Incidence and risk factors for secondary failure after acute obstetric sphincter injury repair - an audit of 239 women.

AIM: The rate of secondary failure after obstetric sphincter injury repair is unknown, with the literature reporting rates ranging from 0.1% to 53%. We aimed to perform an audit to identify the rate and risk factors for failure of sphincter repair in a cohort of postpartum women using endoanal ultrasound (EAUS) and manometry, assessing the risk factors and impact of these events. METHOD: Prospective data were collected within a 2 year period from patients who attended the perineal clinic at Eastern Health. Variables of primary repair and presence of postpartum complications were recorded and subsequently analysed. RESULTS: Of 239 patients with obstetric anal sphincter injury (OASI) included, 100 (41.8%) had EUAS evidence of sphincter defects. Only 20% with secondary repair failure were symptomatic with faecal or flatal incontinence at a mean follow-up of 23.4 months postpartum. Patients with secondary repair failure had lower anal resting (p = 0.006) and maximum squeeze pressures compared with patients with intact repairs (p < 0.001). In terms of variables that were investigated, namely location, operator hierarchy, type of repair and material used, none had a statistically significant correlation with secondary repair failure of OASI. Postpartum complications had an overall incidence of 12.7%, and those with any complication were found to have an increased rate of secondary failure of repair (p = 0.157). CONCLUSION: Using EAUS to confirm secondary failure of repair, incidence was 41.4% in this cohort. There were no identifiable modifiable variables that reduced the risk of secondary failure of repair. Further prospective research with increased sample size and longer follow-up periods is required to assess the validity of the findings.

Normal Values and Clinical Use of Bedside Sonographic Assessment of Postoperative Gastric Emptying: A Prospective Cohort Study.

BACKGROUND: GI dysfunction is common after abdominal surgery. However, assessment and diagnosis currently lack objective measurement. OBJECTIVE: The purpose of this study was to evaluate the feasibility and clinical use of bedside sonographic assessment of gastric emptying by measuring the time to complete emptying of a standard volume of ingested water in patients after colorectal surgery. DESIGN: This was a prospective cohort study. SETTINGS: The study was conducted at a single tertiary institution in Sydney. PATIENTS: Healthy volunteers (n = 30) were studied to establish a reference range. Gastric emptying was then measured in patients (n = 39) before and after colorectal surgery. INTERVENTION: Assessment of gastric emptying was performed on days 1 to 4 by measuring antral cross-sectional area every 10 minutes after ingestion of 250 mL of water. MAIN OUTCOME MEASURES: The time to complete emptying of water was used as a surrogate measure of gastric emptying. Information concerning postoperative outcomes, GI symptoms, and recovery was also recorded. RESULTS: The median time to complete emptying of water for healthy volunteers was 20 minutes (range, 10-40 minutes). The study protocol was completed in 30 of 39 patients. The time to complete emptying of water on day 2 had the best discriminatory power to identify patients with ileus (sensitivity, 85.71%; specificity, 82.61%). Gastric emptying was normal in 20 of 30 (67%) patients, with only 1 case of ileus (false negative). These patients had less nausea (p = 0.0003), earlier intake of solid diet (p = 0.001), and shorter hospital stay (p = 0.040) compared with patients with abnormal gastric emptying. LIMITATIONS: Ultrasound is operator dependent with a learning curve. CONCLUSIONS: Bedside sonographic assessment of gastric emptying is feasible and reliable. Assessment of antral contents with a single ultrasound 40 minutes after ingestion of water enables classification of patients into those with normal and abnormal gastric emptying. When performed on postoperative day 2, it has good sensitivity/specificity for discriminating patients with ileus.

Laser hemorrhoidoplasty in the treatment of symptomatic hemorrhoids: a pilot Australian study.

Purpose: Traditional therapeutic approaches to the surgical management of hemorrhoid disease such as hemorrhoidectomies are plagued with severe postoperative pain and protracted recovery. Our pilot study aims to the laser hemorrhoidoplasty (LH) patients with symptomatic hemorrhoid disease that have failed conservative management for the first time in an Australian population. Methods: Thirty patients were prospectively enrolled to undergo LH. Postoperative pain, time to return to function, and quality of life (QoL) were determined through the Hemorrhoid Disease Symptom Score and Short Health Scale adapted for hemorrhoidal disease and compared to a historical group of 43 patients who underwent a Milligan-Morgan hemorrhoidectomy by the same surgeon at 3, 6, and 12 months. Results: The LH group had significantly lower mean predicted pain scores on days 1 and 2 and lower defecation pain scores and lower opioid analgesia use on days 1, 2, 3, and 4. The median time to return to normal function was significantly lower in the LH group (2 days vs. 9 days; P<0.001). Similarly, the median days to return to the workplace was significantly lower in the LH group (6 days vs. 13 days; P=0.007). During long-term follow-up (12 months), hemorrhoid symptoms and all QoL measures were significantly improved, especially among those with grade II to III disease. Conclusion: This pilot study demonstrates low pain scores with this revivified procedure in an Australian population, indicating possible expansion of the therapeutic options available for this common condition. Further head-to-head studies comparing LH to other hemorrhoid therapies are required to further determine the most efficacious therapeutic approach.

Perianal sepsis in neutropaenic patients with haematological malignancies: the role of magnetic resonance imaging and surgery.

