Robotic Assisted En-Bloc Removal of Kidney, Ureter and Bladder Wall for Endometriosis.

STUDY OBJECTIVE: To highlight a case where a nephroureterectomy and partial bladder cystectomy needed to be done due to endometriosis. DESIGN: A video article demonstrating a case study and the surgical management. SETTING: Ureteral endometriosis is a complex form of endometriosis [1]. If left untreated, the ureter can become significantly compressed leading to hydroureter, hydronephrosis and complete loss of kidney function [2]. INTERVENTIONS: This is a case of a 29-year-old patient with pelvic pain and cyclical rectal bleeding. Further investigation showed significant left hydronephrosis and almost complete loss of left kidney function (8% on renogram). MRI revealed endometriosis involving the posterior bladder wall and distal left ureter, a large full-thickness sigmoid nodule and a large left endometrioma. The patient underwent a robotic-assisted left nephroureterectomy, partial cystectomy (bladder), excision of pelvic endometriosis and sigmoid resection. This procedure was performed jointly with the gynecologist, urologist, and colorectal surgeon and the SOSURE technique was employed [3]. The specimen (left kidney, whole length of ureter and bladder wall around ureteric orifice) was removed en-bloc through a small 3cm extension of the umbilical incision. As the distance between the sigmoid nodule and the anal verge was 35cm, which was above the limit of the transanal circular stapler, a limited resection was performed over a discoid excision. The patient made a good recovery postoperatively. CONCLUSION: Ureteral endometriosis is an indolent and aggressive condition which can lead to silent kidney loss. It is essential that hydronephrosis and hydroureter is ruled out in cases with deep endometriosis. Isolated hydronephrosis should also prompt a suspicion for endometriosis.

Therapeutic Antibodies in Cancer Treatment in the UK.

The growing understanding of the molecular mechanisms of carcinogenesis accelerated the development of monoclonal therapeutic antibodies to specifically target multiple cancer pathways. Recombinant protein therapeutics now constitute a large proportion of yearly approved medicines. Oncology, autoimmune diseases and to a smaller degree the prophylaxis of organ transplant rejection are their main application areas. As of the date of this review, 37 monoclonal antibody products are approved for use in cancer treatments in the United Kingdom. Currently, the antibody therapeutics market is dominated by monoclonal immunoglobulins (IgGs). New types of recombinant antibody therapeutics developed more recently include bispecific recombinant antibodies and other recombinantly produced functional proteins. This review focuses on the approved therapeutic antibodies used in cancer treatment in the UK today and describes their antigen targets and molecular mechanisms involved. We provide convenient links to the relevant databases and other relevant resources for all antigens and antibodies mentioned. This review provides a comprehensive summary of the different monoclonal antibodies that are currently in clinical use primarily in malignancy, including their function, which is of importance to those in the medical field and allied specialties.

Bottom-Up Approach to the Discovery of Clinically Relevant Biomarker Genes: The Case of Colorectal Cancer.

Traditional approaches to genome-wide marker discovery often follow a common top-down strategy, where a large scale 'omics' investigation is followed by the analysis of functional pathways involved, to narrow down the list of identified putative biomarkers, and to deconvolute gene expression networks, or to obtain an insight into genetic alterations observed in cancer. We set out to investigate whether a reverse approach would allow full or partial reconstruction of the transcriptional programs and biological pathways specific to a given cancer and whether the full or substantially expanded list of putative markers could thus be identified by starting with the partial knowledge of a few disease-specific markers. To this end, we used 10 well-documented differentially expressed markers of colorectal cancer (CRC), analyzed their transcription factor networks and biological pathways, and predicted the existence of 193 new putative markers. Incredibly, the use of a validation marker set of 10 other completely different known CRC markers and the same procedure resulted in a very similar set of 143 predicted markers. Of these, 138 were identical to those found using the training set, confirming our main hypothesis that a much-expanded set of disease markers can be predicted by starting with just a small subset of validated markers. Further to this, we validated the expression of 42 out of 138 top-ranked predicted markers experimentally using qPCR in surgically removed CRC tissues. We showed that 41 out of 42 mRNAs tested have significantly altered levels of mRNA expression in surgically excised CRC tissues. Of the markers tested, 36 have been reported to be associated with aspects of CRC in the past, whilst only limited published evidence exists for another three genes (BCL2, PDGFRB and TSC2), and no published evidence directly linking genes to CRC was found for CCNA1, SHC1 and TGFB3. Whilst we used CRC to test and validate our marker discovery strategy, the reported procedures apply more generally to cancer marker discovery.

