Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis.

BACKGROUND: Colonic stenting has failed to show an improvement in mortality rates in comparison with emergency surgery for acute large-bowel obstruction. However, it remains unclear which patients are more likely to benefit from this procedure. OBJECTIVE: The aim of this study is to identify factors that may be predictive of successful outcome of colonic stenting in acute large-bowel obstruction. DESIGN: All patients undergoing colonic stenting for acute large-bowel obstruction between 1999 and 2013 were studied. The demographics and characteristics of the obstructing lesion were analyzed. SETTINGS: This investigation was conducted at a district general hospital. PATIENTS: A total of 126 (76 men; median age, 76 y; range, 42-94 y) with acute large-bowel obstruction were included in the analysis. INTERVENTION: The insertion of a self-expanding metal stent was attempted for each patient to relieve the obstruction. MAIN OUTCOME MEASURES: The primary outcomes measured were technical success in the deployment of the stent, clinical decompression, and perforation rates. RESULTS: Technical deployment of the stent was accomplished in 108 of 126 (86%) patients; however, only 89 (70%) achieved clinical decompression. Successful deployment and clinical decompression was associated with colorectal cancer (p = 0.03), shorter strictures (p = 0.01), and wider angulation distal to the obstruction (p = 0.049). Perforation was associated with longer strictures (p = 0.03). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Colonic stenting in acute large-bowel obstruction is more likely to be successful in shorter, malignant strictures with less angulation distal to the obstruction. Longer benign strictures are less likely to be successful and may be associated with an increased risk of perforation.

The multidisciplinary management of gastrointestinal cancer. Multimodal treatment of rectal cancer.

Greater understanding of the natural history of rectal cancer, and the knowledge that a histologically involved circumferential margin due to inadequate lateral dissection confers a high risk of local recurrence have driven technical advances in surgical technique with meticulous surgical dissection along embryological planes. Significant improvements in local control and overall survival have been seen for patients with resectable rectal cancer. However, even high-quality surgery cannot always achieve a curative resection for locally advanced cancers that extend below the levators, having transgressed the mesorectal fascia. Magnetic resonance imaging is now accepted as a practical method of clinical staging, and can accurately predict pre-operatively the likelihood of achieving a clear circumferential margin. Technological advances in radiation planning and new effective cytotoxic drugs also give scope for dealing with unresectable rectal cancer, and the potential for controlling distant micrometastases. Hence, modern multimodal treatment of rectal cancer attempts to integrate surgery, radiotherapy and chemotherapy, and address the two distinct problems of local recurrence and metastatic disease. Multidisciplinary teams achieve the best results. This paper discusses the surgical management of rectal cancer, the pathology, the principles of imaging, and the lessons learnt from randomized trials of radiotherapy and chemoradiation.

Endoscopic placement of flatus tube using "lasso" technique with snare wire.

A 55-year old man presented with acute sigmoid volvulus. The distal level of obstruction was above the level which could be reached by the rigid sigmoidoscope to allow decompression, and so a flatus tube was "lassoed" onto the side of a flexible endoscope which allowed accurate placement under direct vision. This technique allows accurate placement of catheters, feeding tubes and other devices endoscopically, which cannot be placed through the instrument channel of the endoscope.

Anterior anal sphincter repair: results in a district general hospital.

