Transanal endoscopic microsurgery for rectal lesions in a specialist regional early rectal cancer centre: the Mersey experience.

AIM: Organ-preserving local excision by transanal endoscopic microsurgery (TEM) for early rectal cancer offers significantly lower morbidity as compared to formal rectal cancer resection with acceptable outcomes. This study presents our 6-year experience of TEM for rectal lesions referred to a specialist early rectal cancer centre in the UK. METHOD: Data were collected for all patients referred for TEM of suspected early rectal cancer to a regional specialist early rectal cancer multidisciplinary team (MDT) over a 6-year period. RESULTS: One hundred and forty-one patients who underwent full-thickness TEM for suspected or confirmed early rectal cancer were included. Thirty patients were referred for TEM following incomplete endoscopic polypectomy. Final pathology was benign in 77 (54.6%) cases and malignant in 64 (45.4%). Of the 61 confirmed adenocarcinomas, TEM resections were pT0 in 17 (27.9%), pT1 in 32 (51.7%), pT2 in 11 (18.0%) and pT3 in 1 (1.6%). Thirty-eight of 61 patients (62.3%) had one or more poor histological prognostic features and these patients were offered further treatment. Twenty-three of 61 (37.7%) patients with rectal adenocarcinoma required no further treatment following TEM. Forty-three cases of rectal adenocarcinoma were available for establishing recurrence rates. Two of 43 patients (4.7%) developed a recurrence at a median follow-up of 28.7 months (12.1-66.5 months). The overall estimated 5-year overall survival rate was 87.9% and the disease-free survival rate was 82.9%. CONCLUSION: Acceptable outcomes are possible for TEM surgery with appropriate patient selection, effective technique, expert histopathology, appropriate referral for adjuvant treatment and meticulous follow-up. This can be achieved through an early rectal cancer MDT in a dedicated specialist regional centre.

Probiotics affect the clinical inflammatory parameters of experimental gingivitis in humans.

OBJECTIVES: To determine the effects of a probiotic milk drink consumed over a period of 28 days, regarding the expression of clinical inflammatory parameters of the oral gingiva during various phases of plaque-induced gingivitis. METHODS: Twenty-eight adults with healthy gingiva took part in a prospective and clinical-controlled study. The test group was advised to consume a probiotic milk drink (Yacult) daily during a period of 4 weeks; the control group did not receive any probiotic food or drink. After 2 weeks of consumption of the probiotic drink, participants were advised not to brush their teeth for 14 days. Subsequently, at baseline as well as on days 1, 3, 5, 7 and 14, the following clinical parameters were assessed: plaque index (PI), gingival index (GI), gingival crevicular fluid (GCF) volume and bleeding on probing (BOP). RESULTS: At baseline, the PI was significantly higher in the test group compared with controls (0.44±0.50 vs 0.09±0.24 PI; P=0.0001). The termination of oral hygiene increased clinical inflammatory parameters in both groups. At day 14, the parameters PI, GI, GCF volume and BOP were significantly higher compared with baseline values (P=0.0001). At day 14, BOP levels (18.75±12.32 vs 36.88±12.54%) and GCF volume (18.78±16.7 vs 35.72±16.1 Periotron units) were significantly lower in the test group compared with the control group (P=0.005). CONCLUSION: The results of our study indicate that a daily consumption of a probiotic milk drink reduces the effects of plaque-induced gingival inflammation associated with a higher plaque score due to the high-carbohydrate content of the probiotic milk beverage.

Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction.

OBJECTIVE: Whilst trans-abdominal fixation +/- resection offers better functional results and lower recurrence than perineal procedures, mesh rectopexy is complicated by constipation. Laparoscopic autonomic nerve-sparing, ventral rectopexy allows correction of the underlying abnormalities of the rectum, vagina, bladder and pelvic floor. METHOD: A prospective database was used to audit our 7-year experience of this technique. The recto-vaginal septum was mobilized anteriorly to the pelvic floor avoiding nerve damage. A prolene mesh was sutured to the ventral rectum, posterior vagina and vaginal fornix and secured to the sacral promontory. Patients were assessed with questionnaires and Cleveland Clinic scores. RESULTS: Eighty patients, six males, median age 59 years (range 31-90) underwent laparoscopic prolapse surgery between Jan 1997 and Dec 2005; 55% had full thickness prolapse and 46% rectal anal intussusception. Five had a solitary rectal ulcer. A total of 58% had undergone previous surgery; hysterectomy 33%, posterior colporrhaphy 15%, posterior rectopexy 6%, Delorme's rectal mucosectomy 5% and Birch colposuspension 3%. Half (54%) were incontinent (mean Wexner score 11, range 2-17) and 31% reported symptoms of obstructed defecation; seven had slow transit constipation and underwent resection. The median operative time was 125 min (range 50-210) with one conversion. Median time to diet was 12 h and median length of stay 3 days (1-12). No patient has developed recurrent full thickness prolapse at a median follow-up of 54 months (30-96). Incontinence improved in 39 of 43 patients (91%); median post-operative Wexner score 1 (0-9). Obstructed defecation resolved in 20 of 25 patients (80%). Pelvic pain resolved in all but one. Complications occurred in 21%; faecal impaction 4%, wound infection 2%, bleeding 2%, leak 1%, chest infection 1%, retention 1%. Three developed minor evacuatory difficulties and two, urinary stress incontinence. CONCLUSION: Laparoscopic ventral rectopexy is safe with relatively low morbidity. In the medium-term, it provides good results for prolapse and associated symptoms of incontinence and obstructed defecation.

Laparoscopic reversal of Hartmann's rectosigmoidectomy.