Colorectal Cancer Diagnosis: The Obstacles We Face in Determining a Non-Invasive Test and Current Advances in Biomarker Detection.

Globally, colorectal cancer (CRC) is the third most common cancer, with 1.4 million new cases and over 700,000 deaths per annum. Despite being one of the most common cancers, few molecular approaches to detect CRC exist. Carcinoembryonic antigen (CEA) is a known serum biomarker that is used in CRC for monitoring disease recurrence or response to treatment. However, it can also be raised in multiple benign conditions, thus having no value in early detection or screening for CRC. Molecular biomarkers play an ever-increasing role in the diagnosis, prognosis, and outcome prediction of disease, however, only a limited number of biomarkers are available and none are suitable for early detection and screening of CRC. A PCR-based Epi proColon® blood plasma test for the detection of methylated SEPT9 has been approved by the USFDA for CRC screening in the USA, alongside a stool test for methylated DNA from CRC cells. However, these are reserved for patients who decline traditional screening methods. There remains an urgent need for the development of non-invasive molecular biomarkers that are highly specific and sensitive to CRC and that can be used routinely for early detection and screening. A molecular approach to the discovery of CRC biomarkers focuses on the analysis of the transcriptome of cancer cells to identify differentially expressed genes and proteins. A systematic search of the literature yielded over 100 differentially expressed CRC molecular markers, of which the vast majority are overexpressed in CRC. In terms of function, they largely belong to biological pathways involved in cell division, regulation of gene expression, or cell proliferation, to name a few. This review evaluates the current methods used for CRC screening, current availability of biomarkers, and new advances within the field of biomarker detection for screening and early diagnosis of CRC.

The use of the faecal immunochemical test during the COVID-19 pandemic to triage urgent colorectal cancer referrals.

AIM: During the first wave of the COVID-19 pandemic in 2020, elective gastrointestinal endoscopy services were abbreviated for fear of viral transmission. However, urgent suspected colorectal cancer (CRC) referrals continued. Serendipitously, a national study suggested that a new faecal immunochemical test (FIT) might be helpful in triaging patients with colorectal alarm symptoms. METHODS: This was a single centre observational study of patients referred using NG12 criteria between March and August 2020. Patients were triaged to the urgent cancer pathway for FIT ≥ 10 µg/g and investigated using the latest National Health Service England guidance. Demographic data, method of investigations, cancer and polyp detection rates were compared to patients referred in the 6 months prior to the use of FIT as a triage tool. RESULTS: In all, 1192 patients (median age 70) were referred using NG12 guidelines during the pandemic period, compared with 1592 patients (median age 72) in the previous 6 months. CRC detection was similar in both groups (n = 45, 2.8% vs. n = 38, 3.5%; P = 0.248). Two patients with a negative FIT (0.36%) had CRC. Using FIT as a triage tool resulted in a significant reduction in the use of endoscopy (n = 477, 43.6% vs. n = 1186, 74.5%; P > 0.001) with a significant increase in CT scanning (n = 696, 63.6% vs. n = 750, 47.1%; P < 0.001). CONCLUSION: The use of FIT in NG12 patients triaged during the first wave of the COVID-19 pandemic reduced endoscopy but not CT scanning and did not compromise CRC detection rates. It is a safe method that aids in reducing the burden on services greatly. A negative FIT test does not absolutely exclude CRC.

