Long-term outcome of laparoscopic mesh rectopexy for solitary rectal ulcer syndrome.

OBJECTIVE: To determine the long-term outcome of laparoscopic mesh rectopexy for solitary rectal ulcer syndrome (SRUS). PATIENTS AND METHODS: A retrospective review of 11 patients who underwent laparoscopic mesh rectopexy for refractory SRUS between 1993 and 1996. All patients were followed up initially with rigid sigmoidoscopy and seven were involved in long-term evaluation (follow-up at 71-106 months, median 89 months) involving a sickness impact profile questionnaire. RESULTS: Complete endoscopic healing of the ulcer was demonstrated in all 11 patients up to one year postoperatively but one suffered recurrence later. Of seven assessed long-term, none experienced endoscopic recurrence. Six continued to enjoy a significant reduction in symptoms and an improved quality of life. One had persistent problems and demonstrated little symptomatic improvement. CONCLUSION: Laparoscopic mesh rectopexy offers a minimally invasive option for selected patients who remain severely symptomatic despite maximal conservative therapy for SRUS, with demonstrable ulcer healing and long-term improvement in symptoms and quality of life. Larger studies are required to fully evaluate its efficacy compared to 'conventional' surgical options.

Prospective audit of quality of colonoscopy in a surgical coloproctology unit.

OBJECTIVE: The aim of this study was to prospectively audit the quality of colonoscopy and patient acceptance in a Surgical Coloproctology Unit over a one-year period. PATIENTS AND METHODS: 202 consecutive colonoscopies were evaluated over a 12-month period performed by a Consultant, Specialist Registrars and Research fellows. Data where recorded for adequacy of bowel preparation, completion rate, adequacy of sedation, patient tolerance and duration of the procedure. Adequacy of bowel preparation was monitored by scoring bowel content and the percentage of bowel wall visualised. Patients completed a questionnaire to express their sedation satisfaction, discomfort during the procedure and overall satisfaction. RESULTS: The success rate of bowel preparation was 94%. Completion rate was 90% in intended full colonoscopies by the Consultant and Registrars and 74% by more junior grade endoscopists (overall 86%). The mean dose of midazolam and pethidine was higher in patients with unsatisfactory sedation than those with satisfactory sedation. The pain score was higher when trainees performed the procedure than when performed by the Consultant. Fourteen patients refused to undergo the procedure again due to procedure discomfort (n = 7), inadequate sedation (n = 2) and bowel preparation discomfort (n = 5). CONCLUSION: A high completion rate was achieved, compared with published results. However, further improvements are possible especially by improving the performance of junior endoscopists and by ensuring optimal bowel preparation. Patients' tolerance of colonoscopy was highly acceptable but may also be improved by the same methods.

Sacral nerve stimulation for faecal incontinence in the UK.

BACKGROUND: Sacral nerve stimulation (SNS) is an effective therapy for faecal incontinence. Published studies derive largely from single centres and there is a need to determine the broader applicability of this procedure. METHODS: Prospective data were collected for all patients undergoing SNS in the UK. Records were reviewed to determine the outcome of treatment. RESULTS: In three UK centres 59 patients underwent peripheral nerve evaluation, with 46 (78 per cent) proceeding to permanent implantation. Of these 46 patients (40 women) all but two had improved continence at a median of 12 (range 1-72) months. Faecal incontinence improved from a median (range) of 7.5 (1-78) to 1 (0-39) episodes per week (P < 0.001). Urgency improved in all but five of 39 patients in whom ability to defer defaecation was determined, improving from a median of 1 (range 0-5) to 10 (range from 1 to more than 15) min (P < 0.001). Maximum anal squeeze pressure and sensory function to rectal distension changed significantly. Significant improvement occurred in general health (P = 0.024), mental health (P = 0.008), emotional role (P = 0.034), social function (P = 0.013) and vitality (P = 0.009) subscales of the Short Form 36 health survey questionnaire. There were no major complications. One implant was removed. CONCLUSION: SNS is a safe and effective treatment, in the medium to long term, for faecal incontinence when conservative treatment has failed.

Porcine dermal collagen graft in abdominal-wall reconstruction.

We describe the use of a porcine dermal collagen graft in the reconstruction of a large abdominal-wall defect in a woman. The graft was not rejected and, after 1 year, was not associated with incisional hernia. This graft may become an alternative to synthetic-mesh and flap reconstructions because, despite being of a similar tensile strength, it promotes less adhesion, is incorporated into the host tissue and is less prone to infection.

