The treatment of anal fistula: second ACPGBI Position Statement - 2018.

It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement.

BACKGROUND: Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE). METHODS: A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations. RESULTS: Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications. CONCLUSION: This position statement updates clinicians on current evidence around perineal closure after APE surgery.

The colorectal surgeon's personality may influence the rectal anastomotic decision.

AIM: Colorectal surgeons regularly make the decision to anastomose, defunction or form an end colostomy when performing rectal surgery. This study aimed to define personality traits of colorectal surgeons and explore any influence of such traits on the decision to perform a rectal anastomosis. METHOD: Fifty attendees of The Association of Coloproctology of Great Britain and Ireland 2016 Conference participated. After written consent, all underwent personality testing: alexithymia (inability to understand emotions), type of thinking process (intuitive versus rational) and personality traits (extraversion, agreeableness, openness, emotional stability, conscientiousness). Questions were answered regarding anastomotic decisions in various clinical scenarios and results analysed to reveal any influence of the surgeon's personality on anastomotic decision. RESULTS: Participants were: male (86%), consultants (84%) and based in England (68%). Alexithymia was low (4%) with 81% displaying intuitive thinking (reflex, fast). Participants scored higher in emotional stability (ability to remain calm) and conscientiousness (organized, methodical) compared with population norms. Personality traits influenced the next anastomotic decision if: surgeons had recently received criticism at a departmental audit meeting; were operating with an anaesthetist that was not their regular one; or there had been no anastomotic leaks in their patients for over 1 year. CONCLUSION: Colorectal surgeons have speciality relevant personalities that potentially influence the important decision to anastomose and could explain the variation in surgical practice across the UK. Future work should explore these findings in other countries and any link of personality traits to patient-related outcomes.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease.

AIM: There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS: Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS: All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION: These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

The effect of acetazolamide on intra-ocular pressure after Trendelenburg positioning - a randomised double-blind crossover trial in volunteers.

Recent evidence suggests Trendelenburg positioning can produce a significant rise in intra-ocular pressure. Peri-operative vision loss in patients undergoing laparoscopic colorectal surgery has been reported with the rise in intra-ocular pressure suggested as a possible factor. Acetazolamide decreases intra-ocular pressure by reducing the formation of aqueous humour, so we aimed to investigate if it could attenuate the intra-ocular pressure rise that can occur in the Trendelenburg position. Nine healthy volunteers were recruited and randomly assigned to a double-blind crossover comparison of placebo or acetazolamide with a minimal 4 days' washout period before the second study day. One and a half hours after taking the medication, volunteers lay head-down at 17° for 4 h. Intraocular pressure measurements were repeated in both eyes every 30 min over a 4-h period. There were two males and seven female volunteers, with a mean (SD) age of 54.3 (18.5) years. The mean (SD) increase in intra-ocular pressure following 4 h in the Trendelenburg position was 3.17 (4.63) mmHg after the placebo, and 0.02 (4.01) mmHg (p = 0.02) after acetazolamide. We have shown than acetazolamide can attenuate the rise that occurs in intra-ocular pressure when in the Trendelenburg position.

The influence of laparoscopy on incisional hernia rates: a retrospective analysis of 1057 colorectal cancer resections.

AIM: The aim of this study was to evaluate the incidence of incisional hernia formation after laparoscopic and open surgery for colorectal cancer. METHOD: A retrospective analysis was conducted of 1057 colorectal cancer resection cases (289 laparoscopic, 768 open) performed in a single national laparoscopic training centre between January 2006 and December 2011. Clinical notes and serial computed tomography scans were reviewed, with any incisional hernia including those at a surgical incision, port site, stoma and stoma closure site identified and the size of the defect measured. RESULTS: The overall incisional hernia rate was 14.8%. There was no significant difference between the open and laparoscopic groups (14.4% vs 15.9%, P = 0.566). Excluding stoma-related hernia, 10.7% of the open group developed a surgical wound hernia, and 11.1% of the laparoscopic group developed a hernia at a port site, extraction site or surgical midline incision. There was no statistical difference between the two groups (P = 0.853). The defects were smaller in the laparoscopic group (P < 0.005). There were significantly more parastomal hernias in the laparoscopic group (40%) than in the open group (12.7%, P < 0.001). CONCLUSION: The incidence of incisional hernia formation was similar after laparoscopic or open surgery for colorectal cancer. Parastomal hernia was more frequent after laparoscopic surgery.