Sacral nerve stimulation versus the magnetic sphincter augmentation device for adult faecal incontinence: the SaFaRI RCT.

BACKGROUND: Preliminary studies using the FENIX™ (Torax Medical, Minneapolis, MN, USA) magnetic sphincter augmentation device suggest that it is safe to use for the treatment of adult faecal incontinence, but efficacy data are limited. OBJECTIVE: To compare FENIX with sacral nerve stimulation for the treatment of adult faecal incontinence in terms of safety, efficacy, quality of life and cost-effectiveness. DESIGN, SETTING AND PARTICIPANTS: Multicentre, parallel-group, unblinded, randomised trial comparing FENIX with sacral nerve stimulation in participants suffering moderate to severe faecal incontinence. INTERVENTIONS: Participants were randomised on an equal basis to either sacral nerve stimulation or FENIX. Follow-up occurred 2 weeks postoperatively and at 6, 12 and 18 months post randomisation. MAIN OUTCOME AND MEASURE: The primary outcome was success, defined as device in use and ≥ 50% improvement in Cleveland Clinic Incontinence Score at 18 months post randomisation. Secondary outcomes included complication rates, quality of life and cost-effectiveness. Between 30 October 2014 and 23 March 2017, 99 participants were randomised across 18 NHS sites (50 participants to FENIX vs. 49 participants to sacral nerve stimulation). The median time from randomisation to FENIX implantation was 57.0 days (range 4.0-416.0 days), and the median time from randomisation to permanent sacral nerve stimulation was 371.0 days (range 86.0-918.0 days). A total of 45 out of 50 participants underwent FENIX implantation and 29 out of 49 participants continued to permanent sacral nerve stimulation. The following results are reported, excluding participants for whom the corresponding outcome was not evaluable. Overall, there was success for 10 out of 80 (12.5%) participants, with no statistically significant difference between the two groups [FENIX 6/41 (14.6%) participants vs. sacral nerve stimulation 4/39 (10.3%) participants]. At least one postoperative complication was experienced by 33 out of 45 (73.3%) participants in the FENIX group and 9 out of 40 (22.5%) participants in the sacral nerve stimulation group. A total of 15 out of 50 (30%) participants in the FENIX group ultimately had to have their device explanted. Slightly higher costs and quality-adjusted life-years (incremental = £305.50 and 0.005, respectively) were observed in the FENIX group than in the sacral nerve stimulation group. This was reversed over the lifetime horizon (incremental = -£1306 and -0.23 for costs and quality-adjusted life-years, respectively), when sacral nerve stimulation was the optimal option (net monetary benefit = -£3283), with only a 45% chance of FENIX being cost-effective. LIMITATIONS: The SaFaRI study was terminated in 2017, having recruited 99 participants of the target sample size of 350 participants. The study is, therefore, substantially underpowered to detect differences between the treatment groups, with significant uncertainty in the cost-effectiveness analysis. CONCLUSIONS: The SaFaRI study revealed inefficiencies in the treatment pathways for faecal incontinence, particularly for sacral nerve stimulation. The success of both FENIX and sacral nerve stimulation was much lower than previously reported, with high postoperative morbidity in the FENIX group. FUTURE WORK: Further research is needed to clarify the treatment pathways for sacral nerve stimulation and to determine its true clinical and cost-effectiveness. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16077538. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 18. See the NIHR Journals Library website for further project information.