OBJECTIVE: Previous series have evaluated the overlapping anterior anal sphincter repair, but with short-term follow-up and a wide range of results. We assessed our results of the anterior sphincter repair in patients with faecal incontinence. PATIENTS AND METHODS: This was a retrospective study of 20 patients who underwent an anterior anal sphincter repair between October 1994 and July 1999. In 12 of the patients, a polypropylene mesh was inserted in the repair to act as re-inforcement. Pre-operatively, all patients had an anterior anal sphincter defect diagnosed with endo-anal ultrasound. Clinical evaluation included the patient's assessment of improvement and the Cleveland Clinic Continence Score before and after surgery. Manometric studies were performed pre-operatively and a median time of 11.5 mouths postoperatively. RESULTS: At a median follow-up of 13 months (range, 3-61 months), 16 out of 20 (80%) patients said that surgery had improved their symptoms. There was a significant improvement in the continence score from 14 (range, 4-15) before operation to 7 (range, 0-15) after operation (P < 0.01). There were no significant differences in mean anal sphincter length, mean resting and maximum squeeze anal canal pressures before and after surgery. Similar results were obtained in patients with and without mesh re-inforcement. CONCLUSIONS: In our institution, the overlapping anterior anal sphincter repair is successful in relieving symptoms in patients with faecal incontinence due to an anterior sphincter defect. This improvement, however, is not associated with any significant changes in anorectal manometric parameters.

Lower gastrointestinal adverse effects of NSAIDS: an extreme example of a common problem.

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed throughout the world. Their adverse effects on the upper gastrointestinal (GI) tract are well documented and well known among clinicians and often mitigated against by coprescribing proton pump inhibitors. This case exemplifies the lesser-known lower GI adverse effects of NSAIDS. A 55-year-old patient took a large mixed overdose including more than 11 g of diclofenac. He went onto require subtotal colectomy following widespread perforations of an ulcerated large bowel as a direct result of exposure to a high-dose of NSAIDs. However, the upper GI tract remained relatively unaffected in comparison. This case highlights important lessons from recent literature identifying an increasing incidence of lower GI complications of NSAIDS, the limited protective effect of PPIs on the lower GI tract and the need for clinicians to now consider the integrity of the whole GI tract when prescribing NSAIDS.

Strangulated inguinal hernia presenting as haemoperitoneum.

A 57-year-old man presented with abdominal pain following a collapse, with peritonism in his lower abdomen. He was haemodynamically stable, with haemoglobin of 12.6 g/dl. His significant medical history included open bilateral inguinal hernia repairs. CT demonstrated fluid within the abdominal cavity, and an area of stranding lying medially within the left iliac fossa. Ultra-sound guided fluid aspiration demonstrated frank blood. During admission, the patient noted a recurrence of his left inguinal hernia. Laparotomy revealed haemoperitoneum, and a haematoma arising in the left iliac fossa, walled off by mesentery of the sigmoid colon and adherent omentum. The open repair of the recurrent inguinal hernia identified the sac contents to be similar to the omentum. This association implies the omentum had herniated within the inguinal canal, tore or avulsed, resulting in haemorrhage from the proximal omental blood vessel resulting in haemoperitonism.

An unusual cause of lower gastrointestinal haemorrhage.

A previously unreported cause of lower gastrointestinal haemorrhage in a 63-year-old female patient on clopidogrel for cardiac comorbidities is presented. Endoscopy suggested a small bowel or colonic aetiology but failed to accurately localise the source. The patient became haemodynamically unstable despite conservative management and temporary cessation of clopidogrel. CT angiography demonstrated a pseudoaneurysm arising from the superior rectal artery. Percutaneous embolisation using coils was performed to successfully occlude the pseudoaneurysm, prevent further haemorrhage and avoid emergency colonic resection.

Giant cystic lymphangioma in childhood: a rare differential for the acute abdomen.

Cystic lymphangiomata are rare benign tumours of childhood resulting from an abnormal development of the lymphatic system, most commonly arising in the head and axillary region. We report a case of haemorrhagic intra-abdominal cystic lymphangiomata presenting as an acute abdomen. A 5-year-old girl was admitted with low-grade fever, generalised abdominal pain and elevated inflammatory markers, and a clinical diagnosis of acute appendicitis was made. At operation, two large fluid-filled haemorrhagic cystic lesions were found to occupy most of the abdominal cavity. The lesions were completely excised and histological examination identified them as cystic lymphangiomata. This case report and literature review highlights aspects of the presentation which might have resulted in a preoperative diagnosis, which is seldom achieved.