Outcome of argon beam and LASER ablation of large rectal adenomas.

OBJECTIVE: Endoscopic ablation of large rectal adenomas is being increasingly used as primary treatment. Despite the avoidance of general anaesthesia and the prevention of more major procedures, patients undergoing endoscopic ablation have the disadvantage of multiple treatment sessions and the lack of adequate tissue sample for complete histological study. The aim of this study was to analyse the outcome of all patients with large rectal polyps treated with endoscopic ablation. PATIENTS AND METHODS: Between 1993 and 1998, 29 patients who underwent endoscopic ablation of large rectal adenoma were identified. All their case notes were analysed and information was collected on recurrence, treatment episodes, complications, the incidence of carcinoma and the necessity for further procedures. RESULTS: At a median 40 (range 4-67) months follow-up, 41% of patients had recurrence of their adenoma and 14% had been diagnosed with adenocarcinoma. Only 24% of patients had been discharged while 21% were clear but were still under surveillance. Seven (24%) patients had complications, 6 stenosis and one severe bleeding. All stenosis occurred in patients who had more than 10 treatment sessions. In all, 31% of patients needed further endoanal or abdominal surgery and the median time to making this decision was 28 (range 4-66) months. There were no deaths. CONCLUSION: Laser and argon ablation of large rectal adenomas has proved very disappointing. It should be reserved for patients who are unfit to undergo general anaesthesia.

Per anal excision of large rectal adenomas using an endoscopic stapler.

Large rectal adenomas can be approached per-anally by open excision or by transanal endoscopic microsurgery (TEMS). We describe the adaptation of an endoscopic linear stapler-cutter for per anal excision of rectal polyps. It can be used for difficult polyps with minimal risk of complications and is easier and more accessible than TEMS.

Rectal retroflexion: an essential part of lower gastrointestinal endoscopic examination.

PURPOSE: Retroflexion of the endoscope during rectal examination may increase diagnostic yield but is not routinely performed because of concerns about safety and a lack of appreciation of its importance. The purpose of this study was to examine the yield, safety, and tolerance of endoscopic rectal retroflexion. METHODS: Prospective cohorts of subjects undergoing unsedated screening flexible sigmoidoscopy were examined with and without routine retroflexion. Pain scores were recorded. RESULTS: A total of 526 subjects (mean age 60 (range, 55-66) years) underwent flexible sigmoidoscopy in the first period when the endoscope was not routinely retroflexed. Of these, 480 (mean age 60 (range, 55-66) years) were subsequently examined with routine retroflexion. Retroflexion was impossible in 17 subjects (3.5 percent) because of discomfort. In the second group, 12 subjects (2.5 percent) had polyps in the lower rectum seen only on retroflexion. Of these, eight had metaplastic and four had adenomatous polyps (3 tubular <5 mm, 1 tubulovillous 15 mm). There was no difference in mean pain scores between the groups (no retroflexion = 2.13, retroflexion = 2.18). CONCLUSION: With an adenoma pick-up rate of 8 to 12 percent for screening flexible sigmoidoscopy, retroflexion increases adenoma detection by approximately 1 percent without adverse effects and should be an integral part of flexible sigmoidoscopy.

Clinical, echocardiographic, and angiographic profile of patients with double-chambered right ventricle: experience with 48 cases.

Forty-eight patients with double-chambered right ventricle (DCRV) were prospectively studied over a 3-year period. Clinical, echocardiographic, hemodynamic, and angiographic studies were done in all. Three patients were studied postoperatively also. Fifteen patients underwent surgery confirming the diagnosis. Echocardiography detected anomalous muscle bundles (AMBs) in 39/41 patients in whom this study was carried out. Angiographically AMBs were best demonstrated in anteroposterior views in a systolic frame. Common associated anomalies found with DCRV were ventricular septal defects (69%), pulmonary valve stenosis (38%), and double-outlet right ventricle (10%).

Cyclin D3 expression, cell proliferation and pathological stage of human primary colorectal cancer.

Cyclin D3 promotes cell cycle progression but its expression and prognostic significance in human colorectal cancer is unknown. This study assayed cyclin D3 expression against cell cycle phase fraction and Duke's stage in 35 fresh human primary colorectal cancers. DNA content, cell cycle phase fraction and cyclin D3 expression were assessed by flow cytometry in disaggregated tumors. Cyclin D3 expression and S-phase fraction were independently related to Duke's stage. In Duke's stage C tumors, a higher proportion of cells expressed cyclin D3 (14.4 vs. 8.8%, mean; p < 0.05 by Mann-Whitney U test) and were in DNA synthesis (S) phase (21.1 vs. 9.7%, mean; p < 0.05 by Mann-Whitney U test). Neoplastic deregulation of cyclin D3 expression may provide a selective growth advantage which is related to stage in human colorectal cancer.