Faecal incontinence is a distressing condition for patients, and surgery is recommended if symptoms are having an effect on quality of life. One of the treatments recommended for faecal incontinence by the National Institute for Health and Care Excellence is sacral nerve stimulation, which aims to improve continence by stimulating the nerves to the back passage. A newer treatment involves surgery to implant a string of magnetic beads around the anal canal using the FENIX™ device (Torax Medical, Minneapolis, MN, USA). The aim of this study was to assess the benefits and risks of the FENIX device compared with sacral nerve stimulation. The SaFaRI study aimed to recruit 350 participants with faecal incontinence, but was stopped early because of the manufacturer withdrawing the FENIX device for strategic reasons. In total, we recruited 99 participants. Fifty participants were allocated to receive the FENIX device and 49 participants were allocated to receive sacral nerve stimulation. The observed success rates with both devices were low: at 18 months following their entry into the study, 6 out of 41 (14.6%) participants in the FENIX group and 4 out of 39 (10.3%) participants in the sacral nerve stimulation group had the device both in use and producing a benefit. A total of 5 out of 50 (10.0%) participants allocated to receive the FENIX device did not have a device implanted, and 15 out of 45 (33.3%) participants who did have the FENIX device implanted needed to have it removed because of complications during the 18-month follow-up period. A total of 21 out of 49 (42.9%) participants allocated to receive sacral nerve stimulation did not have a permanent sacral nerve stimulation device implanted, and 0 of the 28 who did have a permanent sacral nerve stimulation device implanted needed to have it removed during the 18-month follow-up period. The costs associated with the FENIX device were higher because of a greater number of participants experiencing complications, meaning that the FENIX device is unlikely to be cost-effective in the treatment of faecal incontinence compared with sacral nerve stimulation.

Perineal wound healing following ileoanal pouch excision.

INTRODUCTION: There is paucity of information relating to perineal wound healing when pouch failure after ileal pouch anal anastomosis necessitates pouch excision (PE). The aim of this study is to evaluate perineal healing and factors associated with the development of persistent perineal sinus (PPS) after PE. METHODS: Perineal wound-related outcomes for patients who underwent PE from 1985-2009 were evaluated by type of closure (extrasphincteric, intersphincteric, and sphincter-preserving (SP)) and other factors (presence of Crohn's disease (CD) and/or perineal fistulae). Primary outcomes were PPS and delayed healing (healing after PPS development). RESULTS: One hundred ten patients (CD 48 %) underwent PE. PPS occurred in 39.8 % patients, 51 % had delayed perineal healing with further procedures, with an overall healing rate of 80.7 %. Closure technique was not associated with PPS (p = 0.37) or eventual healing (p = 0.94). For CD patients, risk of PPS (41 vs. 39 %, p = 0.83) and delayed healing (44 vs. 59 %, p = 0.61) was similar to non-CD patients, but uncomplicated healing took longer (p = 0.04). Four of 15 (26.7 %) patients who underwent SP closure developed PPS; all eventually healed with secondary sphincter excision. CONCLUSIONS: Perineal healing may be prolonged after pouch excision. Since eventual healing can be achieved in most patients, perineal dissection and closure can be tailored to the individual circumstance. Sphincter preservation may be used in non-CD patients if future reconstruction is possible. Extrasphincteric closure is preferable with cancer or perineal sepsis. Sphincter resection allows for complete healing in patients who undergo SP dissection and develop PPS.

Risk and location of cancer in patients with preoperative colitis-associated dysplasia undergoing proctocolectomy.

OBJECTIVE: To evaluate the influence of preoperative dysplasia grade, appearance, and site on risk and location of cancer in patients with colitis. BACKGROUND: The ability to predict the presence and location of cancer in colitis patients with dysplasia is essential to facilitate recommendations regarding the necessity and type of surgery. METHODS: Ulcerative and indeterminate colitis patients who underwent proctocolectomy for dysplasia were retrospectively selected. Patient characteristics and findings at colonoscopic surveillance were associated with findings on the surgical specimen by regression analysis. RESULTS: From 1984 to 2007, 348 proctocolectomy specimens with preoperative dysplasia showed cancer in 51 (15%) and dysplasia in 172 (49%) cases. Patients with preoperative high-grade dysplasia (HGD) had cancer in 29% compared with 3% in low-grade dysplasia (LGD) (P < 0.001). Patients with preoperative dysplasia-associated lesion/mass (DALM) had cancer in 25% compared with 8% in flat dysplasia (P < 0.001). In LGD with DALM, the risk of cancer was not significantly higher than in flat LGD (7% vs 2%, P = 0.3), but risk of cancer or HGD was higher with a threefold increase (29% vs 9%, P = 0.015). On multivariate analysis, HGD, DALM, and disease duration were independent risk factors for postoperative cancer. In patients with isolated colonic dysplasia above the sigmoid level, postoperative rectal involvement was limited. CONCLUSIONS: Risk of cancer for patients with HGD or DALM is substantial. Despite low risk of cancer in patients with flat LGD, threshold for surgery should be low given the high prevalence of postoperative pathologic findings. Only in selected cases, colonoscopic surveillance after discussion of associated risks may be acceptable, provided high patient compliance can be assured. Surgery should be considered in all other cases, because it is the only modality that can eliminate the risk of cancer. The location of preoperative dysplasia may allow for the clarification of the need for proctectomy especially in the poor risk surgical patient.

