Thirty years of the Association of Coloproctology of Great Britain and Ireland.

This is a summary of the history of the Association of Coloproctology of Great Britain and Ireland from its inception in the late 1980s to the present day.

Pragmatic lifestyle intervention in patients recovering from colon cancer: a randomized controlled pilot study.

OBJECTIVE: To investigate the feasibility of a pragmatic lifestyle intervention in patients who had recently completed surgery and chemotherapy for colon cancer and to obtain preliminary data of its impact on important health outcomes. DESIGN: A prospective, randomized, controlled pilot trial. SETTING: University rehabilitation facility. PARTICIPANTS: Eighteen (N=18) colon cancer survivors (mean age=69y; range, 52-80y), Dukes stage A to C. INTERVENTIONS: Participants were randomized 6 to 24 months postoperatively to either a 12-week program of combined exercise and dietary advice or standard treatment. MAIN OUTCOME MEASURES: Exercise and dietary behavior, fatigue, health-related quality of life (QOL), aerobic exercise tolerance, functional capacity, muscle strength, and anthropometery were assessed at baseline and immediately after the intervention. RESULTS: Adherences to supervised and independent exercise during the intervention were 90% and 94%, respectively, and there was low attrition (6%). The lifestyle intervention elicited improvements in exercise behavior (P=.068), fatigue (P=.005), aerobic exercise tolerance (P=.010), chair sit-to-stand performance (P=.003), and waist-to-hip ratio (P=.002). A positive change in dietary fiber intake (P=.044) was also observed in the intervention group. No change in QOL was observed (P=.795). CONCLUSIONS: These preliminary results suggest that a pragmatic lifestyle intervention implemented 6 to 24 months after primary treatment for colon cancer was feasible. We observed a significant impact on dietary behavior, fatigue, aerobic exercise tolerance, functional capacity, and waist-to-hip ratio. These findings need to be confirmed with a larger-scale definitive randomized controlled trial.

A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon).

BACKGROUND: No standardized approach is available for the management of complicated appendicitis defined as appendiceal abscess and phlegmon. This study used meta-analytic techniques to compare conservative treatment versus acute appendectomy. METHODS: Comparative studies were identified by a literature search. The end points evaluated were overall complications, need for reoperation, duration of hospital stay, and duration of intravenous antibiotics. Heterogeneity was assessed and a sensitivity analysis was performed to account for bias in patient selection. RESULTS: Seventeen studies (16 nonrandomized retrospective and 1 nonrandomized prospective) reported on 1,572 patients: 847 patients received conservative treatment and 725 had acute appendectomy. Conservative treatment was associated with significantly less overall complications, wound infections, abdominal/pelvic abscesses, ileus/bowel obstructions, and reoperations. No significant difference was found in the duration of first hospitalization, the overall duration of hospital stay, and the duration of intravenous antibiotics. Overall complications remained significantly less in the conservative treatment group during sensitivity analysis of studies including only pediatric patients, high-quality studies, more recent studies, and studies with a larger group of patients. CONCLUSION: The conservative management of complicated appendicitis is associated with a decrease in complication and reoperation rate compared with acute appendectomy, and it has a similar duration of hospital stay. Because of significant heterogeneity between studies, additional studies should be undertaken to confirm these findings.

Nicorandil-induced terminal ileal ulceration--a probable link.

Nicorandil, a commonly prescribed anti-anginal agent, has been reported to be associated with ulceration in various parts of the gastrointestinal tract. A 68-year-old general practitioner presented with severe rectal bleeding and abdominal pain associated with terminal ileal ulceration diagnosed by colonoscopy. Capsule endoscopy revealed no other source of bleeding and CT was normal. Diclofenac and/or aspirin were assumed to be causative factors and discontinued. Aspirin was temporarily resumed then discontinued after a second massive, but self-limiting, haemorrhage and persistent abdominal pain. Repeat colonoscopy 5 weeks later confirmed that the previously documented terminal ileal ulceration had worsened. Histopathology was consistent with localised mucosal ischaemia. Nicorandil was withdrawn, after which no further episode of bleeding occurred and his pain settled. Repeat colonoscopy 3 months later confirmed complete healing. This report implicates nicorandil as a cause of terminal ileal ulceration leading to life-threatening rectal bleeding and abdominal pain.

