Multicentre study of short-course radiotherapy and transanal endoscopic microsurgery for early rectal cancer.

BACKGROUND: Organ-preserving treatment for early-stage rectal cancer may avoid the substantial perioperative morbidity and functional sequelae associated with total mesorectal excision (TME). The initial results of an organ-preserving approach using preoperative short-course radiotherapy (SCRT) and transanal endoscopic microsurgery (TEMS) are presented. METHODS: Patients with cT1-2N0 rectal cancers staged using high-quality MRI and endorectal ultrasonography received SCRT, with TEMS 8-10 weeks later, at four regional referral centres between 2007 and 2013. Patients were generally considered high risk for TME surgery (a small number refused TME). RESULTS: Following SCRT and TEMS, 60 (97 per cent) of 62 patients had an R0 resection. Histopathological staging identified 20 ypT0 tumours, 23 ypT1, 18 ypT2 and one ypT3. Preoperative uT category was significantly associated with a complete pathological response, which was achieved in 13 of 27 patients with uT0/uT1 disease and in five of 29 with uT2 (P = 0·010). Acute complications affected 19 patients, the majority following TEMS. No fistulas occurred and no stomas were formed. Surveillance detected four intraluminal local recurrences at a median follow-up of 13 months, all in patients with tumours staged as ypT2. Salvage TME achieved R0 resection in three patients and a stent was placed in one patient owing to co-morbidities. CONCLUSION: SCRT with TEMS was effective in the majority of patients considered high risk for (or who refused) TME surgery.

Poor outcome of a defunctioning stoma after pouch construction for ulcerative colitis.

BACKGROUND: Restorative proctocolectomy for ulcerative colitis can have complications necessitating a later defunctioning ileostomy with uncertain outcome. This analysis was undertaken to assess the outcome in patients needing a later defunctioning ileostomy after pouch construction in patients with ulcerative colitis. METHOD: The notes of our series of 154 patients who underwent restorative proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis were reviewed and 28 patients identified who needed a later defunctioning ileostomy to deal with complications. RESULTS: A later defunctioning ileostomy was necessary in 28 patients to deal with the following complications: sepsis in 11 patients (5 pouches failed), fistulas in 7 (5 pouches failed), poor function including ileoanal stenosis in 5 (all 5 failed), postoperative intraabdominal bleeding in 2 (both saved), pouchitis in 2 (1 excised) and small bowel obstruction in 1 (saved). 16 pouches were eventually excised or permanently defunctioned (59%). CONCLUSION: Complications necessitating a later defunctioning stoma after pouch construction carry a poor prognosis, especially when used for ileoanal stenosis and fistulae.

Long-term results of total pelvic floor repair for postobstetric fecal incontinence.

PURPOSE: This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence. METHOD: Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18-78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology. RESULTS: Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome. CONCLUSION: Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.

Pouch salvage. Long-term outcome.

PURPOSE: The aim of this study was to determine the outcome of pouch salvage operations and the factors that may influence successful reconstructions. METHODS: This retrospective review includes data from 198 patients who had undergone restorative proctocolectomy at a single institution during an 11-year period. All patients who had undergone attempted pouch salvage and who still had a pouch in situ were reviewed by both postal questionnaire and at interview in the outpatients clinic. RESULTS: Of 198 patients who underwent restorative proctocolectomy and ileal pouch-anal anastomosis, 27 (13.6 percent) presented with pouch-specific complications requiring pouch salvage. A further five patients requiring pouch salvage were referred from other centers. Of 32 patients who underwent attempted pouch salvage, 16 (50 percent) had a successful outcome, 12 (37.5 percent) had pouch excision, and 3 (9 percent) are still defunctioned. There was one death (3 percent) in this series. Pelvic sepsis was a major cause of pouch failure, being present in 50 percent (8/16) of failed salvage procedures, and accounting for 58 percent (7/12) of pouch excisions. CONCLUSIONS: Salvage surgery for major complications following ileoanal pouch construction is worthwhile in the absence of major pelvic sepsis. Overall success rate is 50 percent, and these results may be acceptable to highly motivated patients.

Pitfalls and outcome in ileo-anal pouch surgery for ulcerative colitis.

We have examined the long-term results of pouch surgery in 154 patients initially thought to have ulcerative colitis. Pouch survival was 81% at 5 years and 72% at 10 years. Chronic sepsis was the commonest factor for pouch failure (P < 0.001). Re-operations were required in 60 patients (39%). Pouch salvage was used in 30 patients and was successful in 16. Function using a 12-point score was good (0-3) in 40%, moderate (4-6) in 31% or poor (> 6) in 29%. Quality-of-life assessment indicated that 81% were satisfied, but anxiety was associated with a poor outcome. Age over 60 years was not associated with impaired function. So far, 21 patients are thought to have Crohn's disease, of whom 5 have small bowel involvement above the pouch, 11 have had their pouch excised or are permanently defunctioned.

Causes of failure and life expectancy of the ileoanal pouch.

180 ileoanal pouches constructed over 10 years and followed for at least 2 years (154 for Inflammatory Bowel Disease (IBD) and 26 for Familial Adenomatous Polyposis (FAP)) were reviewed. 23 pouches have been excised to date, 8 remain defunctioned (pouch failure FAP 7.7%, IBD 18.8%). The reasons for excision were: ischemia (n = 6), pelvic sepsis (n = 5), severe stenosis (n = 3), underlying Crohn's disease (n = 3), poor function (n = 5) and fistula (n = 1). The reasons for defunction were: Crohn's disease (n = 1), pelvic sepsis (n = 5) and ileoanal stenosis (n = 2). The projected overall pouch survival rate (Life table analysis) at 5 years was 81% (confidence interval 74-87%). Beyond 7 years, the figures to calculate survival became unreliable (small numbers). There was a significant association between pouch failure and pelvic sepsis (Fisher's exact test P < 0.0001) and between failure and fistula formation (P < 0.02). Multiple regression analysis showed pelvic sepsis and recurrent pouchitis to be independent factors of pouch failure. Pouch failure can occur many years after initial operation. Long-term follow up is recommended.

Results from pouch salvage.

Over an 11-year period, 17 salvage procedures were performed on a failed ileal pouch-anal anastomosis carried out for ulcerative colitis from a series of 157 patients. Ten pouches were saved, four excised and three defunctioned. Salvage procedures included five operations for fistulas (three of five successful), six reoperations on the ileoanal anastomosis (five of six successful), three new pouches after previous pouch excision (all failed), and three miscellaneous: excision of an efferent limb (successful), pouchpexy for a pouch prolapse (successful) and postanal repair for incontinence (failed). Pouch salvage may be successful in the motivated patient who wishes to avoid a permanent ileostomy.