Dysplasia associated with Crohn's colitis: segmental colectomy or more extended resection?

BACKGROUND AND OBJECTIVE: There is limited data on the appropriate management of dysplasia in Crohn's colitis. An evidence-based surgical strategy is provided. METHODS: Patients with a pathologic diagnosis of dysplasia in Crohn's colitis from 1987 to 2009 were identified. Patients were classified by dysplasia grade (low grade or LGD, high grade or HGD). Clinical, endoscopic, operative, and pathologic data were retrieved. Factors associated with a final cancer diagnosis were analyzed. Survival data on patients undergoing limited versus radical resection for cancer and HGD was compared. RESULTS: From 1987 to 2009, 50 patients underwent a colectomy for Crohn's colitis-associated dysplasia. The predictive value of HGD for a final HGD or cancer diagnosis was 73%. The predictive value of LGD on biopsy for HGD in the colectomy was 36%. Sixteen patients (44%) who underwent a total proctocolectomy (TPC) or subtotal colectomy (STC) had multifocal dysplasia. Four of 10 (40%) cancer patients had evidence of dysplasia remote from cancer site on pathologic examination. During follow-up, there were 3 cancer-related deaths. One patient died of metachronous cancer after STC. CONCLUSIONS: The findings confirm the risk of cancer in patients with CD dysplasia. Because of the multifocal nature of dysplasia in Crohn's colitis, TPC is recommended in good-risk patients. In specific circumstances, such as poor-risk patients especially in the setting of LGD, close endoscopic surveillance or alternatively segmental or STC with close postoperative endoscopic surveillance, depending upon the individual circumstance, may be discussed.

Influence of neoadjuvant radiotherapy on anastomotic leak after restorative resection for rectal cancer.

PURPOSE: This study was undertaken to determine whether neoadjuvant radiotherapy is associated with an increased risk of anastomotic leak for rectal cancer patients undergoing restorative resection. METHODS: From 1980 to 2010, patients who underwent restorative resection for rectal cancer (tumors within 15 cm of anal verge) were identified from a prospective institutional database and grouped based on whether they received neoadjuvant radiotherapy (+RT) or not (-RT). The main outcome was anastomotic leak documented by imaging (contrast leak), intra-operative or clinical (signs of peritonitis) findings and confirmed by staff surgeon assessment. Using multivariate (MV) analysis risk factors for leak were identified, presented as OR (95 % CI). RESULTS: One thousand eight hundred sixty-two patients were included in the analysis, 28 % in the +RT group. Eighty-six percent of +RT patients received neoadjuvant chemoradiotherapy. The overall leak rate was 6.3 %, with no significant difference in +RT and -RT groups (8 % vs 5.7 %, p = 0.06). The +RT group had a lower mean age at surgery (58 vs 63 year, p < 0.001), more male (75 % vs 62 %, p < 0.001) and more ASA 3/4 (44 % vs 35 %, p < 0.001) patients, greater use of defunctioning ostomy (87 % vs 44 %, p < 0.001) and colo-anal anastomosis (77 % vs 34 %, p < 0.001). Mean tumor distance from the anal verge was lower in +RT group (6.6 vs 9.7 cm, p < 0.001). On MV analysis, male sex (OR 1.64 (1.03-2.62), p = 0.038), ASA 4 (OR 4.70 (2.07-10.7), p < 0.001), tumor distance from anal verge ≤ 5 cm (OR 2.49 (1.37-4.52), p = 0.003), and tumor size at surgery ≥ 4 cm (OR 1.75 (1.15-2.65), p = 0.009) were independently associated with leak. +RT was not independently associated with leak (OR 1.44 (0.85-2.46), p = 0.18), while defunctioning ostomy did not reduce leak occurrence (OR 0.75 (0.44-1.28), p = 0.29). CONCLUSIONS: The findings suggest that neoadjuvant radiotherapy is not independently associated with an anastomotic leak for rectal cancer patients undergoing restorative resection and support a selective policy towards the use of a defunctioning ostomy on a case by case basis based on intra-operative judgment and consideration of tumor location, size, and patient characteristics.