Colonic epithelial cell proliferation in hereditary non-polyposis colorectal cancer.

BACKGROUND: Despite the recent discovery of four genes responsible for up to 90% of all cases of hereditary non-polyposis colorectal cancer (HNPCC), there will still be families in whom predictive testing is not possible. A phenotypic biomarker would therefore be useful. An upwards shift of the proliferative compartment in colonic crypts is reported to be one of the earliest changes in premalignant mucosa. AIMS: To assess the role of crypt cell proliferation as a phenotypic biomarker in HNPCC. PATIENTS: Thirty five patients at 50% risk of carrying the HNPCC gene (21 of whom subsequently underwent predictive testing and hence gene carrier status was known) and 18 controls. METHODS: Crypt cell proliferation was measured at five sites in the colon using two different techniques. Labelling index was determined using the monoclonal antibody MIB1 and whole crypt mitotic index was measured using the microdissection and crypt squash technique. The distribution of proliferating cells within the crypts was also assessed. RESULTS: There were no significant differences in the total labelling index or mean number of mitoses per crypt, nor in the distribution of proliferating cells within the crypt, between the study and control groups at any site. When the 21 patients in whom gene carrier status was known were analysed separately there were no significant differences in the measured indices of proliferation between the HNPCC gene carriers and non-gene carriers. CONCLUSION: Crypt cell proliferation is not a discriminative marker of gene carriage in HNPCC.

Hereditary non-polyposis colorectal cancer.

Hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal dominant condition in which affected individuals develop colorectal cancer or extracolonic cancers, most commonly endometrial, at an early age. Recent advances in molecular genetics have led to the identification and sequencing of four genes thought to be responsible for the majority of cases of hereditary non-polyposis colorectal cancer. A description of the disease along with details of the underlying genetics and pathological features are presented. Current management and screening policies in these pedigrees are not clearly established. This article discusses some of the controversies in the light of predictive testing.

Abnormalities in the contractile properties of colonic smooth muscle in idiopathic slow transit constipation.

BACKGROUND: The underlying pathophysiology of idiopathic slow transit constipation (ISTC) remains unclear. At present, there is little evidence to implicate a smooth muscle myopathy in the aetiology of this condition. This study compared the effect of cisapride on the cholinergic response of colonic muscle strips from patients with this condition with that of control tissue. METHODS: Isometric tension production was recorded from circular smooth muscle strips taken from five patients undergoing colectomy for ISTC in response to cumulative concentrations of carbachol (100 nmol/1-100 mumol/l) alone and in the presence of cisapride 400 nmol/l. Similar dose-response activity was obtained for a control group consisting of six patients undergoing resection for colorectal carcinoma. RESULTS: In the absence of cisapride, smooth muscle from patients with carcinoma exhibited a significantly lower sensitivity to cholinergic stimulation (agonist concentration required to produce half-maximal activation (EC50) 4.83 mumol/l) than that from patients with ISTC (EC50 1.63 mumol/l, P = 0.036), and also a greater maximal frequency of the oscillatory activity associated with the increase in isometric tension (0.070 versus 0.049 Hz, P = 0.035). Cisapride had no effect on the sensitivity to carbachol of the carcinoma tissue but brought about a significant reduction in the sensitivity of smooth muscle from patients with ISTC (EC50 3.24 mumol/l, P = 0.043). CONCLUSION: These findings indicate that colonic smooth muscle from patients with ISTC is hypersensitive to cholinergic stimulation and suggest the existence of a smooth muscle myopathy in this condition.

Clinical impact of colonoscopic screening in first-degree relatives of patients with hereditary non-polyposis colorectal cancer.

Sixty-one asymptomatic individuals with an affected first-degree relative from five large hereditary non-polyposis colorectal cancer (HNPCC) kindreds were screened by colonoscopy. Neoplasms were found in nine (15 per cent) of 61 individuals on the first screen. Five subjects had a single adenoma while two had two adenomas each. There were two patients (3 per cent) with malignant neoplasms: one with a Dukes B adenocarcinoma and one with synchronous Dukes C adenocarcinomas in the caecum and ascending colon. These findings support the hypothesis that adenomas do not occur in large numbers in HNPCC families but, because of the high malignant conversion rate, biennial colonoscopy with removal of polyps seen is recommended.