PNET/Ewing's sarcoma of the rectum: a case report and review of the literature.

A 34-year-old female presented with anorectal pain and rectal bleeding due to an extensive rectal tumour. A trephine loop ileostomy was fashioned and biopsies were initially reported to show a poorly differentiated cloacogenic carcinoma. CT revealed numerous liver metastases. A histological review and immunohistochemical studies subsequently favoured a primitive neuroectodermal tumour (PNET). Stem-cell supported chemoradiotherapy resulted in complete resolution of her primary tumour and liver metastases. Serial CT scanning and endoscopy revealed no recurrence after 7 years of follow-up, when she presented with a malignant anal fissure. Imaging and subsequently abdominoperineal resection revealed no evidence of metastases from either the anal cancer or the PNET tumour. Histopathology showed a T1N0R0 basaloid squamous carcinoma originating from grade III squamous intraepithelial neoplasia with no obvious wart viral infection.

Infected midurethral tape presenting as an ischiorectal abscess.

This is the first reported case of an ischiorectal abscess after a midurethral intravaginal slingplasty (IVS). The patient presented with recurrent ischiorectal abscess which was initially thought to be an unusual presentation of a fistula in ano. Subsequent examination under anaesthesia, however, revealed a fistulous tract extending from the right postero-lateral perianal opening to the vagina where the tape was noted to be eroded and infected. The abscess healed only after removal of the source of infection i.e. the IVS tape. In this report, we also discuss the two main types of meshes used as midurethral slings, the ways in which they differ and the arguments for and against using them.

The long-term efficacy of fissurectomy and botulinum toxin injection for chronic anal fissure in females.

INTRODUCTION: Healing rates for botulinum toxin injection for anal fissure may be improved if combined with fissurectomy. This procedure has a decreased risk of incontinence, which is particularly important in females. We investigated the long-term efficacy of fissurectomy and botulinum toxin injection for chronic resistant fissures in females. METHODS: Female patients who consented underwent excision of the fissure edges and injection of 25-100 units of botulinum into the intersphincteric space. Patients were followed up 2 months after the procedure and over a period of up to 39 months. RESULTS: Forty-six patients (mean age, 42 years) were recruited. No patient had incontinence symptoms preoperatively. At a median follow-up period of 11 months, there was a cure rate of 85 percent in 44 patients. After a median follow-up of 22 months, 12 more patients were lost to follow-up. Of the remaining patients, 16 (50 percent) suffered recurrence during the follow-up period. Five patients required further surgical intervention. Three patients suffered chronic perianal infection requiring antibiotic treatment or surgery. There was one case of incontinence at final assessment: the patient complained of urge incontinence, which has persisted for more than 18 months. CONCLUSIONS: Fissurectomy and botulinum toxin injection for the treatment of chronic anal fissure in females seems to be effective in the medium-term but there is a high rate of late recurrence. However, only a minority of patients proceed to more invasive surgical intervention, which may make it a useful option in patients not suitable for lateral sphincterotomy.

Intermittent torsion of a megapouch: report of a case.

We report an unusual presentation of pouch dysfunction because of excessive pouch enlargement or "mega pouch" and probable torsion. The patient presented with abdominal pain that was positional. Contrast-enhanced computerized tomography showed pouch anastomotic staples extending into the right upper quadrant. At operation, gross pouch enlargement with dilation of the afferent ileum was confirmed. Reduction pouch-plasty resulted in pain resolution and maintenance of satisfactory function.

Anaerobic meningitis secondary to a rectothecal fistula arising from an anterior sacral meningocele: report of a case and review of the literature.