Preoperative hypoalbuminemia is associated with adverse outcomes after ileoanal pouch surgery.

BACKGROUND: This study examines the association between preoperative albumin and ileoanal pouch (IPAA) outcomes and the utility of serum albumin in the decision to perform a staged IPAA with an initial subtotal colectomy. METHODS: From 2001-2009, patients were identified from an institutional pouch database and albumin values were extracted from the clinic data repository. Hypoalbuminemic (albumin <3.5 g/dL) patients were compared with patients with normal albumin. The primary outcome was pouch failure. Secondary outcomes were anastomotic leak, length of stay, function, and quality of life after pouch surgery. RESULTS: Out of 405 patients, 34 were hypoalbuminemic pre-IPAA. Pre-IPAA hypoalbuminemia was associated with pouch failure (P = 0.004). Pre-IPAA hypoalbuminemia was an independent predictor of anastomotic leak (P = 0.017). Pre-IPAA hypoalbuminemia was an independent predictor of prolonged length of stay (LOS) (P < 0.001). Hypoalbuminemic patients who underwent index total proctocolectomy (TPC) with IPAA vs. subtotal colectomy (STC) and delayed IPAA had increased perioperative transfusion (P = 0.03) and median LOS at IPAA (P = 0.002). CONCLUSIONS: Preoperative serum albumin is an easily available, inexpensive marker in risk stratifying patients undergoing ileoanal pouch surgery. Serum albumin may provide an objective indicator in supporting the decision to undertake a subtotal colectomy as a first step rather than total proctocolectomy with immediate pouch creation.

Is adjuvant chemotherapy really needed after curative surgery for rectal cancer patients who are node-negative after neoadjuvant chemoradiotherapy?

PURPOSE: Adjuvant chemotherapy is currently offered, as standard, after curative resection for patients with rectal cancer who receive neoadjuvant chemoradiation (NCRT). We postulate that adjuvant chemotherapy adds minimal oncologic benefit for patients who undergo total mesorectal excision who are node-negative after neoadjuvant chemoradiation. METHODS: From a prospective, institutional cancer database, rectal cancer patients who completed neoadjuvant chemoradiation and curative surgery (2000-2008) and were node-negative on final pathology were identified. Patient, tumor, treatment characteristics, and oncologic outcomes were compared for patients who completed intended adjuvant chemotherapy (group chemo) or did not receive any chemotherapy (group no-chemo). RESULTS: Chemo (n=58) and no-chemo (n=70) patients had similar age (P=0.13), gender (P=0.67), body mass index (P=0.46), American Society of Anesthesiologists class (P=0.67), preoperative tumor stage (P=0.16), type of surgery (P=0.76), and postoperative complications. The no-chemo group had greater complete pathologic response (n=34, 48.6% vs. n=14, 24.1%). After prolonged follow-up, local recurrence (P=1), disease-free survival (P=0.41), and overall survival (P=0.52) were similar. Oncologic benefits of adjuvant chemotherapy were especially questionable for patients with complete pathologic response (chemo vs. no-chemo, local recurrence at 5 years: 0 vs. 2.9%, P>0.99), disease-free (79.1% vs. 88%, P=0.51), and overall survival (90.9% vs. 95.2%, P=0.41). CONCLUSIONS: These results question the routine use of adjuvant chemotherapy for patients with rectal cancer who undergo curative surgery who have been rendered node-negative by neoadjuvant chemoradiation.

