The first 1000 patients on an internet-based colorectal neoplasia database across private and public medicine in Australia: development of a binational model for the Colorectal Surgical Society of Australia and New Zealand.

BACKGROUND: Collection of multi-institutional data pertaining to the treatment of bowel cancer has been hindered by poor clinician compliance with data entry and the lack of incentive to participate. OBJECTIVE: This study aimed to establish if a novel browser-based model of data collection results in complete data capture. DESIGN: A Web-based data collection interface was custom written, offering automated reporting modules for clinical outcome to participants and an automated reporting system for outstanding data fields, and summary reporting of surgical quality outcomes. The software was combined with a clinical feedback system incorporating fortnightly data review meetings, at the time of clinical multidisciplinary meetings. PATIENTS AND SETTING: Selected were 932 consecutive patients with opt-out consent from 3 hospital sites, including public and private medicine. MAIN OUTCOME MEASURES: The primary outcomes measured were the analysis of data completeness and accuracy and ensuring that the highest-quality data were used for clinical audit of the surgical practices of Australian colorectal surgeons for the purpose of quality assurance. RESULTS: A total of 932 men and women, 22 to 94 years of age, treated for colorectal neoplasia were evaluated. We obtained 100% completion (>27,000 data points) of perioperative data registered by 8 specialist colorectal surgeons and a full-time database manager. CONCLUSIONS: Data completeness and validity are essential for clinical databases to serve the purpose of quality assurance, benchmarking, and research. The results confirm the safety and efficacy of colorectal cancer surgery in both the public and private sector in Australia. The combination of a simple multiuser interface, defined data points, automated result-reporting modules, and data-deficiency reminder module resulted in 100% data compliance in nearly 1000 clinical episodes. The unprecedented success of this model has lead to the Colorectal Surgical Society of Australia and New Zealand adopting this model for data collection for Australia and New Zealand as the binational database.

Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence.

INTRODUCTION: Surgery is the mainstay of treatment of anal fistulas. Low fistulas are often laid open, but higher fistulas present a more difficult problem. Patient choice centres on a compromise between risk of recurrence and risk of impairment of continence. We aimed to determine the efficacy and safety of fistulotomy at a tertiary referral centre, in particular the additional risk of impairment of continence following fistulotomy of the often recurrent, multiply-operated patients seen. METHODS: Patients undergoing surgery under the senior author (RKSP) for an anal fistula during the study period (2005-2006) were identified, and a thorough review of the patients' clinical records was undertaken. Demographic, fistula anatomy, treatment and follow-up data were obtained. RESULTS: Eighty-four patients underwent either fistulotomy (50), insertion of permanent loose (drainage) seton (28) or EUA with or without drainage of abscess. Mean length of follow up was 11 months (SD 14.22). In the fistulotomy group, we found an overall success rate of 93 %. Secondary extensions were associated with failure to achieve cure (P = 0.008). Nine patients (20 %) suffered deterioration in continence after surgery. A longer time to referral was associated with impaired final continence. In the group referred from a surgeon in secondary care, 91 % of patients were cured, and continence impairment (mostly minor) rose from 32 % at referral to 40 % after surgery. CONCLUSIONS: We have shown that it is safe and reasonable to offer fistulotomy to appropriate patients despite previous surgery and within the tertiary setting. By so doing, a very high rate of healing can be achieved in patients who have previously failed. The additional risk of impairment of continence is around one in five, and in the majority will represent only minor incontinence.

Familial adenomatous polyposis: not all masses are desmoids.

Familial adenomatous polyposis (FAP) is a multi-system disease characterised by the development of hundreds to thousands of colorectal adenomas which inevitably progress to carcinoma without treatment. It is commonly associated with extra colonic lesions including osteomas, epidermoid cysts and desmoid tumours. Desmoid tumours are troublesome due to their size and bulk and are a significant cause of morbidity and mortality in FAP. This series highlights three cases in which patients with FAP developed masses thought initially to be manifestations of the condition. Further investigation in fact demonstrated neurofibromatosis type 1 in all three patients. All masses in FAP patients cannot be assumed to be disease related (desmoid, osteoma, epidermoid cyst or carcinoma).

Post-traumatic pelvic extramedullary haemopoetic tissue causing lower urinary tract symptoms.

Extramedullary haemopoiesis (EMH) is the abnormal development and growth of haemopoietic tissue outside the bone marrow. It is usually asymptomatic and occurs in the presence of myelodysplastic syndromes. In this report, we describe the first post-traumatic EMH presenting with lower urinary tract symptoms.

For many high anal fistulas, lay open is still a good option.

BACKGROUND: Optimal treatment for high/complex anal fistulas is uncertain. We have studied one surgeon's results over a ten-year period, concentrating on high fistulas. METHODS: Demographic, fistula anatomy and treatment data were recorded for all patients undergoing surgery for anal fistula. Outcome data were recorded for patients who had been followed up for a minimum of 4 weeks. RESULTS: One hundred and eighty patients were studied. Outcome data were available for 52 low and 84 high fistulas. Fistulotomy was performed for 50 low and 48 high fistulas, with closure rates of 98 and 96%, respectively. There was fistula recurrence in two patients with high fistulas. Symptoms of sphincter disturbance were similar after lay open of low and high fistulas. Treatment of a high fistula by drainage seton had a lower rate of inadvertent passage of flatus but a similar rate of minor soiling compared with fistulotomy. CONCLUSIONS: Lay open of low and high anal fistulas is effective and associated with a similar, predictable rate of minor sphincter disturbance, amounting to a third to one quarter of patients with mild leakage of flatus and mucus. Patients with high fistulas can be cured, but when a surgeon is in doubt, a second opinion at an expert centre should be sought before definitive intervention.