewarded with good results. Surgeons should try to make their surgery easier and the tips offered here are steps that will do this.

The use of a wound protector to prevent port site recurrence may not be totally logical.

The wound protector has been used widely to prevent port site metastases (PSM). Although port site metastases ties in with poor survival, it is not because of PSM itself, but rather because PSM is a sign of more widespread metastatic disease. Whilst being touted as a method of preventing PSM, it fails to address the bigger issue of preventing intra-abdominal recurrence. Proper surgical technique in tumour handling following rigorous oncological principles, and not just putting in a wound protector is the key to good surgery with low recurrences and excellent survival rates.

The management of desmoids in patients with familial adenomatous polyposis (FAP).

Desmoids are rare in the general population but occurs in between 10 to 20% of patients with familial adenomatous polyposis (FAP). This risk is about 852 times the risk for the population at large. Desmoids are benign neoplasms that are capable of infiltrating locally with a high risk of recurrence (25-65%) even after extirpating surgery. Desmoids in FAP may occur extra-abdominally, or within the abdominal wall or most commonly intra-abdominally within the mesentery or retroperitoneal. Desmoids are a major problem in patients with FAP. Mortality from desmoids is high in such patients and ranges from 18 to 31%, compared to peri-ampullary carcinomas at about 22% and cancer in the retained rectum at only about 8%. Simple drug treatment with tamoxifen or NSAIDS like sulindac should be used as first line treatment as it carries a response in 30-50% of patients. Surgery should be reserved for extra-abdominal tumours alone and only when needed. Surgery for intra-abdominal desmoids should really only be attempted for intestinal obstruction or ureteric obstruction. Dacarbazine-Doxorubicin chemotherapy may have dramatic response in some cases. Genetic transfer may unlock this disease in future and may give patients with FAP and severe desmoids hope for the future.

The role of traditional Chinese medicine in colorectal cancer treatment.

Surgery, chemotherapy and radiotherapy have been the mainstay of colorectal cancer treatment. There is however current intense research on traditional Chinese medicine (TCM) as novel or additional treatment methods for colorectal cancer. This article reviews the current use of TCM in colorectal cancer so as to increase the awareness of colorectal surgeons. The pathogenesis of colorectal cancer according to TCM is discussed. TCM has been used successfully during the perioperative period to relieve intestinal obstruction, reduce postoperative ileus and reduce urinary retention after rectal surgery. Good results have been reported in the treatment of the complications of chemotherapy and radiation enterocolitis. Favourable results have also been shown in the use of TCM either alone or in combination with chemotherapy to treat advanced colorectal cancer. Molecular studies have shown some TCM compounds to reduce tumour cell proliferation and induce apoptosis. Although the reported results of TCM have been exciting thus far, problems of lack of consensus on treatment regimes and questions on the reliability, validity and applicability of published studies prevent its widespread use. There is now an urgent need for colorectal surgeons to work with TCM physicians in the continuing research on this 6,000-year-old art so as to realize its full potential for our patients.

Omentum as a cover for abdominal wall loss.

A case of necrotising fasciitis with full-thickness loss of the entire abdominal wall is reported after an uncomplicated elective low anterior resection. Salvage was accomplished by early wide surgical extirpation and repeated re-explorations and debridements. The presence of ample omentum helped prevent evisceration and allowed granulation tissue to gradually seal the abdominal cavity over a period of 4 months without further reconstructive procedures.

Mucosal flap excision for treatment of remnant prolapsed hemorrhoids or skin tags after stapled hemorrhoidopexy.

Stapled hemorrhoidopexy may leave residual skin tags or external components following its use in large prolapsed piles. Excision of redundant mucosa above the dentate line and reconstitution to the staple line reduces these prolapsed elements. We describe a novel technique that removes residual skin tags and piles while remaining true to the spirit of stapled hemorrhoidopexy.

Prospective, randomized trial comparing intraoperative colonic irrigation with manual decompression only for obstructed left-sided colorectal cancer.

BACKGROUND: This is a prospective, randomized, controlled trial comparing the outcome of intraoperative colonic irrigation with that of manual decompression for acutely obstructing colorectal cancers distal to the splenic flexure. METHODS: All patients admitted to our department from June 1999 to August 2002 with obstructing left-sided colorectal cancers were recruited. Patients were randomized intraoperatively and were excluded if deemed unsuitable for segmental resection and primary anastomosis. Twenty-five patients were randomized to receive colonic irrigation and twenty-eight to receive manual decompression. Perioperative parameters and outcome including mortality and anastomotic leak were recorded. RESULTS: Both groups of patients were comparable in terms of gender and age. The time taken for mobilization, decompression, and irrigation in the colonic irrigation group (median, 31 minutes) was significantly longer than that for the manual decompression group (median, 13 minutes) (P; = 0.0005). However, the total time of the operation was similar for both groups. Times for recovery of bowel function, of wound infection, and until discharge from the hospital were also similar. In the manual decompression group there were two cases of anastomotic leak (8 percent, 2/25) requiring reoperation but none (0/24) in the colonic irrigation group. However, this difference was not statistically significant. CONCLUSION: Manual decompression of proximal colon without irrigation is as safe as colonic irrigation in one-stage surgical management of obstructing left-sided colorectal cancer.

Dynamic graciloplasty for total anorectal reconstruction after abdominoperineal resection for rectal tumour.

AIM: To review the results of dynamic graciloplasty for total anorectal reconstruction after abdominoperineal resection (APR) for rectal cancer. PATIENTS AND METHODS: Chart reviews were done on 17 patients who had dynamic graciloplasty following abdominoperineal resection and details of post-operative complications, bowel functions and recurrences were obtained. RESULTS: Seventeen patients (12 males) had dynamic graciloplasty after APR for low rectal tumours. The median age was 58.5 years (range 33-78). Three patients from overseas were lost to follow-up, and three still have not had the defunctioning stoma closed. Only 11 patients were available for evaluation of function. The median time from graciloplasty to continence to solids and liquids is 15.7 months (range 0.4-21.9 months). Six patients had defecatory problems, requiring daily irrigation to evacuate. Nine patients were continent without need for gracilis stimulation. Only two patients needed gracilis stimulation to maintain continence. Fifty percent of rectal carcinoma patients had developed a recurrence. CONCLUSION: Dynamic graciloplasty had a high morbidity and did not always bring about normal defecatory function. Gracilis stimulation was not needed to achieve continence in all cases. Conversely, dynamic graciloplasty may lead to defecatory difficulties in a large number of patients. Graciloplasty should only be considered three years after the initial APR to avoid performing the procedure in a patient who may develop recurrence as well as to select patients who are psychologically prepared for the surgery and its complications.