Key attributes of a modern surgical trainer: perspectives from consultants and trainees in the United kingdom.

OBJECTIVE: This study identifies key attributes of a modern surgical trainer as defined by individual trainees and consultant training faculty members. DESIGN: Using a collaborative inquiry process, we conducted focus groups and semistructured interviews with 32 trainees and 10 consultant trainers in general surgery. This study was undertaken in a single postgraduate deanery in the United Kingdom. Key trainer attributes were identified and categorized into themes. RESULTS: Key attributes identified by core trainees (CTs) were enthusiasm, giving feedback, setting targets, completing online assessments, and inspiring trainees. From specialty trainees (STs), key attributes were leading in difficult situations, patience, ensuring trainees perform cases, inspiring trainees, and being a role model. Key attributes from consultants were engaging other trainers, awareness of individual needs, ensuring trainees perform cases, discussing problems sympathetically, and patience. Effective communication was the principal trainer theme for CTs and STs identified the principal theme of leadership. These themes were emphasized also by trainers. CONCLUSIONS: Trainees and trainers have different beliefs on the attributes a good surgical trainer should possess. These findings may be used to promote understanding between trainees and trainers of the expectations and difficulties faced by surgical consultants.

The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn's colitis.

OBJECTIVE: This study evaluates surgical procedures for Crohn's colitis. The risk of recurrence and how it interacts with future avoidance of permanent stoma and quality of life (QoL) is studied. BACKGROUND: Segmental and subtotal colectomy are widely used surgical options in isolated Crohn's colitis. It is not clear which procedure offers the best outcomes. METHODS: Patients undergoing index resection for isolated colonic Crohn's disease (CD) from 1995 to 2009, were identified from a prospectively maintained CD database. Patients were categorized into subtotal colectomy or segmental groups. Demographics, disease characteristics, operative details, morbidity, stoma formation, recurrence requiring surgery and QoL data were extracted. Recurrence and stoma free survival was calculated for each group and independent risk factors for recurrence and stoma formation identified. RESULTS: One hundred and eight patients (49 segmental, 59 subtotal) underwent primary colectomy with anastomosis. Segmental colectomy patients had significantly reduced recurrence free survival (P = 0.032) but not stoma free survival P = 0.62 on univariate analysis. On multivariate analysis, the presence of perianal sepsis (P = 0.032) and >1 medical comorbidity (P = 0.01), but not segmental colectomy, were associated with reduced SFS. There was no difference in Cleveland Global Quality of Life (P = 0.88), or Short Form Inflammatory Bowel Disease Questionnaire scores between groups (P = 0.92). CONCLUSIONS: Using a strictly defined cohort of patients, we were unable to identify segmental resection as an independent risk factor for recurrence or stoma formation and no reduction in QoL scores to suggest an adverse effect of recurrence was observed. Segmental colectomy affords good function, and our data supports the practice of a conservative approach with anastomosis in anatomically linked CD.

Factors associated with ileoanal pouch failure in patients developing early or late pouch-related fistula.