Have changes in colorectal surgery training impacted on mortality in cancer patients? A retrospective cohort study of 51,562 procedures.

INTRODUCTION: The aim of this study was to explore whether there were any differences in consultant colorectal surgeon training and adjusted 90-day postoperative colorectal cancer mortality rates (AMR). METHODS: We undertook a retrospective analysis of outcomes data published on the Association of Coloproctology of Great Britain and Ireland (ACPGBI) website. A total of 51,562 procedures for patients in England diagnosed with large bowel cancer between 2010 and 2015, registered under 551 consultants were included. Consultants were split into two cohorts. The first group were the pre-Calman Trained Consultants (pre-CTr), who completed their training before 1998. The second group-the post-Calman Trained Consultants (post-CTr)-included those who received their Certificate of Completion of Training (CCT) under the Calman Training Principles (CTC, 1998-2007) and the Modernising Medical Careers Curriculum (MMC, 2008 and onwards). The outcome measure was an AMR. RESULTS: The pre-CTr cohort (n=84) consisted of 3.6% female colorectal consultants (n=3/84), whereas the post-CTr cohort (n=467) consisted of 14.3% female colorectal consultants (n=67/467) (p=0.006). In this cross-sectional analysis over 5 years, the average pre-CTr undertook a greater number of colorectal resections than their post-CTr peers: median procedures (interquartile range, IQR): 104 (59) vs 89 (57) respectively, p=0.008. The median AMR was significantly greater among pre-CTrs compared with post-CTrs, median AMR (IQR): 2.7% (2.0) vs 2.1% (2.9), p=0.022. CONCLUSIONS: These data indicate that the implementation of the MMC and Calman training principles for colorectal training is associated with a statistically lower AMR compared with other historical training periods. This merits further exploration.

Use of a gentamicin-impregnated collagen sheet (Collatamp(®) ) following implantation of a sacral nerve stimulator for faecal incontinence.

AIM: Gentamicin-impregnated collagen (Collatamp(®) ) is well described for the prevention of infection in surgery. This technical note describes its intraoperative use as a prophylactic measure to prevent infection following implantation of a sacral nerve stimulator for faecal incontinence. METHOD: Following implantation of the Interstim II Neurostimulator (Medtronic Neuromodulation, 710 Medtronic Parkway, Minneapolis, USA) in a subcutaneous pocket overlying the gluteal muscle, a single sheet of 10cm × 10cm gentamicin-impregnated collagen is placed within the wound covering the implant. The subcutaneous tissue and skin are then closed in separate layers. RESULTS: To date eight patients [median age 46.5 (30-59) years] have received prophylactic cover with gentamicin-impregnated collagen following permanent sacral nerve stimulator implantation. At a median interval of 89.5 (51-128) days, none of these patients developed a wound infection at the site of the neurostimulator implant. CONCLUSION: Gentamicin-impregnated collagen (Collatamp(®) ) used in the implantation of a sacral nerve stimulator may be a useful addition to the technique.

Raised intraocular pressure (IOP) and perioperative visual loss in laparoscopic colorectal surgery: a catastrophe waiting to happen? A systematic review of evidence from other surgical specialities.