A regional audit of the investigation and treatment of colorectal and pelvic floor disorders (1984-1991).

The activities of a regional physiology unit established for the investigation of colorectal and pelvic floor physiology in health and disease in a clinically relevant setting has been audited and its evolution described over a period of eight years. Trends in surgical treatment of some of these disorders over the same period have also been documented in the Lothian Region. Although there has been little change in the number of patients investigated annually patterns of investigation appear to change. Sphincter manometry, proctometrography and somatosensory reflex measurements have remained the most frequently performed and useful investigations. Spinal stimulation studies increased transiently because of a collaborative investigation of bowel and bladder function in patients with spinal injuries. A considerable increase in surface EMG tests and dynamic proctography has occurred. These trends are thought to be related to interest in defining evacuation dysfunction of the rectum and related problems of the pelvic floor. Isotope proctography now rivals barium videoproctography; at the same time the use of manometric colonic motility studies has diminished. Anal ultrasonography has replaced sphincter mapping in the last year and is being applied to other aspects of anorectal pathology. The last 4 years have seen the introduction and increasing use of non-surgical therapeutic modalities for the treatment of faecal incontinence and constipation: reflex electronic sphincter stimulation, biofeedback and the use of a prokinetic agent to promote colonic motility. Concomitant changes in the surgery of constipation and reconstructive anorectal procedures have been observed. It is recommended that coloproctology units should have easy access to at least one such investigation laboratory within their catchment area together with appropriate auditing facilities.

Autonomic influences on colorectal motility and pelvic surgery.

The nervous control of the motility of the human distal bowel was investigated by two physiological studies of electrical stimulation of sacral parasympathetic outflow in patients with high spinal injuries and in patients with intractable constipation following pelvic surgery. Identical and reproducible motility responses of the left colon, rectum, and anal sphincters were obtained by sequential electrical stimulation of anterior sacral roots S2, S3, and S4 in patients with spinal injury. S2 stimulation provoked isolated low-pressure colorectal contractions. S3 stimulation initiated frequency-dependent high-pressure colorectal motor activity which appeared peristaltic and was enhanced with repetitive stimuli. S4 stimulation increased colonic and rectal tone. Quantitative responses were maximal at the splenic flexure and rectum. Pelvic floor activity was stimulated in increasing magnitude from S2 to S4. These results of distal bowel motility were achieved by an implanted Brindley stimulator. A newer generation of externally active stimulators are envisaged for the control of lower bowel in fecal incontinence. Women with intractable constipation following hysterectomy had significantly increased rectal volume and compliance together with deficits of rectal sensory function. Following stimulation with Prostigmine (neostigmine) a colorectal motility gradient was paradoxically reversed in the patients following hysterectomy, thus constituting a functional obstruction. Denervation supersensitivity was demonstrable in 2 patients tested with carbachol provocation. These findings suggest dysfunction in the autonomic innervation of the hindgut in some patients following hysterectomy.

Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis.

OBJECTIVE: To evaluate the feasibility and safety of laparoscopic cholecystectomy in severe acute cholecystitis. DESIGN: Analysis of data collected prospectively from a consecutive series of 350 laparoscopic operations. SETTING: Two general surgical units in a teaching hospital. SUBJECTS: 31 patients with a diagnosis of severe acute cholecystitis based on clinical examination, investigation results, and operative findings. INTERVENTIONS: Initial intravenous fluids and broad spectrum antibiotics followed by laparoscopic cholecystectomy within 72 hours of presentation. MAIN OUTCOME MEASURES: Failure to complete the operation laparoscopically, length of postoperative stay in hospital, early postoperative morbidity, interval from operation to full activity, and return to work. RESULTS: Laparoscopic cholecystectomy was attempted in 19 patients with empyema of the gall bladder and 12 who had severe cholecystitis which failed to settle on medical management. A total of 29 operations were successfully completed with two conversions to open surgery. Two minor postoperative complications occurred, and one case of retained common bile duct stones with jaundice was treated by endoscopic retrograde cholangiopancreatography and papillotomy. Median postoperative hospital stay was two days, with return to normal activity in seven days and to work in two weeks. There were no deaths related to the operation. CONCLUSIONS: In the presence of severe acute cholecystitis laparoscopic cholecystectomy is feasible in most patients, with minimal risk of injury to surrounding structures and considerable benefits. It is recommended that laparoscopic cholecystectomy should be attempted in these patients when appropriate surgical skill is available.