OBJECTIVE: The aim of this study was to analyse the outcome of laparoscopic restoration of bowel continuity post Hartmann's procedure. METHOD: A prospectively electronic database of colorectal laparoscopic procedures between April 2001 and December 2006 has been used to identify surgical outcomes in 28 consecutive patients who have undergone laparoscopic reversal of an open Hartmann's procedure (LRH). RESULTS: Twenty-eight patients (11 males), median age 66 (32-89), median body mass index 26 have undergone an attempted LRH over a 5-year period. Twenty (71%) had undergone surgery for complicated diverticulitis, eight (29%) for cancer; two followed an anastomotic dehiscence post-laparoscopic high anterior resection. The median operation time was 80 min (40-255 min). Twenty-six procedures (93%) were completed laparoscopically. There was one late conversion (to release a small bowel loop from the pelvis). A small, fibrotic rectal stump split whilst attempting a stapled anastomosis - the procedure was abandoned. The median time to normal diet was 18 h and median hospital stay was 3 days (1-63). There were three (11%) readmissions; wound infection (two) and abdominal pain. There were two deaths (7%) - mesenteric emboli and anticoagulant induced upper gastrointestinal haemorrhage. CONCLUSIONS: We believe that in the hands of appropriately trained and experienced surgeons, laparoscopic 'reversal' of a Hartmann's procedure is a feasible, safe and largely predictive operation that allows for early return of gastrointestinal function and very early hospital discharge.

Laparoscopic appendicectomy: a training model for laparoscopic right hemicolectomy?

OBJECTIVE: To analyse the outcome of laparoscopic appendicectomy and right hemicolectomy and see if the surgical approach to the former can be applied to the latter. METHOD: A prospective electronic laparoscopic database identified 330 appendicectomies and 78 right hemicolectomies (using this approach) between 1996 and 2005. RESULTS: Three hundred and thirty patients (188 males: median age 38 years, range 17-74 years) underwent laparoscopic appendicectomy; 270 (82%) were performed by trainees (higher surgical trainee 71%, basic surgical trainee 12%). The median operative time for trainees was 35 min (14-75 min) with a conversion rate 2%. There were no intra-operative complications. The postoperative complication rate excluding minor wound infection (5.5%) was 1.5%. There were no deaths. The median hospital stay was 2 days (1-15 days). The 30-day readmission rate was 1%. Seventy-eight patients (23-93 years) underwent laparoscopic right hemicolectomy during 2004/5; trainees performed parts thereof in the majority or all of the surgery in 25 cases. The median operation time was 55 min: trainees 115 (65-145 min). There was one conversion. The median hospital stay was 4 days (2-23 days) falling to 3 for the last 20 operations (1-8 days). There were two readmissions for wound sepsis and small bowel obstruction and three deaths (3.8%): anastomotic leak (one), C difficile infection leading to renal failure (one) and duodenal perforation (one). CONCLUSION: Laparoscopic appendicectomy is a safe, predictable, easily learnt operation and an ideal model for learning the skills and principles required for more advanced laparoscopic colorectal interventions and in particular, right hemicolectomy.

A prospective evaluation of stapled haemorrhoidopexy/rectal mucosectomy in the management of 3rd and 4th degree haemorrhoids.

OBJECTIVE: We have audited our 5 years experience of circumferential-stapled haemorrhoidopexy (PPH). METHOD: A prospectively collected electronic data base of our 5-year experience to September 2005 has been examined. RESULTS: A total of 357 consecutive patients (220 - 62% women, median age 46 years; range 28-92) with symptomatic third- and fourth-degree haemorrhoids (ratio 222:135) have undergone a stapled haemorrhoidopexy/rectal mucosectomy. One hundred and thirty-two (37%) had failed previous banding; 42 (12%) had undergone a Milligan-Morgan haemorrhoidectomy in the past. All but one was performed under general anaesthetic. Mean duration of surgery was 15 min (range 11-40); 299 (84%) were planned day cases (three patients were admitted overnight for pain relief (2) and retention of urine) and 57 were planned successful overnight stays. Reactive postoperative bleeding requiring a blood transfusion occurred in three patients (0.8%): one returned to theatre (0.2%). Three patients (0.8%) had a secondary haemorrhage requiring a hospital visit, one was admitted overnight. Four patients complaining of severe pain were managed in the community. Transient urgency was reported in 92 patients (26%); 58 (63%) were men, faecal impaction 4 (1.1%), minor staple line stenosis requiring dilatation 5 (1.4%), peri-anal sepsis from an associated untreated chronic anal fissure 1 (0.2%). Normal work was resumed between 3 and 31 days (median 7). Five patients re-presented with recurrent symptoms between 14 & 18 months: further treatment comprised a repeat PPH in three (one was very painful), banding 1 and reassurance alone. A further patient re-presented with minor soiling which responded to physiotherapy. CONCLUSION: Stapled haemorrhoidopexy/rectal mucosectomy is a safe, effective and predictable treatment of third- and fourth- degree haemorrhoids and in the majority of patients can be carried out on a day case basis.

Evidence of nerve sheath differentiation and high grade morphology in sclerosing epithelioid fibrosarcoma.

Sclerosing epithelioid fibrosarcoma is a recently described sarcoma in which ultrastructural evidence of fibroblastic differentiation forms part of the diagnostic criteria. This report describes a further case of this tumour, which showed evidence of both fibroblastic and perineurial differentiation by immunohistochemistry and electron microscopy, and which had areas of high grade morphology. The tumour metastasised and the patient died of disease 12 months after presentation. The relevance of these findings to diagnosis and differentiation in these tumours is discussed.