BACKGROUND: Case reports of healthy patients experiencing total perioperative visual loss (POVL) after elective laparoscopic surgery, including colorectal resection, are appearing increasingly frequently in the literature. We reviewed the literature exploring the relationship between patient positioning and intraocular pressure (IOP) across all surgical specialties. This was then applied to the potential risk of developing POVL in patients undergoing laparoscopic colorectal surgery. METHODS: A systematic review of the relevant literature was performed to identify all studies exploring the relationship between intraocular pressure and patient positioning. RESULTS: Eight relevant studies on both elective patients and healthy non-anaesthetised volunteers in the spinal, neurosurgical and urological fields were identified which explore the changes in IOP according to patient positioning. These all reported significant rises in IOP in both head-down positioning and prone positioning, and the strongest effects were seen in those patients placed in combined head-down and prone position (such as prone jackknife). Rises in IOP were time-dependent in all studies. CONCLUSIONS: Patients undergoing laparoscopic colorectal surgery in a prolonged head-down position are likely to experience raised IOP and thus are at risk of POVL. Those having a laparoscopic abdominoperineal excision with prone positioning for the perineal component are probably those in the greatest danger. Surgeons need to be aware of this under-recognised but potentially catastrophic complication.

Fresh frozen cadavers: an under-utilized resource in laparoscopic colorectal training in the United Kingdom.

AIM: To describe the use of fresh frozen cadavers in laparoscopic colorectal training. METHOD: The cadavers are washed and frozen to -20°C within a week of procurement before being thawed at room temperature prior to use. RESULTS: Fresh frozen cadavers provide perfect anatomy, normal tissue consistency and a realistic operative training experience. CONCLUSION: Fresh frozen cadavers have a number of clear advantages over other training models in laparoscopic colorectal surgery but are currently not widely used.

Leaving a mark: the frequency and accuracy of tattooing prior to laparoscopic colorectal surgery.

AIM: Intra-operative localization of small cancers and polyps during laparoscopic colorectal surgery is difficult due to reduced tactile feedback. The consequences of failing to identify the lesion for resection can result in open conversion or removal of the wrong segment of bowel. METHOD: Data were collected from a prospectively-kept database over a 12-month period from April 2008 to March 2009 and analysed retrospectively. Details concerning the documentation, visibility and accuracy of tattoos were recorded. RESULTS: Eighty-five patients (88 lesions) underwent laparoscopic resection for a benign or malignant colorectal tumour during 1 year from April 2008. Eighty-one patients underwent endoscopic visualization of the tumour as a first or second procedure. Of these 81 patients, 83 lesions were visualized endoscopically and 54 (65.1%) were tattooed in 52 patients. In the 52 patients, 36 (69%) of the tattoos were carried out on the first endoscopy. At operation the tattoo was judged to be visible and accurate in 70%, visible but inaccurate in 7% and not visible in 15%. It was significantly easier to see the tattoo in women (19/21 women vs 21/29 men; P=0.03) but there was no relationship between tattoo visibility and BMI. An accurate tattoo did not reduce the conversion rate (P=0.71). No tattoo-related complications were encountered. CONCLUSION: The practice of tattooing colorectal cancers is variable in frequency, technique and accuracy. We advocate that all colonic lesions suspicious for cancer should be tattooed during endoscopy at a defined distance below the tumour, adhering to a departmental protocol in case surgery is required.

Fibrin glue for the treatment of fistulae in ano--a method worth sticking to?