BACKGROUND: Perianal sepsis occurs in up to 10% of neutropaenic patients with haematological malignancy and is associated with significant morbidity and mortality. The management of this condition is challenging in neutropaenic patients due to its atypical pathophysiology. The aim of this study is to assess the role of magnetic resonance imaging (MRI) and surgery in neutropaenic patients with perianal sepsis. METHODS: A retrospective chart review was performed on all neutropenic patients with a haematological malignancy who had a diagnosis of perianal sepsis during the inpatient admission between 2008 and 2017. Patient characteristics, symptoms, haematological data, MRI result, surgical intervention, intraoperative findings and outcomes including recurrence and mortality were collected. RESULTS: Nineteen neutropaenic patients with haematological malignancy were treated for perianal sepsis, eight (42%) patients were managed conservatively and 11 (58%) were managed surgically. Nine patients underwent MRI, which identified a collection in 88% of cases despite severe neutropaenia. In patients with a collection identified on MRI prior to surgery, 80% had a drainable collection confirmed intraoperatively. Post-operative complications included two cases of sepsis from a presumed perianal source and one death. A total of 82% of patients experienced symptom resolution after surgery compared to 88% of patients managed conservatively. CONCLUSION: This study has demonstrated that MRI is a useful diagnostic tool in evaluating perianal sepsis in patients with haematological malignancy, even during periods of severe neutropenia. We found that both conservative and surgical management strategies lead to resolution of symptoms.

Colorectal cancer screening in Australia: An update

Background: Colorectal cancer is the second most common cancer in Australia. The National Health and Medical Research Council (NHMRC) has introduced new recommendations for the prevention, early detection and management of colorectal cancer. General practitioners play a key part in the advocacy, risk stratification and implementation of colorectal cancer screening on the basis of a patient's individual risk. Objective: The aim of this paper is to summarise the NHMRC recommendations pertaining to screening so that they may be applied in general practice. Discussion: The recommended strategy for population screening in Australia remains the immunochemical faecal occult blood test, commencing at age 50 years in asymptomatic individuals with no family history of colorectal cancer. This test is to be performed every two years to age 74 years. Individuals with a family history of colorectal cancer will need appropriate risk stratification. Aspirin should now be considered for all patients aged 50­70 years in the prevention of colorectal cancer.

Systematic review of the impact of sacral neuromodulation on clinical symptoms and gastrointestinal physiology.

BACKGROUND: Sacral neuromodulation (SNM) has emerged as a treatment option for faecal incontinence (FI). However, its objective effect on symptoms and anorectal function is inconsistently described. This study aimed to systematically review the impact of SNM on clinical symptoms and gastrointestinal physiology in patients with FI, including factors that may predict treatment outcome. METHODS: An electronic search of MEDLINE (1946-2014)/EMBASE database was performed in accordance with PRISMA guidelines. Articles that reported the relevant outcome measures following SNM were included. Clinical outcomes evaluated included: frequency of FI episodes, FI severity score and success rates. Its impact on anorectal and gastrointestinal physiology was also evaluated. RESULTS: Of 554 citations identified, data were extracted from 81 eligible studies. Meta-analysis of the data was precluded due to lack of a comparison group in most studies. After permanent SNM, 'perfect' continence was noted in 13-88% of patients. Most studies reported a reduction in weekly FI episodes (median difference of the mean -7.0 (range: -24.8 to -2.7)) and Wexner scores (median difference of the mean -9 (-14.9 to -6)). A trend towards improved resting and squeeze anal pressures and a reduction in rectal sensory volumes were noted. Studies failed to identify any consistent impact on other physiological parameters or clinicophysiological factors associated with success. CONCLUSION: SNM improves clinical symptoms and reduces number of incontinence episodes and severity scores in patients with FI, in part by improving anorectal physiological function. However, intervention studies with standardized outcome measures and physiological techniques are required to robustly assess the physiological impact of SNM.

Left paraduodenal hernia causing small bowel obstruction.

A case of small bowel obstruction secondary to a left paraduodenal hernia is illustrated together with its radiological features and intra-operative appearance. Paraduodenal hernias are rare congenital causes of small bowel obstruction, and various approaches to surgical treatment are available including conventional open and minimally invasive laparoscopic techniques. This case presents one possible option for surgical management and briefly reviews the literature for the various surgical techniques and strategies available to the surgeon when faced with a left paraduodenal hernia.

How do patients aged 85 and older fare with abdominal surgery?

OBJECTIVES: To review the outcomes of patients aged 85 and older after abdominal surgery in terms of mortality, morbidity, and change in residential status and to analyze factors predicting such outcomes. DESIGN: Retrospective clinical cohort study. SETTING: A tertiary regional hospital in Victoria, Australia. PARTICIPANTS: One hundred seventy-nine patients aged 85 and older who had abdominal surgery between 1998 and 2008. MEASUREMENTS: Mortality, complications (morbidity), and change in residential status. RESULTS: The patient sample had a mean age of 88.6, a mortality rate of 17.3%, and a morbidity rate of 62.8%. Approximately two-thirds (64%) of all abdominal surgeries were emergency surgeries. Factors predicting mortality included American Society of Anesthesiologists (ASA) score and premorbid residential status. Risk factors predicting severity of complications were ASA score and emergency surgery. Significant factors contributing to change in residential status were ASA score and severity of complications. Age, sex, and number of comorbidities were not significant factors. CONCLUSION: Patients aged 85 and older experienced mortality rates of 17.3% after abdominal surgery. ASA score and premorbid residential status appear to be more important than age in determining risk for abdominal surgery in older persons.