An anterior sacral meningocele is a diverticulum of the thecal sac protruding anteriorly from the sacral spinal canal into the extraperitoneal presacral space. It is a rare congenital anomaly comprising of a thin wall of fibrous connective tissue, and containing cerebrospinal fluid and, occasionally, adjacent nerve fibers. We report an unusual case of a 48-year-old male who presented with meningitis secondary to a rectothecal fistula arising from an anterior sacral meningocele.

Nicorandil and idiopathic anal ulceration.

PURPOSE: Several reports have implicated nicorandil as a reversible cause of anal ulceration. We have recently commenced a specialist clinic for patients presenting with severe anal ulceration to assess treatment in this difficult group. Recognition of this association may avoid unnecessary surgery. METHODS: Twenty-six patients treated with nicorandil had severe painful anal ulceration. Examination under anesthesia was required to biopsy the lesions to exclude neoplasia or inflammatory bowel disease. In total, three patients had proximal diverting stomas without subsequent ulcer resolution, two had perineal debridement with one requiring subsequent skin grafting, and one had an abdominoperineal excision for unremitting pain. RESULTS: The association of perianal ulceration with nicorandil became apparent only in the latter part of this series. Ten ulcers successfully re-epithelialized when nicorandil was stopped. Nine patients reported anal pain relief and partial healing on clinical examination at two months but failed to show subsequent complete resolution. One patient agreed to nicorandil cessation and reported symptomatic anal pain relief at two weeks but subsequently developed unstable angina requiring hospital admission. Nicorandil was recommenced with anal pain relapse. CONCLUSIONS: Failure to recognize nicorandil as an etiologic factor in the development of anal ulceration, when other potential underlying well-recognized inflammatory or neoplastic processes have been excluded, may lead to unnecessary surgical intervention in a group of high-risk patients. One of our patients had a potentially avoidable abdominoperineal resection. Pharmaceutical manipulation with alternative antiangina medication may induce healing. Pharmacologic manipulation should be coordinated with a physician to minimize precipitation of unstable angina.

A prospective clinicopathological and endoscopic evaluation of flat and depressed colorectal lesions in the United Kingdom.

OBJECTIVES: Flat and depressed colorectal lesions are now reported in Western populations. The malignant potential, anatomical distribution, and other clinicopathological features have not been established in this group. This study aimed to assess prospectively the prevalence, clinicopathological, and endoscopic features of flat and depressed colorectal lesions in the United Kingdom. METHODS: A single endoscopist performed colonoscopy on 850 consecutive patients presenting for routine colonoscopy. All endoscopies were performed using a high magnification colonoscope with chromoscopy to facilitate detection of flat and depressed colorectal lesions. RESULTS: A total of 458 flat lesions were identified. Of these, 173 (38%) were hyperplastic and 285 (62%) adenomatous or beyond. Of the 173 hyperplastic flat lesions, 162 (94%) were located in the recto-sigmoid region. Of the 267 adenomas, 66 (25%) had areas of high grade dysplasia (HGD), with 54/66 (82%) being present in the right colon. Flat lesions <8 mm in diameter was more likely to contain HGD than those <8 mm (p<0.001). Nine of the 10 (90%) flat invasive adenoacarcinomas were in the right colon and all had a depressed morphological component. In contrast, HGD was observed in 58/466 (12%) of protuberant (sessile/pedunculated) adenomas of which 95% (55/58) were located in the left colon. In addition, HGD was present in 17% of all sessile adenomas versus 44.6% of flat lesions >8 mm in diameter (p=0.001). Of the 14 protuberant carcinomas, 13/14 (93%) were in the left colon. Synchronous lesions were found in 96/816 (12%) of cases. Of the 816 patients with two or more left-sided protuberant adenomas <8 mm (with or without HGD), 89 (11%) had one or more flat lesions in the right colon with HGD. CONCLUSIONS: Flat adenomas and carcinomas have a high malignant potential compared to protuberant lesions and have a propensity for developing in the right hemi-colon. Total colonoscopy is required to detect such lesions, as only 18% of flat lesions would be in reach of the flexible sigmoidoscope.