OBJECTIVE: The current evidence for fibrin glue as a treatment for anal fistulae is mixed. This study reviews the experience of fibrin glue as a treatment for anal fistulae in a single tertiary referral centre and attempts to identify factors related to failure of therapy and the length of follow-up required. METHOD: Patients with fistulae in ano that were treated with fibrin glue between February 2004 and August 2008 were analysed. All procedures were performed by two colorectal consultants based at the Queens Medical Centre, Nottingham. All patients were followed-up to assess the outcome of this treatment. RESULTS: Forty patients (21 male, 19 female) with a mean age of 46.5 years were studied. The mean duration of symptoms prior to presentation was 39 months (range 4-240 months). Presenting symptoms included perianal discharge (72.5%), perianal abscess (57.5%), pain (12.5%), PR bleeding (7.5%), itching (5%) and urgency (2.5%). Patients had a minimum of two follow-up appointments and the median follow-up period was 5.2 months (range 1-16 months). Following MRI and operative assessment, 28 (70%) of the 40 fistulae were considered complex (high trans-sphincteric, extra-sphincteric, pouch-vaginal). Patients who had inflammatory bowel disease were classified as simple tracts but all failed to heal (three patients). Twenty of the complex fistulae failed to heal. Three patients who had repeat application of glue for their complex fistulae failed to heal on follow-up. Of the remaining 12 patients who had simple fistulae in ano, five (41.7%) healed completely. There were no complications such as abscess, related to treatment. All patients who were asymptomatic at 3 months did not develop any further recurrence. CONCLUSION: Fibrin glue is a simple treatment strategy, preserves sphincter function with minimal adverse side effects. It should therefore be considered as possible first line treatment in simple fistulae but it is less likely to be successful in complex or those fistulae associated with inflammatory bowel disease. Repeat gluing is unlikely to be successful. Fistulae that have failed to heal by 3 months will need further treatment.

Colonic tattooing in laparoscopic surgery - making the mark?

OBJECTIVE: Laparoscopic surgery for colorectal cancer is now widespread. Small lesions in the colon can be difficult to palpate and with lack of tactile sensation, it is essential to accurately localize them preoperatively. This is a review article on current methods of tattooing including the use of different agents and associated complications. Aim To review current techniques in preoperative tumour localization and methods used for colonic tattooing including agents used, dosage and potential complications. METHOD: A literature search (Medline and Pubmed) was performed with manual cross referencing of all articles related to colonic tattooing. RESULTS: Methods for localizing colonic tumours for laparoscopic resection include preoperative barium enema examination, CT colonography and intraoperative colonoscopy. The most effective method is, however, by tattooing with India ink performed endoscopically before surgery. CONCLUSION: India ink is a reliable method of marking tumour location within the colon as prelude to laparoscopic resection. Surgeons must, however, be aware of potential complications associated with this technique.

Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors.

In recent decades wide-ranging changes have occurred in medical school curricula. Time spent studying gross anatomy has declined amidst controversy as to how, what, and when teaching is best delivered. This reduced emphasis has led to concerns amongst clinicians that a new generation of doctors are leaving medical school with insufficient anatomical knowledge. Previous studies have established that medical students value their anatomy teaching during medical school. None have sought to establish views on the sufficiency of this teaching. We investigate the opinions of newly qualified doctors at a UK medical school and relate these opinions to career intentions and academic performance in the setting of a traditional dissection and prosection-based course. Overall nearly half of respondents believe they received insufficient anatomy teaching. A substantial proportion called for the integration of anatomy teaching throughout the medical school course. Trainees intent on pursuing a surgical career were more likely to believe anatomy teaching was insufficient than those pursuing a nonsurgical career; however, overall there was no statistical difference in relation to the mean for any individual career group. This study adds to the current debates in anatomical sciences education, indicating that overall, regardless of career intentions, new doctors perceive the need for greater emphasis on anatomical teaching.

Vaccine-induced apoptosis: a novel clinical trial end point?

The functional end point of immunotherapy is to induce tumor regression. Because immune effector mechanisms usually result in apoptosis, the aim of this study was to determine whether measurement of tumor apoptosis ex vivo is a good end point to evaluate the efficacy of cancer vaccines. A prototype vaccine, 105AD7, was administered to colorectal cancer patients before resection of their primary tumors. There was a significant increase in apoptosis of tumor cells within immunized patients compared with control patients as assessed by immunohistochemistry (P = 0.005; n = 16) or by flow cytometry (P = 0.003; n = 34). Preoperative immunization and measurement of tumor cell apoptosis may be a valuable clinical end point for evaluation of new vaccine and other biological approaches.