BACKGROUND: The natural history of a pouch-related fistula in terms of timing of its development and its impact on pouch survival is poorly defined. OBJECTIVE: This study aimed to evaluate factors associated with the time of onset of ileoanal pouch-related fistulas and predictors of pouch failure after the development of fistulas. DESIGN: This study is an evaluation of prospectively collected data from a cohort of patients with pouch-related fistulas. SETTING: Patients were identified from a prospective ileoanal pouch database, with data recorded from 1983 to 2009. PARTICIPANTS: Patients who participated had developed a fistula after ileoanal pouch surgery. Patients were classified according to the time of onset, origin, and target of pouch fistulas into "early" and late" groups. MAIN OUTCOME MEASURE: Ileoanal pouch failure was the main outcome measure. RESULTS: Three hundred six patients (158 early-onset, 148 late-onset) with 373 pouch-related fistulas were identified. The early-onset group had a higher mean body mass index (P = .013) and more patients in this group developed a postoperative leak (P < .001), whereas diagnosis revision to Crohn's disease was more frequent in the late-onset group (P = .018). Overall, pouch failure occurred in 89 (29%) patients. Major abdominal procedures were more common in the early-onset group (18 vs 6%). There was no difference in pouch failure between the early- and late-onset groups (P = .24). On multivariate analysis, a current Crohn's diagnosis (P < .001), major fistula (P = .022), history of colectomy before ileoanal pouch (P = .005), handsewn anastomosis (P = .008), anastomotic leak (P = .012), and body mass index over 30 (P = .018) were independent risk factors for failure. No individual risk factor for failure was separately associated with either early or late fistula groups. CONCLUSIONS: The timing and etiology of pouch fistula appear to be interrelated. There is a temporal association between procedure-related sepsis and early and delayed diagnosis of Crohn's disease and late fistula development. Cause of the fistula and associated factors rather than timing after IPAA is associated with long term pouch retention.

Stapled hemorrhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials.

PURPOSE: This study was designed to determine whether conventional hemorrhoidectomy or stapled hemorrhoidopexy is superior for the management of hemorrhoids. METHODS: A systematic review of all randomized trials comparing conventional hemorrhoidectomy with stapled hemorrhoidopexy was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched using the terms "hemorrhoid*" or "haemorrhoid*" and "stapl*." A list of clinical outcomes was extracted. Meta-analysis was calculated if possible. RESULTS: Fifteen trials recruiting 1,077 patients were included. Follow-up ranged from 6 weeks to 37 months. Qualitative analysis showed that stapled hemorrhoidopexy is less painful compared with hemorrhoidectomy. Stapled hemorrhoidopexy has a shorter inpatient stay (weighted mean difference, -1.02 days; 95 percent confidence interval, -1.47 to -0.57; P = 0.0001), operative time (weighted mean difference, -12.82 minutes; 95 percent confidence interval, -22.61 to -3.04; P = 0.01), and return to normal activity (standardized mean difference, -4.03 days; 95 percent confidence interval, -6.95 to -1.10; P = 0.007). Studies in a day-case setting do not prove that stapled hemorrhoidopexy is more feasible than conventional hemorrhoidectomy. Stapled hemorrhoidopexy has a higher recurrence rate (odds ratio, 3.64; 95 percent confidence interval, 1.40-9.47; P = 0.008) at a minimum follow-up of six months. CONCLUSIONS: Although stapled hemorrhoidopexy is widely used, the data available on long-term outcomes is limited. The variability in case selection and reported end points are difficulties in interpreting results. Stapled hemorrhoidopexy has unique potential complications and is a less effective cure compared with hemorrhoidectomy. With this understanding, it may be offered to patients seeking a less painful alternative to conventional surgery. Hemorrhoidectomy remains the "gold standard" of treatment.

Heterotopic pancreas in the spleen: malignant degeneration to mucinous cystadenocarcinoma.

We report the clinicopathological findings of a patient who presented with a primary splenic cystic tumour arising from heterotopic pancreatic tissue. The pancreas was normal on radiological and intraoperative examination. Histological analysis of the specimen demonstrated a mucinous cystadenocarcinoma with remnants of normal pancreatic tissue within the substance of the spleen. Immunohistochemistry characterized the tumour as being pancreatic in origin with overexpression of p53 protein. Five cases of primary mucinous cystadenocarcinoma of the spleen originating from heterotopic pancreatic tissue have been described; to our knowledge, this is the first case to provide conclusive immunohistochemical evidence to support this proposition.