A neoadjuvant clinical trial in colorectal cancer patients of the human anti-idiotypic antibody 105AD7, which mimics CD55.

Thirty-five patients received 105AD7 human anti-idiotype vaccination prior to surgery for colorectal carcinoma. Patients were immunized before and also received one to two immunizations after surgical resection of their colorectal cancer. The vaccine was well tolerated with no associated toxicity. Lymphocytic infiltration within the resected tumors was quantified by immunohistochemistry and image analysis. Enhanced infiltration of helper T cells (CD4) and natural killer (NK) cells (CD56) were observed in the tumors from immunized patients when compared with tumors from stage, grade, site, age, and sex matched unimmunized patients. NK activity was increased in the blood, peaking 7-10 days post immunization and then dropping rapidly and correlating with NK extravasation within the tumor. Comparison of the amino acid sequences of 105AD7 anti-idiotype and the antigen it mimics, CD55, has predicted that patients with HLA-DR1, HLA-DR3, and HLA-DR7 haplotypes should show helper T cell responses following 105AD7 vaccination. Eighty-three percent of patients expressing these haplotypes responded to 105AD7, whereas 88% of patients who failed to express these haplotypes were nonresponders. With a median follow-up of 4 years (range, 2.5-6 years) 65% of patients remained disease free. This trial shows that 105AD7 stimulates antitumor inflammatory responses allowing extravasation within tumor deposits of both helper T cells and NK cells. This represents a way of evaluating immune responses in patients both within the blood and at the tumor site. The study confirms that immunization with a human anti-idiotypic antibody results in immune responses in 83% of patients with a permissive haplotype.

Immunotherapy for colorectal cancer.

BACKGROUND: Advances in molecular biology have enabled specific antigens present on colorectal cells to be characterized, against which immune responses may be generated. This, in combination with our inability to significantly alter survival from this condition, has resurrected an interest in immunotherapy as a potential treatment option. DATA SOURCES: The information contained in this review was obtained following a search of MEDLINE and BIDS (Bath Information Data System), using the key words immunotherapy, colorectal cancer, antibody, anti-idiotype, peptide vaccine, viral vector, and vaccine. In addition, journals related to this field were systematically searched. CONCLUSION: A number of approaches currently constitute immunotherapeutic options for colorectal cancer. A number of treatment modalities are already in phase III studies, although clearly not all will fulfill their initial promise. Surgeons need to be aware of the advances in this rapidly expanding field, and keep an open mind as to their efficacy.

Laparoscopic colorectal cancer surgery.

BACKGROUND: A number of controversies exist in the laparoscopic treatment of colorectal cancer, and thus the technique has so far failed to gain widespread acceptance throughout the United Kingdom. This review aims to discuss these issues in the context of ongoing published trials, assessing both purported advantages and disadvantages. METHODS: The United States National Library of Medicine Medline database, and the Bath Information Data Service (BIDS) were searched using keywords related to laparoscopic colorectal cancer surgery. Recent surgical journals were also reviewed for relevant publications. Attempts have been made to quote only the most recent work from institutions with multiple publications using the same group of patients, in order to present the most coherent picture. The data are presented as randomized controlled trials, nonrandomized controlled studies, and series comprising more than 10 patients. CONCLUSIONS: This review confirms that laparoscopic colorectal cancer surgery is technically feasible. In addition patients lose less blood, have less immunosuppression, and have shorter postoperative ileus, in-patient stay, and require less analgesia. However, concerns still remain as to the development of port-site metastases, the longer operating times, and the overall cost of the equipment. In view of these concerns, the place of laparoscopically assisted colorectal cancer surgery is likely to remain controversial for some years yet. Randomized, controlled trials are as yet too few to provide definitive answers to all these issues.